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Alpheis S, Sinke C, Burek J, Krüger THC, Altenmüller E, Scholz DS. Stress in Musicians with and Without Focal Dystonia Is Not Reflected in Limbic Circuit Activation. Mov Disord 2024. [PMID: 39077793 DOI: 10.1002/mds.29941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 06/11/2024] [Accepted: 07/08/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND Musicians' dystonia (MD) is a movement disorder with several established risk factors, but the exact pathophysiology remains unknown. Recent research suggests dysfunction in sensory-motor, basal ganglia, cerebellar, and limbic loops as potential causes. Adverse childhood experiences are also considered risk factors. OBJECTIVE This study aimed to investigate whether MD patients have experienced more childhood trauma, leading to increased stress reactivity and neural vulnerability to movement disorders. METHODS Using functional magnetic resonance imaging and the Montreal Imaging Stress Task, 40 MD patients were compared with 39 healthy musicians (HMs). Whole-brain analysis and regions of interest analysis were performed. Parameter estimates and subjective stress levels were compared between groups and correlated with the Childhood Trauma Questionnaire. RESULTS MD patients reported significantly higher childhood trauma scores than healthy control subjects, but they did not differ in their subjective stress experiences. Stress-related activity of limbic areas was neither found in the whole sample nor between the two groups. Instead, increased activity of visual association and temporal areas was observed, but this activation did not differ between patients and HMs. However, patients showed a tendency toward reduced precuneus activity under stress. Adverse childhood experiences were negatively correlated with precuneus, thalamus, and substantia nigra activity across all participants. CONCLUSIONS Overall, MD patients and HMs had similar subjective and neurological reactions to stress but differed in childhood trauma experiences and precuneus activity under stress. Further research about the functional connectivity between precuneus, cerebellum, thalamus, and basal ganglia in musicians is needed. © 2024 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Stine Alpheis
- Institute of Music Physiology and Musicians' Medicine, Hannover University of Music, Drama and Media, Hannover, Germany
- Department of Musicians' Health, University of Music Lübeck, Lübeck, Germany
- Institute of Medical Psychology, University of Lübeck, Lübeck, Germany
| | - Christopher Sinke
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | | | - Tillmann H C Krüger
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Eckart Altenmüller
- Institute of Music Physiology and Musicians' Medicine, Hannover University of Music, Drama and Media, Hannover, Germany
| | - Daniel S Scholz
- Department of Musicians' Health, University of Music Lübeck, Lübeck, Germany
- Institute of Medical Psychology, University of Lübeck, Lübeck, Germany
- Department of Psychology, University of Lübeck, Lübeck, Germany
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2
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Gill JS, Nguyen MX, Hull M, van der Heijden ME, Nguyen K, Thomas SP, Sillitoe RV. Function and dysfunction of the dystonia network: an exploration of neural circuits that underlie the acquired and isolated dystonias. DYSTONIA 2023; 2:11805. [PMID: 38273865 PMCID: PMC10810232 DOI: 10.3389/dyst.2023.11805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Dystonia is a highly prevalent movement disorder that can manifest at any time across the lifespan. An increasing number of investigations have tied this disorder to dysfunction of a broad "dystonia network" encompassing the cerebellum, thalamus, basal ganglia, and cortex. However, pinpointing how dysfunction of the various anatomic components of the network produces the wide variety of dystonia presentations across etiologies remains a difficult problem. In this review, a discussion of functional network findings in non-mendelian etiologies of dystonia is undertaken. Initially acquired etiologies of dystonia and how lesion location leads to alterations in network function are explored, first through an examination of cerebral palsy, in which early brain injury may lead to dystonic/dyskinetic forms of the movement disorder. The discussion of acquired etiologies then continues with an evaluation of the literature covering dystonia resulting from focal lesions followed by the isolated focal dystonias, both idiopathic and task dependent. Next, how the dystonia network responds to therapeutic interventions, from the "geste antagoniste" or "sensory trick" to botulinum toxin and deep brain stimulation, is covered with an eye towards finding similarities in network responses with effective treatment. Finally, an examination of how focal network disruptions in mouse models has informed our understanding of the circuits involved in dystonia is provided. Together, this article aims to offer a synthesis of the literature examining dystonia from the perspective of brain networks and it provides grounding for the perspective of dystonia as disorder of network function.
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Affiliation(s)
- Jason S. Gill
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, TX, United States
| | - Megan X. Nguyen
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, TX, United States
| | - Mariam Hull
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Meike E. van der Heijden
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, TX, United States
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, United State
| | - Ken Nguyen
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, TX, United States
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, United State
| | - Sruthi P. Thomas
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, United States
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Roy V. Sillitoe
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, TX, United States
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, United State
- Department of Neuroscience, Baylor College of Medicine, Houston, TX, United States
- Development, Disease Models and Therapeutics Graduate Program, Baylor College of Medicine, Houston, TX, United States
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3
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Gelineau-Morel R, Smyser C, Leeder JS. Identifying Effective Treatments for Dystonia in Patients With Cerebral Palsy: A Precision Therapeutics Approach. Neurology 2023; 101:752-759. [PMID: 37463749 PMCID: PMC10624496 DOI: 10.1212/wnl.0000000000207593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 05/12/2023] [Indexed: 07/20/2023] Open
Abstract
Recent focus on improving the recognition of dystonia in cerebral palsy (DCP) has highlighted the need for more effective treatments. Evidence supports improved functional outcomes with early interventions for patients with cerebral palsy, but it is not known which interventions are most effective for DCP. Current pharmacologic recommendations for DCP are based largely on anecdotal evidence, with medications demonstrating minimal to moderate improvements in dystonia and variable efficacy between patients. Patients, families, and clinicians have identified the need for new and improved treatments in DCP, naming this as the top research theme in a recent Neurology® publication. Precision therapeutics focuses on providing early effective interventions that are individualized to every patient and can guide research priorities to improve treatments for DCP. This commentary outlines current obstacles to improving treatment of DCP and addresses how precision therapeutics can address each of these obstacles through 4 key components: (1) identification of predictive biomarkers to select patients likely to develop DCP in the future and for whom early intervention may be appropriate to delay or prevent full manifestation of dystonia, (2) stratification of patients with DCP into subgroups according to shared features (clinical, functional, biochemical, etc) to provide a targeted intervention based on those shared features, (3) administration of an individualized dose of an effective intervention to ensure adequate concentrations of the therapeutic entity at the site of action, and (4) monitoring of objective biomarkers of response to intervention. With implementation of each of these components of precision therapeutics, new and more effective treatments for every person with DCP can be realized.
