Acta Neurochirurgica

, Volume 153, Issue 12, pp 2329–2335 | Cite as

Deep brain stimulation of the subthalamic nucleus versus the zona incerta in the treatment of essential tremor

  • Patric BlomstedtEmail author
  • Ulrika Sandvik
  • Jan Linder
  • Anna Fredricks
  • Lars Forsgren
  • Marwan I. Hariz
Clinical Article



Deep brain stimulation (DBS) is an effective treatment for essential tremor (ET). Currently the ventrolateral thalamus is the target of choice, but the posterior subthalamic area (PSA), including the caudal zona incerta (cZi), has demonstrated promising results, and the subthalamic nucleus (STN) has been suggested as a third alternative. The objective of the current study was to evaluate the effect of STN DBS in ET and to compare this to cZi DBS.


Four patients with ET were implanted with two ipsilateral electrodes, one in the STN and one in the cZi. All contacts were evaluated concerning the acute effect on tremor, and the effect of chronic DBS in either target was analyzed.


STN and cZi both proved to be potent targets for DBS in ET. DBS in the cZi was more efficient, since the same degree of tremor reduction could here be achieved at lower energy consumption. Three patients became tremor-free in the treated hand with either STN or cZi DBS, while the fourth had a minor residual tremor after stimulation in either target.


In this limited material, STN DBS was demonstrated to be an efficient treatment for ET, even though cZi DBS was more efficient. The STN may be an alternative target in the treatment of ET, pending further investigations to decide on the relative merits of the different targets.


Essential tremor DBS Subthalamic nucleus Posterior subthalamic area Zona incerta 



This work was supported by grants from the University of Umeå and from the Foundation for Clinical Neuroscience at the University Hospital of Umeå. Marwan Hariz is supported by the Parkinson Appeal U.K. He has occasionally received honoraria from Medtronic for speaking at meetings. The authors have nothing further to acknowledge.

