How DBS is programmed for head tremor

DBS programming means choosing which electrode contacts to use and how strong the stimulation should be. At our center the stimulator is switched on the day after surgery. After a successful operation, head tremor usually stops almost as soon as stimulation begins; some centers wait about two weeks before the first switch-on. Each contact in the Vim and the PSA is tested one by one, and the contact — or combination — that gives the best tremor control with the widest margin before side effects is chosen for long-term stimulation ^[1]. Remote programming by secure video call is free for 3 to 5 years, depending on the package chosen; after that it remains available, without limit, for a fee.

Key facts

Programming starts the day after surgery.
Each contact in the Vim and the PSA is tested one by one.
The contact with the widest therapeutic window is chosen ^[1].
Using both targets generally allows lower settings at each ^[1].
Remote programming is free for 3–5 years depending on the package, then available for a fee.

The first session: the day after surgery

Each contact is tested separately, starting from the deepest (in the PSA) and moving up into the Vim.
The current is increased in small steps while the tremor and any side effects are observed.
The contact with the widest “therapeutic window” — the gap between the setting that stops the tremor and the setting that causes side effects — is chosen.
If one contact is not enough, a second contact in the other target is added and the combination is tested ^[1].

In the published series, testing started at a pulse width of 60 microseconds and a frequency of 130 Hz. Final settings ranged from 2 to 5 mA in the Vim and 1.3 to 3.5 mA in the PSA; when both targets were used, lower settings were generally needed at each ^[1].

Tremor that returns with stress or excitement

Some patients notice that the tremor comes back slightly when they are angry, excited or under stress. This is uncommon after a successful operation. We use specific settings for it, and double targeting gives us more room to adjust; with these settings, at most a very mild tremor remains in such moments.

Adjustments over time

Settings are refined during the stay in Istanbul.
Later adjustments are made remotely by secure video call; the programmer changes the settings while watching the tremor.
If the effect lessens or the condition progresses, the second target can be activated without surgery.

Remote programming

Remote programming by secure video call is free for 3 to 5 years, depending on the package chosen; after that it remains available, without limit, for a fee. Remote programming works with compatible systems such as the Abbott Liberta™ with NeuroSphere™ Virtual Clinic. Adaptive systems such as the Medtronic Percept™ can sense brain signals and adjust stimulation automatically.

What you can control yourself

Patients receive a handheld controller to check the battery, switch stimulation on and off, and — if the programmer allows — choose between preset programs.

Signs that your settings need adjusting

The tremor slowly returns or increases
New tingling, slurred speech or unsteadiness
A change in how the tremor reacts to stress or tiredness

Contact the team by WhatsApp; most adjustments are made in a video session.

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

Frequently asked questions

Do I have to stay in Istanbul for programming?

Only for the first sessions during your stay. After that, programming is done remotely from your home country.

What if my tremor returns after a few years?

The settings are adjusted, and with double targeting the second target can be added by reprogramming. 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).

Can I switch the stimulator off?

Yes, with your controller — for example for some medical procedures. The tremor returns while it is off.

How often will I need programming?

Most adjustments happen in the first weeks and months. After that, many patients need only occasional sessions, usually remotely.

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/