Department of Neuroscience, Graduate School.
Department of Neurosurgery, Chungbuk National University Hospital, College of Medicine, Chungbuk National University.
Medicine (Baltimore). 2021 Apr 16;100(15):e25461. doi: 10.1097/MD.0000000000025461.
Deep brain stimulation (DBS) of the ventralis intermedius nucleus (Vim) provides a safe and effective therapy for medically refractory essential tremor (ET). However, DBS may be risky in elderly patients and those with ischemic brain lesions. Gamma Knife radiosurgery (GKS) is a minimally invasive procedure, but bilateral thalamotomy is dangerous.
We report a case of ventralis oralis anterior nucleus (Voa) DBS for dominant hand tremor plus Voa GKS for nondominant hand tremor in a very elderly patient with medically intractable ET.
An 83-year-old right-handed woman visited our hospital with a medically intractable ET. Because of the ischemic lesion in the right basal ganglia, we decided to perform left unilateral DBS instead of bilateral DBS.
We chose Voa as the target for DBS because, clinically, her tremor was mainly confined to her hands, and Voa had better intraoperative microelectrode recording results than Vim.
After 2 years, her right-hand tremor remained in an improved state, but she still had severe tremor in her left hand. Therefore, we performed GKS targeting the right Voa. One year after surgery, the patient's hand tremor successfully improved without any complications.
Salvage Voa GKS after unilateral Voa DBS is a valuable option for very elderly patients and patients with ischemic brain lesions. We suggest that Voa GKS thalamotomy is as useful and safe a surgical technique as Vim GKS for dystonic hand tremor. To the best of our knowledge, this is the first case report using salvage Voa as the only target for ET.
对于药物难治性原发性震颤（essential tremor，ET），腹侧中间核（ventralis intermedius nucleus，Vim）深部脑刺激（deep brain stimulation，DBS）是一种安全有效的治疗方法。然而，DBS 可能对老年患者和有缺血性脑损伤的患者存在风险。伽玛刀放射外科手术（Gamma Knife radiosurgery，GKS）是一种微创的治疗方法，但双侧丘脑切开术有风险。
我们报告了一例非常高龄的药物难治性 ET 患者，行优势手震颤的腹侧前核（ventralis oralis anterior nucleus，Voa）DBS 和非优势手震颤的 Voa GKS。
患者为 83 岁的右利手女性，因药物难治性 ET 就诊于我院。由于右侧基底节区存在缺血性病灶，我们决定行单侧左侧 DBS 而非双侧 DBS。
我们选择 Voa 作为 DBS 的靶点，因为从临床角度来看，她的震颤主要局限于手部，而且 Voa 的术中微电极记录结果优于 Vim。
术后 2 年，她的右手震颤仍处于改善状态，但左手震颤仍严重。因此，我们对右侧 Voa 行 GKS。术后 1 年，患者手部震颤成功改善，无任何并发症。
在单侧 Voa DBS 后行挽救性 Voa GKS 是治疗非常高龄患者和有缺血性脑损伤患者的一种有价值的选择。我们认为，对于扭转性手震颤，Voa GKS 丘脑切开术与 Vim GKS 一样有用且安全。据我们所知，这是首例使用挽救性 Voa 作为 ET 唯一靶点的病例报告。
