June 12, 2026

@michaelokun

When tremor comes back after focused ultrasound: should you re-lesion or switch to DBS? Focused ultrasound thalamotomy creates a small lesion in a brain target involved in tremor control. Deep brain stimulation (DBS) uses an implanted electrode to deliver adjustable electrical stimulation to the same brain network. Nur Walker-Pizarro and colleagues describe in a new paper in Tremor and Other Hyperkinetic Movements how DBS can successfully rescue recurrent essential tremor following MRI-guided focused ultrasound thalamotomy. Key points: - Tremor recurrence after focused ultrasound does not necessarily mean the original procedure failed; it may reflect progression of a chronic neurological condition. - In this case, staged bilateral VIM DBS provided durable tremor control after tremor returned following an initially successful focused ultrasound procedure. - Therapeutic DBS stimulation was achieved even within a previously lesioned thalamic target, suggesting that focused ultrasound and DBS may complement one another over time. My take: This paper highlights an important reality. Essential tremor is a progressive disease, and no single intervention is likely to be the final chapter for every patient. Focused ultrasound and DBS should not be viewed as competing therapies. They may be different tools that can be deployed at different times in a person's journey. The ability to adjust DBS over time remains one of its greatest strengths, especially when symptoms evolve. I am biased as an author of this paper, so read for yourself and decide. Here are 5 points that resonated w/ me: 1- Tremor recurrence after focused ultrasound occurs in a subset of patients and should trigger a thoughtful reassessment rather than an automatic repeat procedure. 2- Essential tremor frequently progresses over time, and treatment plans should anticipate future needs. 3- DBS offers flexibility because stimulation can be adjusted as symptoms change. 4- Prior focused ultrasound does not necessarily prevent successful DBS therapy later in the disease course. 5- The future will likely be personalized, matching the right surgical approach to the right patient at the right stage of disease.