1
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Vogt L, Quiroz V, Ebrahimi-Fakhari D. Emerging therapies for childhood-onset movement disorders. Curr Opin Pediatr 2024; 36:331-341. [PMID: 38655812 PMCID: PMC11047116 DOI: 10.1097/mop.0000000000001354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW We highlight novel and emerging therapies in the treatment of childhood-onset movement disorders. We structured this review by therapeutic entity (small molecule drugs, RNA-targeted therapeutics, gene replacement therapy, and neuromodulation), recognizing that there are two main approaches to treatment: symptomatic (based on phenomenology) and molecular mechanism-based therapy or 'precision medicine' (which is disease-modifying). RECENT FINDINGS We highlight reports of new small molecule drugs for Tourette syndrome, Friedreich's ataxia and Rett syndrome. We also discuss developments in gene therapy for aromatic l-amino acid decarboxylase deficiency and hereditary spastic paraplegia, as well as current work exploring optimization of deep brain stimulation and lesioning with focused ultrasound. SUMMARY Childhood-onset movement disorders have traditionally been treated symptomatically based on phenomenology, but focus has recently shifted toward targeted molecular mechanism-based therapeutics. The development of precision therapies is driven by increasing capabilities for genetic testing and a better delineation of the underlying disease mechanisms. We highlight novel and exciting approaches to the treatment of genetic childhood-onset movement disorders while also discussing general challenges in therapy development for rare diseases. We provide a framework for molecular mechanism-based treatment approaches, a summary of specific treatments for various movement disorders, and a clinical trial readiness framework.
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Affiliation(s)
- Lindsey Vogt
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto Ontario, Canada
| | - Vicente Quiroz
- Movement Disorders Program, Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Darius Ebrahimi-Fakhari
- Movement Disorders Program, Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
- F.M. Kirby Neurobiology Center, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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2
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Decraene B, Smeets S, Remans D, Ortibus E, Vandenberghe W, Nuttin B, Theys T, De Vloo P. Deep Brain Stimulation for GNAO1-Associated Dystonia: A Systematic Review and Meta-Analysis. Neuromodulation 2024; 27:440-446. [PMID: 37999699 DOI: 10.1016/j.neurom.2023.10.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/30/2023] [Accepted: 10/11/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVES Guanine nucleotide-binding protein alpha-activating activity polypeptide O (GNAO1) syndrome, a rare congenital monogenetic disorder, is characterized by a neurodevelopmental syndrome and the presence of dystonia. Dystonia can be very pronounced and even lead to a life-threatening status dystonicus. In a small number of pharmaco-refractory cases, deep brain stimulation (DBS) has been attempted to reduce dystonia. In this study, we summarize the current literature on outcome, safety, and outcome predictors of DBS for GNAO1-associated dystonia. MATERIALS AND METHODS We conducted a systematic review and meta-analysis on individual patient data. We included 18 studies describing 28 unique patients. RESULTS The mean age of onset of symptoms was 2.4 years (SD 3.8); 16 of 28 patients were male, and dystonia was nearly always generalized (20/22 patients). Symptoms were present before DBS for a median duration of 19.5 months, although highly variable, occurring between 3 and 168 months. The exact phenotype, genotype, and radiologic abnormalities varied and seemed to be of little importance in terms of DBS outcome. All studies described an improvement in dystonia. Our meta-analysis focused on pallidal DBS and found an absolute and relative improvement in Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) of 32.5 points (37.9%; motor part; p = 0.001) and 5.8 points (21.5%; disability part; p = 0.043) at last follow-up compared with preoperative state; 80% of patients were considered responders (BFMDRS-M reduction by ≥25%). Although worsening over time does occur, an improvement was still observed in patients after >10 years. All reported cases of status dystonicus resolved after DBS surgery. Skin erosion and infection were observed in 18% of patients. CONCLUSION Pallidal DBS can be efficacious and safe in GNAO1-associated dystonia.
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Affiliation(s)
- Brecht Decraene
- Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, University of Leuven, Leuven, Belgium; Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium.
