Thalamic Stimulation In Multiple Sclerosis
Schulder M, Sernas T, Mahalick D, Adler R, Cook S
Stereotact Funct NeuroSurg 1999 Apr;72(2-4):196-201
New Jersey Medical School, Division of NeuroSurgery and Dept of NeuroScience, Newark, N.J., USA
To assess Tremor control and side effects in patients with Multiple Sclerosis (MS) treated with chronic Thalamic stimulation for relief of Upper Extremity Tremor.
Five patients were studied before and after Thalamic placement of a Deep Brain stimulation (DBS) System.
Preoperative and postoperative evaluation included Magnetic Resonance Imaging, Extended Disability Status Scale (EDSS), the Bain-Finchley Visual Analog Scale for Tremor, video recording and NeuroPsychological testing.
Stereotactic targeting of the Vim Nucleus was done using Computed Tomography; intraoperative testing was done under local anesthesia before permanent implantation.
Functionally useful Tremor suppression was obtained in 3/5 patients.
NeuroPsychological deficits of higher Cortical function, Memory and VisuoSpatial coordination were observed in all patients before surgery.
In 1 patient with improved postoperative VisuoSpatial coordination, worsened Memory was found.
New BrainStem Plaque formation was seen several weeks after surgery in 1 patient who had an acute worsening of MS which improved after high-dose IntraVenous Steroids.
Chronic Thalamic stimulation may help selected patients with MS-induced Tremor.
Given the complexity of their underlying illness, patients must be selected carefully, and long-term follow-up is vital to evaluate the true utility of DBS.
Copyright 2000 S. Karger AG, Basel
A Case Of Multiple Sclerosis With Paroxysmal Attacks Of Facial Paresthesia, Unilateral Hand Tremor, Epigastric Pain And Urinary Incontinence
Nagahama Y, Kitabayashi T, Akiguchi I, Shibasaki H, Kimura J
Rinsho Shinkeigaku 1992 Jan;32(1):52-6
Kyoto Univ, School of Medicine, Dept of Neurology
PMID# 1628436; UI# 92331314
A Japanese woman, aged 42, was admitted because of Paroxysmal attacks consisting of Paresthesias of the left face, Tremor in the right hand, Epigastric Pain and Urinary Incontinence.
A year prior to the admission, she noticed some difficulty in writing, Dysarthria and unsteadiness of walking. These symptoms had been persistent since then.
At the end of March, 1991, these symptoms rapidly worsened, and she fell down frequently. She also experienced pain behind both Eyes, numbness in her left fingers and toe, Urinary Frequency and the above-mentioned attacks.
Neurological Examination disclosed Bilateral Internuclear Ophthalmoplegia and upbeating Nystagmus on upward gaze.
Titubation in the head, Scanning Speech, Dysmetria in all limbs, exaggerated reflexes in jaw and both legs, bilateral Extensor Plantar reflexes and Ankle Clonus.
SEP showed delayed Cortical response with stimulation of the Median Nerves bilaterally and of the right Posterior Tibial Nerve. P40 was absent with the left Posterior Tibial Nerve stimulation.
VEP was normal. T2-weighted image of MRI showed multiple high intensity areas located around the Third Ventricle, Crus Cerebri and the right upper part of the Pons.
The diagnosis of Multiple Sclerosis was made. Each Paroxysmal attack started with numbness in the left face and burning sensation in the neck. Almost simultaneously Tremor in the right hand began.
The surface EMG showed the rhythmic contractions in the dorsal hand muscles and wrist extensors at a frequency of 6-7 Hz, and sometimes it revealed synchronized contractions of finger flexors and the dorsal hand muscles.
A few seconds later she felt painful sensation in the Epigastric region, and the Tremor gradually increased in its intensity.
MRI Findings In A Patient With Multiple Sclerosis And "HyperKinesies Voltionnelles" As A Main Symptom
Nakamura R, Kamakura K, Iwata M, Tsuchiya K, Takatani O
Rinsho Shinkeigaku 1990 Apr;30(4):427-31
National Defense Medical College
Third Dept of Internal Medicine
PMID# 2387113; UI# 90352904
A 23-year-old female was admitted to our hospital complaining of Tremor in the upper extremities and Gait disturbance.
Beginning at age 18, this patient experienced tingling of the right fingers, Gait disturbance, Dysesthesia of both hands, and Tremor in the upper extremities.
These symptoms disappeared several weeks after each onset. At age 21, Gait disturbance and coarse Tremor in the upper extremities developed. They were exaggerated and occurred repeatedly.
On Neurological Examination, the right Optic Disc was slightly pale. She had Nystagmus in all directions with Ocular movements. Deep tendon reflexes were hypoactive throughout.
There was no Tremor in the upper extremities at rest, but during the voluntary movements especially in maintaining certain posture coarse Tremor developed.
When performing goal-directed motion, such as finger-nose test, the Tremor became worse near the terminal position.
The patient's gait was broad-based, with the trunk trembling. There were no Sensory disturbances, Dysarthria, or Bowel or Bladder Dysfunction. Laboratory studies were normal except for high IgG% in the CerebroSpinal Fluid.
