Objective: 1) To evaluate the effect of deep brain stimulation (DBS) in Orthostatic Tremor (OT) on standing time and quality of life (QoL), and 2) to relate the effects to stimulation of the dendatoruberothalamic tract (DRT), medial lemniscus (ML), and pyramidal tract (PT).

Background: Primary OT is a rare and disabling hyperkinetic movement disorder that causes disability and affects QoL [1]. Medication is often ineffective in alleviating the tremor and/or is accompanied by bothersome side-effects [1, 2, 3]. DBS of the ventral intermediate nucleus of the thalamus (VIM) and/or of the posterior subthalamic area (PSA) is used to treat OT. The number of published cases is limited and the effect of DBS for OT is uncertain.

Method: Six severely affected OT-patients (standing time <30s) received bilateral DBS (VIM/PSA). Prospectively collected measures included standing time (main outcome), neurophysiological measures, QoL, surgical complications and stimulation induced side-effects. The final location of the DBS electrodes was determined. Effects of DBS were related to proximity of the active electrode contacts to white matter tracts (i.e., DRT, ML and PT).

Results: Standing time was increased (5 of 6 patients), also during long-term follow-up (4 of 6 patients), whereas QoL decreased during follow-up (group results). All patients experienced side-effects, including dysarthria and balance problems. In all patients a part of the DRT was in the volume of tissue activated (VTA). The ML and the PT were within the VTA in respectively three and four patients.

Conclusion: Overall, DBS seems a possibly effective treatment in OT with improvement of standing time in the majority of patients. QoL is a matter of concern, that needs to be addressed in future studies. The improved standing time is likely related to stimulation of the DRT, while the observed side-effect dysarthria can be related to stimulation of the ML and PT.

References: [1] Gerschlager W, Brown P. Orthostatic tremor – a review. Handb Clin Neurol 2011;100:457-62. https://doi.org/10.1016/B978-0-444-52014-2.00035-5 [2] Contarino MF, Bour LJ, Schuurman PR, Blok ER, Odekerken VJ, van den Munckhof P, et al. Thalamic deep brain stimulation for orthostatic tremor: Clinical and neurophysiological correlates. Parkinsonism Relat Disord 2015;21(8):1005-7. https://doi.org/10.1016/j.parkreldis.2015.06.008 [3] Hassan A, Ahlskog JE, Matsumoto JY, Milber JM, Bower JH, Wilkinson JR. Orthostatic tremor: Clinical, electrophysiologic, and treatment findings in 184 patients. Neurology 2016;86(5):458-64. https://doi.org/10.1212/WNL.0000000000002328

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