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Abstract
During the past 25 years, botulinum toxin type A (BoNT-A) has become the most widely used medical intervention in children with cerebral palsy. In this review we consider the gaps in our knowledge in the use of BoNT-A and reasons why muscle morphology and function in children with cerebral palsy are impaired. We review limitations in our knowledge regarding the mechanisms underlying the development of contractures and the difficulty in preventing them. It is clear from this review that injection of BoNT-A in the large muscles of both the upper and lower limbs of children with cerebral palsy will result in a predictable decrease in muscle activity, which is usually reported as a reduction in spasticity, for between 3 and 6 months. These changes are noted by the use of clinical tools such as the Modified Ashworth Scale and the Modified Tardieu Scale. Decreased muscle over-activity usually results in improved range of motion in distal joints. Injection of the gastrocnemius muscle for toe-walking in a child with hemiplegia or diplegia usually has the effect of increasing the passive range of dorsiflexion at the ankle. In our review, we found that this may result in a measurable improvement in gait by the use of observational gait scales or gait analysis, in some children. However, improvements in gait function are not always achieved and are small in magnitude and short lived. We found that some of the differences in outcomes in clinical trials may relate to the use of adjunctive interventions such as serial casting, orthoses, night splints and intensive therapy. We note that the majority of clinical trials of the use of BoNT-A in children with cerebral palsy have focussed on a single injection cycle and this is insufficient to understand the balance between benefit and harm. Most outcomes were reported in terms of changes in muscle tone and there were fewer studies with robust methodology that reported improvements in function. Changes in the domains of activities and participation have rarely been reported in studies to date. There were no clinical reviews to date that consider the findings of studies in human volunteers and in experimental animals and their relevance to clinical protocols. In this review we found that studies in human volunteers and in experimental animals show muscle atrophy after an injection of BoNT-A for at least 12 months. Muscle atrophy was accompanied by loss of contractile elements in muscle and replacement with fat and connective tissue. It is not currently known if these changes, mediated at a molecular level, are reversible. We conclude that there is a need to revise clinical protocols by using BoNT-A more thoughtfully, less frequently and with greatly enhanced monitoring of the effects on injected muscle for both short-term and long-term benefits and harms.
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Affiliation(s)
- Iqbal Multani
- Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia
- Orthopaedic Department, Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Jamil Manji
- Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia
- Orthopaedic Department, Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Tandy Hastings-Ison
- Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia
- Hugh Williamson Gait Laboratory, Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Abhay Khot
- Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia
- Orthopaedic Department, Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia
- Hugh Williamson Gait Laboratory, Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Kerr Graham
- Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia.
- Orthopaedic Department, Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia.
- Hugh Williamson Gait Laboratory, Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia.
- University of Melbourne, Parkville, Australia.
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52
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Chae M, Hong S, Jung NY, Chang WS, Cho SR. Outcomes of Intrathecal Baclofen Therapy Compared With Deep Brain Stimulation in a Patient With Dystonic Cerebral Palsy: A Case Report. Ann Rehabil Med 2019; 43:335-340. [PMID: 31311256 PMCID: PMC6637060 DOI: 10.5535/arm.2019.43.3.335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/01/2018] [Indexed: 01/05/2023] Open
Abstract
Deep brain stimulation (DBS) in internal globus pallidus is considered to be a good option for controlling generalized dystonia in patients with this condition. In this relation, it is known that DBS has already been shown to have significant effects on primary dystonia, but is seen as controversial in secondary dystonia including cerebral palsy (CP). On the other hand, intrathecal baclofen (ITB) has been known to reduce spasticity and dystonia in patients who did not respond to oral medications or botulinum toxin treatment. Here, we report a patient with dystonic CP, who received the ITB pump implantation long after the DBS and who noted remarkable improvement in the 36-Item Short Form Health Survey, Dystonia Rating Scale, Modified Barthel Index, and visual analog scale scores for pain after an ITB pump implantation was used as compared with DBS. To our knowledge, the present case report is the first to demonstrate the effects of an ITB pump on reducing pain and dystonia and improving quality of life and satisfaction, compared with DBS in a patient with CP.
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Affiliation(s)
- Minji Chae
- Department of Rehabilitation Medicine and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seungbeen Hong
- Department of Rehabilitation Medicine and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Na Young Jung
- Department of Neurosurgery and Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Won Seok Chang
- Department of Neurosurgery and Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Rae Cho
- Department of Rehabilitation Medicine and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea.,Brain Korea 21 PLUS Project for Medical Science, Yonsei University, Seoul, Korea
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53
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Mathon B, Amelot A, Clemenceau S, Carpentier A, Boch AL. In Reply: Commentary: La Pitié-Salpêtrière Hospital in Paris: The Historic Cradle of Neurosurgery. Neurosurgery 2019; 84:E444-E445. [DOI: 10.1093/neuros/nyz056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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54
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Deep brain stimulation for dystonia-choreoathetosis in cerebral palsy: Pallidal versus thalamic stimulation. Parkinsonism Relat Disord 2019; 63:209-212. [DOI: 10.1016/j.parkreldis.2019.01.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 01/28/2019] [Accepted: 01/29/2019] [Indexed: 02/02/2023]
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55
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Kim JH, Jung NY, Chang WS, Jung HH, Cho SR, Chang JW. Intrathecal Baclofen Pump Versus Globus Pallidus Interna Deep Brain Stimulation in Adult Patients with Severe Cerebral Palsy. World Neurosurg 2019; 126:e550-e556. [DOI: 10.1016/j.wneu.2019.02.092] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/07/2019] [Accepted: 02/08/2019] [Indexed: 11/29/2022]
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56
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Koeglsperger T, Palleis C, Hell F, Mehrkens JH, Bötzel K. Deep Brain Stimulation Programming for Movement Disorders: Current Concepts and Evidence-Based Strategies. Front Neurol 2019; 10:410. [PMID: 31231293 PMCID: PMC6558426 DOI: 10.3389/fneur.2019.00410] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 04/04/2019] [Indexed: 11/16/2022] Open
Abstract
Deep brain stimulation (DBS) has become the treatment of choice for advanced stages of Parkinson's disease, medically intractable essential tremor, and complicated segmental and generalized dystonia. In addition to accurate electrode placement in the target area, effective programming of DBS devices is considered the most important factor for the individual outcome after DBS. Programming of the implanted pulse generator (IPG) is the only modifiable factor once DBS leads have been implanted and it becomes even more relevant in cases in which the electrodes are located at the border of the intended target structure and when side effects become challenging. At present, adjusting stimulation parameters depends to a large extent on personal experience. Based on a comprehensive literature search, we here summarize previous studies that examined the significance of distinct stimulation strategies for ameliorating disease signs and symptoms. We assess the effect of adjusting the stimulus amplitude (A), frequency (f), and pulse width (pw) on clinical symptoms and examine more recent techniques for modulating neuronal elements by electrical stimulation, such as interleaving (Medtronic®) or directional current steering (Boston Scientific®, Abbott®). We thus provide an evidence-based strategy for achieving the best clinical effect with different disorders and avoiding adverse effects in DBS of the subthalamic nucleus (STN), the ventro-intermedius nucleus (VIM), and the globus pallidus internus (GPi).
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Affiliation(s)
- Thomas Koeglsperger
- Department of Neurology, Ludwig Maximilians University, Munich, Germany.,Department of Translational Neurodegeneration, German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Carla Palleis
- Department of Neurology, Ludwig Maximilians University, Munich, Germany.,Department of Translational Neurodegeneration, German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Franz Hell
- Department of Neurology, Ludwig Maximilians University, Munich, Germany.,Graduate School of Systemic Neurosciences, Ludwig-Maximilians-Universität München, Martinsried, Germany
| | - Jan H Mehrkens
- Department of Neurosurgery, Ludwig Maximilians University, Munich, Germany
| | - Kai Bötzel
- Department of Neurology, Ludwig Maximilians University, Munich, Germany
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57
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Cernera S, Okun MS, Gunduz A. A Review of Cognitive Outcomes Across Movement Disorder Patients Undergoing Deep Brain Stimulation. Front Neurol 2019; 10:419. [PMID: 31133956 PMCID: PMC6514131 DOI: 10.3389/fneur.2019.00419] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 04/05/2019] [Indexed: 12/19/2022] Open
Abstract
Introduction: Although the benefit in motor symptoms for well-selected patients with deep brain stimulation (DBS) has been established, cognitive declines associated with DBS can produce suboptimal clinical responses. Small decrements in cognition can lead to profound effects on quality of life. The growth of indications, the expansion of surgical targets, the increasing complexity of devices, and recent changes in stimulation paradigms have all collectively drawn attention to the need for re-evaluation of DBS related cognitive outcomes. Methods: To address the impact of cognitive changes following DBS, we performed a literature review using PubMed. We searched for articles focused on DBS and cognition. We extracted information about the disease, target, number of patients, assessment of time points, cognitive battery, and clinical outcomes. Diseases included were dystonia, Tourette syndrome (TS), essential tremor (ET), and Parkinson's disease (PD). Results: DBS was associated with mild cognitive issues even when rigorous patient selection was employed. Dystonia studies reported stable or improved cognitive scores, however one study using reliable change indices indicated decrements in sustained attention. Additionally, DBS outcomes were convoluted with changes in medication dose, alleviation of motor symptoms, and learning effects. In the largest, prospective TS study, an improvement in attentional skills was noted, whereas smaller studies reported variable declines across several cognitive domains. Although, most studies reported stable cognitive outcomes. ET studies largely demonstrated deficits in verbal fluency, which had variable responses depending on stimulation setting. Recently, studies have focused beyond the ventral intermediate nucleus, including the post-subthalamic area and zona incerta. For PD, the cognitive results were heterogeneous, although deficits in verbal fluency were consistent and related to the micro-lesion effect. Conclusion: Post-DBS cognitive issues can impact both motor and quality of life outcomes. The underlying pathophysiology of cognitive changes post-DBS and the identification of pathways underpinning declines will require further investigation. Future studies should employ careful methodological designs. Patient specific analyses will be helpful to differentiate the effects of medications, DBS and the underlying disease state, including disease progression. Disease progression is often an underappreciated factor that is important to post-DBS cognitive issues.
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Affiliation(s)
- Stephanie Cernera
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, United States
| | - Michael S Okun
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida College of Medicine and McKnight Brain Institute, Gainesville, FL, United States
| | - Aysegul Gunduz
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, United States.,Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida College of Medicine and McKnight Brain Institute, Gainesville, FL, United States
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58
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Tustin K, Elze MC, Lumsden DE, Gimeno H, Kaminska M, Lin JP. Gross motor function outcomes following deep brain stimulation for childhood-onset dystonia: A descriptive report. Eur J Paediatr Neurol 2019; 23:473-483. [PMID: 30846371 DOI: 10.1016/j.ejpn.2019.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 01/30/2019] [Accepted: 02/17/2019] [Indexed: 12/20/2022]
Abstract
AIM To examine the impact of deep brain stimulation (DBS) on gross motor function in children with dystonic movement disorders. METHOD Prospective audit involving children implanted 2007-2015, followed for up to two years. Outcomes were evaluated across aetiological sub-groups (inherited, acquired, idiopathic) using the GMFM-88 and BFMDRS movement scale (BFM-M). The predictive value of proportion of life lived with dystonia (PLD) and baseline motor capacity were evaluated. RESULTS Data was available for 60 children (median surgery age 10y11mo). Inherited monogenetic dystonias demonstrated a median increase in GMFM-88 scores of 6.9% (p = 0.021) and 14.5% (p = 0.116) at one and two years. Heredodegenerative and idiopathic dystonias showed disparate responses, with non-significant changes seen in GMFM-88 and BFM-M scores, with the exception of improved one-year BFM-M scores in the idiopathic group [median change 5.5, p = 0.021]. Median GMFM-88 and BFM-M change scores were near zero for acquired dystonias, though improvement was noted in 9/18 CP cases with one-year GMFM-88 data. No significant relationship was found between PLD, or baseline GMFM-88, and GMFM-88 change following DBS. CONCLUSION Gross motor response to DBS is similar in profile to literature reporting results using impairment-based dystonia rating scales. Relatively consistent improvements were seen in inherited monogenetic ("primary") dystonias, while highly variable, often disappointing, gross motor responses were found in acquired, heredodegenerative, and idiopathic dystonias. In view of such response variability, alternatives to mean group studies, such as single case experimental designs with multiple replications, are needed to determine the efficacy of DBS in childhood-onset dystonias. Ongoing research is needed to identify factors that predict treatment response.
