Essential Tremor: Deep Brain Stimulation

  • Adela WuEmail author
  • Casey Halpern


Comprising of axial and/or kinetic tremors, essential tremor (ET) is a debilitating and common movement disorder that negatively affects up to 1% of the global population. When patients fail medical therapy, deep brain stimulation (DBS) is one of the current standards of care for medically refractory ET treatment. Using stereotactic methods, surgeons may stimulate the ventral intermediate thalamic nucleus (VIM) and novel targets, such as the posterior subthalamic area and the zona incerta, with long-term benefits and significant tremor reduction. Other alternatives include stereotactic radiosurgery and MRI-guided focused ultrasound (FUS).


Essential tremor Movement disorder Deep brain stimulation (DBS) Stereotactic Ventral intermediate thalamic nucleus (VIM) Posterior subthalamic area (PSA) Zona incerta Focused ultrasound (FUS) Thalamotomy Radiosurgery 


  1. 1.
    Louis ED, Ferreira JJ. How common is the most common adult movement disorder? Update on the worldwide prevalence of essential tremor. Mov Disord. 2010;25(5):534–41. Scholar
  2. 2.
    Chandran V, Pal PK, Reddy JYC, Thennarasu K, Yadav R, Shivashankar N. Non-motor features in essential tremor. Acta Neurol Scand. 2012;125(5):332–7. Scholar
  3. 3.
    Lorenz D, Poremba C, Papengut F, Schreiber S, Deuschl G. The psychosocial burden of essential tremor in an outpatient- and a community-based cohort. Eur J Neurol. 2011;18(7):972–9. Scholar
  4. 4.
    Lorenz D, Schwieger D, Moises H, Deuschl G. Quality of life and personality in essential tremor patients. Mov Disord. 2006;21(8):1114–8. Scholar
  5. 5.
    Paschen S, Deuschl G. Patient evaluation and selection for movement disorders surgery: the changing spectrum of indications. Prog Neurol Surg. 2018;33:80–93. Scholar
  6. 6.
    Lyons KE, Pahwa R. Deep brain stimulation and tremor. Neurotherapeutics. 2008;5(2):331–8. Scholar
  7. 7.
    Munhoz RP, Picillo M, Fox SH, et al. Eligibility criteria for deep brain stimulation in Parkinson’s disease, tremor, and dystonia. Can J Neurol Sci. 2016;43(4):462–71. Scholar
  8. 8.
    Deuschl G, Raethjen J, Hellriegel H, Elble R. Treatment of patients with essential tremor. Lancet Neurol. 2011;10(2):148–61. Scholar
  9. 9.
    Merchant SH, Kuo S-H, Qiping Y, et al. Objective predictors of “early tolerance” to ventral intermediate nucleus of thalamus deep brain stimulation in essential tremor patients. Clin Neurophysiol. 2018;129(8):1628–33. Scholar
  10. 10.
    Khan FR, Henderson JM. Deep brain stimulation surgical techniques. Handb Clin Neurol. 2013;116:27–37. Scholar
  11. 11.
    Papavassiliou E, Rau G, Heath S, et al. Thalamic deep brain stimulation for essential tremor: relation of lead location to outcome. Neurosurgery. 2004;54(5):1120–9; discussion 1129–1130. Accessed 2 Dec 2018.CrossRefGoogle Scholar
  12. 12.
    Nowacki A, Schlaier J, Debove I, Pollo C. Validation of diffusion tensor imaging tractography to visualize the dentatorubrothalamic tract for surgical planning. J Neurosurg. 2018;130:1–10. Scholar
  13. 13.
    Seddighi AS, Seddighi A, Nikouei A. Deep brain nucleus targeting in Parkinson’s disease and essential tremor by image guided surgery using neuronavigation system with tractography and volume of tissue of activated assessment. Hell J Nucl Med. 2017;20 Suppl:14–9. Accessed 1 Dec 2018.PubMedGoogle Scholar
  14. 14.
