• Maarten Bot, Fleur van Rootselaar, Maria Fiorella Contarino, Vincent Odekerken, Joke Dijk, Rob de Bie, Richard Schuurman, and Pepijn van den Munckhof.
• Department of Neurosurgery, Academic Medical Center, Amsterdam, The Nether-lands.
• Oper Neurosurg (Hagerstown). 2018 Aug 1; 15 (2): 144-152.

BackgroundVentral intermediate nucleus (VIM) deep brain stimulation (DBS) and posterior subthalamic area (PSA) DBS suppress tremor in essential tremor (ET) patients, but it is not clear which target is optimal. Aligning both targets in 1 surgical trajectory would facilitate exploring stimulation of either target in a single patient.ObjectiveTo evaluate aligning VIM and PSA in 1 surgical trajectory for DBS in ET.MethodsTechnical aspects of trajectories, intraoperative stimulation findings, final electrode placement, target used for chronic stimulation, and adverse and beneficial effects were evaluated.ResultsIn 17 patients representing 33 trajectories, we successfully aligned VIM and PSA targets in 26 trajectories. Trajectory distance between targets averaged 7.2 (range 6-10) mm. In all but 4 aligned trajectories, optimal intraoperative tremor suppression was obtained in the PSA. During follow-up, active electrode contacts were located in PSA in the majority of cases. Overall, successful tremor control was achieved in 69% of patients. Stimulation-induced dysarthria or gait ataxia occurred in, respectively, 56% and 44% of patients. Neither difference in tremor suppression or side effects was noted between aligned and nonaligned leads nor between the different locations of chronic stimulation.ConclusionAlignment of VIM and PSA for DBS in ET is feasible and enables intraoperative exploration of both targets in 1 trajectory. This facilitates positioning of electrode contacts in both areas, where multiple effective points of stimulation can be found. In the majority of aligned leads, optimal intraoperative and chronic stimulation were located in the PSA.

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