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Affiliation(s)
- Rose Gelineau-Morel
- From the Division of Neurology (R.G.-M.), Children's Mercy Kansas City; School of Medicine (R.G.-M., J.S.L.), University of Missouri-Kansas City; Department of Pediatrics (R.G.-M., J.S.L.), University of Kansas Medical Center, Kansas City; Department of Pediatrics (C.S.), Department of Neurology (C.S.), and Mallinckrodt Institute of Radiology (C.S.), Washington University in St. Louis; and Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation (J.S.L.), Children's Mercy Kansas City, MO.
| | - Christopher Smyser
- From the Division of Neurology (R.G.-M.), Children's Mercy Kansas City; School of Medicine (R.G.-M., J.S.L.), University of Missouri-Kansas City; Department of Pediatrics (R.G.-M., J.S.L.), University of Kansas Medical Center, Kansas City; Department of Pediatrics (C.S.), Department of Neurology (C.S.), and Mallinckrodt Institute of Radiology (C.S.), Washington University in St. Louis; and Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation (J.S.L.), Children's Mercy Kansas City, MO
| | - J Steven Leeder
- From the Division of Neurology (R.G.-M.), Children's Mercy Kansas City; School of Medicine (R.G.-M., J.S.L.), University of Missouri-Kansas City; Department of Pediatrics (R.G.-M., J.S.L.), University of Kansas Medical Center, Kansas City; Department of Pediatrics (C.S.), Department of Neurology (C.S.), and Mallinckrodt Institute of Radiology (C.S.), Washington University in St. Louis; and Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation (J.S.L.), Children's Mercy Kansas City, MO
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4
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Ehrlich SK, Battistella G, Simonyan K. Temporal Signature of Task-Specificity in Isolated Focal Laryngeal Dystonia. Mov Disord 2023; 38:1925-1935. [PMID: 37489600 PMCID: PMC10615685 DOI: 10.1002/mds.29557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/06/2023] [Accepted: 06/28/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Laryngeal dystonia (LD) is focal task-specific dystonia, predominantly affecting speech but not whispering or emotional vocalizations. Prior neuroimaging studies identified brain regions forming a dystonic neural network and contributing to LD pathophysiology. However, the underlying temporal dynamics of these alterations and their contribution to the task-specificity of LD remain largely unknown. The objective of the study was to identify the temporal-spatial signature of altered cortical oscillations associated with LD pathophysiology. METHODS We used high-density 128-electrode electroencephalography (EEG) recordings during symptomatic speaking and two asymptomatic tasks, whispering and writing, in 24 LD patients and 22 healthy individuals to investigate the spectral dynamics, spatial localization, and interregional effective connectivity of aberrant cortical oscillations within the dystonic neural network, as well as their relationship with LD symptomatology. RESULTS Symptomatic speaking in LD patients was characterized by significantly increased gamma synchronization in the middle/superior frontal gyri, primary somatosensory cortex, and superior parietal lobule, establishing the altered prefrontal-parietal loop. Hyperfunctional connectivity from the left middle frontal gyrus to the right superior parietal lobule was significantly correlated with the age of onset and the duration of LD symptoms. Asymptomatic whisper in LD patients had not no statistically significant changes in any frequency band, whereas asymptomatic writing was characterized by significantly decreased synchronization of beta-band power localized in the right superior frontal gyrus. CONCLUSION Task-specific oscillatory activity of prefrontal-parietal circuitry is likely one of the underlying mechanisms of aberrant heteromodal integration of information processing and transfer within the neural network leading to dystonic motor output. © 2023 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Stefan K. Ehrlich
- Department of Otolaryngology - Head & Neck Surgery, Harvard Medical School and Massachusetts Eye and Ear, 243 Charles Street, Boston, MA 02114, USA
| | - Giovanni Battistella
- Department of Otolaryngology - Head & Neck Surgery, Harvard Medical School and Massachusetts Eye and Ear, 243 Charles Street, Boston, MA 02114, USA
| | - Kristina Simonyan
- Department of Otolaryngology - Head & Neck Surgery, Harvard Medical School and Massachusetts Eye and Ear, 243 Charles Street, Boston, MA 02114, USA
- Department of Neurology - Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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5
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Zito GA, Tarrano C, Ouarab S, Jegatheesan P, Ekmen A, Béranger B, Valabregue R, Hubsch C, Sangla S, Bonnet C, Delorme C, Méneret A, Degos B, Bouquet F, Apoil Brissard M, Vidailhet M, Hasboun D, Worbe Y, Roze E, Gallea C. Fixel-Based Analysis Reveals Whole-Brain White Matter Abnormalities in Cervical Dystonia. Mov Disord 2023. [PMID: 37148555 DOI: 10.1002/mds.29425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/04/2023] [Accepted: 04/12/2023] [Indexed: 05/08/2023] Open
Abstract
BACKGROUND Cervical dystonia (CD) is a form of isolated focal dystonia typically associated to abnormal head, neck, and shoulder movements and postures. The complexity of the clinical presentation limits the investigation of its pathophysiological mechanisms, and the neural networks associated to specific motor manifestations are still the object of debate. OBJECTIVES We investigated the morphometric properties of white matter fibers in CD and explored the networks associated with motor symptoms, while regressing out nonmotor scores. METHODS Nineteen patients affected by CD and 21 healthy controls underwent diffusion-weighted magnetic resonance imaging. We performed fixel-based analysis, a novel method evaluating fiber orientation within specific fiber bundles, and compared fiber morphometric properties between groups. Moreover, we correlated fiber morphometry with the severity of motor symptoms in patients. RESULTS Compared to controls, patients exhibited decreased white matter fibers in the right striatum. Motor symptom severity negatively correlated with white matter fibers passing through inferior parietal areas and the head representation area of the motor cortex. CONCLUSIONS Abnormal white matter integrity at the basal ganglia level may affect several functional networks involved, for instance, in motor preparation and execution, visuomotor coordination, and multimodal integration. This may result in progressive maladaptive plasticity, culminating in overt symptoms of dystonia. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