| | - Sara Smeets
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Daan Remans
- Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, University of Leuven, Leuven, Belgium
| | - Els Ortibus
- Department of Development and Regeneration, University of Leuven, Leuven, Belgium; Child Youth Institute, Leuven, Belgium
| | - Wim Vandenberghe
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium; Laboratory for Parkinson Research, Department of Neurosciences, University of Leuven, Leuven, Belgium
| | - Bart Nuttin
- Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, University of Leuven, Leuven, Belgium; Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Tom Theys
- Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, University of Leuven, Leuven, Belgium; Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Philippe De Vloo
- Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, University of Leuven, Leuven, Belgium; Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
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Romito LM, Leta V, Garavaglia B, Panteghini C, Zorzi G, Elia AE, Colucci F, Carecchio M, Eleopra R. Reply to: "Heterogeneous Phenotypic Evolution in ANO3-Related Dystonia Due to the Recurrent p.Glu510Lys Variant". Mov Disord 2024; 39:632-633. [PMID: 38525607 DOI: 10.1002/mds.29733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 03/26/2024] Open
Affiliation(s)
- Luigi M Romito
- Department of Clinical Neurosciences, Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Valentina Leta
- Department of Clinical Neurosciences, Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Parkinson's Centre of Excellence at King's College Hospital and King's College London, London, United Kingdom
| | - Barbara Garavaglia
- Medical Genetics and Neurogenetics Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Celeste Panteghini
- Medical Genetics and Neurogenetics Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giovanna Zorzi
- Department of Pediatric Neuroscience, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Antonio E Elia
- Department of Clinical Neurosciences, Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Fabiana Colucci
- Department of Clinical Neurosciences, Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | | | - Roberto Eleopra
- Department of Clinical Neurosciences, Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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4
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Rački V, Hero M, Papić E, Rožmarić G, Čizmarević NS, Chudy D, Peterlin B, Vuletić V. Applicability of clinical genetic testing for deep brain stimulation treatment in monogenic Parkinson's disease and monogenic dystonia: a multidisciplinary team perspective. Front Neurosci 2023; 17:1282267. [PMID: 38027472 PMCID: PMC10667448 DOI: 10.3389/fnins.2023.1282267] [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: 08/23/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
In this perspective article, we highlight the possible applicability of genetic testing in Parkinson's disease and dystonia patients treated with deep brain stimulation (DBS). DBS, a neuromodulatory technique employing electrical stimulation, has historically targeted motor symptoms in advanced PD and dystonia, yet its precise mechanisms remain elusive. Genetic insights have emerged as potential determinants of DBS efficacy. Known PD genes such as GBA, SNCA, LRRK2, and PRKN are most studied, even though further studies are required to make firm conclusions. Variable outcomes depending on genotype is present in genetic dystonia, as DYT-TOR1A, NBIA/DYTPANK2, DYT-SCGE and X-linked dystonia-parkinsonism have demonstrated promising outcomes following GPi-DBS, while varying outcomes have been documented in DYT-THAP1. We present two clinical vignettes that illustrate the applicability of genetics in clinical practice, with one PD patient with compound GBA mutations and one GNAL dystonia patient. Integrating genetic testing into clinical practice is pivotal, particularly with advancements in next-generation sequencing. However, there is a clear need for further research, especially in rarer monogenic forms. Our perspective is that applying genetics in PD and dystonia is possible today, and despite challenges, it has the potential to refine patient selection and enhance treatment outcomes.
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Affiliation(s)
- Valentino Rački
- Department of Neurology, Clinical Hospital Center Rijeka, Rijeka, Croatia
- Department of Neurology, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Mario Hero
- Department of Neurology, Clinical Hospital Center Rijeka, Rijeka, Croatia
- Department of Neurology, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Eliša Papić
- Department of Neurology, Clinical Hospital Center Rijeka, Rijeka, Croatia
- Department of Neurology, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Gloria Rožmarić
- Department of Neurology, Clinical Hospital Center Rijeka, Rijeka, Croatia
| | - Nada Starčević Čizmarević
- Department of Medical Genomics and Biology, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Darko Chudy
- Department of Neurosurgery, Clinical Hospital Dubrava, Zagreb, Croatia
| | - Borut Peterlin
- Clinical Institute of Genomic Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Vladimira Vuletić
- Department of Neurology, Clinical Hospital Center Rijeka, Rijeka, Croatia
- Department of Neurology, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
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Schuberth K, Ramani PK, Beemarajan E, Veerapandiyan A. Child Neurology: KMT2B-Related Dystonia in a Young Child With Worsening Gait Abnormality. Neurology 2023; 101:328-332. [PMID: 37041082 PMCID: PMC10437018 DOI: 10.1212/wnl.0000000000207300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 03/02/2023] [Indexed: 04/13/2023] Open
Abstract
KMT2B gene-related dystonia (DYT-KMT2B) is a primarily childhood-onset movement disorder that usually starts with lower limb dystonia progressing into generalized dystonia. Our patient described in this study experienced difficulty gaining weight, laryngomalacia, and feeding difficulties during infancy and later developed gait difficulties, frequent falls, and toe walking. Gait assessment revealed prominent bilateral intoeing, intermittent ankle inversion, and extension of left leg. At times, the gait seemed to be spastic. Whole-exome sequencing revealed a novel de novo heterozygous likely pathogenic variant, c.7913 T > A (p.V2638E), in the KMT2B gene located in chromosome 19. This variant, which has not been previously published as pathogenic or benign in the literature, can be added to the repertoire of KMT2B variants causing inherited dystonias.