An ElectroMyogram using surface electrodes recorded rhythmic bursts of about 4c/s, alternating between the Extensor and the Flexor muscles of the right arm.
MRI of T2-weighted images showed many high-intensity areas located around the bilateral Ventricles and near the area of the Decussation of Superior Cerebellar Peduncle.
A diagnosis of Multiple Sclerosis was made in this case based on the patient's history of illness and MRI findings.
The Tremor in her right upper extremity was too intense and coarse to be described as Tremor, and should better be called "Hyperkinesies Volitionnelles (HV)".
Chronic Deep Brain Stimulation For The Treatment Of Tremor In Multiple Sclerosis: Review And Case Reports
Wishart HA, Roberts DW, Roth RM, McDonald BC, Coffey DJ, Mamourian AC, Hartley C, Flashman LA, Fadul CE, Saykin AJ
J Neurol NeuroSurg Psychiatry 2003 Oct;74(10):1392-7
Dartmouth Medical School, Department of Psychiatry, Lebanon, New Hampshire 03756-0001, USA
Deep Brain Stimulation (DBS) offers a non-ablative alternative to Thalamotomy for the surgical treatment of medically refractory Tremor in Multiple Sclerosis.
However, relatively few outcomes have been reported.
To provide a systematic review of the published cases of DBS use in Multiple Sclerosis and to present four additional patients.
Quantitative and qualitative review of the published reports and description of a case series from one center.
In the majority of reported cases (n=75), the surgical target for DBS implantation was the VentroInteroMedial Nucleus of the Thalamus.
Tremor reduction and improvement in daily functioning were achieved in most patients, with 87.7% experiencing at least some sustained improvement in Tremor control postsurgery.
Effects on daily functioning were less consistently assessed across studies; in papers reporting relevant data, 76.0% of patients experienced improvement in daily functioning.
Adverse effects were similar to those reported for DBS in other patient populations.
Few of the studies reviewed used highly standardized quantitative outcome measures, and follow up periods were generally one year or less.
Nonetheless, the data suggest that chronic DBS often produces improved Tremor control in Multiple Sclerosis.
Complete cessation of Tremor is not necessarily achieved, there are cases in which Tremor control decreases over time, and frequent reprogramming appears to be necessary.
Kinematic Analysis Of Thalamic Versus SubThalamic NeuroStimulation In Postural And Intention Tremor
Herzog J, Hamel W, Wenzelburger R, Pötter M, Pinsker MO, Bartussek J, Morsnowski A, Steigerwald F, Deuschl G, Volkmann J
Brain 2007 Jun;130(Pt 6):1608-25
Christian Albrechts University Kiel, Department of Neurology, Germany
Deep Brain Stimulation of the Thalamus (Thalamic DBS) is an established therapy for medically intractable Essential Tremor and Tremor caused by Multiple Sclerosis.
In both disorders, motor disability results from complex interaction between Kinetic Tremor and accompanying Ataxia with voluntary movements. In clinical studies, the efficacy of Thalamic DBS has been thoroughly assessed.
However, the optimal anatomical target structure for NeuroStimulation is still debated and has never been analyzed in conjunction with objective measurements of the different aspects of motor impairment.
In 10 Essential Tremor and 11 Multiple Sclerosis patients, we analyzed the effect of Thalamic DBS through each contact of the quadripolar electrode on the ContraLateral Tremor Rating Scale, accelerometry and kinematic measures of reach-to-grasp-movements.
These measures were correlated with the anatomical position of the stimulating electrode in stereotactic space and in relation to nuclear boundaries derived from intraoperative microrecording.
We found a significant impact of the stereotactic z-coordinate of stimulation contacts on the TRS, accelerometry total power and spatial deviation in the deceleration and target period of reach-to-grasp-movements.
Most effective contacts clustered within the SubThalamic Area (STA) covering the posterior Zona Incerta and PreLemniscal Radiation.
Stimulation within this region led to a mean reduction of the Lateralized Tremor Rating Scale by 15.8 points which was significantly superior to stimulation within the Thalamus (P < 0.05, student's t-test).
STA stimulation resulted in reduction of the accelerometry total power by 99%, whereas stimulation at the Ventral Thalamic border (68%) or within the Thalamus proper (2.5%) was significantly less effective (P < 0.01).
Concomitantly, STA stimulation led to a significantly higher increase of Tremor frequency and decrease in EMG synchronization compared to stimulation within the Thalamus proper (P < 0.001).
In reach-to-grasp movements, STA stimulation reduced the spatial variability of the movement path in the deceleration period by 28.9% and in the target period by 58.4%.
Whereas stimulation within the Thalamus was again significantly less effective (P < 0.05), with a reduction in the deceleration period between 6.5 and 21.8% and in the target period between 1.2 and 11.3%.
An analysis of the nuclear boundaries from intraoperative microrecording confirmed the anatomical impression that most effective electrodes were located within the STA.
Our data demonstrate a profound effect of Deep Brain Stimulation of the Thalamic region on Tremor and Ataxia in Essential Tremor and Tremor caused by Multiple Sclerosis.
The better efficacy of stimulation within the STA compared to Thalamus proper favors the concept of a modulation of Cerebello-Thalamic Projections underlying the improvement of these symptoms.