| | - Clément Tarrano
- Movement Investigation and Therapeutics Team, Paris Brain Institute, Sorbonne University, Inserm U1127, CNRS UMR7225, Paris, France
- Department of Neurology, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Salim Ouarab
- Movement Investigation and Therapeutics Team, Paris Brain Institute, Sorbonne University, Inserm U1127, CNRS UMR7225, Paris, France
| | - Prasanthi Jegatheesan
- Movement Investigation and Therapeutics Team, Paris Brain Institute, Sorbonne University, Inserm U1127, CNRS UMR7225, Paris, France
| | - Asya Ekmen
- Movement Investigation and Therapeutics Team, Paris Brain Institute, Sorbonne University, Inserm U1127, CNRS UMR7225, Paris, France
| | - Benoît Béranger
- Center for NeuroImaging Research (CENIR), Paris Brain Institute, Sorbonne University, Inserm U1127, CNRS UMR 7225, Paris, France
| | - Romain Valabregue
- Center for NeuroImaging Research (CENIR), Paris Brain Institute, Sorbonne University, Inserm U1127, CNRS UMR 7225, Paris, France
| | - Cécile Hubsch
- Movement Investigation and Therapeutics Team, Paris Brain Institute, Sorbonne University, Inserm U1127, CNRS UMR7225, Paris, France
| | - Sophie Sangla
- Movement Investigation and Therapeutics Team, Paris Brain Institute, Sorbonne University, Inserm U1127, CNRS UMR7225, Paris, France
| | - Cécilia Bonnet
- Movement Investigation and Therapeutics Team, Paris Brain Institute, Sorbonne University, Inserm U1127, CNRS UMR7225, Paris, France
| | - Cécile Delorme
- Movement Investigation and Therapeutics Team, Paris Brain Institute, Sorbonne University, Inserm U1127, CNRS UMR7225, Paris, France
| | - Aurélie Méneret
- Movement Investigation and Therapeutics Team, Paris Brain Institute, Sorbonne University, Inserm U1127, CNRS UMR7225, Paris, France
- DMU Neurosciences, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Bertrand Degos
- Movement Investigation and Therapeutics Team, Paris Brain Institute, Sorbonne University, Inserm U1127, CNRS UMR7225, Paris, France
- Neurology Unit, AP-HP, Avicenne University Hospital, Sorbonne Paris Nord, Bobigny, France
- Center for Interdisciplinary Research in Biology, Collège de France, CNRS UMR7241/INSERM U1050, Université PSL, Paris, France
| | - Floriane Bouquet
- Movement Investigation and Therapeutics Team, Paris Brain Institute, Sorbonne University, Inserm U1127, CNRS UMR7225, Paris, France
| | | | - Marie Vidailhet
- Movement Investigation and Therapeutics Team, Paris Brain Institute, Sorbonne University, Inserm U1127, CNRS UMR7225, Paris, France
- DMU Neurosciences, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Dominique Hasboun
- Movement Investigation and Therapeutics Team, Paris Brain Institute, Sorbonne University, Inserm U1127, CNRS UMR7225, Paris, France
- Department of Neurology, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Yulia Worbe
- Movement Investigation and Therapeutics Team, Paris Brain Institute, Sorbonne University, Inserm U1127, CNRS UMR7225, Paris, France
- Department of Neurophysiology, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Emmanuel Roze
- Movement Investigation and Therapeutics Team, Paris Brain Institute, Sorbonne University, Inserm U1127, CNRS UMR7225, Paris, France
- DMU Neurosciences, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Cécile Gallea
- Movement Investigation and Therapeutics Team, Paris Brain Institute, Sorbonne University, Inserm U1127, CNRS UMR7225, Paris, France
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6
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Battistella G, Simonyan K. Clinical Implications of Dystonia as a Neural Network Disorder. ADVANCES IN NEUROBIOLOGY 2023; 31:223-240. [PMID: 37338705 DOI: 10.1007/978-3-031-26220-3_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Isolated dystonia is a neurological disorder of diverse etiology, multifactorial pathophysiology, and wide spectrum of clinical presentations. We review the recent neuroimaging advances that led to the conceptualization of dystonia as a neural network disorder and discuss how current knowledge is shaping the identification of biomarkers of dystonia and the development of novel pharmacological therapies.
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Affiliation(s)
- Giovanni Battistella
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, USA
| | - Kristina Simonyan
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, USA.
- Department of Neurology, Massachusetts General Hospital, and Harvard Medical School, Boston, MA, USA.
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7
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Yeung W, Richards AL, Novakovic D. Botulinum Neurotoxin Therapy in the Clinical Management of Laryngeal Dystonia. Toxins (Basel) 2022; 14:toxins14120844. [PMID: 36548741 PMCID: PMC9784062 DOI: 10.3390/toxins14120844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/26/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022] Open
Abstract
Laryngeal dystonia (LD), or spasmodic dysphonia (SD), is a chronic, task-specific, focal movement disorder affecting the larynx. It interferes primarily with the essential functions of phonation and speech. LD affects patients' ability to communicate effectively and significantly diminishes their quality of life. Botulinum neurotoxin was first used as a therapeutic agent in the treatment of LD four decades ago and remains the standard of care for the treatment of LD. This article provides an overview of the clinical application of botulinum neurotoxin in the management of LD, focusing on the classification for this disorder, its pathophysiology, clinical assessment and diagnosis, the role of laryngeal electromyography and a summary of therapeutic injection techniques, including a comprehensive description of various procedural approaches, recommendations for injection sites and dosage considerations.