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Affiliation(s)
- Kaitlyn Schuberth
- From the Division of Neurology, Department of Pediatrics (K.S., P.K.R., E.B., A.V.), Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Praveen K Ramani
- From the Division of Neurology, Department of Pediatrics (K.S., P.K.R., E.B., A.V.), Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Eniya Beemarajan
- From the Division of Neurology, Department of Pediatrics (K.S., P.K.R., E.B., A.V.), Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Aravindhan Veerapandiyan
- From the Division of Neurology, Department of Pediatrics (K.S., P.K.R., E.B., A.V.), Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR.
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6
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AlMajali M, Patel MS, Patel NK, Zhang JK, Tapia C, Bucholz RD, Chand P. A Technique of Deep Brain Stimulation of the Globus Pallidus Interna for Dystonia Under General Anesthesia With Sevoflurane. Cureus 2023; 15:e40819. [PMID: 37485182 PMCID: PMC10362972 DOI: 10.7759/cureus.40819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
Background Globus pallidus interna (GPi) deep brain stimulation (DBS) is an established surgical procedure that confers a benefit in medication refractory dystonia. Patients with generalized dystonia require general anesthesia (GA) for the surgery as their movements may hinder the surgical procedure. General anesthetics tend to dampen the microelectrode recordings (MERs) from the GPi. Methods We describe our experience with a series of consecutive patients with dystonia who underwent bilateral GPi DBS using standard DBS and MER under GA using sevoflurane as the maintenance general anesthetic drug. All patients had Medtronic 3,387 leads implanted and connected to an RC battery. Patients underwent sequential programming of the DBS after the surgery. Results The mean age of the 13 patients who underwent DBS of the GPi for dystonia was 46.5 years with a range from 29 to 71 years. Every patient in our case series received various doses of (1.37% to 2.11%) inhaled sevoflurane for anesthesia maintenance. Sevoflurane provided adequate anesthesia and allowed accurate MERs from the GPi. No adverse effects were encountered. On follow-up and sequential DBS programming, patients had significant improvements in dystonia attesting to the accuracy of the electrode placements. Conclusions We report our experience using sevoflurane for maintenance of GA for bilateral GPi DBS for dystonia. The main benefits identified have been adequate anesthesia and reduction of dystonia-related movements to allow the performance of the DBS surgery. The MER signals from the GPi were not suppressed by sevoflurane. This allowed accurate mapping and placement of the DBS implants in the GPi.
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Affiliation(s)
| | - Mayur S Patel
- Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Niel K Patel
- Internal Medicine, University of California San Diego, San Diego, USA
- Internal Medicine, Saint Louis University School of Medicine, St. Louis, USA
| | | | | | - Richard D Bucholz
- Neurological Surgery, Saint Louis University School of Medicine, Saint Louis, USA
| | - Pratap Chand
- Neurology, Saint Louis University School of Medicine, Saint Louis, USA
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7
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Zhao ZP, Nie C, Jiang CT, Cao SH, Tian KX, Yu S, Gu JW. Modulating Brain Activity with Invasive Brain-Computer Interface: A Narrative Review. Brain Sci 2023; 13:brainsci13010134. [PMID: 36672115 PMCID: PMC9856340 DOI: 10.3390/brainsci13010134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/17/2022] [Accepted: 01/05/2023] [Indexed: 01/15/2023] Open
Abstract
Brain-computer interface (BCI) can be used as a real-time bidirectional information gateway between the brain and machines. In particular, rapid progress in invasive BCI, propelled by recent developments in electrode materials, miniature and power-efficient electronics, and neural signal decoding technologies has attracted wide attention. In this review, we first introduce the concepts of neuronal signal decoding and encoding that are fundamental for information exchanges in BCI. Then, we review the history and recent advances in invasive BCI, particularly through studies using neural signals for controlling external devices on one hand, and modulating brain activity on the other hand. Specifically, regarding modulating brain activity, we focus on two types of techniques, applying electrical stimulation to cortical and deep brain tissues, respectively. Finally, we discuss the related ethical issues concerning the clinical application of this emerging technology.
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Affiliation(s)
- Zhi-Ping Zhao
- School of Biological Science and Medical Engineering, Beihang University, Beijing 100191, China
| | - Chuang Nie
- Strategic Support Force Medical Center, Beijing 100101, China
| | - Cheng-Teng Jiang
- Savaid Medical School, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Sheng-Hao Cao
- Brainnetome Center and National Laboratory of Pattern Recognition, Chinese Academy of Sciences, Beijing 100190, China
- School of Artificial Intelligence, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Kai-Xi Tian
- Brainnetome Center and National Laboratory of Pattern Recognition, Chinese Academy of Sciences, Beijing 100190, China
- School of Future Technology, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Shan Yu
- Brainnetome Center and National Laboratory of Pattern Recognition, Chinese Academy of Sciences, Beijing 100190, China
- School of Future Technology, University of Chinese Academy of Sciences, Beijing 100049, China
- Correspondence: (S.Y.); (J.-W.G.); Tel.: +86-010-8254-4786 (S.Y.); +86-010-6635-6729 (J.-W.G.)
| | - Jian-Wen Gu
- School of Biological Science and Medical Engineering, Beihang University, Beijing 100191, China
- Strategic Support Force Medical Center, Beijing 100101, China
- Correspondence: (S.Y.); (J.-W.G.); Tel.: +86-010-8254-4786 (S.Y.); +86-010-6635-6729 (J.-W.G.)