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Affiliation(s)
- Kylee Tustin
- Complex Motor Disorder Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Floor 2 Beckett House, Lambeth Palace Road, London, SE1 7EU, United Kingdom.
| | | | - Daniel E Lumsden
- Complex Motor Disorder Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Floor 2 Beckett House, Lambeth Palace Road, London, SE1 7EU, United Kingdom
| | - Hortensia Gimeno
- Complex Motor Disorder Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Floor 2 Beckett House, Lambeth Palace Road, London, SE1 7EU, United Kingdom; King's College London, Institute of Psychiatry, Psychology and Neurosciences, Psychology Department, London, SE5 8AF, United Kingdom
| | - Margaret Kaminska
- Complex Motor Disorder Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Floor 2 Beckett House, Lambeth Palace Road, London, SE1 7EU, United Kingdom
| | - Jean-Pierre Lin
- Complex Motor Disorder Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Floor 2 Beckett House, Lambeth Palace Road, London, SE1 7EU, United Kingdom
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59
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Deep stimulation in neurosurgery. КЛИНИЧЕСКАЯ ПРАКТИКА 2019. [DOI: 10.17816/clinpract10163-71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The technique of deep brain stimulation is used to treat patients with various diseases of the central nervous system who are not amenable to conservative therapy, while open interventions in them are associated with a high risk of complications. In the review, we evaluate the efficiency of the deep stimulation of different regions of the brain in some pharmacoresistant forms of diseases.
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60
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Cadwgan J, Goodwin J, Fairhurst C. Fifteen-minute consultation: Modern-day art and science of managing cerebral palsy. Arch Dis Child Educ Pract Ed 2019; 104:66-73. [PMID: 29907583 DOI: 10.1136/archdischild-2017-313793] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 03/19/2018] [Accepted: 05/15/2018] [Indexed: 11/03/2022]
Abstract
While there remains limited intervention to address the damage to the developing brain, current multidisciplinary management of cerebral palsy (CP) needs to minimise the impact of secondary musculoskeletal complications. A focus on comorbidities to maximise function for activity and participation by supporting the child and family in their environment is required. Comprehensive clinical guidance was published by National Institute for Health and Care Excellence (NICE) earlier this year. This article aims to provide a practical clinical approach to the child and family based on:(1) art: empathy, listening and weighing up the clinical picture of the child and family in context; diagnosis, the need for support and space; and care coordination at the right time; and (2) science: the current science in CP care is rapidly expanding in terms of plasticity, pathophysiology, functional assessments and treatments.
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Affiliation(s)
- Jill Cadwgan
- Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust (Kings Health Partners), London, UK.,Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Jane Goodwin
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Charlie Fairhurst
- Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust (Kings Health Partners), London, UK
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61
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Abstract
BACKGROUND Outcomes after orthopaedic interventions in patients with dystonic cerebral palsy (DCP) are historically regarded as unpredictable. This study aims to evaluate the overall outcome of orthopaedic surgery in children with DCP. METHOD Children with DCP who underwent lower limb orthopaedic surgery with a minimum follow-up of 12 months were included. Data collected included age at time of surgery, surgical procedures performed, Gross Motor Function Classification System (GMFCS) level, and Barry Albright Dystonia Scale (BADS) score. The cohort was divided into 2 groups. Group 1 (GMFCS levels I to III), mean age 12 years 7 months and group 2 (GMFCS levels IV to V), mean age 10 years 7 months. Group 1 had surgery aimed at deformity correction to improve gait and mobility, and group 2 for the management or prevention of hip displacement. Outcome measures analyzed were: the incidence of unpredictable results related to surgery and early recurrence of deformity in both groups. Functional mobility scale scores were evaluated for group 1 and hip migration percentage for group 2. Linear mixed models were used to take into account repeated measures over time and correlations between measurements from the same patient. RESULTS Group 1 (n=18); had low BADS scores and were considered to have mild dystonia. Three children experienced unpredictable results, 2 had early recurrence of deformity, 3 had a decline, and 1 child improved in the functional mobility scale.Group 2 (n=19); had high BADS scores and were considered to have moderate to severe dystonia. Nine surgical events involved bony procedures and 15 were soft tissue surgery only. One surgical event lead to unpredictable results and 2 children had early recurrence of deformity. Postoperatively, a linear trend of increasing migration percentage [0.49% (95% confidence interval, 0.23-0.74; P=0.0002)] was seen up to 21 months. There was no significant change after 21 months [-0.08% (95% confidence interval, -0.24 to +0.041; P=0.18)]. CONCLUSIONS This study suggests that unpredictable results and early recurrence of deformity following orthopaedic surgery in children with DCP are not as common as previously regarded. Furthermore, functional mobility and hip morphology can be improved. LEVEL OF EVIDENCE Level IV-this is a case-series.
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62
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Mohammad SS, Paget SP, Dale RC. Current therapies and therapeutic decision making for childhood-onset movement disorders. Mov Disord 2019; 34:637-656. [PMID: 30919519 DOI: 10.1002/mds.27661] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 02/12/2019] [Indexed: 12/13/2022] Open
Abstract
Movement disorders differ in children to adults. First, neurodevelopmental movement disorders such as tics and stereotypies are more prevalent than parkinsonism, and second, there is a genomic revolution which is now explaining many early-onset dystonic syndromes. We outline an approach to children with movement disorders starting with defining the movement phenomenology, determining the level of functional impairment due to abnormal movements, and screening for comorbid psychiatric conditions and cognitive impairments which often contribute more to disability than the movements themselves. The rapid improvement in our understanding of the etiology of movement disorders has resulted in an increasing focus on precision medicine, targeting treatable conditions and defining modifiable disease processes. We profile some of the key disease-modifying therapies in metabolic, neurotransmitter, inflammatory, and autoimmune conditions and the increasing focus on gene or cellular therapies. When no disease-modifying therapies are possible, symptomatic therapies are often all that is available. These classically target dopaminergic, cholinergic, alpha-adrenergic, or GABAergic neurochemistry. Increasing interest in neuromodulation has highlighted that some clinical syndromes respond better to DBS, and further highlights the importance of "disease-specific" therapies with a future focus on individualized therapies according to the genomic findings or disease pathways that are disrupted. We summarize some pragmatic applications of symptomatic therapies, neuromodulation techniques, and some rehabilitative interventions and provide a contemporary overview of treatment in childhood-onset movement disorders. © 2019 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Shekeeb S Mohammad
- Kids Neuroscience Centre, The Kids Research Institute at the Children's Hospital at Westmead, Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Westmead, NSW, Australia.,Movement Disorders Unit, T.Y. Nelson Department of Neurology, the Children's Hospital at Westmead and Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Simon P Paget
- Kids Rehab, the Children's Hospital at Westmead and Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Russell C Dale
- Kids Neuroscience Centre, The Kids Research Institute at the Children's Hospital at Westmead, Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Westmead, NSW, Australia.,Movement Disorders Unit, T.Y. Nelson Department of Neurology, the Children's Hospital at Westmead and Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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63
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Le Pichon JB, Riordan SM, Shapiro SM. Hyperbilirubinemia and the Risk for Brain Injury. Neurology 2019. [DOI: 10.1016/b978-0-323-54392-7.00010-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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64
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Gruber D, Südmeyer M, Deuschl G, Falk D, Krauss JK, Mueller J, Müller JU, Poewe W, Schneider GH, Schrader C, Vesper J, Volkmann J, Winter C, Kupsch A, Schnitzler A. Neurostimulation in tardive dystonia/dyskinesia: A delayed start, sham stimulation-controlled randomized trial. Brain Stimul 2018; 11:1368-1377. [DOI: 10.1016/j.brs.2018.08.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 08/12/2018] [Accepted: 08/14/2018] [Indexed: 11/30/2022] Open
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65
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Kosutzka Z, Tisch S, Bonnet C, Ruiz M, Hainque E, Welter M, Viallet F, Karachi C, Navarro S, Jahanshahi M, Rivaud‐Pechoux S, Grabli D, Roze E, Vidailhet M. Long‐term GPi‐DBS improves motor features in myoclonus‐dystonia and enhances social adjustment. Mov Disord 2018; 34:87-94. [DOI: 10.1002/mds.27474] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 04/26/2018] [Accepted: 05/15/2018] [Indexed: 12/27/2022] Open
Affiliation(s)
- Zuzana Kosutzka
- Sorbonne Université, Faculté de Médecine; CNRS UMR 7225, UMR S 1127 Institut du Cerveau et de la Moelle épinière Paris France
- Second Department of Neurology, Faculty of Medicine Comenius University Bratislava Slovakia
| | - Stephen Tisch
- Department of Neurology, St Vincent's Hospital University of New South Wales Sydney Australia
| | - Cecilia Bonnet
- Sorbonne Université, Faculté de Médecine; CNRS UMR 7225, UMR S 1127 Institut du Cerveau et de la Moelle épinière Paris France
- APHP, Hôpital Salpêtrière Département de Neurologie Paris France
| | - Marta Ruiz
- Sorbonne Université, Faculté de Médecine; CNRS UMR 7225, UMR S 1127 Institut du Cerveau et de la Moelle épinière Paris France
- APHP, Hôpital Salpêtrière Département de Neurologie Paris France
| | - Elodie Hainque
- Sorbonne Université, Faculté de Médecine; CNRS UMR 7225, UMR S 1127 Institut du Cerveau et de la Moelle épinière Paris France
- APHP, Hôpital Salpêtrière Département de Neurologie Paris France
| | - Marie‐Laure Welter
- Sorbonne Université, Faculté de Médecine; CNRS UMR 7225, UMR S 1127 Institut du Cerveau et de la Moelle épinière Paris France
- Neurophysiology Department CHU Rouen Rouen France
| | - Francois Viallet
- Laboratoire Parole et Langage, UMR 7309 Aix‐Marseille University Aix‐en‐Provence France
- Neurology Department Aix en Provence Hospital Aix‐en‐Provence France
| | - Carine Karachi
- Sorbonne Université, Faculté de Médecine; CNRS UMR 7225, UMR S 1127 Institut du Cerveau et de la Moelle épinière Paris France
- APHP, Hôpital Salpêtrière Département de Neurochirurgie Paris France
| | - Soledad Navarro
- Sorbonne Université, Faculté de Médecine; CNRS UMR 7225, UMR S 1127 Institut du Cerveau et de la Moelle épinière Paris France
- APHP, Hôpital Salpêtrière Département de Neurochirurgie Paris France
| | - Marjan Jahanshahi
- Sobell Department of Motor Neuroscience & Movement Disorders and the National Hospital for Neurology & Neurosurgery London UK
| | - Sophie Rivaud‐Pechoux
- Sorbonne Université, Faculté de Médecine; CNRS UMR 7225, UMR S 1127 Institut du Cerveau et de la Moelle épinière Paris France
| | - David Grabli
- Sorbonne Université, Faculté de Médecine; CNRS UMR 7225, UMR S 1127 Institut du Cerveau et de la Moelle épinière Paris France
- APHP, Hôpital Salpêtrière Département de Neurologie Paris France
| | - Emmanuel Roze
- Sorbonne Université, Faculté de Médecine; CNRS UMR 7225, UMR S 1127 Institut du Cerveau et de la Moelle épinière Paris France
- APHP, Hôpital Salpêtrière Département de Neurologie Paris France
| | - Marie Vidailhet
- Sorbonne Université, Faculté de Médecine; CNRS UMR 7225, UMR S 1127 Institut du Cerveau et de la Moelle épinière Paris France
- APHP, Hôpital Salpêtrière Département de Neurologie Paris France
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Eggink H, Szlufik S, Coenen MA, van Egmond ME, Moro E, Tijssen MA. Non-motor effects of deep brain stimulation in dystonia: A systematic review. Parkinsonism Relat Disord 2018; 55:26-44. [DOI: 10.1016/j.parkreldis.2018.06.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 05/17/2018] [Accepted: 06/16/2018] [Indexed: 12/15/2022]
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Sanger TD, Robison A, Arguelles E, Ferman D, Liker M. Case Report: Targeting for Deep Brain Stimulation Surgery Using Chronic Recording and Stimulation in an Inpatient Neuromodulation Monitoring Unit, With Implantation of Electrodes in GPi and Vim in a 7-Year-Old Child With Progressive Generalized Dystonia. J Child Neurol 2018; 33:776-783. [PMID: 30066598 DOI: 10.1177/0883073818787741] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Deep brain stimulation for secondary dystonia has been limited by unknown optimal targets for individual children. OBJECTIVES We report the first case of a 7-year-old girl with severe generalized dystonia due to acquired striatal necrosis in whom we used a new method for identifying targets for deep brain stimulation. METHODS We implanted temporary depth electrodes in 5 different nuclei bilaterally in the basal ganglia and thalamus, with test stimulation and recording during 1 week while the child was an inpatient in a neuromodulation monitoring unit. RESULTS Single-unit activity in ventral intermedius Vim, internal globus pallidus (GPi), and subthalamic (STN) nuclei occurred during dystonic spasms and correlated with electromyography. Stimulation in Vim eliminated dystonic spasms. Subsequent implantation of 4 permanent deep brain stimulation electrodes in bilateral Vim and Gpi nuclei resolved dystonic spasms. CONCLUSION The use of temporary stimulation and recording electrodes to identify deep brain stimulation targets is a promising new technique that could improve outcomes in children with acquired dystonia.