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Affiliation(s)
- Winnie Yeung
- Voice Research Laboratory, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Department of Otolaryngology, The Canterbury Hospital, Campsie, NSW 2194, Australia
- Correspondence:
| | - Amanda L. Richards
- Department of Otolaryngology, The Royal Melbourne Hospital, Parkville, VIC 3050, Australia
| | - Daniel Novakovic
- Voice Research Laboratory, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Department of Otolaryngology, The Canterbury Hospital, Campsie, NSW 2194, Australia
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8
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MacIver CL, Tax CMW, Jones DK, Peall KJ. Structural magnetic resonance imaging in dystonia: A systematic review of methodological approaches and findings. Eur J Neurol 2022; 29:3418-3448. [PMID: 35785410 PMCID: PMC9796340 DOI: 10.1111/ene.15483] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND PURPOSE Structural magnetic resonance techniques have been widely applied in neurological disorders to better understand tissue changes, probing characteristics such as volume, iron deposition and diffusion. Dystonia is a hyperkinetic movement disorder, resulting in abnormal postures and pain. Its pathophysiology is poorly understood, with normal routine clinical imaging in idiopathic forms. More advanced tools provide an opportunity to identify smaller scale structural changes which may underpin pathophysiology. This review aims to provide an overview of methodological approaches undertaken in structural brain imaging of dystonia cohorts, and to identify commonly identified pathways, networks or regions that are implicated in pathogenesis. METHODS Structural magnetic resonance imaging studies of idiopathic and genetic forms of dystonia were systematically reviewed. Adhering to strict inclusion and exclusion criteria, PubMed and Embase databases were searched up to January 2022, with studies reviewed for methodological quality and key findings. RESULTS Seventy-seven studies were included, involving 1945 participants. The majority of studies employed diffusion tensor imaging (DTI) (n = 45) or volumetric analyses (n = 37), with frequently implicated areas of abnormality in the brainstem, cerebellum, basal ganglia and sensorimotor cortex and their interconnecting white matter pathways. Genotypic and motor phenotypic variation emerged, for example fewer cerebello-thalamic tractography streamlines in genetic forms than idiopathic and higher grey matter volumes in task-specific than non-task-specific dystonias. DISCUSSION Work to date suggests microstructural brain changes in those diagnosed with dystonia, although the underlying nature of these changes remains undetermined. Employment of techniques such as multiple diffusion weightings or multi-exponential relaxometry has the potential to enhance understanding of these differences.
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Affiliation(s)
- Claire L. MacIver
- Neuroscience and Mental Health Research InstituteDivision of Psychological Medicine and Clinical NeurosciencesCardiff University School of MedicineCardiffUK,Cardiff University Brain Imaging Centre (CUBRIC)Cardiff UniversityCardiffUK
| | - Chantal M. W. Tax
- Cardiff University Brain Imaging Centre (CUBRIC)Cardiff UniversityCardiffUK,Image Sciences InstituteUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Derek K. Jones
- Cardiff University Brain Imaging Centre (CUBRIC)Cardiff UniversityCardiffUK
| | - Kathryn J. Peall
- Neuroscience and Mental Health Research InstituteDivision of Psychological Medicine and Clinical NeurosciencesCardiff University School of MedicineCardiffUK
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9
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Salazar Leon LE, Sillitoe RV. Potential Interactions Between Cerebellar Dysfunction and Sleep Disturbances in Dystonia. DYSTONIA 2022; 1. [PMID: 37065094 PMCID: PMC10099477 DOI: 10.3389/dyst.2022.10691] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Dystonia is the third most common movement disorder. It causes debilitating twisting postures that are accompanied by repetitive and sometimes intermittent co- or over-contractions of agonist and antagonist muscles. Historically diagnosed as a basal ganglia disorder, dystonia is increasingly considered a network disorder involving various brain regions including the cerebellum. In certain etiologies of dystonia, aberrant motor activity is generated in the cerebellum and the abnormal signals then propagate through a “dystonia circuit” that includes the thalamus, basal ganglia, and cerebral cortex. Importantly, it has been reported that non-motor defects can accompany the motor symptoms; while their severity is not always correlated, it is hypothesized that common pathways may nevertheless be disrupted. In particular, circadian dysfunction and disordered sleep are common non-motor patient complaints in dystonia. Given recent evidence suggesting that the cerebellum contains a circadian oscillator, displays sleep-stage-specific neuronal activity, and sends robust long-range projections to several subcortical regions involved in circadian rhythm regulation, disordered sleep in dystonia may result from cerebellum-mediated dysfunction of the dystonia circuit. Here, we review the evidence linking dystonia, cerebellar network dysfunction, and cerebellar involvement in sleep. Together, these ideas may form the basis for the development of improved pharmacological and surgical interventions that could take advantage of cerebellar circuitry to restore normal motor function as well as non-motor (sleep) behaviors in dystonia.
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Affiliation(s)
- Luis E. Salazar Leon
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
- Department of Neuroscience, Baylor College of Medicine, Houston, Texas, USA
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, Texas, 77030, USA
| | - Roy V. Sillitoe
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
- Department of Neuroscience, Baylor College of Medicine, Houston, Texas, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Development, Disease Models & Therapeutics Graduate Program, Baylor College of Medicine, Houston, Texas, USA
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, Texas, 77030, USA
- Address correspondence to: Dr. Roy V. Sillitoe, Tel: 832-824-8913, Fax: 832-825-1251,
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10
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Gelineau-Morel R, Kruer MC, Garris JF, Libdeh AA, Barbosa DAN, Coffman KA, Moon D, Barton C, Vera AZ, Bruce AB, Larsh T, Wu SW, Gilbert DL, O’Malley JA. Deep Brain Stimulation for Pediatric Dystonia: A Review of the Literature and Suggested Programming Algorithm. J Child Neurol 2022; 37:813-824. [PMID: 36053123 PMCID: PMC9912476 DOI: 10.1177/08830738221115248] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Deep brain stimulation (DBS) is an established intervention for use in pediatric movement disorders, especially dystonia. Although multiple publications have provided guidelines for deep brain stimulation patient selection and programming in adults, there are no evidence-based or consensus statements published for pediatrics. The result is lack of standardized care and underutilization of this effective treatment. To this end, we assembled a focus group of 13 pediatric movement disorder specialists and 1 neurosurgeon experienced in pediatric deep brain stimulation to review recent literature and current practices and propose a standardized approach to candidate selection, implantation target site selection, and programming algorithms. For pediatric dystonia, we provide algorithms for (1) programming for initial session and follow-up sessions, and (2) troubleshooting side effects encountered during programming. We discuss common side effects, how they present, and recommendations for management. This topical review serves as a resource for movement disorders specialists interested in using deep brain stimulation for pediatric dystonia.
