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 , Parkinson tremor , and myoclonic tremor in myoclonus dystonia ). 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: firstname.lastname@example.org
Received February 09, 2014
Accepted August 13, 2014