1Department of Neurosurgery, University of Nebraska Medical Center, Omaha, Nebraska.
2Department of Neurosurgery, University of California, Los Angeles, California.
J Neurosurg. 2022 Apr 29;137(6):1811-1820. doi: 10.3171/2022.3.JNS212374. Print 2022 Dec 1.
In patients with essential tremor (ET) treated with standard deep brain stimulation (sDBS) whose ET had progressed and who no longer received optimal benefit from sDBS, directional deep brain stimulation (dDBS) may provide better tremor control. Current steering may provide better coverage of subcortical structures related to tremor control in patients with ET and significant progression without optimal response to sDBS.
This study included 6 patients with ET initially treated with sDBS whose tremor later progressed and who then underwent reimplantation with dDBS to optimize their tremor control. To investigate the differences in the local effects of sDBS and dDBS, the authors generated the volume of tissue activation (VTA) to calculate the sweet spots associated with the best possible tremor control with no side effects. Then, to investigate the anatomical structures associated with maximal tremor control, the white matter pathways of the posterior subthalamic areas (PSAs) were generated and their involvement with the sDBS and dDBS sweet spots was calculated.
Tremor improvement was significantly better with dDBS (68.4%) than with sDBS (48.7%) (p = 0.017). The sDBS sweet spot was located within the ventral intermediate nucleus, whereas the sweet spot of the dDBS was mainly located within the PSA. The sweet spots of both sDBS and dDBS involved a similar portion of the cerebellothalamic pathway. However, the dDBS had greater involvement of the pallidofugal pathways than the sDBS.
In patients with ET treated with sDBS who later had ET progression, dDBS provided better tremor control, which was related to directionality and a more ventral position. The involvement of both the cerebellothalamic and pallidofugal pathways obtained with dDBS is associated with additional improvement over the sDBS.
在接受标准深部脑刺激（sDBS）治疗的特发性震颤（ET）患者中，其震颤进展且不再从 sDBS 中获得最佳获益，定向深部脑刺激（dDBS）可能提供更好的震颤控制。在 ET 患者中，电流导向可能在无最佳 sDBS 反应的情况下，为与震颤控制相关的皮质下结构提供更好的覆盖范围。
本研究纳入了 6 例最初接受 sDBS 治疗的 ET 患者，他们的震颤后来进展，然后接受 dDBS 重新植入以优化震颤控制。为了研究 sDBS 和 dDBS 的局部效应差异，作者生成了组织激活体积（VTA）以计算与无副作用的最佳震颤控制相关的最佳刺激点。然后，为了研究与最大震颤控制相关的解剖结构，生成了后丘脑下区（PSA）的白质通路，并计算了它们与 sDBS 和 dDBS 刺激点的关系。
dDBS（68.4%）的震颤改善明显优于 sDBS（48.7%）（p = 0.017）。sDBS 刺激点位于腹侧中间核内，而 dDBS 的刺激点主要位于 PSA 内。sDBS 和 dDBS 的刺激点都涉及相似的小脑丘脑通路部分。然而，与 sDBS 相比，dDBS 涉及更多的苍白球传出通路。
在接受 sDBS 治疗的 ET 患者中，后来出现 ET 进展的患者，dDBS 提供了更好的震颤控制，这与方向性和更腹侧位置有关。dDBS 获得的小脑丘脑和苍白球传出通路的参与与 sDBS 相比，额外改善了震颤控制。
