Objective: To report a case of medication refractory Holmes tremor in a patient with pontine stroke and multisystem atrophy-cerebellar type (MSA-C) successfully treated with bilateral, simultaneous VIM and STN deep brain stimulation by Boston Scientific non-directional lead with 8-contacts.

Background: Holmes tremor has resting, postural and kinetic components which are often disabling and medication refractory. Cerebello-thalamic and dopaminergic-igrostriatal circuits are thought to have role in its causation. VIM, globus pallidus pars interna, and/or STN have been effectively used typically requiring stimulation parameters higher than in Parkinson’s disease and Essential tremor. Dividing stimulation in target areas may require lesser stimulation, lesser power consumption and hence improve battery life.

Method: Pre-surgical evaluation, surgical implantation of DBS and DBS programming sessions.

Results: A 64 years old right-handed male with history of pontine stroke and MSA-C with medication refractory Holmes tremor right > left underwent bilateral Boston Scientific non-directional 8-contact lead placement in bilateral VIM and STN. Electrode placement was confirmed by intra-operative electrophysiologic mapping and pre/post-operative imaging studies. After three DBS programming sessions patient had excellent improvement of his kinetic, postural and resting tremors. His most recent DBS settings on Left VIM/STN were Case+   5-(10%)  6-(80%)   7-(10%); Amplitude 2.7 milliamps, pulse width 60 microseconds and frequency 130 Hertz and on right VIM/STN were Case+ 14-(70%)  13-(30%); amplitude 1.7 milliamps, pulse width 60 microseconds and frequency 130 Hertz. Post DBS programming patient was able to carry all his activities of daily living and hence significantly improved his quality of life.

Conclusion: Both VIM and STN are effective targets for DBS in medication-refractory Holmes tremor. Simultaneous stimulation of both targets and dividing stimulation in terms of percentage in both targets helped achieve excellent clinical response with lower needed stimulation parameters than expected. This could lead to lesser battery consumption and less frequent battery replacement while maintaining excellent clinical response.

References: Images, DBS leads, table, and references to be provided during poster/platform presentation

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MDS Abstracts - https://www.mdsabstracts.org/abstract/treatment-of-medication-refectory-holmes-tremor-by-simultaneous-thalamic-ventral-intermediate-vim-nucleus-and-subthalamic-nucleus-stn-deep-brain-stimulation-a-case-report/