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Affiliation(s)
- Rose Gelineau-Morel
- Division of Neurology, Department of Pediatrics, Children’s Mercy Hospital, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City, Missouri, 64108
| | - Michael C Kruer
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children’s Hospital & University of Arizona College of Medicine - Phoenix, Phoenix, AZ, 85016
| | - Jordan F Garris
- Division of Pediatric Neurology, Department of Neurology, University of Virginia, PO Box 800394, Charlottesville, VA, 22908−0394
| | - Amal Abu Libdeh
- Division of Pediatric Neurology, Department of Neurology, University of Virginia, PO Box 800394, Charlottesville, VA, 22908−0394
| | - Daniel A N Barbosa
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Edwards Bldg, Stanford, CA, 94305
| | - Keith A Coffman
- Division of Neurology, Department of Pediatrics, Children’s Mercy Hospital, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City, Missouri, 64108
| | - David Moon
- Department of Child Neurology, Division of Neurosciences, Helen DeVos Children’s Hospital, 100 Michigan St NE, Grand Rapids, MI 49503
| | - Christopher Barton
- Department of Neurology, University of Louisville School of Medicine, Louisville, Kentucky; Division of Child Neurology, Norton Children’s Medical Group, 231 E Chestnut St, Louisville, KY 40202
| | - Alonso Zea Vera
- Department of Neurology, Children’s National Hospital, 111 Michigan Ave NW, Washington, DC, 20010
| | - Adrienne B Bruce
- Division of Pediatric Neurology, Department of Pediatrics, Prisma Health, 200 Patewood Drive A350, Greenville, SC, USA 29615; University of South Carolina School of Medicine Greenville, 607 Grove Road, Greenville, SC, 29605
| | - Travis Larsh
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, 3333 Burnet Ave, Location E4, Suite 110, Cincinnati, OH 45229
| | - Steve W Wu
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, 3333 Burnet Ave, Location E4, Suite 110, Cincinnati, OH 45229
| | - Donald L Gilbert
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, 3333 Burnet Ave, Location E4, Suite 110, Cincinnati, OH 45229
| | - Jennifer A O’Malley
- Department of Neurology, Division of Child Neurology, Stanford University School of Medicine, 750 Welch Road, Suite 317, Palo Alto, California, 94304
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11
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Simonyan K, Ehrlich SK, Andersen R, Brumberg J, Guenther F, Hallett M, Howard MA, Millán JDR, Reilly RB, Schultz T, Valeriani D. Brain-Computer Interfaces for Treatment of Focal Dystonia. Mov Disord 2022; 37:1798-1802. [PMID: 35947366 PMCID: PMC9474652 DOI: 10.1002/mds.29178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/20/2022] [Accepted: 07/19/2022] [Indexed: 11/12/2022] Open
Abstract
Task-specificity in isolated focal dystonias is a powerful feature that may successfully be targeted with therapeutic brain-computer interfaces. While performing a symptomatic task, the patient actively modulates momentary brain activity (disorder signature) to match activity during an asymptomatic task (target signature), which is expected to translate into symptom reduction.
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Affiliation(s)
- Kristina Simonyan
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Stefan K. Ehrlich
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, Massachusetts, USA
| | - Richard Andersen
- Division of Biology and Biological Engineering, California Institute of Technology, Pasadena, California, USA
| | - Jonathan Brumberg
- Department of Speech-Language-Hearing: Sciences & Disorders, University of Kansas, Lawrence, Kansas, USA
| | - Frank Guenther
- Department of Speech, Language, & Hearing Sciences, Boston University, Boston, Massachusetts, USA
- Department of Biomedical Engineering, Boston University, Boston, Massachusetts, USA
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Picower Institute for Learning and Memory, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Matthew A. Howard
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - José del R. Millán
- Department of Electrical and Computer Engineering, University of Texas at Austin, Austin, Texas, USA
- Department of Neurology, University of Texas at Austin, Austin, Texas, USA
| | - Richard B. Reilly
- Center for Biomedical Engineering, Trinity College Institute of Neuroscience, School of Medicine, School of Engineering, Trinity College Dublin and the University of Dublin, Dublin, Ireland
| | - Tanja Schultz
- Faculty 03 Mathematics and Computer Science, University of Bremen, Bremen, Germany
| | - Davide Valeriani
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, Massachusetts, USA
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12
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Brown AM, van der Heijden ME, Jinnah HA, Sillitoe RV. Cerebellar Dysfunction as a Source of Dystonic Phenotypes in Mice. CEREBELLUM (LONDON, ENGLAND) 2022:10.1007/s12311-022-01441-0. [PMID: 35821365 DOI: 10.1007/s12311-022-01441-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 06/15/2023]
Abstract
There is now a substantial amount of compelling evidence demonstrating that the cerebellum may be a central locus in dystonia pathogenesis. Studies using spontaneous genetic mutations in rats and mice, engineered genetic alleles in mice, shRNA knockdown in mice, and conditional genetic silencing of fast neurotransmission in mice have all uncovered a common set of behavioral and electrophysiological defects that point to cerebellar cortical and cerebellar nuclei dysfunction as a source of dystonic phenotypes. Here, we revisit the Ptf1aCre/+;Vglut2flox/flox mutant mouse to define fundamental phenotypes and measures that are valuable for testing the cellular, circuit, and behavioral mechanisms that drive dystonia. In this model, excitatory neurotransmission from climbing fibers is genetically eliminated and, as a consequence, Purkinje cell and cerebellar nuclei firing are altered in vivo, with a prominent and lasting irregular burst pattern of spike activity in cerebellar nuclei neurons. The resulting impact on behavior is that the mice have developmental abnormalities, including twisting of the limbs and torso. These behaviors continue into adulthood along with a tremor, which can be measured with a tremor monitor or EMG. Importantly, expression of dystonic behavior is reduced upon cerebellar-targeted deep brain stimulation. The presence of specific combinations of disease-like features and therapeutic responses could reveal the causative mechanisms of different types of dystonia and related conditions. Ultimately, an emerging theme places cerebellar dysfunction at the center of a broader dystonia brain network.
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Affiliation(s)
- Amanda M Brown
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, USA
- Jan and Dan Duncan Neurological Research Institute at Texas Children's Hospital, Houston, TX, 77030, USA
| | - Meike E van der Heijden
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, USA
- Jan and Dan Duncan Neurological Research Institute at Texas Children's Hospital, Houston, TX, 77030, USA
| | - H A Jinnah
- Departments of Neurology, Human Genetics and Pediatrics, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Roy V Sillitoe
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, USA.
- Jan and Dan Duncan Neurological Research Institute at Texas Children's Hospital, Houston, TX, 77030, USA.
- Department of Neuroscience, Baylor College of Medicine, Houston, TX, USA.
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
- Development, Disease Models & Therapeutics Graduate Program, Baylor College of Medicine, Houston, TX, USA.