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Affiliation(s)
- Terence D Sanger
- 1 Department of Neurology, Children's Hospital Los Angeles, Los Angeles, CA, USA.,2 Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, USA
| | - Aaron Robison
- 3 Department of Neurosurgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Enrique Arguelles
- 2 Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, USA
| | - Diana Ferman
- 1 Department of Neurology, Children's Hospital Los Angeles, Los Angeles, CA, USA.,2 Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, USA
| | - Mark Liker
- 3 Department of Neurosurgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
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Sanger TD. A Computational Model of Deep-Brain Stimulation for Acquired Dystonia in Children. Front Comput Neurosci 2018; 12:77. [PMID: 30294268 PMCID: PMC6158364 DOI: 10.3389/fncom.2018.00077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 08/28/2018] [Indexed: 11/13/2022] Open
Abstract
The mechanism by which deep brain stimulation (DBS) improves dystonia is not understood, partly heterogeneity of the underlying disorders leads to differing effects of stimulation in different locations. Similarity between the effects of DBS and the effects of lesions has led to biophysical models of blockade or reduced transmission of involuntary activity in individual cells in the pathways responsible for dystonia. Here, we expand these theories by modeling the effect of DBS on populations of neurons. We emphasize the important observation that the DBS signal itself causes surprisingly few side effects and does not normally appear in the electromyographic signal. We hypothesize that, at the population level, massively synchronous rhythmic firing caused by DBS is only poorly transmitted through downstream populations. However, the high frequency of stimulation overwhelms incoming dystonic activity, thereby substituting an ineffectively transmitted exogenous signal for the endogenous abnormal signal. Changes in sensitivity can occur not only at the site of stimulation, but also at downstream sites due to synaptic and homeostatic plasticity mechanisms. The mechanism is predicted to depend strongly on the stimulation frequency. We provide preliminary data from simultaneous multichannel recordings in basal ganglia and thalamus in children with secondary dystonia. We also provide illustrative simulations of the effect of stimulation frequency on the transmission of the DBS pulses through sequential populations of neurons in the dystonia pathway. Our experimental results and model provide a new hypothesis and computational framework consistent with the clinical features of DBS in childhood acquired dystonia.
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Affiliation(s)
- Terence D Sanger
- Department of Biomedical Engineering, Biokinesiology, and Child Neurology, University of Southern California, Los Angeles, CA, United States
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Abstract
OBJECTIVE To review the literature related to different treatment strategies for the general population of individuals with amputation, spinal cord injury, and cerebral palsy, as well as how this may impact pain management in a correlated athlete population. DATA SOURCES A comprehensive literature search was performed linking pain with terms related to different impairment types. MAIN RESULTS There is a paucity in the literature relating to treatment of pain in athletes with impairment; however, it is possible that the treatment strategies used in the general population of individuals with impairment may be translated to the athlete population. There are a wide variety of treatment options including both pharmacological and nonpharmacological treatments which may be applicable in the athlete. CONCLUSIONS It is the role of the physician to determine which strategy of the possible treatment options will best facilitate the management of pain in the individual athlete in a sport-specific setting.
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Cury RG, Kalia SK, Shah BB, Jimenez-Shahed J, Prashanth LK, Moro E. Surgical treatment of dystonia. Expert Rev Neurother 2018; 18:477-492. [PMID: 29781334 DOI: 10.1080/14737175.2018.1478288] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Treatment of dystonia should be individualized and tailored to the specific needs of patients. Surgical treatment is an important option in medically refractory cases. Several issues regarding type of the surgical intervention, targets, and predict factors of benefit are still under debate. Areas covered: To date, several clinical trials have proven the benefit and safety of deep brain stimulation (DBS) for inherited and idiopathic isolated dystonia, whereas there is still insufficient evidence in combined and acquired dystonia. The globus pallidus internus (GPi) is the target with the best evidence, but data on the subthalamic nucleus seems also to be promising. Evidence suggests that younger patients with shorter disease duration experience greater benefit following DBS. Pallidotomy and thalamotomy are currently used in subset of carefully selected patients. The development of MRI-guided focused ultrasound might bring new options to ablation approach in dystonia. Expert commentary: GPi-DBS is effective and safe in isolated dystonia and should not be delayed when symptoms compromise quality of life and functionality. Identifying the best candidates to surgery on acquired and combined dystonias is still necessary. New insights about pathophysiology of dystonia and new technological advances will undoubtedly help to tailor surgery and optimize clinical effects.
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Affiliation(s)
- Rubens Gisbert Cury
- a Service de Neurologie, Centre Hospitalier Universitaire de Grenoble , Université Grenoble Alpes , Grenoble , France.,b Department of Neurology, School of Medicine , University of São Paulo , São Paulo , Brazil
| | - Suneil Kumar Kalia
- c Division of Neurosurgery and Krembil Research Institute, Department of Surgery , University of Toronto , Toronto , Canada
| | - Binit Bipin Shah
- d Parkinson's Disease and Movement Disorders Center, Department of Neurology , University of Virginia , Charlottesville , VA , USA
| | - Joohi Jimenez-Shahed
- e Parkinson's Disease Center and Movement Disorders Clinic , Baylor College of Medicine , Houston , TX , USA
| | | | - Elena Moro
- a Service de Neurologie, Centre Hospitalier Universitaire de Grenoble , Université Grenoble Alpes , Grenoble , France
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Russ JB, Nallappan AM, Robichaux-Viehoever A. Management of Pediatric Movement Disorders: Present and Future. Semin Pediatr Neurol 2018; 25:136-151. [PMID: 29735111 DOI: 10.1016/j.spen.2018.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Management of movement disorders in children is an evolving field. This article outlines the major categories of treatment options for pediatric movement disorders and general guidelines for their use. We review the evidence for existing therapies, which continue to lack large-scale controlled trials to guide treatment decisions. The field continues to rely on extrapolations from adult studies and lower quality evidence such as case reports and case series to guide treatment guidelines and consensus statements. Developments in new pharmaceuticals for rare diseases have begun to provide hope for those cases in which a genetic diagnosis can be made. Advances in surgical therapies such as deep brain stimulation as well as new modes of treatment such as gene therapy, epigenetic modulation, and stem cell therapy hold promise for improving outcomes in both primary and secondary causes of movement disorders. There is a critical need for larger, multicenter, controlled clinical trials to fully evaluate treatments for pediatric movement disorders.
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Affiliation(s)
- Jeffrey B Russ
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Akila M Nallappan
- Undergraduate Program, Case Western Reserve University, Cleveland, OH
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Fehlings D, Brown L, Harvey A, Himmelmann K, Lin JP, Macintosh A, Mink JW, Monbaliu E, Rice J, Silver J, Switzer L, Walters I. Pharmacological and neurosurgical interventions for managing dystonia in cerebral palsy: a systematic review. Dev Med Child Neurol 2018; 60:356-366. [PMID: 29405267 DOI: 10.1111/dmcn.13652] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2017] [Indexed: 12/22/2022]
Abstract
AIM To systematically review evidence for pharmacological/neurosurgical interventions for managing dystonia in individuals with cerebral palsy (CP) to inform a care pathway. METHOD Searches included studies with a minimum of five participants with dystonia in CP receiving oral baclofen, benzodiazepines (clonazepam, diazepam, lorazepam), clonidine, gabapentin, levodopa, trihexyphenidyl, botulinum toxin, intrathecal baclofen (ITB), or deep brain stimulation (DBS). Evidence was classified according to American Academy of Neurology guidelines. RESULTS Twenty-eight articles underwent data extraction: one levodopa, five trihexyphenidyl, three botulinum toxin, six ITB, and 13 DBS studies. No articles for oral baclofen, benzodiazepines, clonidine, or gabapentin met the inclusion criteria. Evidence for reducing dystonia was level C (possibly effective) for ITB and DBS; level C (possibly ineffective) for trihexyphenidyl; and level U (inadequate data) for botulinum toxin. INTERPRETATION For dystonia reduction, ITB and DBS are possibly effective, whereas trihexyphenidyl was possibly ineffective. There is insufficient evidence to support oral medications or botulinum toxin to reduce dystonia. There is insufficient evidence for pharmacological and neurosurgical interventions to improve motor function, decrease pain, and ease caregiving. The majority of the pharmacological and neurosurgical management of dystonia in CP is based on clinical expert opinion. WHAT THIS PAPER ADDS Intrathecal baclofen and deep brain stimulation are possibly effective in reducing dystonia. Current evidence does not support effectiveness of oral medications or botulinum toxin to reduce dystonia. Evidence is inadequate for pharmacological/neurosurgical interventions impact on improving motor function, pain/comfort, and easing caregiving. The majority of the care pathway rests on expert opinion.
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Affiliation(s)
- Darcy Fehlings
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
| | - Leah Brown
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
| | - Adrienne Harvey
- Developmental Disability and Rehabilitation Research, Murdoch Childrens Research Institute, Parkville, Vic, Australia
| | - Kate Himmelmann
- Department of Pediatrics, Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jean-Pierre Lin
- Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's and St Thomas', NHS Foundation Trust, Kings' Health Partners, London, UK
| | - Alexander Macintosh
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
| | - Jonathan W Mink
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | - Elegast Monbaliu
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - James Rice
- Paediatric Rehabilitation Department, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Jessica Silver
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
| | - Lauren Switzer
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
| | - Ilana Walters
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
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Peter N, Kleinjung T. Neuromodulation for tinnitus treatment: an overview of invasive and non-invasive techniques. J Zhejiang Univ Sci B 2018; 20:116-130. [PMID: 29770647 DOI: 10.1631/jzus.b1700117] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Tinnitus is defined as a perception of sound without any external sound source. Chronic tinnitus is a frequent condition that can affect the quality of life. So far, no causal cure for tinnitus has been documented, and most pharmacologic and psychosomatic treatment modalities aim to diminish tinnitus' impact on the quality of life. Neuromodulation, a novel therapeutic modality, which aims at alternating nerve activity through a targeted delivery of a stimulus, has emerged as a potential option in tinnitus treatment. This review provides a brief overview of the current neuromodulation techniques as tinnitus treatment options. The main intention is to provide updated knowledge especially for medical professionals counselling tinnitus patients in this emerging field of medicine. Non-invasive methods such as repetitive transcranial magnetic stimulation, transcranial electrical stimulation, neurofeedback, and transcutaneous vagus nerve stimulation were included, as well as invasive methods such as implanted vagus nerve stimulation and invasive brain stimulation. Some of these neuromodulation techniques revealed promising results; nevertheless, further research is needed, especially regarding the pathophysiological principle as to how these neuromodulation techniques work and what neuronal change they induce. Various studies suggest that individually different brain states and networks are involved in the generation and perception of tinnitus. Therefore, in the future, individually tailored neuromodulation strategies could be a promising approach in tinnitus treatment for achieving a more substantial and longer lasting improvement of complaints.
