Abstract
Deep brain stimulation (DBS) in the thalamic ventral intermediate (Vim) or the subthalamic nucleus (STN) reportedly improves medication-refractory Parkinson’s disease (PD) tremor. However, little is known about the potential synergic effects of combined Vim and STN DBS. We describe a 79-year-old man with medication-refractory tremor-dominant PD. Bilateral Vim DBS electrode implantation produced insufficient improvement. Therefore, the patient underwent additional unilateral left-sided STN DBS. Whereas Vim or STN stimulation alone led to partial improvement, persisting tremor resolution occurred after simultaneous stimulation. The combination of both targets may have a synergic effect and is an alternative option in suitable cases.
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Anheim M, Batir A, Fraix V, Silem M, Chabardès S, Seigneuret E, Krack P, Benabid AL, Pollak P (2008) Improvement in Parkinson disease by subthalamic nucleus stimulation based on electrode placement: effects of reimplantation. Arch Neurol 65:612–616
Blomstedt P, Fytagoridis A, Åström M, Linder J, Forsgren L, Hariz MI (2012) Unilateral caudal zona incerta deep brain stimulation for Parkinsonian tremor. Parkinsonism Relat Disord 18:1062–1066
Blomstedt P, Lindvall P, Linder J, Olivecrona M, Forsgren L, Hariz MI (2012) Reoperation after failed deep brain stimulation for essential tremor. World Neurosurg 78:7554.e1–7554.e5
Coenen VA, Allert N, Paus S, Kronenbürger M, Urbach H, Mädler B (2014) Modulation of the cerebello-thalamo-cortical network in thalamic deep brain stimulation for tremor: a diffusion tensor imaging study. Neurosurgery 75:657–670
Ellis TM, Foote KD, Fernandez HH, Sudhyadhom A, Rodriguez RL, Zeilman P, Jacobson CE 4th, Okun MS (2008) Reoperation for suboptimal outcomes after deep brain stimulation surgery. Neurosurgery 63:754–761
Fraix V, Pollak P, Moro E, Chabardes S, Xie J, Ardouin C, Benabid AL (2005) Subthalamic nucleus stimulation in tremor dominant parkinsonian patients with previous thalamic surgery. J Neurol Neurosurg Psychiatry 76:246–248
Gallay MN, Jeanmonod D, Liu J, Morel A (2008) Human pallidothalamic and cerebellothalamic tracts: anatomical basis for functional stereotactic neurosurgery. Brain Struct Funct 212:443–463
Granziera C, Pollo C, Russmann H, Staedler C, Ghika J, Villemure JG, Burkhard PR, Vingerhoets FJ (2008) Sub-acute delayed failure of subthalamic DBS in Parkinson’s disease: the role of micro-lesion effect. Parkinsonism Relat Disord 14:109–113
Hamel W, Herzog J, Kopper F, Pinsker M, Weinert D, Müller D, Krack P, Deuschl G, Mehdorn HM (2007) Deep brain stimulation in the subthalamic area is more effective than nucleus ventralis intermedius stimulation for bilateral intention tremor. Acta Neurochir (Wien) 149:749–758
Hariz MI, Krack P, Alesch F, Augustinsson LE, Bosch A, Ekberg R, Johansson F, Johnels B, Meyerson BA, N’Guyen JP, Pinter M, Pollak P, von Raison F, Rehncrona S, Speelman JD, Sydow O, Benabid AL (2008) Multicentre European study of thalamic stimulation for parkinsonian tremor: a 6 years follow-up. J Neurol Neurosurg Psychiatry 79:694–699
Khan S, Gill SS, Mooney L, White P, Whone A, Brooks DJ, Pavese N (2012) Combined pedunculopontine-subthalamic stimulation in Parkinson disease. Neurology 78:1090–1095
Khan S, Javed S, Mooney L, White P, Plaha P, Whone A, Gill SS (2012) Clinical outcomes from bilateral versus unilateral stimulation of the pedunculopontine nucleus with and without concomitant caudal zona incerta region stimulation in Parkinson’s disease. Br J Neurosurg 26:722–725
Khan S, Mooney L, Plaha P, Javed S, White P, Whone AL, Gill SS (2011) Outcomes from stimulation of the caudal zona incerta and pedunculopontine nucleus in patients with Parkinson’s disease. Br J Neurosurg 25:273–280
