Objective: We report a unique case of post-stroke tremor (PST) with a robust response to deep brain stimulation (DBS) of the ventral intermediate nucleus of the thalamus (Vim).

Background: DBS is an effective treatment for tremors associated with Parkinson’s disease and essential tremor, however little data exists on the use of DBS for the treatment of PST. The variability of responses to DBS may arise from different levels of network dysfunction and different levels of structural damage that impair successful neuromodulation.

Method: We report a case of a 67-year-old male with longstanding history of essential tremor, who had a left hemispheric stroke including thalamic perforators, which changed the character of his tremor. The new tremor exhibited a remarkable resting component along with exacerbation of the postural and kinetic components, which became the main source of disability. The workup included a brain MRI and a DaT scan, showing decreased uptake on the left hemisphere, this is suspected to be secondary to structural damage and tissue loss following his stroke. The tremor was refractory to management with trials of primidone, propranolol, and high doses of levodopa (1000mg/day). Given this, the patient underwent implantation of left Vim DBS with good clinical outcomes as measured by the essential tremor rating assessment (TETRAS), and right hemibody TETRAS subscores.

Results: Pre-operative TETRAS score was 15, with a right hemibody score of 7. Post-operatively, a robust tremor suppression was seen at the initial programming visit, with TETRAS improving to 11.5, with a right hemibody score of 0.5 (92% reduction for the contralateral subscores). Turning the device off led to acute worsening of his TETRAS right hemibody subscores to 8, suggesting a neuromodulatory rather than a lesional effect. At the suggested initial settings C+, 2-, set at 2.3mA, 60s pulse width, and 130hz frequency, the patient has not needed to adjust any parameters.

Conclusion: Unilateral VIM DBS for PST led to robust tremor suppression at 3 month follow up. Despite poor literature suggesting minimal response of PST to DBS, we hypothesize that DBS may be a feasible treatment option for individuals with PST arising from insults that lead to a disrupted tremor network with an intact dysfunctional target that can be still modulated.  Further studies are needed to assess the efficacy, indications, and patient specific factors that predict good clinical response to DBS for these patients.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/vim-dbs-for-post-stroke-tremor-a-case-report/