DBS for isolated head tremor
Isolated head tremor responds well to double-target deep brain stimulation. In Prof. YILMAZ’s peer-reviewed series of 22 patients with rare tremor syndromes treated with double-target Vim+PSA DBS, the mean tremor reduction was 89% (range 50–100%), and 6 of 7 patients with isolated head tremor had a tremor score of 0 at 12 months, as rated blindly by two movement disorder specialists [1]. The patients had had head tremor for at least four years, with no tremor elsewhere and no dystonic signs [1]. Our longest-followed head tremor patient still has a tremor score of 0 six and a half years after double-target DBS; the score was 4 before surgery (our case series; results vary).
Key facts
Play video: Head Tremor Before & 1 Year After DBS — Surgery Without Shaving Her Head
Play video: Head Tremor Before & After DBS: How DBS Gave Her Life Back
Open the head tremor video library on this site.
Why isolated head tremor needs a special approach
DBS for head tremor has mostly been reported when it is part of essential tremor or Parkinson’s disease; DBS for isolated head tremor is rare in the literature [1]. Head tremor without limb tremor responds less predictably to standard Vim stimulation. Reaching both the Vim and the PSA on each side allows the stimulation to be focused where it works best for midline tremor [1]. See how the technique works.
Why both sides
It is very difficult to tell which half of the brain drives a head tremor, and both halves control the neck muscles. For isolated head tremor we always operate on both sides, in the same session.
Who is a candidate?
- Head tremor that limits daily or social life
- Insufficient benefit from medication or botulinum toxin
- Good general health
Results in detail
Before surgery, five of the seven patients scored 4 (the most severe), one scored 3 and one scored 2. Six reached 0 after surgery. In the seventh, one electrode had to be repositioned and the other was later removed because of infection and re-implanted three months afterward; this patient scored 1 at 12 months [1].
Published evidence from our center
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. Stereotactic and Functional Neurosurgery 2024;102:224–239.
- 22 patients treated between 2019 and 2023 with bilateral Vim+PSA DBS: 7 isolated head tremor, 4 dystonic tremor, 8 Holmes tremor, 2 voice tremor and 1 tremor caused by liver disease.
- Mean tremor score fell from 3.70 to 0.45 at 12 months; mean tremor reduction 89% (range 50–100%).
- 6 of 7 patients with isolated head tremor reached a tremor score of 0.
- Ratings were made blindly, with stimulation on and off, by two movement disorder specialists.
- To the authors’ knowledge, the largest published case series of double-target Vim+PSA DBS in rare tremor syndromes [1].
Read the article on PubMed (PMID 38934181) · How the double-target technique works
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.
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
Is bilateral surgery always needed for isolated head tremor?
Will I see the result before I go home?
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/
