PROJECT SUMMARY AND ABSTRACT Essential tremor (ET) is the most common movement disorder in the United States, affecting 4% of all adults over the age of 40. For individuals whose motor symptoms are refractory to medication and significantly impair their daily living, deep brain stimulation (DBS) is considered to be the only bilateral therapeutic option. Despite recent advances in DBS technology, a significant portion of ET patients with DBS implants will receive inadequate tremor control because of poorly placed DBS leads, while others will lose efficacy of the therapy after 1-2 years due in part to inflexible neurostimulator programming options. There is a strong and growing clinical need for implantable DBS lead designs and programming algorithms that can enable clinicians to better sculpt electric fields within the brain, especially in cases where stimulation through a poorly placed DBS lead results in low-threshold side-effects. Our proposed study will integrate high-field magnetic resonance imaging, histological neurotracing of fiber pathways, computational modeling of DBS, and single-cell electrophysiology methods to further develop and experimentally-validate a novel semi-automated machine learning algorithm that facilitates hypothesis-driven determination of subject-specific neurostimulator settings through directional DBS leads. Specifically, we will: 1) identify the neural pathways involved in the reduction of action and postural tremor using directional DBS leads and a novel particle swarm optimization algorithm based on subject-specific anatomy; 2) quantify how tremor-related information is modulated on the single-cell, population, and network levels by therapeutic DBS in a preclinical large-animal model of harmline-induced tremor; and 3) investigate how therapeutic windows (i.e. the threshold difference between postural and action tremor abolishment and side effect emergence) change over time with human DBS therapy targeting one or more pathways within the cerebello-thalamoc-cortical network. Together, this project will (a) experimentally evaluate and translate a novel DBS programming algorithm to human ET patients, (b) provide a much more detailed map of the neural pathways underlying the therapeutic effects of DBS (on postural and action tremor) and side effects of DBS (on dysarthria, paresthesia, ataxia), (c) rigorously investigate how DBS for treating tremor works mechanistically at the single cell and network levels within the brain, and (d) probe the neural pathways involved in the worsening of tremor symptoms for ET patients over time.

NARRATIVE Deep brain stimulation (DBS) is a proven therapy for patients with medication-refractory essential tremor, but a significant portion of patients with these implants do not receive adequate tremor control because of poorly placed DBS leads or inflexible DBS programming options. There is a strong and growing clinical need for implantable DBS lead designs that can enable clinicians to better sculpt electric fields in the brain to improve the functional outcome for all patients requiring DBS to manage their essential tremor. Our research study will experimentally evaluate a novel machine learning algorithm for programming directional DBS leads implanted within thalamus to more precisely identify and effectively target the pathways and circuits involved in (a) cessation of action and postural tremor, and (b) worsening of tremor symptoms over time.