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Affiliation(s)
- Nicole Peter
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zürich, Zürich 8091, Switzerland
| | - Tobias Kleinjung
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zürich, Zürich 8091, Switzerland
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Deep brain stimulation for dystonia due to cerebral palsy: A review. Eur J Paediatr Neurol 2018; 22:308-315. [PMID: 29396170 DOI: 10.1016/j.ejpn.2017.12.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/07/2017] [Accepted: 12/07/2017] [Indexed: 01/08/2023]
Abstract
Cerebral palsy (CP) is a heterogeneous group of syndromes that cause a non-progressive disorder of early onset, with abnormal control of movement and posture. Various aetiologies can cause the CP clinical spectrum, but all have a disruption of motor control in common. CP can be divided into four major types based on the motor disability: predominant spastic, dyskinetic, ataxic and mixed form. Dyskinetic CP (DCP) is the most common cause of acquired dystonia in children. The treatment of DCP is challenging because most individuals have mixed degrees of chorea, athetosis and dystonia. Pharmacological treatment is often unsatisfactory. Functional neurosurgery, in particular deep brain stimulation targeting the basal ganglia or the cerebellum, is emerging as a promising therapeutic approach in selected patients with DCP. We evaluated herein the effects of DBS on patients with DCP in a review of published patient data in the largest available studies.
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Can clinical neurophysiology assist in patient selection for DBS in pediatric dystonia? Clin Neurophysiol 2018; 129:460-461. [PMID: 29325858 DOI: 10.1016/j.clinph.2017.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 12/13/2017] [Indexed: 11/23/2022]
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Abstract
PURPOSE OF REVIEW Deep brain stimulation (DBS) has recently emerged as an important management option in children with medically refractory dystonia. DBS is most commonly used, best studied, and thought to be most efficacious for a select group of childhood or adolescent onset monogenic dystonias (designated with a standard 'DYT' prefix). We review how to clinically recognize these types of dystonia and the relative efficacy of DBS for key monogenic dystonias. RECENT FINDINGS Though used for dystonia in adults for several years, DBS has only lately been used in children. Recent evidence shows that patients with shorter duration of dystonia often experience greater benefit following DBS. This suggests that early recognition of the appropriate dystonic phenotypes and consideration of DBS in these patients may improve the management of dystonia. SUMMARY DBS should be considered early in patients who have medically refractory dystonia, especially for the monogenic dystonias that have a high response rate to DBS. It is important to differentiate between these monogenic dystonias and dystonias of other causes to properly prognosticate for these patients and to determine whether DBS is an appropriate management option.
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Somatosensory Evoked Potentials and Central Motor Conduction Times in children with dystonia and their correlation with outcomes from Deep Brain Stimulation of the Globus pallidus internus. Clin Neurophysiol 2017; 129:473-486. [PMID: 29254860 PMCID: PMC5786451 DOI: 10.1016/j.clinph.2017.11.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 11/14/2017] [Accepted: 11/17/2017] [Indexed: 12/13/2022]
Abstract
A high proportion (47%) of children with dystonia have evidence of abnormal sensory pathway function. Central motor conduction times (CMCTs) and somatosensory evoked potentials (SEPs) show a significant relationship with deep brain stimulation (DBS) outcome, independent of aetiology or cranial MRI. CMCTs and SEPs can guide patient selection and help counsel families about potential benefit of DBS.
Objectives To report Somatosensory Evoked Potentials (SEPs) and Central Motor Conduction Times (CMCT) in children with dystonia and to test the hypothesis that these parameters predict outcome from Deep Brain Stimulation (DBS). Methods 180 children with dystonia underwent assessment for Globus pallidus internus (GPi) DBS, mean age 10 years (range 2.5–19). CMCT to each limb was calculated using Transcranial Magnetic Stimulation. Median and posterior tibial nerve SEPs were recorded over contralateral and midline centro-parietal scalp. Structural abnormalities were assessed with cranial MRI. One-year outcome from DBS was assessed as percentage improvement in Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS-m). Results Abnormal CMCTs and SEPs were found in 19% and 47% of children respectively and were observed more frequently in secondary than primary dystonia. Of children proceeding to DBS, better outcome was seen in those with normal (n = 78/89) versus abnormal CMCT (n = 11/89) (p = 0.002) and those with normal (n = 35/51) versus abnormal SEPs (n = 16/51) (p = 0.001). These relationships were independent of dystonia aetiology and cranial MRI findings. Conclusions CMCTs and SEPs provide objective evidence of motor and sensory pathway dysfunction in children with dystonia and relate to DBS outcome. Significance CMCTs and SEPs can contribute to patient selection and counselling of families about potential benefit from neuromodulation for dystonia.
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78
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Meoni S, Fraix V, Castrioto A, Benabid AL, Seigneuret E, Vercueil L, Pollak P, Krack P, Chevrier E, Chabardes S, Moro E. Pallidal deep brain stimulation for dystonia: a long term study. J Neurol Neurosurg Psychiatry 2017; 88:960-967. [PMID: 28972096 DOI: 10.1136/jnnp-2016-315504] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 04/27/2017] [Accepted: 08/16/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pallidal deep brain stimulation (globus pallidus internus (GPi) DBS) is the best therapeutic option for disabling isolated idiopathic (IID) and inherited (INH) dystonia. Acquired dystonia (AD) may also benefit from GPi DBS. Efficacy and safety in the long-term remained to be established. OBJECTIVE To retrospectively assess long-term clinical outcomes and safety in dystonic patients who underwent GPi DBS. METHODS Patients were videotaped and assessed preoperatively and postoperatively (1-year and at last available follow-up) using the Burke-Fahn-Marsden Dystonia Rating Scale (motor score (BFMDRS-M); disability score (BFMDRS-D)). RESULTS Sixty-one patients were included (follow-up 7.9±5.9 years; range 1-20.7). In IID and INH (n=37), the BFMDRS-M improved at first (20.4±24.5; p<0.00001) and last (22.2±18.2; p<0.001) follow-ups compared with preoperatively (50.5±28.0). In AD (n=19), the BFMDRS-M ameliorated at 1-year (40.8±26.5; p<0.02) and late follow-ups (44.3±24.3; p<0.04) compared with preoperatively (52.8±24.2). In INH dystonia with other neurological features (n=4) there was no motor benefit. In IID and INH, the BFMDRS-D improved at 1-year (9.5±7.5; p<0.0002) and late follow-ups (10.4±7.8; p<0.016) compared with preoperatively (13.3±6.9). In AD, the BFMDRS-D reduced at 1-year (12.0±8.1; p<0.01) and late follow-ups (12.7 ±6.1; p=0.2) compared with preoperatively (14.35±5.7). Most adverse events were hardware related. CONCLUSIONS GPi DBS is an effective and safe treatment in most patients with dystonia.
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Affiliation(s)
- Sara Meoni
- Division of Neurology, CHU of Grenoble, Grenoble Alpes University, Grenoble, France.,Division of Neurology, A.O.U.C., University of Florence, Florence, Italy
| | - Valérie Fraix
- Division of Neurology, CHU of Grenoble, Grenoble Alpes University, Grenoble, France
| | - Anna Castrioto
- Division of Neurology, CHU of Grenoble, Grenoble Alpes University, Grenoble, France
| | - Alim Louis Benabid
- Division of Neurology, CHU of Grenoble, Grenoble Alpes University, Grenoble, France
| | - Eric Seigneuret
- Division of Neurology, CHU of Grenoble, Grenoble Alpes University, Grenoble, France
| | - Laurent Vercueil
- Division of Neurology, CHU of Grenoble, Grenoble Alpes University, Grenoble, France
| | - Pierre Pollak
- Division of Neurology, CHU of Grenoble, Grenoble Alpes University, Grenoble, France.,Department of Neurology, University Hospital of Geneva, Geneva, Switzerland
| | - Paul Krack
- Division of Neurology, CHU of Grenoble, Grenoble Alpes University, Grenoble, France.,Department of Neurology, University Hospital of Geneva, Geneva, Switzerland
| | - Eric Chevrier
- Division of Neurology, CHU of Grenoble, Grenoble Alpes University, Grenoble, France
| | - Stephan Chabardes
- Division of Neurology, CHU of Grenoble, Grenoble Alpes University, Grenoble, France
| | - Elena Moro
- Division of Neurology, CHU of Grenoble, Grenoble Alpes University, Grenoble, France
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Monbaliu E, Himmelmann K, Lin JP, Ortibus E, Bonouvrié L, Feys H, Vermeulen RJ, Dan B. Clinical presentation and management of dyskinetic cerebral palsy. Lancet Neurol 2017; 16:741-749. [PMID: 28816119 DOI: 10.1016/s1474-4422(17)30252-1] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 06/02/2017] [Accepted: 06/29/2017] [Indexed: 12/21/2022]
Abstract
Cerebral palsy is the most frequent cause of severe physical disability in childhood. Dyskinetic cerebral palsy (DCP) is the second most common type of cerebral palsy after spastic forms. DCP is typically caused by non-progressive lesions to the basal ganglia or thalamus, or both, and is characterised by abnormal postures or movements associated with impaired tone regulation or movement coordination. In DCP, two major movement disorders, dystonia and choreoathetosis, are present together most of the time. Dystonia is often more pronounced and severe than choreoathetosis, with a major effect on daily activity, quality of life, and societal participation. The pathophysiology of both movement disorders is largely unknown. Some emerging hypotheses are an imbalance between indirect and direct basal ganglia pathways, disturbed sensory processing, and impaired plasticity in the basal ganglia. Rehabilitation strategies are typically multidisciplinary. Use of oral drugs to provide symptomatic relief of the movement disorders is limited by adverse effects and the scarcity of evidence that the drugs are effective. Neuromodulation interventions, such as intrathecal baclofen and deep brain stimulation, are promising options.
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Affiliation(s)
- Elegast Monbaliu
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium; Dominiek Savio Instituut, Gits, Belgium
| | - Kate Himmelmann
- Department of Pediatrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jean-Pierre Lin
- Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, London, UK
| | - Els Ortibus
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Laura Bonouvrié
- Department of Rehabilitation Medicine, VU University Medical Center Amsterdam, Amsterdam, Netherlands
| | - Hilde Feys
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - R Jeroen Vermeulen
- Department of Neurology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Bernard Dan
- Department of Neurology, Université Libre de Bruxelles, Brussels, Belgium; Inkendaal Rehabilitation Hospital, Vlezenbeek, Belgium.
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Johans SJ, Swong KN, Hofler RC, Anderson DE. A Stepwise Approach: Decreasing Infection in Deep Brain Stimulation for Childhood Dystonic Cerebral Palsy. J Child Neurol 2017; 32:871-875. [PMID: 28604158 DOI: 10.1177/0883073817713900] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Dystonia is a movement disorder characterized by involuntary muscle contractions, which cause twisting movements or abnormal postures. Deep brain stimulation has been used to improve the quality of life for secondary dystonia caused by cerebral palsy. Despite being a viable treatment option for childhood dystonic cerebral palsy, deep brain stimulation is associated with a high rate of infection in children. The authors present a small series of patients with dystonic cerebral palsy who underwent a stepwise approach for bilateral globus pallidus interna deep brain stimulation placement in order to decrease the rate of infection. Four children with dystonic cerebral palsy who underwent a total of 13 surgical procedures (electrode and battery placement) were identified via a retrospective review. There were zero postoperative infections. Using a multistaged surgical plan for pediatric patients with dystonic cerebral palsy undergoing deep brain stimulation may help to reduce the risk of infection.
