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Modulation of the Cerebello-Thalamo-Cortical Network in Thalamic Deep Brain Stimulation for Tremor: A Diffusion Tensor Imaging Study

Coenen, Volker A. MD*; Allert, Niels MD; Paus, Sebastian MD§; Kronenbürger, Martin MD; Urbach, Horst MD; Mädler, Burkhard PhD*

doi: 10.1227/NEU.0000000000000540
Research-Human-Clinical Studies

BACKGROUND: Deep brain stimulation alleviates tremor of various origins. Several regions like the ventralis intermediate nucleus of thalamus, the caudal zona incerta, and the posterior subthalamic region are generally targeted. Previous work with fiber tractography has shown the involvement of the cerebello-thalamo-cortical network in tremor control.

OBJECTIVE: To report the results of a prospective trial in a group of patients with tremor who underwent post hoc tractographic analysis after treatment with traditional thalamic deep brain stimulation.

METHODS: A total of 11 patients (aged 64 ± 17 years, 6 male) were enrolled (essential tremor [6], Parkinson tremor [3], and myoclonic tremor in myoclonus dystonia [2]). Patients received 1 (3 patients), 2 (7 patients), or 3 (1 patient) quadripolar electrodes. A 32-direction diffusion tensor magnetic resonance imaging sequence was acquired preoperatively. Tractography was processed postoperatively for evaluation and the dentato-rubro-thalamic tract (DRT) was individually tracked. Electrode positions were determined with helical computed tomography. Electric fields (EFs) were simulated according to individual stimulation parameters in a standardized atlas brain space (ICBM-MNI 152).

RESULTS: Tremor was reduced in all patients (69.4% mean) on the global (bilateral) tremor score. Effective contacts were located inside or in proximity to the DRT. In moderate tremor reduction (2 patients), the EFs were centered on its anterior border. In good and excellent tremor reduction (9 patients), EFs focused on its center.

CONCLUSION: Deep brain stimulation of the cerebello-thalamo-cortical network reduces tremor. The DRT connects 3 traditional target regions for deep brain stimulation in tremor disease. Tractography techniques can be used to directly visualize the DRT and, therefore, optimize target definition in individual patients.

ABBREVIATIONS: ACPC, anterior commissure-posterior commissure

CeTCoCe, cerebello-thalamo-cortical-cerebellar loop

CoTCo, cortico-thalamo-cortical loop

cZI, caudal zona incerta

DBS, deep brain stimulation

DRT, dentato-rubro-thalamic tract

DTI, diffusion tensor magnetic resonance imaging

EF, electric field

ET, essential tremor

ETRS, Essential Tremor Rating Scale

FOV, field of view

FT, fiber tractography

ICBM-MNI 152, Montreal Neurological Institute Brain Atlas

VOP, ventralis oralis posterior nucleus of thalamus

pSTR, posterior subthalamic region

STN, subthalamic nucleus

TE, echo time

TR, repetition time

Vim, ventral intermediate nucleus of thalamus

*Department of Stereotactic and Functional Neurosurgery, Freiburg University Medical Center, Freiburg (i.Br.), Germany;

Neurological Rehabilitation Center “Godeshöhe,” Bonn, Germany;

§Department of Neurology, University Hospital Bonn, Bonn, Germany;

Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, Maryland;

Department of Neuroradiology, Freiburg University Medical Center, Freiburg (i.Br.), Germany

Correspondence: Volker Arnd Coenen, MD, Department of Stereotactic and Functional Neurosurgery, Freiburg University Medical Center, Freiburg (i.Br.), Germany. E-mail:

Received February 09, 2014

Accepted August 13, 2014

Copyright © by the Congress of Neurological Surgeons