    Sajonz BEA, Amtage F, Reinacher PC, et al. Deep brain stimulation for tremor tractographic versus traditional (DISTINCT): study protocol of a randomized controlled feasibility trial. JMIR Res Protoc. 2016;5(4):e244. Scholar
  15. 15.
    King NKK, Krishna V, Sammartino F, et al. Anatomic targeting of the optimal location for thalamic deep brain stimulation in patients with essential tremor. World Neurosurg. 2017;107:168–74. Scholar
  16. 16.
    Starr PA, Martin AJ, Ostrem JL, Talke P, Levesque N, Larson PS. Subthalamic nucleus deep brain stimulator placement using high-field interventional magnetic resonance imaging and a skull-mounted aiming device: technique and application accuracy. J Neurosurg. 2010;112(3):479–90. Scholar
  17. 17.
    Burchiel KJ, McCartney S, Lee A, Raslan AM. Accuracy of deep brain stimulation electrode placement using intraoperative computed tomography without microelectrode recording. J Neurosurg. 2013;119(2):301–6. Scholar
  18. 18.
    Benabid AL, Pollak P, Louveau A, Henry S, de Rougemont J. Combined (thalamotomy and stimulation) stereotactic surgery of the VIM thalamic nucleus for bilateral Parkinson disease. Appl Neurophysiol. 1987;50(1–6):344–6. Accessed 1 Dec 2018.PubMedGoogle Scholar
  19. 19.
    Flora ED, Perera CL, Cameron AL, Maddern GJ. Deep brain stimulation for essential tremor: a systematic review. Mov Disord. 2010;25(11):1550–9. Scholar
  20. 20.
    Cury RG, Fraix V, Castrioto A, et al. Thalamic deep brain stimulation for tremor in Parkinson disease, essential tremor, and dystonia. Neurology. 2017;89(13):1416–23. Scholar
  21. 21.
    Crowell JL, Shah BB. Surgery for dystonia and tremor. Curr Neurol Neurosci Rep. 2016;16(3):22. Scholar
  22. 22.
    Nazzaro JM, Pahwa R, Lyons KE. Long-term benefits in quality of life after unilateral thalamic deep brain stimulation for essential tremor. J Neurosurg. 2012;117(1):156–61. Scholar
  23. 23.
    Baizabal-Carvallo JF, Kagnoff MN, Jimenez-Shahed J, Fekete R, Jankovic J. The safety and efficacy of thalamic deep brain stimulation in essential tremor: 10 years and beyond. J Neurol Neurosurg Psychiatry. 2014;85(5):567–72. Scholar
  24. 24.
    Blomstedt P, Hariz G-M, Hariz MI, Koskinen L-OD. Thalamic deep brain stimulation in the treatment of essential tremor: a long-term follow-up. Br J Neurosurg. 2007;21(5):504–9. Scholar
  25. 25.
    Hariz G-M, Blomstedt P, Koskinen L-OD. Long-term effect of deep brain stimulation for essential tremor on activities of daily living and health-related quality of life. Acta Neurol Scand. 2008;118(6):387–94. Scholar
  26. 26.
    Benabid AL, Pollak P, Gervason C, et al. Long-term suppression of tremor by chronic stimulation of the ventral intermediate thalamic nucleus. Lancet (Lond, Engl). 1991;337(8738):403–6. Accessed December 15, 2018.CrossRefGoogle Scholar
  27. 27.
    Koller WC, Lyons KE, Wilkinson SB, Troster AI, Pahwa R. Long-term safety and efficacy of unilateral deep brain stimulation of the thalamus in essential tremor. Mov Disord. 2001;16(3):464–8. Accessed 15 Dec 2018.CrossRefGoogle Scholar
  28. 28.