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Affiliation(s)
- Stephen J Johans
- 1 Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Kevin N Swong
- 1 Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Ryan C Hofler
- 1 Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Douglas E Anderson
- 1 Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, USA
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Reese R, Volkmann J. Deep Brain Stimulation for the Dystonias: Evidence, Knowledge Gaps, and Practical Considerations. Mov Disord Clin Pract 2017; 4:486-494. [PMID: 30363085 PMCID: PMC6090587 DOI: 10.1002/mdc3.12519] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 06/10/2017] [Accepted: 06/17/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) of the globus pallidus internus (GPi-DBS) is among the most effective treatment options for dystonias. Because the term "dystonia" is defined by a characteristic phenomenology of involuntary muscle contractions, which may present with a large clinical and pathogenetic heterogeneity, decision making for or against GPi-DBS can be difficult in individual patients. METHODS A search of the PubMed database for research and review articles, focused on "deep brain stimulation" and "dystonia" was used to identify clinical trials and to determine current concepts in the surgical management of dystonia. Patient selection in previous studies was recategorized by the authors using the new dystonia classification put forward by a consensus committee of experts in dystonia research. The evidence and knowledge gaps are summarized and commented by the authors taking into account expert opinion and personal clinical experience for providing practical guidance in patient selection for DBS in dystonia. RESULTS The literature review shows that pallidal deep brain stimulation is most effective in patients with isolated dystonia irrespective of the underlying etiology. In contrast, patients with combined dystonias are less likely to benefit from DBS, because the associated neurological symptoms (e.g., hypotonia or ataxia), with the exception of myoclonus, do not respond to pallidal neurostimulation. CONCLUSIONS It is important to recognize the clinical features of dystonia, because the distinction between isolated and combined dystonia syndromes may predict the treatment response to pallidal deep brain stimulation. The aim of this review is to help guide clinicians with advising patients about deep brain stimulation therapy for dystonia and refering appropriate candidates to surgical centers.
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Affiliation(s)
- René Reese
- Department of NeurologyRostock University Medical CenterRostockGermany
- Department of NeurologyUniversity Hospital WürzburgWürzburgGermany
| | - Jens Volkmann
- Department of NeurologyUniversity Hospital WürzburgWürzburgGermany
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Pauls KAM, Krauss JK, Kämpfer CE, Kühn AA, Schrader C, Südmeyer M, Allert N, Benecke R, Blahak C, Boller JK, Fink GR, Fogel W, Liebig T, El Majdoub F, Mahlknecht P, Kessler J, Mueller J, Voges J, Wittstock M, Wolters A, Maarouf M, Moro E, Volkmann J, Bhatia KP, Timmermann L. Causes of failure of pallidal deep brain stimulation in cases with pre-operative diagnosis of isolated dystonia. Parkinsonism Relat Disord 2017; 43:38-48. [PMID: 28690015 DOI: 10.1016/j.parkreldis.2017.06.023] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 05/22/2017] [Accepted: 06/27/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Pallidal deep brain stimulation (GPi-DBS) is an effective therapy for isolated dystonia, but 10-20% of patients show improvement below 25-30%. We here investigated causes of insufficient response to GPi-DBS in isolated dystonia in a cross-sectional study. METHODS Patients with isolated dystonia at time of surgery, and <30% improvement on the Burke-Fahn-Marsden dystonia-rating-scale (BFMDRS) after ≥6 months of continuous GPi-DBS were videotaped ON and OFF stimulation, and history, preoperative videos, brain MRI, medical records, stimulation settings, stimulation system integrity, lead location, and genetic information were obtained and reviewed by an expert panel. RESULTS 22 patients from 11 centres were included (8 men, 14 women; 9 generalized, 9 segmental, 3 focal, 1 bibrachial dystonia; mean (range): age 48.7 (25-72) years, disease duration 22.0 (2-40) years, DBS duration 45.5 (6-131) months). Mean BFMDRS-score was 31.7 (4-93) preoperatively and 32.3 (5-101) postoperatively. Half of the patients (n = 11) had poor lead positioning alone or in combination with other problems (combined with: other disease n = 6, functional dystonia n = 1, other problems n = 2). Other problems were disease other than isolated inherited or idiopathic dystonia (n = 5), fixed deformities (n = 2), functional dystonia (n = 3), and other causes (n = 1). Excluding patients with poor lead location from further analysis, non-isolated dystonia accounted for 45.5%, functional dystonia for 27.3%, and fixed deformities for 18.2%. In patients with true isolated dystonia, lead location was the most frequent problem. CONCLUSION After exclusion of lead placement and stimulation programming issues, non-isolated dystonia, functional dystonia and fixed deformities account for the majority of GPi-DBS failures in dystonia.
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Affiliation(s)
| | - Joachim K Krauss
- Department of Neurosurgery, Medizinische Hochschule Hannover, Hannover, Germany
| | | | - Andrea A Kühn
- Department of Neurology, Charite Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Schrader
- Department of Neurology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Martin Südmeyer
- Department of Neurology, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Niels Allert
- Neurological Rehabilitation Center Godeshöhe, Bonn, Germany
| | - Rainer Benecke
- Department of Neurology, Universitätsmedizin Rostock, Rostock, Germany
| | - Christian Blahak
- Department of Neurology, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Jana K Boller
- Department of Neurology, Uniklinik Köln, Cologne, Germany
| | - Gereon R Fink
- Department of Neurology, Uniklinik Köln, Cologne, Germany; Institute of Neuroscience and Medicine (INM-3), Forschungszentrum Jülich, Jülich, Germany
| | - Wolfgang Fogel
- Department of Neurology, Deutsche Klinik für Diagnostik, Wiesbaden, Germany
| | - Thomas Liebig
- Department of Neuroradiology, Uniklinik Köln, Cologne, Germany
| | - Faycal El Majdoub
- Department of Stereotaxic and Functional Neurosurgery, Uniklinik Köln, Cologne, Germany
| | - Philipp Mahlknecht
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Josef Kessler
- Department of Neurology, Uniklinik Köln, Cologne, Germany
| | - Joerg Mueller
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria; Department of Neurology, Vivantes Klinikum Spandau, Berlin, Germany
| | - Juergen Voges
- Department for Stereotactic Neurosurgery, Universitätsklinikum Magdeburg, Magdeburg, Germany; Leibniz Institute of Neurobiology, Magdeburg, Germany
| | | | - Alexander Wolters
- Department of Neurology, Universitätsmedizin Rostock, Rostock, Germany
| | - Mohammad Maarouf
- Department of Stereotaxic and Functional Neurosurgery, Uniklinik Köln, Cologne, Germany
| | - Elena Moro
- Division of Neurology, University Hospital Center of Grenoble, Grenoble, France
| | - Jens Volkmann
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
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Krack P, Martinez-Fernandez R, del Alamo M, Obeso JA. Current applications and limitations of surgical treatments for movement disorders. Mov Disord 2017; 32:36-52. [DOI: 10.1002/mds.26890] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 11/10/2016] [Accepted: 11/13/2016] [Indexed: 12/11/2022] Open
Affiliation(s)
- Paul Krack
- Neurology Division, Department of Clinical Neurosciences; University Hospital of Geneva; Geneva Switzerland
| | | | - Marta del Alamo
- CINAC-Hospital Universitario HM Puerta del Sur; CEU-San Pablo University; Madrid Spain
- Neurosurgery Department; Hospital Universitario Ramon y Cajal; Madrid Spain
| | - Jose A. Obeso
- CINAC-Hospital Universitario HM Puerta del Sur; CEU-San Pablo University; Madrid Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas; Madrid Spain
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Deep brain stimulation for childhood dystonia: Is 'where' as important as in 'whom'? Eur J Paediatr Neurol 2017; 21:176-184. [PMID: 28220756 DOI: 10.1016/j.ejpn.2016.10.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 10/03/2016] [Indexed: 01/07/2023]
Abstract
Deep brain stimulation (DBS) has become a mainstay of dystonia management in adulthood. Typically targeting electrode placement in the GPi, sustained improvement in dystonic symptoms are anticipated in adults with isolated genetic dystonias. Dystonia in childhood is more commonly a symptomatic condition, with dystonia frequently expressed on the background of a structurally abnormal brain. Outcomes following DBS in this setting are much more variable, the reasons for which have yet to be elucidated. Much of the focus on improving outcomes following DBS in dystonia management has been on the importance of patient selection, with, until recently, little discussion of the choice of target. In this review, we advance the argument that patient selection for DBS in childhood cannot be made separate from the choice of target nuclei. The anatomy of common DBS targets is considered, and factors influencing their choice for electrode insertion are discussed. We propose an "ABC" for DBS in childhood dystonia is proposed: Appropriate Child selected; Best nuclei chosen for electrode insertion; Correct position within that nucleus.
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85
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Koy A, Timmermann L. Deep brain stimulation in cerebral palsy: Challenges and opportunities. Eur J Paediatr Neurol 2017; 21:118-121. [PMID: 27289260 DOI: 10.1016/j.ejpn.2016.05.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 05/18/2016] [Accepted: 05/22/2016] [Indexed: 12/31/2022]
Abstract
Cerebral palsy (CP) is the most common cause for acquired dystonia in childhood. Pharmacological treatment is often unsatisfactory and side effects are frequently dose-limiting. Data on outcome of DBS in paediatric patients with dyskinetic CP is very limited and heterogeneous. Reasons for the variability in responses are not entirely known yet. Interestingly, some CP-patients seem to improve subjectively on pallidal stimulation but without measurable changes in impairment scales. Besides dystonia scales, the use of sensitive age-dependent assessments tools is therefore reasonable to capture the full effect. As the course of disease duration as well as the age at operation seem to correlate with DBS outcome in patients with dystonia, DBS at an early stage of development might be beneficial for some of these patients. For the future, well-conducted trials as well as data collection in the international registry is of major importance to increase knowledge about DBS in CP patients, especially those implanted at a young age. Furthermore, selection criteria and guidelines or treatment standards are needed to improve the service for children with dyskinetic CP - especially in light of unsatisfactory medical treatment options.
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Affiliation(s)
- Anne Koy
- Department of Neurology, University Hospital of Cologne, Germany; Department of Paediatrics, University Hospital of Cologne, Germany.
| | - Lars Timmermann
- Department of Neurology, University Hospital of Cologne, Germany
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86
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Bilateral globus pallidus internus deep brain stimulation for dyskinetic cerebral palsy supports success of cochlear implantation in a 5-year old ex-24 week preterm twin with absent cerebellar hemispheres. Eur J Paediatr Neurol 2017; 21:202-213. [PMID: 28017556 DOI: 10.1016/j.ejpn.2016.11.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 11/30/2016] [Accepted: 11/30/2016] [Indexed: 01/20/2023]
Abstract
BACKGROUND Early onset dystonia (dyskinesia) and deafness in childhood pose significant challenges for children and carers and are the cause of multiple disability. It is particularly tragic when the child cannot make use of early cochlear implantation (CI) technology to relieve deafness and improve language and communication, because severe cervical and truncal dystonia brushes off the magnetic amplifier behind the ears. Bilateral globus pallidus internus (GPi) deep brain stimulation (DBS) neuromodulation can reduce dyskinesia, thus supporting CI neuromodulation success. METHODS We describe the importance of the order of dual neuromodulation surgery for dystonia and deafness. First with bilateral GPi DBS using a rechargeable ACTIVA-RC neurostimulator followed 5 months later by unilateral CI with a Harmony (BTE) Advanced Bionics Hi Res 90 K cochlear device. This double neuromodulation was performed in series in a 12.5 kg 5 year-old ex-24 week gestation-born twin without a cerebellum. RESULTS Relief of dyskinesia enabled continuous use of the CI amplifier. Language understanding and communication improved. Dystonic storms abated. Tolerance of sitting increased with emergence of manual function. Status dystonicus ensued 10 days after ACTIVA-RC removal for infection-erosion at 3 years and 10 months. He required intensive care and DBS re-implantation 3 weeks later together with 8 months of hospital care. Today he is virtually back to the level of functioning before the DBS removal in 2012 and background medication continues to be slowly weaned. CONCLUSION This case illustrates that early neuromodulation with DBS for dystonic cerebral palsy followed by CI for deafness is beneficial. Both should be considered early i.e. under the age of five years. The DBS should precede the CI to maximise dystonia reduction and thus benefits from CI. This requires close working between the paediatric DBS and CI services.
