case_images: PMC11225553_01
case_images: Archimedes spirals evolution. A: Prior to staged bilateral Vim DBS, the patient was unable to draw Archimedes spirals with either hand due to severe tremor. B: After initial optimization of the left Vim DBS, his right-hand tremor improved. C: After right Vim lead implantation, there was unexpected ipsilateral worsening of right-hand tremor, and he was unable to engage a pen to paper or draw a spiral (similar to the pre-operative state). D: The left-hand tremor improved following right Vim DBS optimization. E: Following optimization of bilateral DBS, with an increase in left Vim amplitude, there was further improvement of tremor documented in both hands. Created with BioRender.com.
case_images: tohm-14-1-918-g1.jpg
case_images: PMC11225553_01_tohm-14-1-918-g1.jpg
case_images: F1
case_images: The severity of his tremor was evident in his inability to write or to draw an Archimedes spiral with either hand prior to surgery (Figure 1A). This stimulation resulted in a significant improvement in the right upper extremity, including resolution of rest and postural tremor, reduction of intention tremor, kinetic tremor, and Archimedes (spiral-based) tremor to mild-to-moderate amplitude (Figure 1B). Unexpectedly, this procedure led to an acute worsening of the previously optimized right upper extremity tremor (Figure 1C), even before stimulation was turned on. In managing this case, the initial step was to deactivate the left DBS lead and to focus on optimizing the newly implanted right Vim DBS lead (Figure 1D). It is noteworthy that although the right upper extremity tremor initially worsened after the right Vim DBS implantation prior to activation, the patient ultimately experienced better tremor control in both upper extremities after optimizing the new DBS lead through programming and through reactivating the old DBS lead (Figure 1E). This improvement was superior to the tremor control achieved with either left Vim (Figure 1B) or right Vim stimulation alone (Figure 1D).