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13
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Hok P, Hvizdošová L, Otruba P, Kaiserová M, Trnečková M, Tüdös Z, Hluštík P, Kaňovský P, Nevrlý M. Botulinum toxin injection changes resting state cerebellar connectivity in cervical dystonia. Sci Rep 2021; 11:8322. [PMID: 33859210 PMCID: PMC8050264 DOI: 10.1038/s41598-021-87088-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 03/19/2021] [Indexed: 11/30/2022] Open
Abstract
In cervical dystonia, functional MRI (fMRI) evidence indicates changes in several resting state networks, which revert in part following the botulinum neurotoxin A (BoNT) therapy. Recently, the involvement of the cerebellum in dystonia has gained attention. The aim of our study was to compare connectivity between cerebellar subdivisions and the rest of the brain before and after BoNT treatment. Seventeen patients with cervical dystonia indicated for treatment with BoNT were enrolled (14 female, aged 50.2 ± 8.5 years, range 38-63 years). Clinical and fMRI examinations were carried out before and 4 weeks after BoNT injection. Clinical severity was evaluated using TWSTRS. Functional MRI data were acquired on a 1.5 T scanner during 8 min rest. Seed-based functional connectivity analysis was performed using data extracted from atlas-defined cerebellar areas in both datasets. Clinical scores demonstrated satisfactory BoNT effect. After treatment, connectivity decreased between the vermis lobule VIIIa and the left dorsal mesial frontal cortex. Positive correlations between the connectivity differences and the clinical improvement were detected for the right lobule VI, right crus II, vermis VIIIb and the right lobule IX. Our data provide evidence for modulation of cerebello-cortical connectivity resulting from successful treatment by botulinum neurotoxin.
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Affiliation(s)
- Pavel Hok
- Department of Neurology, University Hospital Olomouc, I. P. Pavlova 6, 77900, Olomouc, Czech Republic
- Department of Neurology, Faculty of Medicine and Dentistry of Palacký University Olomouc, Olomouc, Czech Republic
| | - Lenka Hvizdošová
- Department of Neurology, University Hospital Olomouc, I. P. Pavlova 6, 77900, Olomouc, Czech Republic
- Department of Neurology, Faculty of Medicine and Dentistry of Palacký University Olomouc, Olomouc, Czech Republic
| | - Pavel Otruba
- Department of Neurology, University Hospital Olomouc, I. P. Pavlova 6, 77900, Olomouc, Czech Republic
- Department of Neurology, Faculty of Medicine and Dentistry of Palacký University Olomouc, Olomouc, Czech Republic
| | - Michaela Kaiserová
- Department of Neurology, University Hospital Olomouc, I. P. Pavlova 6, 77900, Olomouc, Czech Republic
| | - Markéta Trnečková
- Department of Neurology, University Hospital Olomouc, I. P. Pavlova 6, 77900, Olomouc, Czech Republic
- Department of Computer Science, Faculty of Science of Palacký University Olomouc, Olomouc, Czech Republic
| | - Zbyněk Tüdös
- Department of Radiology, University Hospital Olomouc, Olomouc, Czech Republic
- Department of Radiology, Faculty of Medicine and Dentistry of Palacký University Olomouc, Olomouc, Czech Republic
| | - Petr Hluštík
- Department of Neurology, University Hospital Olomouc, I. P. Pavlova 6, 77900, Olomouc, Czech Republic
- Department of Neurology, Faculty of Medicine and Dentistry of Palacký University Olomouc, Olomouc, Czech Republic
| | - Petr Kaňovský
- Department of Neurology, University Hospital Olomouc, I. P. Pavlova 6, 77900, Olomouc, Czech Republic
- Department of Neurology, Faculty of Medicine and Dentistry of Palacký University Olomouc, Olomouc, Czech Republic
| | - Martin Nevrlý
- Department of Neurology, University Hospital Olomouc, I. P. Pavlova 6, 77900, Olomouc, Czech Republic.
- Department of Neurology, Faculty of Medicine and Dentistry of Palacký University Olomouc, Olomouc, Czech Republic.
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14
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Simonyan K, Barkmeier-Kraemer J, Blitzer A, Hallett M, Houde JF, Jacobson Kimberley T, Ozelius LJ, Pitman MJ, Richardson RM, Sharma N, Tanner K. Laryngeal Dystonia: Multidisciplinary Update on Terminology, Pathophysiology, and Research Priorities. Neurology 2021; 96:989-1001. [PMID: 33858994 DOI: 10.1212/wnl.0000000000011922] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/17/2021] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To delineate research priorities for improving clinical management of laryngeal dystonia, the NIH convened a multidisciplinary panel of experts for a 1-day workshop to examine the current progress in understanding its etiopathophysiology and clinical care. METHODS The participants reviewed the current terminology of disorder and discussed advances in understanding its pathophysiology since a similar workshop was held in 2005. Clinical and research gaps were identified, and recommendations for future directions were delineated. RESULTS The panel unanimously agreed to adopt the term "laryngeal dystonia" instead of "spasmodic dysphonia" to reflect the current progress in characterizations of this disorder. Laryngeal dystonia was recognized as a multifactorial, phenotypically heterogeneous form of isolated dystonia. Its etiology remains unknown, whereas the pathophysiology likely involves large-scale functional and structural brain network disorganization. Current challenges include the lack of clinically validated diagnostic markers and outcome measures and the paucity of therapies that address the disorder pathophysiology. CONCLUSION Research priorities should be guided by challenges in clinical management of laryngeal dystonia. Identification of disorder-specific biomarkers would allow the development of novel diagnostic tools and unified measures of treatment outcome. Elucidation of the critical nodes within neural networks that cause or modulate symptoms would allow the development of targeted therapies that address the underlying pathophysiology. Given the rarity of laryngeal dystonia, future rapid research progress may be facilitated by multicenter, national and international collaborations.
