====== Posterior subthalamic area deep brain stimulation ======

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The [[posterior subthalamic area]] (PSA), including the [[prelemniscal radiation]] and the [[zona incerta]], emerged as a potential new anatomical target to treat ET
((Plaha P, Patel NK, Gill SS. Stimulation of the subthalamic region for essential tremor. J Neurosurg. 2004;101(1):48–54. doi: 10.3171/jns.2004.101.1.0048.))
((Murata J, Kitagawa M, Uesugi H, Saito H, Iwasaki Y, Kikuchi S, et al. Electrostimulation of the posterior subthalamic area for the treatment of intractable proximal tremor. J Neurosurg. 2003;99(4):708–15. doi: 10.3171/jns.2003.99.4.0708.))
((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. doi: 10.1002/mds.22758.))
((Plaha P, Khan S, Gill SS. Bilateral stimulation of the caudal zona incerta nucleus for tremor control. J Neurol Neurosurg Psychiatry. 2008;79(5):504–13. doi: 10.1136/jnnp.2006.112334.)).

===== Clinical trials =====

There is little evidence regarding the possible neuropsychological effects of [[posterior subthalamic area]]-DBS on patients with ET, and there are few studies comparing it with VIM-DBS in this population.In this study, Triguero-Cueva et al. aim to present the evaluation [[protocol]] and neuropsychological battery as used in an ongoing trial of DBS for ET comparing the already mentioned targets.

As part of a randomized, [[double-blind]], [[crossover]] clinical trial comparing the [[effectiveness]] and [[safety]] of PSA-DBS vs. VIM-DBS, 11 patients with refractory ET will undergo a multi-domain neuropsychological battery assessment. This will include a pre-/post-implantation assessment (3 months after the stimulation of each target and 6 months after an open stage of DBS on the most optimal target).

Evidence on the neuropsychological effects of DBS in patients with refractory ET is very scarce, particularly in lesser-explored targets such as PSA. This study could contribute significantly in this field, particularly on pre-procedure safety analysis for tailored patient/technique selection, and to complete the safety analysis of the procedure. Moreover, if proven useful, this proposed neuropsychological assessment protocol could be extensible to other surgical therapies for ET
((Triguero-Cueva L, Marín-Romero B, Madrid-Navarro CJ, Pérez-Navarro MJ, Iáñez-Velasco B, Mínguez-Castellanos A, Katati MJ, Escamilla-Sevilla F. Neuropsychological assessment protocol in an ongoing randomized controlled trial on posterior [[subthalamic area]] vs. ventral intermediate nucleus deep brain stimulation for essential tremor. Front Neurol. 2023 Oct 30;14:1222592. doi: 10.3389/fneur.2023.1222592. PMID: 38020655; PMCID: PMC10643533.))

===== Case series =====

Three right-handed patients diagnosed with Holmes tremor (HT), who suffered from pharmacotherapy-refractory tremor, were eligible for unilateral [[posterior subthalamic area]] [[deep brain stimulation]] (PSA-DBS). All patients were evaluated with the [[Fahn-Tolosa-Marin Tremor Rating Scale]] (FTMTRS) and [[Clinical Global Impression]] scale (CGI) before DBS, 6, and 12 months after the PSA-DBS as well as at the last follow-up. In all patients, we observed a significant improvement of tremor control as demonstrated by changes in the FTMTRS and the CGI scales. Mean improvement of tremor in all patients was 56% for the FTMRTS with a corresponding change in the CGI scale. Our study demonstrates that PSA-DBS is efficacious in the treatment of HT. Indeed, PSA is a promising target for DBS for intractable proximal and distal tremor, even in cases of previous, suboptimal functional neurosurgery. The beneficial effect lasts over a long-term follow-up. PSA-DBS may be considered as an alternative target of DBS in tremor treatment
((Dec-Ćwiek M, Tutaj M, Pietraszko W, Libionka W, Krupa M, Moskała M,
Rudzińska-Bar M, Słowik A, Pera J. Posterior Subthalamic Area Deep Brain
Stimulation for Treatment of Refractory Holmes Tremor. Stereotact Funct
Neurosurg. 2019 Oct 10:1-6. doi: 10.1159/000502563. [Epub ahead of print] PubMed 
PMID: 31600751.
)).