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Deep brain stimulation of the globus pallidus internus or ventralis intermedius nucleus of thalamus for Holmes tremor

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Abstract

Holmes tremor (HT) is a difficult-to-treat, very disabling symptomatic condition which characteristically appears weeks to years after a brain lesion. It features a unique combination of rest, action, and postural tremors. Pharmacotherapy is mostly not effective. Chronic deep brain stimulation (DBS) of ventralis intermedius nucleus (Vim) of thalamus has been described as being the best surgical approach in singular case series; various authors observe, however, cases with partial responses only; therefore, alternatives are still needed. We report ten patients with HT unresponsive to best medical therapy who underwent DBS in our center from March 2002 to June 2012. Based in our previous experience dealing with cases of unsatisfactory Vim intraoperative tremor control and in order to optimize surgical results, presurgical target planning included two Nuclei: Vim and posteroventral Globus pallidus internus (GPi) (Espinoza et al. 2010; Espinoza et al. Stereotact Funct Neurosurg 90(suppl 1):1–202, p 61, 2012). Definitive chosen target was decided after single-cell microelectrode recording, intraoperative test stimulation, thresholds for stimulation-induced adverse effects and best clinical response compared to baseline status. Fahn-Tolosa-Marin tremor rating scale (FTM-TRS) was used to evaluate outcome. The electrode was implanted in the nucleus with the best tremor suppression achievement; on the other hand, GPi DBS was initially decided if one of the following conditions was present: (a) If Vim nucleus anatomy was grossly altered; (b) when intraoperative tremor control was unsatisfactory despite Vim high-intensity stimulation; or (c) if unaffordable side effects or even tremor worsening occurred during intraoperative macrostimulation. Seven patients received definitive Gpi DBS implantation, while three patients received Vim DBS. In all observed cases, we observed an improvement on the TRS. In two cases where Vim thalamic anatomy was altered by the pathological insult GPI was planned from the beginning, and same was true in two additional cases where the Gpi nucleus showed major alterations allowing only Vim planning. Over all cases, the average improvement in tremor was of 2.55 points on the TRS or a 64 % increase in measured results; with a minimum of 1 point (25 %) improvement in one case and a maximum of 4 points (100 % improvement) also in one case. All the results were sustained at 2 years follow-up. One case with predominant resting component, implanted in the GPi, achieved the maximum possible tremor reduction (from 4 to 0 points, meaning 100 % tremor reduction); in the nine resting cases, the average reduction was of 3 points (or 75 %). DBS demonstrated in this case series adequate tremor control in 10 patients unresponsive to medical therapy. Presurgical planning of two targets allowed choosing best optimal response. Gpi stimulation could be considered as an alternative target for cases in which thalamic anatomy is considerably altered or Vim intraoperative stimulation does not produce satisfactory results.

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Acknowledgments

We thank the patients for study participation and cooperation. We are grateful to Medtronic for their courtesy on the use of 3D software under clinical investigation. We thank Dr. Jorge Humberto Marin and Dr. Vanessa Martinez from San Jose University Hospital, Neuroradiology Department Bogotá, Colombia. Very special thanks to Ulrich Albicker from Inomed Germany who helped with the statistics analyses.

Conflict of interest

The authors disclose no financial support for this study, and there is no industry economic support for this manuscript.

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Authors and Affiliations

  1. Department of Stereotactic and Functional Neurosurgery, Movement Disorders and Pain Clinic, CIMAD, Carrera 19A N 82-14, Bogotá, Colombia

    Jairo Alberto Espinoza Martinez, Gabriel J. Arango, Oscar Andrés Escobar & G. Rene Alvarez Berastegui

  2. Marly Clinic, Calle 50 No 9-67, Bogotá, Colombia

    Gabriel J. Arango

  3. Department of Stereotactic and Functional Neurosurgery and Neurology, Hospital das Clinicas, University of São Paulo, São Paulo Medical School, São Paulo, Brazil

    Erich Talamoni Fonoff

  4. Neurosurgery Department, Städtisches Klinikum München, Munich, Germany

    Thomas Reithmeier

  5. Department of Stereotactic and Functional Neurosurgery, University Hospital Freiburg, Breisacher Str. 64, 79106,, Freiburg im Breisgau, Germany

    Luciano Furlanetti & William Omar Contreras Lopez

  6. Institute of Radiology, Department of Neuroradiology, University of São Paulo, Sao Paulo, Brazil

    Fabio Eduardo Fernandes da Silva

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  1. Jairo Alberto Espinoza Martinez
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Correspondence to Jairo Alberto Espinoza Martinez or William Omar Contreras Lopez.

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Comments

Jürgen Voges, Magdeburg, Germany

The authors reported the outcome of ten patients treated with DBS for Holmes tremor. Furthermore, the group presented an algorithm to decide intraoperatively, which target should be finally stimulated. Depending on the individual anatomy referred to the damage of either the motor thalamus (Vim) and related structures or the ventro-postero-lateral pallidum (GPI) and depending on the individual response to intraoperative test stimulation, the patients received either GPI (seven cases) or Vim (three cases) electrodes. The treatment of Holmes tremor is very challenging; the number of publications dealing with DBS treatment of these patients is rare. Thus, reports of innovative approaches as described in this manuscript are important. Even though the authors analyzed their data retrospectively and derived the algorithm for target decision rather from experience and not as a hypothesis tested in a prospective clinical protocol, this approach is worth to be considered for the clinical routine in such difficult cases.

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Espinoza Martinez, J.A., Arango, G.J., Fonoff, E.T. et al. Deep brain stimulation of the globus pallidus internus or ventralis intermedius nucleus of thalamus for Holmes tremor. Neurosurg Rev 38, 753–763 (2015). https://doi.org/10.1007/s10143-015-0636-0

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