DBS for Holmes tremor and secondary head tremor

DBS can reduce Holmes tremor and other secondary tremors when medication does not. In our published double-target series, 8 patients with Holmes tremor caused by multiple sclerosis, cerebellar injury or trauma had an 80% average reduction in tremor scores at 12 months, and a patient with tremor due to liver disease improved by 75% ^[1]. Results in secondary tremor are generally less consistent than in essential tremor, so careful selection is essential ^[2].

Key facts

Holmes tremor improved by 80% on average after double-target DBS ^[1].
All four post-traumatic Holmes tremor patients reached a score of 0 ^[1].
Both patients with multiple sclerosis tremor reached a score of 0 ^[1].
Tremor after cerebellar injury improved by about half.
The underlying condition should be stable before surgery.

**A Story Worth Following: When Tremor No Longer Ran the Day** — A patient with essential tremor, before and after deep brain stimulation.
Shared with the patient’s written consent. Individual results vary.

**Holmes Tremor Before & After DBS: A Recovery in Istanbul** — A patient with Holmes tremor before and after deep brain stimulation in Istanbul.
Shared with the patient’s written consent. Individual results vary.

**Holmes Tremor & Essential Tremor: DBS Off vs. On** — Stimulation switched off and on: the effect of DBS in Holmes tremor and essential tremor.
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.

Who is a candidate?

The underlying condition (stroke, injury, multiple sclerosis) is stable
Tremor is the main disabling problem
Enough strength and coordination remain to benefit from tremor control

The approach

Because these tremors are often coarse and involve the shoulder and trunk, the PSA is particularly useful. Surgical attempts with a single target have often failed in the short or long term in these conditions ^[1]. Prof. YILMAZ combines the PSA with the Vim along one trajectory — see double-target DBS. When the anatomy does not allow a path through both targets, the PSA alone can be used.

Published results by cause

Cause	Result
Trauma (4 patients)	All 4 reached a tremor score of 0 (three from 4, one from 3)
Multiple sclerosis (2 patients)	Both improved to a score of 0
Cerebellar injury (2 patients)	Both improved by 50% (4 → 2)
Liver disease (1 patient)	75% improvement

Source: Yilmaz et al., Stereotact Funct Neurosurg 2024 ^[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

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

How long after a stroke or injury can DBS be done?

Usually once the tremor has been stable for some time and the underlying condition is no longer changing. The timing is decided individually.

Can DBS help tremor from multiple sclerosis?

In selected patients, yes. Both patients with multiple sclerosis in our published series improved to a tremor score of 0 ^[1].

Why did some secondary tremors improve only partly?

Damage to the cerebellum can limit how much of the tremor circuit can be modulated. In our series, the two patients with tremor after cerebellar injury improved by 50% ^[1].

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/
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/