Tremor Recurrence in MR-Guided Focused Ultrasound Thalamotomy for Essential Tremor: DBS vs. Re-lesion

Clinical vignette: A 59-year-old man with essential tremor (ET) and bilateral symptoms initially underwent left thalamic MRI-guided focused ultrasound (MRgFUS) at an outside institution to address tremor in the right upper extremity. Despite an initial improvement, the benefit waned within one year, and there was significant progression of right upper extremity tremor and disabling left upper extremity tremor.

Clinical dilemma: Tremor recurrence following MRgFUS highlights a common clinical challenge in the management of medication-refractory ET. When tremor re-emerges, clinicians must determine whether to pursue re-lesioning or transition to an alternative surgical strategy such as deep brain stimulation (DBS).

Clinical solution: Following a multidisciplinary evaluation, staged bilateral ventral intermediate nucleus of the thalamus DBS (VIM-DBS) surgery was performed and resulted in bilateral tremor control.

Gap in knowledge: There is no consensus regarding the optimal management when tremor recurs post-MRgFUS. Guiding principles for balancing re-lesioning vs. DBS remain undefined in clinical practice.

Highlights

Tremor recurrence following MR-guided focused ultrasound highlights the limitations of fixed lesioning in a progressive disorder. This case illustrates that staged bilateral deep brain stimulation can provide durable, adjustable tremor control even when stimulation is delivered within a previously focused ultrasound lesioned target.