Difference in surgical strategies between thalamotomy and thalamic deep brain stimulation for tremor control

Stereotactic targeting strategies differ between thalamotomy and thalamic deep brain stimulation (DBS) for tremor control. In thalamotomy, a minimal radiofrequency lesion created within the lateral portion of the nucleus ventralis intermedius (Vim) often affords the best control of parkinsonian tremor, supporting the assumption that there is a concentrated cluster of cells within this area which is responsible for tremor. However, this assumption may not always be true; such neural elements sometimes appear to spread out across wide areas. Cells with tremor-frequency activity are widely distributed over the areas extending from the Vim to the nuclei ventralis oralis posterior and anterior (Vop and Voa). All of these cells appear to be more or less involved in tremor generation, especially in patients with essential tremor and post-stroke tremor. In contrast to radiofrequency lesions for thalamotomy, electrodes for DBS can be arranged in such a way that wide areas can be stimulated, if necessary. For this purpose, it is critically important to determine optimal placement and orientation of DBS leads for arranging the electrodes to yield maximal benefits in patients with tremor.