Objective: To identify pre-operative clinical and computerized spiral analysis characteristics that may help ascertain which patients with Essential Tremor (ET) will exhibit ‘early tolerance’ to ventral intermediate nucleus of thalamus (Vim) deep brain stimulation (DBS).

Background: Essential tremor (ET), is the most common cause of adult onset tremors with a heterogeneous phenotype; suggesting different pathophysiologic mechanisms, which may have important therapeutic and prognostic implications. Deep brain stimulation (DBS) of the ventral intermediate nucleus of the thalamus (Vim) is an effective treatment for ET, particularly for medication-resistant disabling cases; however, there may be loss of benefit over time in a subset of patients like due to (i) disease progression and (ii) habituation to DBS. We have encountered recurrent tremor within weeks after DBS surgery, where excellent targeting and tremor control were noted intra-operatively. We have hypothesized that tremor recurrence/habituation may be predictable on the basis of pre-operative clinical and kinematic characteristics. In this study, we sought to identify and characterize if any pre-operative clinical and spiral drawing characteristics may help ascertain which ET patients will exhibit ‘early tolerance’ to Vim DBS.

Methods: Identification of comparative clinical and spiral analysis characteristics of defined cases of ‘early tolerance’ versus patients with sustained satisfactory response treated with Vim DBS surgery for medically-refractory ET, was performed based on retrospective chart review by a clinician blinded to the findings of computerized spiral analysis.

Results: Statistically significant differences in the spiral analysis indices viz Spiral width variability index (SWVI) and Degree of Severity (DoS) were noted in the dominant upper limbs of patients who developed ‘early tolerance’, whereas the clinical characteristics were not significantly different.

Conclusions: Objective measurements of upper limb kinematics using graphonomic tests like spiral analysis should be considered in the pre-operative evaluation for DBS, especially in the setting of moderate-severe predominantly action and proximal postural tremors. Ours is the first investigation looking into the pre-operative clinical and objective physiologic characteristics of the patients who develop ‘early tolerance’ to Vim DBS for ET. The study has significant implications for pre-operative evaluation and potential surgical target selection for the treatment of tremors.

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