    Nguyen JP, Degos JD. Thalamic stimulation and proximal tremor. A specific target in the nucleus ventrointermedius thalami. Arch Neurol. 1993;50(5):498–500. Accessed 1 Dec 2018.CrossRefGoogle Scholar
  29. 29.
    Blomstedt P, Sandvik U, Tisch S. Deep brain stimulation in the posterior subthalamic area in the treatment of essential tremor. Mov Disord. 2010;25(10):1350–6. Scholar
  30. 30.
    Murata J, Kitagawa M, Uesugi H, et al. Electrical stimulation of the posterior subthalamic area for the treatment of intractable proximal tremor. J Neurosurg. 2003;99(4):708–15. Scholar
  31. 31.
    Plaha P, Patel NK, Gill SS. Stimulation of the subthalamic region for essential tremor. J Neurosurg. 2004;101(1):48–54. Scholar
  32. 32.
    Fytagoridis A, Sandvik U, Åström M, Bergenheim T, Blomstedt P. Long term follow-up of deep brain stimulation of the caudal zona incerta for essential tremor. J Neurol Neurosurg Psychiatry. 2012;83(3):258–62. Scholar
  33. 33.
    Sandvik U, Hariz G-M, Blomstedt P. Quality of life following DBS in the caudal zona incerta in patients with essential tremor. Acta Neurochir. 2012;154(3):495–9. Scholar
  34. 34.
    Fytagoridis A, Åström M, Samuelsson J, Blomstedt P. Deep brain stimulation of the caudal zona incerta: tremor control in relation to the location of stimulation fields. Stereotact Funct Neurosurg. 2016;94(6):363–70. Scholar
  35. 35.
    Barbe MT, Reker P, Hamacher S, et al. DBS of the PSA and the VIM in essential tremor. Neurology. 2018;91(6):e543–50. Scholar
  36. 36.
    Barbe MT, Liebhart L, Runge M, et al. Deep brain stimulation of the ventral intermediate nucleus in patients with essential tremor: stimulation below intercommissural line is more efficient but equally effective as stimulation above. Exp Neurol. 2011;230(1):131–7. Scholar
  37. 37.
    Ramirez-Zamora A, Smith H, Kumar V, Prusik J, Phookan S, Pilitsis JG. Evolving concepts in posterior subthalamic area deep brain stimulation for treatment of tremor: surgical neuroanatomy and practical considerations. Stereotact Funct Neurosurg. 2016;94(5):283–97. Scholar
  38. 38.
    Bot M, van Rootselaar F, Contarino MF, et al. Deep brain stimulation for essential tremor: aligning thalamic and posterior subthalamic targets in 1 surgical trajectory. Oper Neurosurg (Hagerstown). 2018;15(2):144–52. Scholar
  39. 39.
    Moldovan A-S, Hartmann CJ, Trenado C, et al. Less is more – pulse width dependent therapeutic window in deep brain stimulation for essential tremor. Brain Stimul. 2018;11(5):1132–9. Scholar
  40. 40.
    De Jesus S, Almeida L, Shahgholi L, et al. Square biphasic pulse deep brain stimulation for essential tremor: the BiP tremor study. Parkinsonism Relat Disord. 2018;46:41–6. Scholar
  41. 41.
    Akbar U, Raike RS, Hack N, et al. Randomized, blinded pilot testing of nonconventional stimulation patterns and shapes in Parkinson’s disease and essential tremor: evidence for further evaluating narrow and biphasic pulses. Neuromodulation. 2016;19(4):343–56. Scholar
  42. 42.
    Raoul S, Faighel M, Rivier I, Vérin M, Lajat Y, Damier P. Staged lesions through implanted deep brain stimulating electrodes: a new surgical procedure for treating tremor or dyskinesias. Mov Disord. 2003;18(8):933–8. Scholar
  43. 43.
    Oh MY, Hodaie M, Kim SH, Alkhani A, Lang AE, Lozano AM. Deep brain stimulator electrodes used for lesioning: proof of principle. Neurosurgery. 2001;49(2):363–7; discussion 367–369. Accessed 2 Dec 2018.PubMedGoogle Scholar
  44. 44.