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87
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Kaminska M, Perides S, Lumsden DE, Nakou V, Selway R, Ashkan K, Lin JP. Complications of Deep Brain Stimulation (DBS) for dystonia in children - The challenges and 10 year experience in a large paediatric cohort. Eur J Paediatr Neurol 2017; 21:168-175. [PMID: 27567277 DOI: 10.1016/j.ejpn.2016.07.024] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 07/20/2016] [Accepted: 07/25/2016] [Indexed: 12/20/2022]
Abstract
Deep brain stimulation (DBS) has been increasingly used for primary and secondary movement disorders in children and young people. Reports of hardware related complications have been sparse for this population and from small cohorts of patients. We report DBS complications from a single large DBS centre with 10 year experience. Data was collected as a prospective audit and additionally from a questionnaire on recharging of the stimulators. 129 patients with a minimum 6 months follow up were identified, mean age10.8 y (range 3.0-18.75), mean follow up 3.3y (range 0.5-10.3), weight 10.4-94.2 kg, 126 new implants (92 Activa RC) and 69 revisions for reasons other than infection. 26 patients were 7y or younger. Surgical site infections (SSI) rates were 10.3% for new implants and revisions, lower 8.6% for new Activa RC and even lower, 4.7%, for new Activa RC in patients under 7y (1/21). SSI occurred within first 6 months and necessitated total system removal in 86% of those infected. Electrode/extension problems were recorded in 18.4% of patients, fracture in 4.6% malfunction in 7.7%, short extension 3.8% and electrode migration in 2.3%. Other complications involved clinically silent intracranial bleed in 1 patient, skin erosions (2.3%), unexpected switching off in 18.7% of Soletra/Kinetra and 3.4% of Activa RC, transient seroma at IPG site in postoperative period (8%). Of the 48 returned recharging questionnaires, 38% of families required recharger replacement and 23% experienced frequent problems maintaining connection during recharging. However, 83% of responders considered recharging not at all or only a little care burden. We identified lower than previously reported DBS infection rates particularly for patients under 7 years, but relatively high incidence of technical problems with electrodes, extensions and in particular recharging. This has to be considered when offering DBS for children with movement disorders.
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Affiliation(s)
- Margaret Kaminska
- Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Sarah Perides
- Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Daniel E Lumsden
- Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Vasiliki Nakou
- Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Richard Selway
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Keyoumars Ashkan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Jean-Pierre Lin
- Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
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88
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Hudson VE, Elniel A, Ughratdar I, Zebian B, Selway R, Lin JP. A comparative historical and demographic study of the neuromodulation management techniques of deep brain stimulation for dystonia and cochlear implantation for sensorineural deafness in children. Eur J Paediatr Neurol 2017; 21:122-135. [PMID: 27562095 DOI: 10.1016/j.ejpn.2016.07.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/15/2016] [Accepted: 07/20/2016] [Indexed: 12/19/2022]
Abstract
UNLABELLED Cochlear implants for sensorineural deafness in children is one of the most successful neuromodulation techniques known to relieve early chronic neurodisability, improving activity and participation. In 2012 there were 324,000 recipients of cochlear implants globally. AIM To compare cochlear implant (CI) neuromodulation with deep brain stimulation (DBS) for dystonia in childhood and explore relations between age and duration of symptoms at implantation and outcome. METHODS Comparison of published annual UK CI figures for 1985-2009 with a retrospective cohort of the first 9 years of DBS for dystonia in children at a single-site Functional Neurosurgery unit from 2006 to 14. RESULTS From 2006 to 14, DBS neuromodulation of childhood dystonia increased by a factor of 3.8 to a total of 126 cases over the first 9 years, similar to the growth in cochlear implants which increased by a factor of 4.1 over a similar period in the 1980s rising to 527 children in 2009. The CI saw a dramatic shift in practice from implantation at >5 years of age at the start of the programme towards earlier implantation by the mid-1990s. Best language results were seen for implantation <5 years of age and duration of cochlear neuromodulation >4 years, hence implantation <1 year of age, indicating that severely deaf, pre-lingual children could benefit from cochlear neuromodulation if implanted early. Similar to initial CI use, the majority of children receiving DBS for dystonia in the first 9 years were 5-15 years of age, when the proportion of life lived with dystonia exceeds 90% thus limiting benefits. CONCLUSION Early DBS neuromodulation for acquired motor disorders should be explored to maximise the benefits of dystonia reduction in a period of maximal developmental plasticity before the onset of disability. Learning from cochlear implantation, DBS can become an accepted management option in children under the age of 5 years who have a reduced proportion of life lived with dystonia, and not viewed as a last resort reserved for only the most severe cases where benefits may be at their most limited.
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Affiliation(s)
- V E Hudson
- Guys', King's and St Thomas' School of Medical Education, United Kingdom.
| | - A Elniel
- Guys', King's and St Thomas' School of Medical Education, United Kingdom
| | | | - B Zebian
- King's College Hospital, United Kingdom
| | - R Selway
- King's College Hospital, United Kingdom
| | - J P Lin
- Evelina London Children's Hospital, United Kingdom.
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Koy A, Weinsheimer M, Pauls KAM, Kühn AA, Krause P, Huebl J, Schneider GH, Deuschl G, Erasmi R, Falk D, Krauss JK, Lütjens G, Schnitzler A, Wojtecki L, Vesper J, Korinthenberg R, Coenen VA, Visser-Vandewalle V, Hellmich M, Timmermann L. German registry of paediatric deep brain stimulation in patients with childhood-onset dystonia (GEPESTIM). Eur J Paediatr Neurol 2017; 21:136-146. [PMID: 27424797 DOI: 10.1016/j.ejpn.2016.05.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 05/22/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Data on paediatric deep brain stimulation (DBS) is limited, especially for long-term outcomes, because of small numbers in single center series and lack of systematic multi-center trials. OBJECTIVES We seek to systematically evaluate the clinical outcome of paediatric patients undergoing DBS. METHODS A German registry on paediatric DBS (GEPESTIM) was created to collect data of patients with dystonia undergoing DBS up to the age of 18 years. Patients were divided into three groups according to etiology (group 1 inherited, group 2 acquired, and group 3 idiopathic dystonia). RESULTS Data of 44 patients with a mean age of 12.8 years at time of operation provided by 6 German centers could be documented in the registry so far (group 1 n = 18, group 2 n = 16, group 3 n = 10). Average absolute improvement after implantation was 15.5 ± 18.0 for 27 patients with pre- and postoperative Burke-Fahn-Marsden Dystonia Rating scale movement scores available (p < 0.001) (group 1: 19.6 ± 19.7, n = 12; group 2: 7.0 ± 8.9, n = 8; group 3: 19.2 ± 20.7, n = 7). Infection was the main reason for hardware removal (n = 6). 20 IPG replacements due to battery expiry were necessary in 15 patients at 3.7 ± 1.8 years after last implantation. DISCUSSION Pre- and postoperative data on paediatric DBS are very heterogeneous and incomplete but corroborate the positive effects of DBS on inherited and acquired dystonia. Adverse events including relatively frequent IPG replacements due to battery expiry seem to be a prominent feature of children with dystonia undergoing DBS. The registry enables collaborative research on DBS treatment in the paediatric population and to create standardized management algorithms in the future.
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Affiliation(s)
- A Koy
- Department of Neurology, University Hospital of Cologne, Germany; Department of Paediatrics, University Hospital of Cologne, Germany.
| | - M Weinsheimer
- Department of Neurology, University Hospital of Cologne, Germany
| | - K A M Pauls
- Department of Neurology, University Hospital of Cologne, Germany
| | - A A Kühn
- Department of Neurology, Charité University Medicine Berlin, Germany
| | - P Krause
- Department of Neurology, Charité University Medicine Berlin, Germany
| | - J Huebl
- Department of Neurology, Charité University Medicine Berlin, Germany
| | - G-H Schneider
- Department of Neurosurgery, Charité University Medicine Berlin, Germany
| | - G Deuschl
- Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
| | - R Erasmi
- Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
| | - D Falk
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
| | - J K Krauss
- Department of Neurosurgery, Medical School, MHH, Hannover, Germany
| | - G Lütjens
- Department of Neurosurgery, Medical School, MHH, Hannover, Germany
| | - A Schnitzler
- Department of Neurology, University Hospital of Düsseldorf, Germany
| | - L Wojtecki
- Department of Neurology, University Hospital of Düsseldorf, Germany
| | - J Vesper
- Department of Stereotactic and Functional Neurosurgery, University Hospital of Düsseldorf, Germany
| | - R Korinthenberg
- Department of Paediatrics, Freiburg University Medical Centre, Germany
| | - V A Coenen
- Department Stereotactic and Functional Neurosurgery, Freiburg University Medical Centre, Germany
| | - V Visser-Vandewalle
- Department of Stereotactic and Functional Neurosurgery, University Hospital of Cologne, Germany
| | - M Hellmich
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Germany
| | - L Timmermann
- Department of Neurology, University Hospital of Cologne, Germany.
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Owen T, Adegboye D, Gimeno H, Selway R, Lin JP. Stable cognitive functioning with improved perceptual reasoning in children with dyskinetic cerebral palsy and other secondary dystonias after deep brain stimulation. Eur J Paediatr Neurol 2017; 21:193-201. [PMID: 27836441 DOI: 10.1016/j.ejpn.2016.10.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/28/2016] [Accepted: 10/11/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Dystonia is characterised by involuntary movements (twisting, writhing and jerking) and postures. Secondary dystonias are described as a heterogeneous group of disorders with both exogenous and endogenous causes. There is a growing body of literature on the effects of deep brain stimulation (DBS) surgery on the motor function in childhood secondary dystonias, however research on cognitive function after DBS is scarce. METHODS Cognitive function was measured in a cohort of 40 children with secondary dystonia following DBS surgery using a retrospective repeated measures design. Baseline pre-DBS neuropsychological measures were compared to scores obtained at least one year following DBS. Cognitive function was assessed using standardised measures of intellectual ability and memory. RESULTS There was no significant change in the assessed domains of cognitive function following DBS surgery. A significant improvement across the group was found on the Picture Completion subtest, measuring perceptual reasoning ability, following DBS. CONCLUSION Cognition remained stable in children with secondary dystonia following DBS surgery, with some improvements noted in a domain of perceptual reasoning. Further research with a larger sample is necessary to further explore this, in particular to further subdivide this group to account for its heterogeneity. This preliminary data has potentially positive implications for the impact of DBS on cognitive functioning within the childhood secondary dystonia population.
