Objective: We present a patient with successful rescue bilateral GPi-DBS implantation with sustained clinical benefit to 24 months for management of reemergent severe dystonic tremor following previous bilateral PSA-DBS 5 years earlier. A prior attempt at additional dentatorubrothalamic tract(DRTT) stimulation using unilateral right VIM rescue DBS provided no discernible clinical benefit.

Background: Deep brain stimulation (DBS) targeting the PSA and VIM is an effective treatment for medically refractory tremor syndromes, however, in complex tremor syndromes including dystonic tremor, the long-term effectiveness of DBS is not well established and tremor re-emergence may occur [1].

Method: Outcomes were assessed with observer-blinded video ratings using Part A of the Fahn-Tolosa-Marin Clinical Rating Scale in Tremor (CRST) version 1.

Results: The patient showed a significant and sustained tremor improvement after bilateral rescue GPi-DBS with a mean tremor reduction of 77% on CRST at 24 month follow up (mean part A CRST score with PSA-DBS stimulation 32.5, mean part A CRST score with both PSA and GPi DBS stimulation 7.5) (figure1).

Conclusion: Long term efficacy of PSA DBS in dystonic tremor is variable, with some patients showing waning benefit due to habituation or disease progression. The practical management in this setting is very difficult, and this case illustrates that rescue GPi-DBS with placement of additional DBS leads may confer long-lasting significant clinical improvement.

Figure 1

References: 1. 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):1416–1423

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MDS Abstracts - https://www.mdsabstracts.org/abstract/a-successful-case-of-bilateral-gpi-rescue-dbs-in-dystonic-tremor-following-tremor-re-emergence-after-previous-bilateral-psa-dbs-five-years-prior/