Normative network-based programming for deep brain stimulation—Concept and case report

Background Essential tremor (ET) is the most common movement disorder, with deep brain stimulation (DBS) of the ventral intermedius nucleus (VIM) serving as the standard surgical treatment for medically refractory patients. However, methods to identify a VIM ‘hotspot’ pose challenges for reliability and scalability. Case presentation This case report presents a normative network-based approach for identification of a putative VIM hotspot using the Human Connectome Project (HCP) database. We demonstrate optimization of DBS outcomes in a patient with medically and advanced DBS programming refractory ET. The standard pre-operative non-contrast T1 was the only imaging required. Results Prior to our analysis, the patient had been programmed with up to 8 mA current on her left brain. Normative network-based analysis localized the hotspot posterolateral to the lead, towards the internal capsule. Current steering to this region demonstrated 80% and 60% tremor reduction in the left and right hands respectively at only 1.8–2.2 mA, without capsular side effect. Outcomes were maintained in following visits and the patient could perform daily activities easier. This approach shortened the programming process and minimized trial-and-error adjustments. Conclusion This study demonstrates the potential utility of a scalable, normative network-based targeting pipeline for optimizing outcome even in challenging, DBS programming-refractory patients. Future complementary studies are warranted to validate our network-based approach.