Kim HJ, Jeon BS, Paek SH, Lee JY, Kim HJ, Kim CK, Kim DG (2010) Bilateral subthalamic deep brain stimulation in Parkinson disease patients with severe tremor. Neurosurgery 67:626–632
Mazzone P, Brown P, Dilazzaro V, Stanzione P, Oliviero A, Peppe A, Santilli V, Insola A, Altibrandi M (2005) Bilateral implantation in globus pallidus internus and in subthalamic nucleus in Parkinson’s disease. Neuromodulation 8:1–6
Mazzone P, Stocchi F, Galati S, Insola A, Altibrandi MG, Modugno N, Tropepi D, Brusa L, Stefani A (2006) Bilateral implantation of centromedian-parafascicularis complex and GPi: a new combination of unconventional targets for deep brain stimulation in severe Parkinson disease. Neuromodulation 9:221–228
Peppe A, Gasbarra A, Stefani A, Chiavalon C, Pierantozzi M, Fermi E, Stanzione P, Caltagirone C, Mazzone P (2008) Deep brain stimulation of CM/PF of thalamus could be the new elective target for tremor in advanced Parkinson’s disease? Parkinsonism Relat Disord 14:501–504
Peppe A, Pierantozzi M, Bassi A, Altibrandi MG, Brusa L, Stefani A, Stanzione P, Mazzone P (2004) Stimulation of the subthalamic nucleus compared with the globus pallidus internus in patients with Parkinson disease. J Neurosurg 101:195–200
Peppe A, Pierantozzi M, Chiavalon C, Marchetti F, Caltagirone C, Musicco M, Stanzione P, Stefani A (2010) Deep brain stimulation of the pedunculopontine tegmentum and subthalamic nucleus: effects on gait in Parkinson’s disease. Gait Posture 32:512–518
Romanelli P, Brontë-Stewart H, Courtney T, Heit G (2003) Possible necessity for deep brain stimulation of both the ventralis intermedius and subthalamic nuclei to resolve Holmes tremor. Case report. J Neurosurg 99:566–571
Stefani A, Lozano AM, Peppe A, Stanzione P, Galati S, Tropepi D, Pierantozzi M, Brusa L, Scarnati E, Mazzone P (2007) Bilateral deep brain stimulation of the pedunculopontine and subthalamic nuclei in severe Parkinson’s disease. Brain 130:1596–1607
Stefani A, Peppe A, Pierantozzi M, Galati S, Moschella V, Stanzione P, Mazzone P (2009) Multi-target strategy for parkinsonian patients: the role of deep brain stimulation in the centromedian-parafascicularis complex. Brain Res Bull 78:113–118
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The authors present the case of a patient with tremor-dominant Parkinson’s disease (PD) who did not improve sufficiently from bilateral DBS targeted to the Vim subnucleus of the thalamus. MR revealed a possibly misplaced left lead. In consideration of the presence of a partial treatment effect a decision was taken not to relocate this lead but instead supplement it with another electrode lead in the STN. Improvement of stimulation equipment has made it possible to retain a lead with partial effect and supplement it with another lead without having to implant yet another pulse generator. Follow-up examinations demonstrated a synergistic effect of these two leads.
This presentation strengthens the argument to retain a partially effective electrode and supplement it with another lead in some other possibly effective target, rather than relocating a single misplaced lead. Furthermore, this article adds to the body of evidence concerning simultaneous stimulation in several target areas, a strategy that subsequent research efforts in the future may prove to be of value, not only as a salvage effort for insufficient initial results but also in select cases as a first-line treatment possibility.
Goran Lind
Stockholm, Sweden
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Oertel, M.F., Schüpbach, W.M.M., Ghika, JA. et al. Combined thalamic and subthalamic deep brain stimulation for tremor-dominant Parkinson’s disease. Acta Neurochir 159, 265–269 (2017). https://doi.org/10.1007/s00701-016-3044-5
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DOI: https://doi.org/10.1007/s00701-016-3044-5