Objective: To prospectively test the hypothesis whether imaging-guided contact selection based on standardized individual tractography of the dentato-rubro-thalamic tract (DRTT) is non-inferior to clinical contact selection in patients with Parkinson’s Disease (PD) and Essential Tremor (ET)

Background: Imaging-guided strategies for deep brain stimulation (DBS) programming provide the chance of reducing programming time and complexity. To date, there are no evidence-based paradigms to specifically address tremor in ET and PD. Converging research points to an involvement of cerebello-thalamo-cortical networks in tremor pathophysiology across diseases. Preliminary evidence suggests that the overlap of the DBS stimulation spread and the DRTT could serve as a marker for the tremor-suppressing DBS effect [1-3].

Method: To prospectively test this hypothesis, tremor control by DBS was evaluated by monopolar clinical testing in 16 ET patients (i.e. 28 hemispheres with clinically relevant contralateral tremor) and 24 PD patients (i.e. 29 hemispheres with clinically relevant contralateral tremor) with directional DBS leads in the ventral intermediate nucleus of the thalamus/posterior subthalamic area (VIM/PSA) in ET or subthalamic nucleus (STN) in PD. The primary outcome was percentage tremor suppression (rest, kinetic, postural) objectively assessed by an accelerometry-based tremor score. The effect of the clinically most effective contact was compared to the effect of the contact with the highest overlap of the stimulation spread and the DRTT, determined via individual tractography, assuming a non-inferiority margin of ≤ 20%.

Results: Tremor control by stimulation via the imaging-based selected contact was non-inferior to the clinically chosen contact for both ET (median difference best clinical vs. best imaging-based contact -8%, 95% CI -11.5% to -3.5%) and PD (median difference -10%, 95% CI -20% to -4%).

Conclusion: This study provides evidence that the overlap of the stimulation spread with the individual DRTT is a suitable marker for imaging-guided DBS programming for Parkinsonian tremor in STN-DBS and ET in VIM/PSA-DBS. In a next step, these results need to be validated in long-term cross-over studies.

References: 1. Petry-Schmelzer J, Dembek T, Steffen J, et al. Selecting the Most Effective DBS Contact in Essential Tremor Patients Based on Individual Tractography. Brain Sci. 2020;10(12):1015. doi:10.3390/brainsci10121015
2. Dembek TA, Petry-Schmelzer JN, Reker P, et al. PSA and VIM DBS efficiency in essential tremor depends on distance to the dentatorubrothalamic tract. NeuroImage Clin. 2020;26:102235. doi:10.1016/j.nicl.2020.102235
3. Abdulbaki A, Kaufmann J, Galazky I, Buentjen L, Voges J. Neuromodulation of the subthalamic nucleus in Parkinson’s disease: the effect of fiber tract stimulation on tremor control. Acta Neurochir (Wien). 2021;163(1):185-195. doi:10.1007/s00701-020-04495-3

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MDS Abstracts - https://www.mdsabstracts.org/abstract/tractography-guided-versus-clinical-determination-of-the-most-effective-contact-for-tremor-control-in-patients-with-deep-brain-stimulation-a-clinical-trial/