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Objective: Deep Brain Stimulation (DBS) of the nucleus ventralis intermedius thalami (Vim, cerebello-thalamic fascicle) became a common and successful therapy in the last decades to treat tremor syndromes e.g. essential tremor or tremor in Parkinson’s disease. MR-Guided High Intensity Focused Ultrasound (MRIgFUS) is used for treatment of tremor-dominant Parkinson’s disease and there is some promising evidence in tremor dominant Parkinson’s disease using the pallido-thalamic tract (fasciculus thalamicus) as target (Fig.1 and Fig 2).
Background: We present the case of a 33-year old man who suffered from a severe brain injury at the age of 20. Two years later he developed a tremor of the right arm progressing over the years. The tremor had a low frequency of 3 Hz and was a combination of rest, postural and action tremor. Several drugs were tried to improve the tremor, e.g. propranolol and levodopa up to 600 mg/d but there was no improvement. MRI of the brain showed severe atrophy pronounced in the frontal lobes bilaterally, the right temporal and the hippocampal region. Additionally, lesions in the left thalamus and midbrain region were revealed.
Methods: DBS was performed in the nucleus ventralis intermedius thalami (Vim, cerebello-thalamic fascicle) contralaterally to the side of the tremor manifestation. Intraoperative testing did not show any improvement of the tremor but severe dystonic side effects occurred due to capsular stimulation. The decision was made to implant a second electrode in the thalamic fascicle (fasciculus thalamicus) resulting in significant improvement of the tremor lasting up more than one year of follow up (Fig 3).
Conclusions: The pallido-thalamic tract (fasciculus thalamicus) seems to be a promising target for tremor suppression by using DBS. Experience from MRIgFUS could be helpful defining new stereotactic targets in DBS.