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Affiliation(s)
- Kristina Simonyan
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT.
| | - Julie Barkmeier-Kraemer
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
| | - Andrew Blitzer
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
| | - Mark Hallett
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
| | - John F Houde
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
| | - Teresa Jacobson Kimberley
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
| | - Laurie J Ozelius
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
| | - Michael J Pitman
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
| | - Robert Mark Richardson
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
| | - Nutan Sharma
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
| | - Kristine Tanner
- From the Department of Otolaryngology-Head and Neck Surgery (K.S.), Harvard Medical School and Massachusetts Eye and Ear, Boston, MA, Department of Neurology (K.S., L.J.O., N.S.), Massachusetts General Hospital, Boston, MA; Division of Otolaryngology (J.B.-K.), University of Utah, Salt Lake City, UT; New York Center for Voice and Swallowing Disorders and Department of Neurology (A.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Otolaryngology-Head and Neck Surgery (J.H.), University of California San Francisco, San Francisco, CA; School of Rehabilitation and Health Sciences (T.J.K.), Massachusetts General Hospital Institute of Health Professions, Boston, MA; Department of Otolaryngology-Head and Neck Surgery (M.J.P.), Columbia University Irving Medical Center, New York, NY; Department of Neurosurgery (R.M.R.), Massachusetts General Hospital, Boston, MA; and Department of Communication Disorders (K.T.), Brigham Young University, Provo, UT
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15
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van der Heijden ME, Kizek DJ, Perez R, Ruff EK, Ehrlich ME, Sillitoe RV. Abnormal cerebellar function and tremor in a mouse model for non-manifesting partially penetrant dystonia type 6. J Physiol 2021; 599:2037-2054. [PMID: 33369735 PMCID: PMC8559601 DOI: 10.1113/jp280978] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/16/2020] [Indexed: 12/21/2022] Open
Abstract
KEY POINTS Loss-of-function mutations in the Thap1 gene cause partially penetrant dystonia type 6 (DYT6). Some non-manifesting DYT6 mutation carriers have tremor and abnormal cerebello-thalamo-cortical signalling. We show that Thap1 heterozygote mice have action tremor, a reduction in cerebellar neuron number, and abnormal electrophysiological signals in the remaining neurons. These results underscore the importance of Thap1 levels for cerebellar function. These results uncover how cerebellar abnormalities contribute to different dystonia-associated motor symptoms. ABSTRACT Loss-of-function mutations in the Thanatos-associated domain-containing apoptosis-associated protein 1 (THAP1) gene cause partially penetrant autosomal dominant dystonia type 6 (DYT6). However, the neural abnormalities that promote the resultant motor dysfunctions remain elusive. Studies in humans show that some non-manifesting DYT6 carriers have altered cerebello-thalamo-cortical function with subtle but reproducible tremor. Here, we uncover that Thap1 heterozygote mice have action tremor that rises above normal baseline values even though they do not exhibit overt dystonia-like twisting behaviour. At the neural circuit level, we show using in vivo recordings in awake Thap1+/- mice that Purkinje cells have abnormal firing patterns and that cerebellar nuclei neurons, which connect the cerebellum to the thalamus, fire at a lower frequency. Although the Thap1+/- mice have fewer Purkinje cells and cerebellar nuclei neurons, the number of long-range excitatory outflow projection neurons is unaltered. The preservation of interregional connectivity suggests that abnormal neural function rather than neuron loss instigates the network dysfunction and the tremor in Thap1+/- mice. Accordingly, we report an inverse correlation between the average firing rate of cerebellar nuclei neurons and tremor power. Our data show that cerebellar circuitry is vulnerable to Thap1 mutations and that cerebellar dysfunction may be a primary cause of tremor in non-manifesting DYT6 carriers and a trigger for the abnormal postures in manifesting patients.
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Affiliation(s)
- Meike E. van der Heijden
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, Texas, USA
| | - Dominic J. Kizek
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, Texas, USA
| | - Ross Perez
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, Texas, USA
| | - Elena K. Ruff
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, Texas, USA
| | - Michelle E. Ehrlich
- Department of Neurology and Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Roy V. Sillitoe
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
- Department of Neuroscience, Baylor College of Medicine, Houston, Texas, USA
- Program in Developmental Biology, Baylor College of Medicine, Houston, Texas, USA
- Development, Disease Models & Therapeutics Graduate Program, Baylor College of Medicine, Houston, Texas, USA
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, Texas, USA
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16
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Khosravani S, Chen G, Ozelius LJ, Simonyan K. Neural endophenotypes and predictors of laryngeal dystonia penetrance and manifestation. Neurobiol Dis 2020; 148:105223. [PMID: 33316367 PMCID: PMC8284879 DOI: 10.1016/j.nbd.2020.105223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 12/08/2020] [Accepted: 12/09/2020] [Indexed: 11/29/2022] Open
Abstract
Focal dystonias are the most common forms of isolated dystonia; however, the etiopathophysiological signatures of disorder penetrance and clinical manifestation remain unclear. Using an imaging genetics approach, we investigated functional and structural representations of neural endophenotypes underlying the penetrance and manifestation of laryngeal dystonia in families, including 21 probands and 21 unaffected relatives, compared to 32 unrelated healthy controls. We further used a supervised machine-learning algorithm to predict the risk for dystonia development in susceptible individuals based on neural features of identified endophenotypes. We found that abnormalities in prefrontal-parietal cortex, thalamus, and caudate nucleus were commonly shared between patients and their unaffected relatives, representing an intermediate endophenotype of laryngeal dystonia. Machine learning classified 95.2% of unaffected relatives as patients rather than healthy controls, substantiating that these neural alterations represent the endophenotypic marker of dystonia penetrance, independent of its symptomatology. Additional abnormalities in premotor-parietal-temporal cortical regions, caudate nucleus, and cerebellum were present only in patients but not their unaffected relatives, likely representing a secondary endophenotype of dystonia manifestation. Based on alterations in the parietal cortex and caudate nucleus, the machine learning categorized 28.6% of unaffected relative as patients, indicating their increased lifetime risk for developing clinical manifestation of dystonia. The identified endophenotypic neural markers may be implemented for screening of at-risk individuals for dystonia development, selection of families for genetic studies of novel variants based on their risk for disease penetrance, or stratification of patients who would respond differently to a particular treatment in clinical trials.
