DBS for complex tremor

“Complex tremor” describes tremor that affects several body parts at once — for example the head, voice and hands — or tremor combined with dystonia or another movement disorder. These patterns are harder to control with a single DBS target. Planning that can reach more than one part of the tremor circuit, such as double-target Vim+PSA stimulation, is designed for exactly these patients ^[1],[2].

Key facts

Complex tremor affects several body parts or mixes tremor with dystonia.
Each component is assessed and targeted separately.
Double-target Vim+PSA stimulation gives more programming options ^[1].
Head and limb tremor usually respond quickly; voice tremor less predictably ^[3].
Dystonic components improve over weeks to months.

**Progressing Tremor Before & After DBS: A 42-Year-Old from Uzbekistan** — A 42-year-old patient from Uzbekistan treated with DBS for a progressing tremor; an example of “yes-yes” head tremor.
Shared with the patient’s written consent. Individual results vary.

**Parkinson's Tremor: No Benefit from STN DBS Abroad, Then a New Start in Istanbul** — A tremor-dominant Parkinson’s patient who had no benefit from STN DBS at another center abroad, after DBS in Istanbul.
Shared with the patient’s written consent. Individual results vary.

**Parkinson's Before & After DBS: A Woman from Kyrgyzstan** — A woman from Kyrgyzstan with Parkinson’s disease, before and after DBS in Istanbul.
Shared with the patient’s written consent. Individual results vary.

**Tremor in Both Arms: Parkinson's Before & After DBS** — A woman from Kyrgyzstan with tremor-dominant Parkinson’s disease affecting both arms, after DBS.
Shared with the patient’s written consent. Individual results vary.

**Tremor-Dominant Parkinson's Before & After DBS: From Georgia to Istanbul** — A patient from Georgia with tremor-dominant Parkinson’s disease, after DBS in Istanbul.
Shared with the patient’s written consent. Individual results vary.

Watch many more head tremor patientsOur YouTube playlist: many head tremor patients filmed before and after DBS

Open the head tremor video library on this site.

Common patterns

Head + voice + hand tremor in essential tremor
Head tremor with cervical dystonia and arm tremor
Proximal (shoulder) and distal (hand) tremor after a brain injury
Tremor combined with slowness and stiffness

Planning

Each component is assessed separately — on video, with rating scales and by examination — and the targets are chosen to cover the most disabling parts. Voice tremor in our published series improved from moderate-to-severe to mild vocal cord tremor in both patients, although the number was too small for statistics ^[1].

Why double targeting helps

Lower intensity at each site. Instead of driving one target hard, the stimulation can be shared between the Vim and the PSA. In our experience this makes numbness, speech and balance side effects easier to avoid; in the published series, settings were generally lower at both sites when both were used ^[1].
A reserve for the future. If the disease progresses, or one target becomes less effective with time, the second target can be added.
Switching without surgery. Moving the stimulation from the Vim to the PSA, or the other way round, is done by reprogramming the stimulator — the electrodes stay where they are.
Little extra burden. Both targets lie along one trajectory, so no additional electrode is needed ^[1].

What to expect

Limb and head tremor usually respond as soon as the stimulator is switched on the day after surgery; voice tremor tends to respond less predictably ^[3], and dystonic components improve more gradually.

Side effects and how they are handled

Stimulation side effects usually appear when the stimulator is first switched on or when settings are increased, and most disappear when the settings are adjusted. In our published series ^[1]:

Tingling (paresthesia) was the most common effect when stimulation began; it faded within minutes without any change of settings.
Slurred speech appeared in one patient after the first electrode, lasted two weeks and resolved by itself; the second side was operated after it had settled.
Unsteadiness occurred in two patients: in one it resolved by itself, in the other after the active contact was moved slightly upward within the Vim and the PSA share was reduced.

Speech side effects were a known drawback when only the Vim was used. In our experience, the PSA is safer than the Vim with respect to speech, and because both targets sit on the same electrode, we can move stimulation away from a site that causes a problem. A well-placed electrode is the key: if an electrode lies too far to the side, speech effects can persist, which is why placement is checked by testing during surgery and by CT afterward ^[1].

Surgical complications are uncommon but real. In the published series, one electrode needed repositioning and two patients developed an infection requiring removal of an electrode, which was later re-implanted in one of them ^[1]. Your individual risk is discussed during the evaluation.

Your surgeon

Prof. Atilla YILMAZ, MD

Every operation is performed personally by Prof. YILMAZ, a stereotactic and functional neurosurgeon who has carried out 1,200+ neuromodulation procedures, including 800+ DBS surgeries, for patients from 60+ countries. He is the first author of the published double-target Vim+PSA series for rare tremor syndromes ^[1].

President, Middle-Eastern Society for Stereotactic and Functional Neurosurgery (MSSFN); Board of Directors, WSSFN and International Neuromodulation Society
Proctor for Medtronic, Abbott and Boston Scientific — the three leading DBS manufacturers appoint him to train other neurosurgeons on their systems
40+ neurosurgeons trained from 30 countries; first-ever DBS surgeries performed in six countries
Trained at the University of Florida (observership with Prof. Okun and Prof. Foote) and Umeå University Hospital, Sweden

Full profile and credentials

Questions to ask before choosing DBS

What type of tremor do I have, and how sure is the diagnosis?
Which target will be used, and why?
Will both sides be operated on?
Who will perform the operation, and how many tremor operations has the surgeon done?
When will the stimulator be switched on, and who will program it after I go home?
What happens if the effect lessens in the future?

Frequently asked questions

Can one operation treat head, voice and hand tremor?

Often yes. Bilateral electrodes placed in the tremor circuit can improve all three, though voice tremor tends to respond less predictably than hand tremor ^[3].

Sources

Yilmaz A, Eray HA, Cakir M, Ceylan M, Blomstedt P. Deep Brain Stimulation with Double Targeting of the VIM and PSA for the Treatment of Rare Tremor Syndromes. Stereotact Funct Neurosurg 2024;102:224–239. DOI 10.1159/000539162. pubmed.ncbi.nlm.nih.gov/38934181/
Tsuboi T, Au KLK, Deeb W, Almeida L, Foote KD, Okun MS, Ramirez-Zamora A. Motor outcomes and adverse effects of deep brain stimulation for dystonic tremor: a systematic review. experts.umn.edu/en/publications/motor-outcomes-and-adverse-effects-of-deep-brain-stimulation-for-/
Putzke JD, Uitti RJ, Obwegeser AA, Wszolek ZK, Wharen RE. Bilateral thalamic deep brain stimulation: midline tremor control. J Neurol Neurosurg Psychiatry 2005;76(5):684–690. pmc.ncbi.nlm.nih.gov/articles/PMC1739619/