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Affiliation(s)
- Tamsin Owen
- Complex Motor Disorders Service, Paediatric Neurosciences, Evelina London Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK; Department of Clinical Psychology, Royal Holloway, University of London, UK.
| | - Dolapo Adegboye
- Complex Motor Disorders Service, Paediatric Neurosciences, Evelina London Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Hortensia Gimeno
- Complex Motor Disorders Service, Paediatric Neurosciences, Evelina London Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK; Department of Psychology, Institute of Psychiatry, King's College London, UK
| | - Richard Selway
- Functional Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Jean-Pierre Lin
- Complex Motor Disorders Service, Paediatric Neurosciences, Evelina London Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK
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Ismail FY, Fatemi A, Johnston MV. Cerebral plasticity: Windows of opportunity in the developing brain. Eur J Paediatr Neurol 2017; 21:23-48. [PMID: 27567276 DOI: 10.1016/j.ejpn.2016.07.007] [Citation(s) in RCA: 274] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 07/06/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Neuroplasticity refers to the inherently dynamic biological capacity of the central nervous system (CNS) to undergo maturation, change structurally and functionally in response to experience and to adapt following injury. This malleability is achieved by modulating subsets of genetic, molecular and cellular mechanisms that influence the dynamics of synaptic connections and neural circuitry formation culminating in gain or loss of behavior or function. Neuroplasticity in the healthy developing brain exhibits a heterochronus cortex-specific developmental profile and is heightened during "critical and sensitive periods" of pre and postnatal brain development that enable the construction and consolidation of experience-dependent structural and functional brain connections. PURPOSE In this review, our primary goal is to highlight the essential role of neuroplasticity in brain development, and to draw attention to the complex relationship between different levels of the developing nervous system that are subjected to plasticity in health and disease. Another goal of this review is to explore the relationship between plasticity responses of the developing brain and how they are influenced by critical and sensitive periods of brain development. Finally, we aim to motivate researchers in the pediatric neuromodulation field to build on the current knowledge of normal and abnormal neuroplasticity, especially synaptic plasticity, and their dependence on "critical or sensitive periods" of neural development to inform the design, timing and sequencing of neuromodulatory interventions in order to enhance and optimize their translational applications in childhood disorders of the brain. METHODS literature review. RESULTS We discuss in details five patterns of neuroplasticity expressed by the developing brain: 1) developmental plasticity which is further classified into normal and impaired developmental plasticity as seen in syndromic autism spectrum disorders, 2) adaptive (experience-dependent) plasticity following intense motor skill training, 3) reactive plasticity to pre and post natal CNS injury or sensory deprivation, 4) excessive plasticity (loss of homeostatic regulation) as seen in dystonia and refractory epilepsy, 6) and finally, plasticity as the brain's "Achilles tendon" which induces brain vulnerability under certain conditions such as hypoxic ischemic encephalopathy and epileptic encephalopathy syndromes. We then explore the unique feature of "time-sensitive heightened plasticity responses" in the developing brain in the in the context of neuromodulation. CONCLUSION The different patterns of neuroplasticity and the unique feature of heightened plasticity during critical and sensitive periods are important concepts for researchers and clinicians in the field of pediatric neurology and neurodevelopmental disabilities. These concepts need to be examined systematically in the context of pediatric neuromodulation. We propose that critical and sensitive periods of brain development in health and disease can create "windows of opportunity" for neuromodulatory interventions that are not commonly seen in adult brain and probably augment plasticity responses and improve clinical outcomes.
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Affiliation(s)
- Fatima Yousif Ismail
- Department of neurology and developmental medicine, The Kennedy Krieger Institute, Johns Hopkins Medical Institutions, MD, USA; Department of pediatrics, College of Medicine and Health Sciences, United Arab Emirates University, Al- Ain, UAE.
| | - Ali Fatemi
- Departments of Neurology and Pediatrics, The Kennedy Krieger Institute, and Johns Hopkins University School of Medicine, MD, USA
| | - Michael V Johnston
- Departments of Neurology and Pediatrics, The Kennedy Krieger Institute, and Johns Hopkins University School of Medicine, MD, USA
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92
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Cif L, Coubes P. Historical developments in children's deep brain stimulation. Eur J Paediatr Neurol 2017; 21:109-117. [PMID: 27693334 DOI: 10.1016/j.ejpn.2016.08.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 08/19/2016] [Accepted: 08/29/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Heterogeneous by the underlying pathobiology and clinical presentation, childhood onset dystonia is most frequently progressive, with related disability and limitations in functions of daily living. Consequently, there is an obvious need for efficient symptomatic therapies. METHODS AND RESULTS Following lesional surgery to basal ganglia (BG) and thalamus, deep brain stimulation (DBS) is a more conservative and adjustable intervention to and validated for internal segment of the globus pallidus (GPi), highly efficient in treating isolated "primary" dystonia and associated symptoms such as subcortical myoclonus. The role of DBS in acquired, neurometabolic and degenerative disorders with dystonia deserves further exploration to confirm as an efficient and lasting therapy. However, the pathobiological background with distribution of the sequellae over the central nervous system and related clinical features, will limit DBS efficacy in these conditions. Cumulative arguments propose DBS in severe life threatening dystonic conditions called status dystonicus as first line therapy, irrespective of the underlying cause. There are no currently available validated selection criteria for DBS in pediatric dystonia. Concurrent targets such as subthalamic nucleus (STN) and several motor nuclei of the thalamus are under exploration and only little information is available in children. DBS programming in paediatric population was adopted from experience in adults. The choice of neuromodulatory DBS parameters could influence not only the initial therapeutic outcome of dystonic symptoms but also its maintenance over time and potentially the occurrence of DBS related side effects. CONCLUSION DBS allows efficient symptomatic treatment of severe dystonia in children and advances pathophysiological knowledge about local and distributed abnormal neural activity over the motor cortical-subcortical networks in dystonia and other movement disorders.
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Affiliation(s)
- Laura Cif
- Unités de Neurochirurgie Fonctionnelle et Pédiatrique, Département de Neurochirurgie, Centre Hospitalier Universitaire Montpellier, France; Unité de Recherche sur les Comportements et Mouvements Anormaux (URCMA), France; Institut de Génomique Fonctionnelle, Centre National de la Recherche Scientifique, Unité Mixte de la Recherche 5203, France; Université Montpellier, 34000, Montpellier, France; Laboratoire de Recherche en Neurosciences Cliniques (LRENC), France.
| | - Philippe Coubes
- Unités de Neurochirurgie Fonctionnelle et Pédiatrique, Département de Neurochirurgie, Centre Hospitalier Universitaire Montpellier, France; Unité de Recherche sur les Comportements et Mouvements Anormaux (URCMA), France; Institut de Génomique Fonctionnelle, Centre National de la Recherche Scientifique, Unité Mixte de la Recherche 5203, France; Université Montpellier, 34000, Montpellier, France
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93
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Ostrem JL, San Luciano M, Dodenhoff KA, Ziman N, Markun LC, Racine CA, de Hemptinne C, Volz MM, Heath SL, Starr PA. Subthalamic nucleus deep brain stimulation in isolated dystonia: A 3-year follow-up study. Neurology 2016; 88:25-35. [PMID: 27903810 DOI: 10.1212/wnl.0000000000003451] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 09/26/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To report long-term safety and efficacy outcomes of a large cohort of patients with medically refractory isolated dystonia treated with subthalamic nucleus (STN) deep brain stimulation (DBS). METHODS Twenty patients (12 male, 8 female; mean age 49 ± 16.3 years) with medically refractory isolated dystonia were studied (14 were followed for 36 months). The primary endpoints were change in Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) motor score and Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) total score at 36 months compared to preoperative baseline. Multiple secondary outcomes were also assessed (ClinicalTrials.gov NCT00773604). RESULTS Eighteen of 20 patients showed improvement 12 months after STN DBS with sustained benefit persisting for 3 years (n = 14). At 36 months, BFMDRS motor scores improved 70.4% from a mean 17.9 ± 8.5 to 5.3 ± 5.6 (p = 0.0002) and total TWSTRS scores improved 66.6% from a mean 41.0 ± 18.9 to 13.7 ± 17.9 (p = 0.0002). Improvement at 36 months was equivalent to that seen at 6 months. Disability and quality of life measures were also improved. Three hardware-related and 24 stimulation-related nonserious adverse events occurred between years 1 and 3 (including 4 patients with dyskinesia). CONCLUSIONS This study offers support for long-term tolerability and sustained effectiveness of STN DBS in the treatment of severe forms of isolated dystonia. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that STN DBS decreases long-term dystonia severity in patients with medically refractory isolated dystonia.
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Affiliation(s)
- Jill L Ostrem
- From the Department of Neurology, Movement Disorders and Neuromodulation Center (J.L.O., M.S.L., K.A.D., N.Z., L.C.M., M.M.V.), and Department of Neurological Surgery (C.A.R., C.d.H., P.A.S.), University of California, San Francisco; and Parkinson's Disease Research, Education, and Clinical Center (J.L.O., L.C.M., S.L.H., P.A.S.), San Francisco Veterans Affairs Medical Center, CA.
| | - Marta San Luciano
- From the Department of Neurology, Movement Disorders and Neuromodulation Center (J.L.O., M.S.L., K.A.D., N.Z., L.C.M., M.M.V.), and Department of Neurological Surgery (C.A.R., C.d.H., P.A.S.), University of California, San Francisco; and Parkinson's Disease Research, Education, and Clinical Center (J.L.O., L.C.M., S.L.H., P.A.S.), San Francisco Veterans Affairs Medical Center, CA
| | - Kristen A Dodenhoff
- From the Department of Neurology, Movement Disorders and Neuromodulation Center (J.L.O., M.S.L., K.A.D., N.Z., L.C.M., M.M.V.), and Department of Neurological Surgery (C.A.R., C.d.H., P.A.S.), University of California, San Francisco; and Parkinson's Disease Research, Education, and Clinical Center (J.L.O., L.C.M., S.L.H., P.A.S.), San Francisco Veterans Affairs Medical Center, CA
| | - Nathan Ziman
- From the Department of Neurology, Movement Disorders and Neuromodulation Center (J.L.O., M.S.L., K.A.D., N.Z., L.C.M., M.M.V.), and Department of Neurological Surgery (C.A.R., C.d.H., P.A.S.), University of California, San Francisco; and Parkinson's Disease Research, Education, and Clinical Center (J.L.O., L.C.M., S.L.H., P.A.S.), San Francisco Veterans Affairs Medical Center, CA
| | - Leslie C Markun
- From the Department of Neurology, Movement Disorders and Neuromodulation Center (J.L.O., M.S.L., K.A.D., N.Z., L.C.M., M.M.V.), and Department of Neurological Surgery (C.A.R., C.d.H., P.A.S.), University of California, San Francisco; and Parkinson's Disease Research, Education, and Clinical Center (J.L.O., L.C.M., S.L.H., P.A.S.), San Francisco Veterans Affairs Medical Center, CA
| | - Caroline A Racine
- From the Department of Neurology, Movement Disorders and Neuromodulation Center (J.L.O., M.S.L., K.A.D., N.Z., L.C.M., M.M.V.), and Department of Neurological Surgery (C.A.R., C.d.H., P.A.S.), University of California, San Francisco; and Parkinson's Disease Research, Education, and Clinical Center (J.L.O., L.C.M., S.L.H., P.A.S.), San Francisco Veterans Affairs Medical Center, CA
| | - Coralie de Hemptinne
- From the Department of Neurology, Movement Disorders and Neuromodulation Center (J.L.O., M.S.L., K.A.D., N.Z., L.C.M., M.M.V.), and Department of Neurological Surgery (C.A.R., C.d.H., P.A.S.), University of California, San Francisco; and Parkinson's Disease Research, Education, and Clinical Center (J.L.O., L.C.M., S.L.H., P.A.S.), San Francisco Veterans Affairs Medical Center, CA
| | - Monica M Volz
- From the Department of Neurology, Movement Disorders and Neuromodulation Center (J.L.O., M.S.L., K.A.D., N.Z., L.C.M., M.M.V.), and Department of Neurological Surgery (C.A.R., C.d.H., P.A.S.), University of California, San Francisco; and Parkinson's Disease Research, Education, and Clinical Center (J.L.O., L.C.M., S.L.H., P.A.S.), San Francisco Veterans Affairs Medical Center, CA
| | - Susan L Heath
- From the Department of Neurology, Movement Disorders and Neuromodulation Center (J.L.O., M.S.L., K.A.D., N.Z., L.C.M., M.M.V.), and Department of Neurological Surgery (C.A.R., C.d.H., P.A.S.), University of California, San Francisco; and Parkinson's Disease Research, Education, and Clinical Center (J.L.O., L.C.M., S.L.H., P.A.S.), San Francisco Veterans Affairs Medical Center, CA
| | - Philip A Starr
- From the Department of Neurology, Movement Disorders and Neuromodulation Center (J.L.O., M.S.L., K.A.D., N.Z., L.C.M., M.M.V.), and Department of Neurological Surgery (C.A.R., C.d.H., P.A.S.), University of California, San Francisco; and Parkinson's Disease Research, Education, and Clinical Center (J.L.O., L.C.M., S.L.H., P.A.S.), San Francisco Veterans Affairs Medical Center, CA
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Abstract
Closed-loop, responsive focal brain stimulation provides a new treatment option for patients with refractory partial onset seizures who are not good candidates for potentially curative epilepsy surgery. The first responsive brain neurostimulator (RNS® System, NeuroPace), provides stimulation directly to the seizure focus when abnormal electrocorticographic is detected. Seizure reductions of 44% at one year increase to 60 to 66% at years 3 to 6 of treatment. There is no negative impact on cognition and mood. Risks are similar to other implanted medical devices and therapeutic stimulation is not perceived.