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Affiliation(s)
- Sanaz Khosravani
- Department of Otolaryngology - Head & Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology - Head & Neck Surgery, Harvard Medical School, Boston, MA, USA
| | - Gang Chen
- National Institute of Mental Health, National Institute of Health, Bethesda, MD, USA
| | - Laurie J Ozelius
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Kristina Simonyan
- Department of Otolaryngology - Head & Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology - Head & Neck Surgery, Harvard Medical School, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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Teive HA, Chen CC. Isolated focal dystonia. Neurology 2020; 95:711-712. [DOI: 10.1212/wnl.0000000000010818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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A microstructural neural network biomarker for dystonia diagnosis identified by a DystoniaNet deep learning platform. Proc Natl Acad Sci U S A 2020; 117:26398-26405. [PMID: 33004625 PMCID: PMC7586425 DOI: 10.1073/pnas.2009165117] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
This research identified a microstructural neural network biomarker for objective and accurate diagnosis of isolated dystonia based on the disorder pathophysiology using an advanced deep learning algorithm, DystoniaNet, and raw structural brain images of large cohorts of patients with isolated focal dystonia and healthy controls. DystoniaNet significantly outperformed shallow machine-learning pipelines and substantially exceeded the current agreement rates between clinicians, reaching an overall accuracy of 98.8% in diagnosing different forms of isolated focal dystonia. These results suggest that DystoniaNet could serve as an objective, robust, and generalizable algorithmic platform of dystonia diagnosis for enhanced clinical decision-making. Implementation of the identified biomarker for objective and accurate diagnosis of dystonia may be transformative for clinical management of this disorder. Isolated dystonia is a neurological disorder of heterogeneous pathophysiology, which causes involuntary muscle contractions leading to abnormal movements and postures. Its diagnosis is remarkably challenging due to the absence of a biomarker or gold standard diagnostic test. This leads to a low agreement between clinicians, with up to 50% of cases being misdiagnosed and diagnostic delays extending up to 10.1 y. We developed a deep learning algorithmic platform, DystoniaNet, to automatically identify and validate a microstructural neural network biomarker for dystonia diagnosis from raw structural brain MRIs of 612 subjects, including 392 patients with three different forms of isolated focal dystonia and 220 healthy controls. DystoniaNet identified clusters in corpus callosum, anterior and posterior thalamic radiations, inferior fronto-occipital fasciculus, and inferior temporal and superior orbital gyri as the biomarker components. These regions are known to contribute to abnormal interhemispheric information transfer, heteromodal sensorimotor processing, and executive control of motor commands in dystonia pathophysiology. The DystoniaNet-based biomarker showed an overall accuracy of 98.8% in diagnosing dystonia, with a referral of 3.5% of cases due to diagnostic uncertainty. The diagnostic decision by DystoniaNet was computed in 0.36 s per subject. DystoniaNet significantly outperformed shallow machine-learning algorithms in benchmark comparisons, showing nearly a 20% increase in its diagnostic performance. Importantly, the microstructural neural network biomarker and its DystoniaNet platform showed substantial improvement over the current 34% agreement on dystonia diagnosis between clinicians. The translational potential of this biomarker is in its highly accurate, interpretable, and generalizable performance for enhanced clinical decision-making.
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de Lima Xavier L, Simonyan K. Neural Representations of the Voice Tremor Spectrum. Mov Disord 2020; 35:2290-2300. [PMID: 32976662 DOI: 10.1002/mds.28259] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 08/04/2020] [Accepted: 08/06/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Voice tremor is a common movement disorder that manifests as involuntary oscillations of laryngeal muscles, leading to rhythmic alterations in voice pitch and loudness. Differential diagnosis of essential tremor of voice (ETv) is often challenging and includes dystonic tremor of voice (DTv), which is characterized by irregular, isometric contractions of laryngeal muscles during dystonic activity. Although clinical characteristics of voice tremor are well described, the pathophysiology underlying its heterogeneous phenomenology remains limited. METHODS We used a multimodal approach of functional magnetic resonance imaging for assessment of brain activity during symptomatic speech production, high-resolution magnetic resonance imaging for the examination of cortical thickness and gray matter volume, and diffusion-weighted imaging for evaluation of white matter integrity to identify disorder-specific neural alterations and their relationships with the symptomatology of ETv and DTv. RESULTS We found a broad overlap between cortical alterations in ETv and DTv, involving sensorimotor regions responsible for the integration of multisensory information during speech production, such as primary sensorimotor, inferior/superior parietal, and inferior temporal cortices. In addition, ETv and DTv showed unique patterns of abnormalities in regions controlling speech motor preparation, which were localized in the cerebellum in ETv and the premotor cortex, insula, and superior temporal gyrus in DTv. Neural alterations in superior parietal and inferior temporal cortices were correlated with ETv severity, whereas changes in the left premotor cortex were associated with DTv severity. CONCLUSIONS Our findings point to the pathophysiological spectrum underlying ETv and DTv and favor a more heterogeneous rather than dichotomous diagnostic classification of these voice tremor disorders. © 2020 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Laura de Lima Xavier
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology - Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Kristina Simonyan
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology - Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
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What Is New in Laryngeal Dystonia: Review of Novel Findings of Pathophysiology and Novel Treatment Options. CURRENT OTORHINOLARYNGOLOGY REPORTS 2020. [DOI: 10.1007/s40136-020-00301-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Hanekamp S, Simonyan K. The large-scale structural connectome of task-specific focal dystonia. Hum Brain Mapp 2020; 41:3253-3265. [PMID: 32311207 PMCID: PMC7375103 DOI: 10.1002/hbm.25012] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/27/2020] [Accepted: 04/06/2020] [Indexed: 12/19/2022] Open
Abstract
The emerging view of dystonia is that of a large‐scale functional network disorder, in which the communication is disrupted between sensorimotor cortical areas, basal ganglia, thalamus, and cerebellum. The structural underpinnings of functional alterations in dystonia are, however, poorly understood. Notably, it is unclear whether structural changes form a larger‐scale dystonic network or rather remain focal to isolated brain regions, merely underlying their functional abnormalities. Using diffusion‐weighted imaging and graph theoretical analysis, we examined inter‐regional white matter connectivity of the whole‐brain structural network in two different forms of task‐specific focal dystonia, writer's cramp and laryngeal dystonia, compared to healthy individuals. We show that, in addition to profoundly altered functional network in focal dystonia, its structural connectome is characterized by large‐scale aberrations due to abnormal transfer of prefrontal and parietal nodes between neural communities and the reorganization of normal hub architecture, commonly involving the insula and superior frontal gyrus in patients compared to controls. Other prominent common changes involved the basal ganglia, parietal and cingulate cortical regions, whereas premotor and occipital abnormalities distinctly characterized the two forms of dystonia. We propose a revised pathophysiological model of focal dystonia as a disorder of both functional and structural connectomes, where dystonia form‐specific abnormalities underlie the divergent mechanisms in the development of distinct clinical symptomatology. These findings may guide the development of novel therapeutic strategies directed at targeted neuromodulation of pathophysiological brain regions for the restoration of their structural and functional connectivity.
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Affiliation(s)
- Sandra Hanekamp
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Kristina Simonyan
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
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