    Pérez-Suárez J, Torres Díaz CV, López Manzanares L, et al. Radiofrequency lesions through deep brain stimulation electrodes in movement disorders: case report and review of the literature. Stereotact Funct Neurosurg. 2017;95(3):137–41. Scholar
  45. 45.
    Martínez-Moreno NE, Sahgal A, De Salles A, et al. Stereotactic radiosurgery for tremor: systematic review. J Neurosurg. 2018;130:1–12. Scholar
  46. 46.
    Niranjan A, Raju SS, Monaco EA, Flickinger JC, Lunsford LD. Is staged bilateral thalamic radiosurgery an option for otherwise surgically ineligible patients with medically refractory bilateral tremor? J Neurosurg. 2018;128(2):617–26. Scholar
  47. 47.
    Niranjan A, Raju SS, Kooshkabadi A, Monaco E, Flickinger JC, Lunsford LD. Stereotactic radiosurgery for essential tremor: retrospective analysis of a 19-year experience. Mov Disord. 2017;32(5):769–77. Scholar
  48. 48.
    Chazen JL, Sarva H, Stieg PE, et al. Clinical improvement associated with targeted interruption of the cerebellothalamic tract following MR-guided focused ultrasound for essential tremor. J Neurosurg. 2018;129(2):315–23. Scholar
  49. 49.
    Zaaroor M, Sinai A, Goldsher D, Eran A, Nassar M, Schlesinger I. Magnetic resonance-guided focused ultrasound thalamotomy for tremor: a report of 30 Parkinson’s disease and essential tremor cases. J Neurosurg. 2018;128(1):202–10. Scholar
  50. 50.
    Goldman MS, Ahlskog JE, Kelly PJ. The symptomatic and functional outcome of stereotactic thalamotomy for medically intractable essential tremor. J Neurosurg. 1992;76(6):924–8. Scholar
  51. 51.
    Nagaseki Y, Shibazaki T, Hirai T, et al. Long-term follow-up results of selective VIM-thalamotomy. J Neurosurg. 1986;65(3):296–302. Scholar
  52. 52.
    Bahgat D, Magill ST, Berk C, McCartney S, Burchiel KJ. Thalamotomy as a treatment option for tremor after ineffective deep brain stimulation. Stereotact Funct Neurosurg. 2013;91(1):18–23. Scholar
  53. 53.
    DiLorenzo DJ, Jankovic J, Simpson RK, Takei H, Powell SZ. Long-term deep brain stimulation for essential tremor: 12-year clinicopathologic follow-up. Mov Disord. 2010;25(2):232–8. Scholar
  54. 54.
    Kim M, Jung NY, Park CK, Chang WS, Jung HH, Chang JW. Comparative evaluation of magnetic resonance-guided focused ultrasound surgery for essential tremor. Stereotact Funct Neurosurg. 2017;95(4):279–86. Scholar
  55. 55.
    Langford BE, Ridley CJA, Beale RC, Caseby SCL, Marsh WJ, Richard L. Focused ultrasound thalamotomy and other interventions for medication-refractory essential tremor: an indirect comparison of short-term impact on health-related quality of life. Value Health. 2018;21(10):1168–75. Scholar
  56. 56.
    Ravikumar VK, Parker JJ, Hornbeck TS, et al. Cost-effectiveness of focused ultrasound, radiosurgery, and DBS for essential tremor. Mov Disord. 2017;32(8):1165–73. Scholar
  57. 57.
    McClelland S, Jaboin JJ. Treatment of the ventral intermediate nucleus for medically refractory tremor: a cost-analysis of stereotactic radiosurgery versus deep brain stimulation. Radiother Oncol. 2017;125(1):136–9. Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of NeurosurgeryStanford UniversityPalo AltoUSA

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