PATIENT SELECTION: ESSENTIAL TREMOR DEEP BRAIN STIMULATION

CANDIDATES FOR DBS THERAPY

Best results are achieved when the patient and caregiver are fully informed about the therapy risks and benefits, surgical procedures, follow-up requirements, and self-care responsibilities.

Deep brain stimulation should be considered when a patient with essential tremor has disabling symptoms and medications are ineffective or have intolerable side effects.

Patients with essential tremor may be candidates for deep brain stimulation if:

• They have a disabling tremor of an upper extremity due to essential tremor or Parkinsonian tremor.
• The tremor causes a significant functional disability.
• The tremor is refractory to pharmacological therapies.
• They are suitable candidates for stereotactic neurosurgery.
• The tremor is of physiologic origin.

The safety and effectiveness of deep brain stimulation therapy for essential tremor has not been established for:

• Bilateral VIM stimulation
• Patients with neurological disease origins other than essential tremor or Parkinson’s disease
• Patients with a previous thalamotomy or surgical ablation procedure
• Patients who are pregnant
• Patients under the age of 18 years
• Patients over the age of 80 years

Use extreme care with lead implantation in patients with a heightened risk of intracranial hemorrhage. Physicians should consider underlying factors, such as previous neurological injury or prescribed medications (anticoagulants), that may predispose a patient to the risk of bleeding.

Physicians should be aware that the risks associated with initial surgery may increase with clinical conditions such as:

• Stroke or neurological disorders
• Cardiovascular disease
• Renal or hepatic failure
• Diabetes mellitus

To help ensure maximum benefits from the neurostimulation system, long-term, post-surgical management of patients is recommended.

Stimulation parameters should be adjusted such that maximal symptom suppression is achieved with minimal side effects. High parameter values may indicate a system problem or less than optimal lead placement. Patients should be informed of the risks of higher parameters, which may result in possible excessive change density, as noted in the appropriate information for prescribers booklet.

ASSESSMENT

The patient should be evaluated to determine the impact of essential tremor on daily life. Deep brain stimulation may be appropriate if:

• The tremors interfere with activities of daily living such as eating, dressing, or writing.
• Tremors prevent the patient from working.
• Medications are ineffective or cause troublesome side effects such as sleepiness, dizziness, or thinking problems.