16 Frame-Based Stereotactic DBS Implantation of Vim for Essential Tremor and Other Cerebellar Outflow Tremors

摘要: Tremor is a common movement disorder that in severe cases can be functionally disabling. Deep brain stimulation (DBS) has emerged in recent decades as the preferred neurosurgical treatment for patients who have failed drug therapy. The ventral intermediate (Vim) nucleus of the thalamus has been established as an effective surgical target for suppressing tremor associated with a variety of disorders, most commonly essential tremor. Patients with distal upper extremity tremor are most likely to benefit from surgery. We perform thalamic DBS with the patient awake and in a stereotactic frame. Preoperative targeting of the Vim is corroborated with microelectrode recordings, which identify characteristic tremor cells within the Vim that burst in synchrony with the patient’s tremor. Macrostimulation confirms tremor arrest and screens for unwanted side effects, notably paresthesias and dysarthria. Many patients are able to discharge from the hospital the day after electrode placement, and they return for implantation of a pulse generator device, which can be performed on an outpatient basis. Stimulation-related adverse effects are common but tend to be transient and sensitive to device reprogramming. Surgical complications may include infection, intracerebral hemorrhage, and device failure or malfunction, though these are rare. Upward of 80% of tremor patients enjoy meaningful long-term tremor suppression. Unlike thalamotomy, DBS can also be performed bilaterally, and it is associated with improvements in functional status.