Essential Tremor, Parkinson’s Disease,
DBS, And Focused Ultrasound.

Essential tremor is an action tremor: the hands shake when you use them, holding a cup, writing, or bringing a fork to your mouth, and it usually affects both hands and often runs in families. Parkinson’s tremor is a resting tremor: the hand shakes in your lap or while walking and quiets when you use it, usually on one side first, and it comes with stiffness and slowness. Some people have features of both, and the evaluation sorts it out.

No. They are different conditions with different causes and different brain circuits. People with essential tremor have a slightly higher chance of developing Parkinson’s over a lifetime, but the tremor itself does not progress into Parkinson’s.

Essential tremor usually worsens slowly over years and can spread from the hands to the head or voice. Parkinson’s disease is progressive, and medication becomes less predictable over time. Neither is a reason to rush, but both are reasons not to wait until the shaking is severe before asking about your options.

A small amount of alcohol quiets the cerebellar-thalamic circuit that drives essential tremor, which is why many patients notice it. It is a clue to the diagnosis, not a treatment; the effect is brief and the tremor often rebounds.

Propranolol and primidone are the standard first choices for essential tremor; gabapentin and topiramate are second-line. If two medicines have failed or the side effects outweigh the benefit, and the tremor affects daily life, it is time to talk about a procedure. For Parkinson’s disease, the trigger is when the medication no longer works reliably through the day, or causes dyskinesia.

Yes. For essential tremor and Parkinson’s disease, a movement disorders neurologist, at UCLA or near you, confirms the diagnosis, makes sure first-line medications have had a fair trial, and for Parkinson’s confirms that you are on the right doses and that surgery is the appropriate next step. Their referral starts the surgical evaluation. For epilepsy, the epilepsy neurologists complete the workup first, and the team then decides whether surgery is an option and which procedure fits. If you do not have a specialist, call and the team will arrange one.

Three things matter: the diagnosis, whether medication has been given a fair trial, and whether the tremor or Parkinson’s symptoms limit your life. Your movement disorders neurologist establishes the first two; Dr. Bari then reviews your history, examines you, and reviews your MRI. For focused ultrasound a skull CT is also needed. The consultation can be done by video to start.

No. Focused ultrasound has no incision and no anesthesia, and Dr. Bari treats patients in their eighties and nineties. General health, walking and balance, and skull anatomy matter more than age. DBS is also performed at advanced ages when health allows.

Ultrasound has to pass through bone. The screening CT gives a number, the skull density ratio, that predicts how well it will. A ratio of about 0.4 or higher is needed for focused ultrasound; below that, the energy does not reach the target reliably. If your ratio is low, Dr. Bari will guide you toward DBS or radiosurgery instead.

Usually yes. Blood thinners and antiplatelet drugs such as aspirin, warfarin, clopidogrel, and the newer anticoagulants are held for about a week around focused ultrasound or DBS, in coordination with the doctor who prescribes them. If they cannot be stopped safely, radiosurgery is an option that needs no interruption.

Yes, in two forms. Thalamotomy treats tremor-dominant Parkinson’s disease. Pallidotomy, on one side, treats Parkinson’s with dyskinesia or motor fluctuations. Both are FDA approved. When stiffness, slowness, and fluctuations on both sides need treatment, DBS is usually the better fit because it treats both sides and can be adjusted.

No. The rule is that symptoms that improve with your best dose of levodopa are the ones DBS improves: tremor, stiffness, slowness, and the swings between doses. Tremor is the exception and often responds even when medication does not. DBS does not reliably help balance, freezing of gait, speech, or thinking, and it does not slow the disease.

For DBS in Parkinson’s disease, yes; neuropsychological testing is part of the standard evaluation because significant memory or thinking problems change the risk-benefit balance. For focused ultrasound for essential tremor it is not usually required.

More than a thousand ultrasound elements in a helmet send sound waves through the intact skull. Each beam alone is harmless. Where they converge, on a spot a few millimeters across in the thalamus, they heat the tissue and make a precise, permanent change. MRI temperature maps show the effect in real time.

You are awake and not sedated, so Dr. Bari can check your tremor between doses and talk with you throughout. The head is shaved and a light frame holds it still under local anesthetic. Most people describe pressure or warmth during the higher-energy doses, sometimes a brief headache, and it is over in about an hour.

In the treatment room. Between the test doses you draw spirals and hold a cup, and the change is visible before the final dose is delivered.

Most patients see more than 80 percent improvement in the treated hand, some see closer to 50 percent, and in Dr. Bari’s hands the average across patients is about 80 percent. He will give you a realistic estimate for your situation at the consultation.