Conflicts of interest



  1. 1.
    Blomstedt P, Hariz GM, Hariz MI, Koskinen LO (2007) Thalamic deep brain stimulation in the treatment of essential tremor: a long-term follow-up. Br J Neurosurg 21:504–509PubMedCrossRefGoogle Scholar
  2. 2.
    Blomstedt P, Hariz MI (2006) Are complications less common in deep brain stimulation than in ablative procedures for movement disorders? Stereotact Funct Neurosurg 84:72–81PubMedCrossRefGoogle Scholar
  3. 3.
    Blomstedt P, Sandvik U, Fytagoridis A, Tisch S (2009) The posterior subthalamic area in the treatment of movement disorders: past, present, and future. Neurosurgery 64:1029–1038PubMedCrossRefGoogle Scholar
  4. 4.
    Blomstedt P, Sandvik U, Tisch S (2010) Deep brain stimulation in the posterior subthalamic area in the treatment of essential tremor. Mov Disord 25:1350–1356PubMedCrossRefGoogle Scholar
  5. 5.
    Chou KL, Hurtig HI, Jaggi JL, Baltuch GH (2005) Bilateral subthalamic nucleus deep brain stimulation in a patient with cervical dystonia and essential tremor. Mov Disord 20:377–380PubMedCrossRefGoogle Scholar
  6. 6.
    Deuschl G, Bain P, Brin M (1998) Consensus statement of the Movement Disorder Society on Tremor. Ad Hoc Scientific Committee. Mov Disord 13(Suppl 3):2–23PubMedGoogle Scholar
  7. 7.
    Fahn S, Tolosa E, Marin C (1993) Clinical rating scale for tremor. In: Jankovic J, Tolosa E (eds) Parkinson´s disease and movementdisorders. Urban and Schwarzenberg Munich, pp 271–280Google Scholar
  8. 8.
    Flora ED, Perera CL, Cameron AL, Maddern GJ (2010) Deep brain stimulation for essential tremor: a systematic review. Mov Disord 25:1550–1559PubMedCrossRefGoogle Scholar
  9. 9.
    Fytagoridis A, Blomstedt P (2010) Complications and side effects of deep brain stimulation in the posterior subthalamic area. Stereotact Funct Neurosurg 88:88–93PubMedCrossRefGoogle Scholar
  10. 10.
    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 ventralis intermedius stimulation for bilateral intention tremor. Acta Neurochirurgica 149:749–758PubMedCrossRefGoogle Scholar
  11. 11.
    Hernando Requejo V, Pastor J, Pedrosa Sanchez M, Luengo Dos Santos A, Sola RG (2004) Treatment of a case of essential tremor with subthalamic stimulation. Rev Neurol 38:637–639PubMedGoogle Scholar
  12. 12.
    Herzog J, Hamel W, Wenzelburger R, Potter M, Pinsker MO, Bartussek J, Morsnowski A, Steigerwald F, Deuschl G, Volkmann J (2007) Kinematic analysis of thalamic versus subthalamic neurostimulation in postural and intention tremor. Brain 130:1608–1625PubMedCrossRefGoogle Scholar
  13. 13.
    Kitagawa M, Murata J, Kikuchi S, Sawamura Y, Saito H, Sasaki H, Tashiro K (2000) Deep brain stimulation of subthalamic area for severe proximal tremor. Neurology 55:114–116PubMedGoogle Scholar
  14. 14.
    Lind G, Lind C, Winter BA, Meyerson B, Linderoth B (2004) Long-term results of treatment for essential tremor with stimulation of the subthalamic nucleus: case studies. Mov Disord 19(suppl 9):S305Google Scholar
  15. 15.
    Lind G, Schechtmann G, Lind C, Winter J, Meyerson BA, Linderoth B (2008) Subthalamic stimulation for essential tremor. Short- and long-term results and critical target area. Stereotact Funct Neurosurg 86:253–258PubMedCrossRefGoogle Scholar
  16. 16.
    Mobin F, De Salles AA, Behnke EJ, Frysinger R (1999) Correlation between MRI-based stereotactic thalamic deep brain stimulation electrode placement, macroelectrode stimulation and clinical response to tremor control. Stereotact Funct Neurosurg 72:225–232PubMedCrossRefGoogle Scholar
  17. 17.
    Murata J, Kitagawa M, Uesugi H, Saito H, Iwasaki Y, Kikuchi S, Tashiro K, Sawamura Y (2003) Electrical stimulation of the posterior subthalamic area for the treatment of intractable proximal tremor. J Neurosurg 99:708–715PubMedCrossRefGoogle Scholar
  18. 18.
    Plaha P, Ben-Shlomo Y, Patel NK, Gill SS (2006) Stimulation of the caudal zona incerta is superior to stimulation of the subthalamic nucleus in improving contralateral parkinsonism. Brain 129:1732–1747PubMedCrossRefGoogle Scholar
  19. 19.
    Plaha P, Khan S, Gill SS (2008) Bilateral stimulation of the caudal zona incerta nucleus for tremor control. J Neurol Neurosurg Psychiatry 79:504–513PubMedCrossRefGoogle Scholar
  20. 20.
    Plaha P, Patel NK, Gill SS (2004) Stimulation of the subthalamic region for essential tremor. J Neurosurg 101:48–54PubMedCrossRefGoogle Scholar
  21. 21.
    Pollak P, Benabid AL, Gross C, Gao DM, Laurent A, Benazzouz A, Hoffmann D, Gentil M, Perret J (1993) Effects of the stimulation of the subthalamic nucleus in Parkinson disease. Rev Neurol (Paris) 149:175–176Google Scholar
  22. 22.
    Stover NP, Okun MS, Evatt ML, Raju DV, Bakay RA, Vitek JL (2005) Stimulation of the subthalamic nucleus in a patient with Parkinson disease and essential tremor. Arch Neurol 62:141–143PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Patric Blomstedt
    • 1
    • 4
    Email author
  • Ulrika Sandvik
    • 1
  • Jan Linder
    • 2
  • Anna Fredricks
    • 2
  • Lars Forsgren
    • 2
  • Marwan I. Hariz
    • 1
    • 3
  1. 1.Department of Clinical Neuroscience, section of NeurosurgeryUmeå UniversityUmeåSweden
  2. 2.Department of Clinical Neuroscience, section of NeurologyUmeå UniversityUmeåSweden
  3. 3.UCL Institute of Neurology, Queen SquareLondonUK
  4. 4.Department of NeurosurgeryUniversity Hospital of Northern SwedenUmeåSweden

Personalised recommendations