Objective: We report a 65-year-old-man with tremor-predominant PD who had left subthalamic nucleus (STN) DBS and right CZi DBS for tremor control.

Background: Deep brain stimulation (DBS) is an established treatment for patients with Parkinson’s disease (PD). Subthalamic nucleus (STN) and globus pallidum interna are traditional targets of DBS. Caudal Zona Increta (CZi) DBS has shown promising efficacy on PD symptoms, especially tremor. The cZi target was also described by Plaha et al. as not having the adverse effects on speech and balance as other areas closer to the STN.

Method: A 65-year-old right-handed man with tremor-predominant PD started having right upper extremity (RUE) resting tremor at the age of 58. He had sub-normal response even at higher doses of levodopa (800 mg/day) and he did not tolerate other PD medications. He underwent left STN DBS at the age of 61, as the tremor predominated on the right. Post-surgery, he had complete resolution of tremor in the RUE and the effect persisted even when the DBS was turned off. At the age of 64, a mild tremor in left upper extremity (LUE) worsened and he returned to the movement disorders team for DBS. When the Left STN DBS was turned off, the tremor did not appear in RUE, but the tremor in LUE worsened. Caudal Zona Increta was chosen as a DBS target because of patient choice, tremor predominance, and to avoid dysarthria or gait instability.

Results: MRI brain did not show any lesions/ injury in left STN or the surrounding region, but we assume that there might have been a microlesion by which his RUE tremor had resolved post-surgery. LUE resting and postural tremor had resolved after right CZi DBS was turned on. Lower contacts were activated with lower voltage, 90-microsecond pulse width, and a 130-hertz frequency was chosen. At higher amplitudes, he had sensory side effects but no dysarthria or gait instability.

Conclusion: Stimulation of the CZi has shown promise in alleviating severe parkinsonian tremor. Our case is unique because of resolution of the RUE tremor post left STN DBS, even when the DBS was turned off and no lesion was noted on MRI brain. This is the first reported case with STN DBS on one side and CZi DBS on the other side for tremor control. Longitudinal follow-up will be required to see if the effect persists and if he develops any adverse effects.

References: Deuschl G, Schade-Brittinger C, Krack P, et al. a randomized trial of deep-brain stimulation for Parkinson’s disease. N Engl J Med 2006;355:896–908. Adolfo Ramirez-Zamora, Heather Smith, Vignessh Kumar, Julia Prusik, Sujoy Phookan, Julie G. Pilitsis. Evolving Concepts in Posterior Subthalamic Area Deep Brain Stimulation for Treatment of Tremor: Surgical Neuroanatomy and Practical Considerations. Stereotact Funct Neurosurg 2016;94:283–297. Blomstedt P, et al. Deep brain stimulation in the caudal zona incerta versus best medical treatment in patients with Parkinson’s disease: a randomized blinded evaluation. J Neurol Neurosurg Psychiatry 2018;89:710–716. P. Plaha, Y. Ben-Shlomo, N. K. Patel, and S. S. Gill, “Stimulation of the caudal zona incerta is superior to stimulation of the subthalamic nucleus in improving contralateral parkinsonism,” Brain, vol. 129, no. 7, pp. 1732–1747, 2006.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/left-stn-dbs-and-right-czi-dbs-in-a-patient-with-tremor-predominant-parkinsons-disease/