In Dr. Bari’s experience: numbness or tingling of the face or hand in one to three percent, slurred speech in about three percent, and balance or walking difficulty in about three percent. These are usually temporary and settle within one to two months, but they can be permanent. There is no incision, so there is no infection risk from an implant.

One side is treated per session. The second side can be considered in selected patients no sooner than nine months later. If both hands, or head or voice tremor, are the main problem from the start, DBS treats both sides in one operation.

The change is permanent, and most patients keep most of their benefit for years. A minority see some tremor return over time. Because the treatment cannot be adjusted afterward, that is one of the tradeoffs against DBS.

Yes, fully, on the day of treatment. Hair interferes with the ultrasound and the water that cools the scalp. It grows back.

Most people go home the same day or the next morning and are back to normal activities within days. There are no stitches to care for.

A thin electrode is placed in the target with stereotactic guidance through a small opening in the skull, on one or both sides, and connected under the skin to a small generator in the chest. The electrodes can be placed awake, with recordings and your feedback confirming the target, or asleep with intraoperative imaging. The generator is placed in a separate, shorter procedure.

Both work well and Dr. Bari offers both. Awake surgery allows real-time testing of the target; asleep surgery relies on imaging and is easier for people who cannot tolerate being awake with a frame. The choice is made with you based on your condition and preference.

In Dr. Bari’s practice, bleeding in the brain in about one percent and infection in about three percent. Hardware problems such as a broken wire or a device that needs revision occur in a small minority over the years. Stimulation side effects such as tingling, speech change, or unsteadiness are usually reversible by adjusting the settings.

Programming begins a few weeks after surgery, once healing has settled, and it usually takes several visits over two to three months to find the settings that suit you. Tremor often responds quickly once the device is on; Parkinson’s symptoms are tuned more gradually as medication is adjusted.

Rechargeable generators last about fifteen years and are charged at home a few times a week. Non-rechargeable generators are replaced in a short outpatient procedure after roughly three to five years, depending on settings.

Modern DBS systems are MRI-conditional, meaning MRI can be done under specific conditions. Tell every doctor and imaging center that you have DBS, carry your device card, and check with the DBS team before any scan.

Very little. Most patients return to full activity. Contact sports and activities with a risk of a blow to the head or chest are discussed individually. Airport security and household electronics are not a problem. Some welding, industrial magnets, and diathermy must be avoided.

Yes. Stimulation can be turned off at any time, and the system can be removed if needed. That reversibility is the main difference from focused ultrasound and radiosurgery.

Focused ultrasound suits people who want no implant, a single session, and a fast recovery, and whose tremor is mainly in one hand. DBS suits people who need both sides treated, have head or voice tremor, have Parkinson’s symptoms beyond tremor, or want the ability to adjust the treatment over the years. Dr. Bari performs both, so the recommendation depends on you, not on the equipment.

Radiosurgery uses focused radiation instead of ultrasound to make the same thalamic lesion, with no incision and no anesthesia. Its effect takes months to appear and cannot be adjusted. It is reserved for people who cannot have DBS or focused ultrasound, for example because of blood thinners that cannot be stopped, heart or lung disease, or skull anatomy that blocks ultrasound.

Yes. Focused ultrasound on one side does not prevent DBS later, and DBS on one side does not prevent treating the other side with either method. Your prior treatments are part of the planning.

Not yet a definitive one. Dr. Bari’s program treats large numbers of patients with each and follows them closely, and he is working on comparative studies. See the clinical trials page for what is enrolling.

Medicare has covered MRI-guided focused ultrasound for essential tremor nationwide since 2020, and most major insurers cover it. DBS for essential tremor and Parkinson’s disease has been covered for many years. Coverage for focused ultrasound in Parkinson’s disease is broadening. The team verifies your coverage before scheduling.

The first consultation can be a video visit. The skull CT and MRI are done in one visit, treatment is typically four to six weeks after consultation, and follow-up can be done remotely with imaging obtained near home. Patients come from across California, neighboring states, and abroad, and the scheduling team groups visits to limit trips.

Your neurologist’s notes, a list of medications tried with their effects, any MRI reports, your completed tremor questionnaire, and your spiral test sheet. For Parkinson’s disease, an assessment of your movement on and off medication is very helpful if your neurologist has done one.

Dr. Bari sees you himself before, during, and after treatment. For DBS, programming is shared with your neurologist. Your primary neurologist remains part of your care throughout.