Double-target DBS for essential tremor: 8-contact lead for cZI and Vim aligned in the same trajectory

Essential tremor (ET) can be disabling and frequently affects a patient's quality of life. Although many patients will benefit from pharmacologic therapy, up to 50% of patients with ET can present unsatisfactory tremor control due to drug adverse effects, comorbidities, or suboptimal response. Those patients may need additional surgical treatment. Bilateral deep brain stimulation (DBS) of the thalamic Vim nucleus has been accepted as the standard treatment, but results are limited by side effects such as speech impairment, ataxia, and stimulation tolerance in the long term1; in extreme cases, reoperation may be required.2 More recently, stimulation of the posterior subthalamic area (PSA) that comprises the prelemniscal radiation and the caudal zona incerta (cZI)3 emerged as a promising target for tremor control with encouraging results. Technology has advanced, providing multiple contact electrodes that can increase possibilities for tremor control and perhaps minimize side effects. We propose bilateral implantation of 8-contact electrodes aligning the Vim and the cZI in the same trajectory, offering multiple stimulation targets with no additional risk. The index case of refractory ET treated with bilateral double-target DBS is presented here.