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Affiliation(s)
- Martha J Morrell
- NeuroPace, Inc, 455 North Bernardo Avenue, Mountain View, CA 94043, USA; Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA.
| | - Casey Halpern
- Department of Neurosurgery, Stanford University, 300 Pasteur Drive A301, MC 5325, Stanford, CA 94305, USA
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95
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McClelland VM, Valentin A, Rey HG, Lumsden DE, Elze MC, Selway R, Alarcon G, Lin JP. Differences in globus pallidus neuronal firing rates and patterns relate to different disease biology in children with dystonia. J Neurol Neurosurg Psychiatry 2016; 87:958-67. [PMID: 26848170 PMCID: PMC5013118 DOI: 10.1136/jnnp-2015-311803] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 12/24/2015] [Indexed: 01/24/2023]
Abstract
BACKGROUND The pathophysiology underlying different types of dystonia is not yet understood. We report microelectrode data from the globus pallidus interna (GPi) and globus pallidus externa (GPe) in children undergoing deep brain stimulation (DBS) for dystonia and investigate whether GPi and GPe firing rates differ between dystonia types. METHODS Single pass microelectrode data were obtained to guide electrode position in 44 children (3.3-18.1 years, median 10.7) with the following dystonia types: 14 primary, 22 secondary Static and 8 progressive secondary to neuronal brain iron accumulation (NBIA). Preoperative stereotactic MRI determined coordinates for the GPi target. Digitised spike trains were analysed offline, blind to clinical data. Electrode placement was confirmed by a postoperative stereotactic CT scan. FINDINGS We identified 263 GPi and 87 GPe cells. Both GPi and GPe firing frequencies differed significantly with dystonia aetiology. The median GPi firing frequency was higher in the primary group than in the secondary static group (13.5 Hz vs 9.6 Hz; p=0.002) and higher in the NBIA group than in either the primary (25 Hz vs 13.5 Hz; p=0.006) or the secondary static group (25 Hz vs 9.6 Hz; p=0.00004). The median GPe firing frequency was higher in the NBIA group than in the secondary static group (15.9 Hz vs 7 Hz; p=0.013). The NBIA group also showed a higher proportion of regularly firing GPi cells compared with the other groups (p<0.001). A higher proportion of regular GPi cells was also seen in patients with fixed/tonic dystonia compared with a phasic/dynamic dystonia phenotype (p<0.001). The GPi firing frequency showed a positive correlation with 1-year outcome from DBS measured by improvement in the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS-m) score (p=0.030). This association was stronger for the non-progressive patients (p=0.006). INTERPRETATION Pallidal firing rates and patterns differ significantly with dystonia aetiology and phenotype. Identification of specific firing patterns may help determine targets and patient-specific protocols for neuromodulation therapy. FUNDING National Institute of Health Research, Guy's and St. Thomas' Charity, Dystonia Society UK, Action Medical Research, German National Academic Foundation.
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Affiliation(s)
- V M McClelland
- Department of Clinical Neurophysiology, King's College Hospital NHS Foundation Trust, London, UK Department of Basic and Clinical Neuroscience, King's College London, London, UK
| | - A Valentin
- Department of Clinical Neurophysiology, King's College Hospital NHS Foundation Trust, London, UK Department of Basic and Clinical Neuroscience, King's College London, London, UK Department of Human Physiology, Faculty of Medicine, Complutense University, Madrid, Spain
| | - H G Rey
- Centre for Systems Neuroscience, University of Leicester, Leicester, UK
| | - D E Lumsden
- Rayne Institute, King's College London, London, UK Complex Motor Disorder Service, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - M C Elze
- Department of Statistics, University of Warwick, Coventry, UK
| | - R Selway
- Department of Functional Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - G Alarcon
- Department of Clinical Neurophysiology, King's College Hospital NHS Foundation Trust, London, UK Department of Basic and Clinical Neuroscience, King's College London, London, UK Department of Human Physiology, Faculty of Medicine, Complutense University, Madrid, Spain
| | - J-P Lin
- Complex Motor Disorder Service, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
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96
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Wojtecki L, Groiss SJ, Hartmann CJ, Elben S, Omlor S, Schnitzler A, Vesper J. Deep Brain Stimulation in Huntington's Disease-Preliminary Evidence on Pathophysiology, Efficacy and Safety. Brain Sci 2016; 6:brainsci6030038. [PMID: 27589813 PMCID: PMC5039467 DOI: 10.3390/brainsci6030038] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 08/18/2016] [Accepted: 08/22/2016] [Indexed: 12/29/2022] Open
Abstract
Huntington's disease (HD) is one of the most disabling degenerative movement disorders, as it not only affects the motor system but also leads to cognitive disabilities and psychiatric symptoms. Deep brain stimulation (DBS) of the pallidum is a promising symptomatic treatment targeting the core motor symptom: chorea. This article gives an overview of preliminary evidence on pathophysiology, safety and efficacy of DBS in HD.
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Affiliation(s)
- Lars Wojtecki
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
| | - Stefan Jun Groiss
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
| | - Christian Johannes Hartmann
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
| | - Saskia Elben
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
| | - Sonja Omlor
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany
| | - Alfons Schnitzler
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
| | - Jan Vesper
- Department of Functional Neurosurgery and Stereotaxy, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
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97
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van den Heuvel CNAM, Tijssen MAJ, van de Warrenburg BPC, Delnooz CCS. The Symptomatic Treatment of Acquired Dystonia: A Systematic Review. Mov Disord Clin Pract 2016; 3:548-558. [PMID: 30363468 DOI: 10.1002/mdc3.12400] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/12/2016] [Accepted: 05/23/2016] [Indexed: 12/27/2022] Open
Abstract
Background Acquired dystonia is caused by an acquired or exogenous event. Although the therapeutic armamentarium used in clinical practice is more or less similar to that used for inherited or idiopathic dystonia, formal proof of the efficacy of these interventions in acquired dystonia is lacking. Methods The authors attempt to provide a comprehensive and systematic review of the current evidence for medical and allied health care treatment strategies in acquired dystonias. The PubMed, Cochrane Library, MEDLINE, Web of Science, PiCarta, and PsycINFO databases were searched up to December 2015, including randomized controlled trials, patient-control studies, and case series or single case reports containing a report on clinical outcome. Results There are level 3 practice recommendations for botulinum toxin injections and globus pallidus pars interna deep brain stimulation for tardive dystonia and dystonic cerebral palsy as well as intrathecal baclofen for dystonic cerebral palsy. There are insufficient and conflicting data on the effect (vs. the hazard) of other pharmacological interventions, and limited work has been done on other forms of neurostimulation and allied health care. Because no class A1 or A2 studies were identified, level 1 or 2 practice recommendations could not be deducted for a specific treatment intervention. Conclusions To improve the current medical and allied health care treatment options for patients with acquired dystonia, high-quality trials that examine the efficacy of therapies need to be performed.
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Affiliation(s)
- Corina N A M van den Heuvel
- Department of Neurology, Donders Institute for Brain, Cognition, and Behavior Radboud University Medical Center Nijmegen the Netherlands
| | - Marina A J Tijssen
- Department of Neurology University Medical Center Groningen Groningen the Netherlands
| | - Bart P C van de Warrenburg
- Department of Neurology, Donders Institute for Brain, Cognition, and Behavior Radboud University Medical Center Nijmegen the Netherlands
| | - Cathérine C S Delnooz
- Department of Neurology University Medical Center Groningen Groningen the Netherlands
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98
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Hoon AH, Vasconcellos Faria A. Pathogenesis, neuroimaging and management in children with cerebral palsy born preterm. ACTA ACUST UNITED AC 2016; 16:302-12. [PMID: 25708073 DOI: 10.1002/ddrr.127] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 07/26/2011] [Indexed: 12/12/2022]
Abstract
With advances in obstetric and perinatal management, the incidence of intraventricular hemorrhage in premature infants has declined, while periventricular leukomalacia remains a significant concern. It is now known that brain injury in children born preterm also involves neuronal-axonal disease in supratentorial and infratentorial structures. The developing brain is especially vulnerable to white matter (WM) injury from 23 to 34 weeks gestation when blood vessels serving the periventricular WM are immature. Oligodendrocyte progenitors, which are beginning to form myelin during this time, are susceptible to attack from oxygen free radicals, glutamate, and inflammatory cytokines. Advances in imaging techniques such as diffusion tensor imaging provide a more complete picture of the location and extent of injury. Effective management of children born preterm with cerebral palsy is predicated on an understanding of sequential links from etiological antecedents to brain neuropathology as revealed with neuroimaging techniques to clinical phenotypes, toward focused interventions with measurable outcomes.
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Affiliation(s)
- Alexander H Hoon
- Johns Hopkins University School of Medicine, Phelps Center for Cerebral Palsy and Neurodevelopmental Medicine, Kennedy Krieger Institute, Baltimore, Maryland.
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99
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Hartmann CJ, Groiss SJ, Vesper J, Schnitzler A, Wojtecki L. Brain stimulation in Huntington's disease. Neurodegener Dis Manag 2016; 6:223-36. [DOI: 10.2217/nmt-2016-0007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Huntington's disease (HD) is a hereditary neurodegenerative disorder which is associated with severe disturbances of motor function, especially choreatic movements, cognitive decline and psychiatric symptoms. Various brain stimulation methods have been used to study brain function in patients with HD. Moreover, brain stimulation has evolved as an alternative or additive treatment option, besides current symptomatic medical treatment. This article summarizes the results of brain stimulation to better understand the characteristics of cortical excitability and plasticity in HD and gives a perspective on the therapeutic role for noninvasive and invasive neuromodulatory brain stimulation methods.
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Affiliation(s)
- Christian Johannes Hartmann
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany
| | - Stefan Jun Groiss
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany
| | - Jan Vesper
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany
| | - Alfons Schnitzler
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany
| | - Lars Wojtecki
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany
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100
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TODA H, SAIKI H, NISHIDA N, IWASAKI K. Update on Deep Brain Stimulation for Dyskinesia and Dystonia: A Literature Review. Neurol Med Chir (Tokyo) 2016; 56:236-48. [PMID: 27053331 PMCID: PMC4870178 DOI: 10.2176/nmc.ra.2016-0002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 03/01/2016] [Indexed: 12/11/2022] Open
Abstract
Deep brain stimulation (DBS) has been an established surgical treatment option for dyskinesia from Parkinson disease and for dystonia. The present article deals with the timing of surgical intervention, selecting an appropriate target, and minimizing adverse effects. We provide an overview of current evidences and issues for dyskinesia and dystonia as well as emerging DBS technology.
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Affiliation(s)
- Hiroki TODA
- Department of Neurosurgery, Tazuke Kofukai Medical Research Institute and Kitano Hospital, Kita, Osaka
| | - Hidemoto SAIKI
- Department of Neurology, Tazuke Kofukai Medical Research Institute and Kitano Hospital, Kita, Osaka
| | - Namiko NISHIDA
- Department of Neurosurgery, Tazuke Kofukai Medical Research Institute and Kitano Hospital, Kita, Osaka
| | - Koichi IWASAKI
- Department of Neurosurgery, Tazuke Kofukai Medical Research Institute and Kitano Hospital, Kita, Osaka
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