Patient Reported Feedback Suggests an Alternative Sweet Spot for DBS Programming in Essential Tremor

Background: Deep brain stimulation (DBS) of the ventral intermediate nucleus (VIM) and caudal zona incerta (cZi) is an established therapy for essential tremor (ET). Clinical outcomes depend on precise electrode placement and optimal stimulation parameters. Effective programming must balance tremor suppression with side-effect risk, yet systematic incorporation of patient-reported feedback remains limited. Objective: To assess whether subjective patient feedback, quantified via a visual analogue scale (VAS), can guide DBS programming for effective tremor control. Methods: In 15 VIM-DBS patients, 1,253 unique stimulation settings were collected, each rated with a VAS reflecting perceived clinical benefit. Associated volumes of tissue activated (VTA) were mapped and analyzed. VAS-optimized settings were compared to standard-of-care (SoC) programming. Voxel-wise permutation statistics identified stimulation sweet and sour spots, while structural and functional connectivity analyses determined neural correlates of subjective benefit. Results: VAS-optimized stimulation achieved tremor suppression comparable to SoC settings but with lower energy consumption. Sweet spots correlated with high VAS ratings localized to the dorsal VIM, whereas sour spots were ventral. Connectivity between sweet spots and prefrontal, frontal, and insular regions positively correlated with perceived benefit. Conclusions: Integrating patient-reported feedback offers a structured, individualized approach to DBS optimization in ET. VAS-guided programming identifies patient-specific sweet spots and delineates connectivity profiles associated with clinical benefit. Notably, VAS-derived sweet spots were more dorsal than previously suggested targets, highlighting the importance of incorporating subjective feedback to refine optimal stimulation regions.