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Chudy D, Raguž M, Vuletić V, Rački V, Papić E, Nenadić Baranašić N, Barišić N. GPi DBS treatment outcome in children with monogenic dystonia: a case series and review of the literature. Front Neurol 2023; 14:1151900. [PMID: 37168666 PMCID: PMC10166204 DOI: 10.3389/fneur.2023.1151900] [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: 01/26/2023] [Accepted: 03/30/2023] [Indexed: 05/13/2023] Open
Abstract
Introduction Dystonia is the third most common pediatric movement disorder and is often difficult to treat. Deep brain stimulation (DBS) of the internal pallidum (GPi) has been demonstrated as a safe and effective treatment for genetic dystonia in adolescents and adults. The results of DBS in children are limited to individual cases or case series, although it has been proven to be an effective procedure in carefully selected pediatric cohorts. The aim of our study was to present the treatment outcome for 7- to 9-year-old pediatric patients with disabling monogenic isolated generalized DYT-THAP1 and DYT-KMT2B dystonia after bilateral GPi-DBS. Patients and results We present three boys aged <10 years; two siblings with disabling generalized DYT-THAP1 dystonia and a boy with monogenic-complex DYT-KMT2B. Dystonia onset occurred between the ages of 3 and 6. Significantly disabled children were mostly dependent on their parents. Pharmacotherapy was inefficient and patients underwent bilateral GPi-DBS. Clinical signs of dystonia improved significantly in the first month after the implantation and continued to maintain improved motor functions, which were found to have improved further at follow-up. These patients were ambulant without support and included in everyday activities. All patients had significantly lower Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) values, indicating >25% improvement over the first 15 months. However, there was a decline in speech and upper limb function, manifesting with bradylalia, bradykinesia, and dysphonia, which decreased after treatment with trihexyphenidyl. Conclusion Although reports of patients with monogenic dystonia, particularly DYT-THAP1, treated with DBS are still scarce, DBS should be considered as an efficient treatment approach in children with pharmacoresistent dystonia, especially with generalized monogenic dystonia and to prevent severe and disabling symptoms that reduce the quality of life, including emotional and social aspects. Patients require an individual approach and parents should be properly informed about expectations and possible outcomes, including relapses and impairments, in addition to DBS responsiveness and related improvements. Furthermore, early genetic diagnosis and the provision of appropriate treatments, including DBS, are mandatory for preventing severe neurologic impairments.
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Affiliation(s)
- Darko Chudy
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia
- Department of Surgery, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Marina Raguž
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia
- School of Medicine, Catholic University of Croatia, Zagreb, Croatia
- *Correspondence: Marina Raguž
| | - Vladimira Vuletić
- Department of Neurology, School of Medicine, University of Rijeka, Rijeka, Croatia
| | - Valentino Rački
- Department of Neurology, School of Medicine, University of Rijeka, Rijeka, Croatia
| | - Eliša Papić
- Department of Neurology, School of Medicine, University of Rijeka, Rijeka, Croatia
| | - Nataša Nenadić Baranašić
- Department of Pediatrics, University Hospital Centre, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Nina Barišić
- Department of Pediatrics, University Hospital Centre, School of Medicine, University of Zagreb, Zagreb, Croatia
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Romano M, Bagnato S, Altavista MC, Avanzino L, Belvisi D, Bologna M, Bono F, Carecchio M, Castagna A, Ceravolo R, Conte A, Cosentino G, Eleopra R, Ercoli T, Esposito M, Fabbrini G, Ferrazzano G, Lalli S, Mascia MM, Osio M, Pellicciari R, Petrucci S, Valente EM, Valentino F, Zappia M, Zibetti M, Girlanda P, Tinazzi M, Defazio G, Berardelli A. Diagnostic and therapeutic recommendations in adult dystonia: a joint document by the Italian Society of Neurology, the Italian Academy for the Study of Parkinson’s Disease and Movement Disorders, and the Italian Network on Botulinum Toxin. Neurol Sci 2022; 43:6929-6945. [DOI: 10.1007/s10072-022-06424-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 09/21/2022] [Indexed: 11/07/2022]
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10
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Garg K, Singh M, Samala R, Rajan R, Gulati S, Goyal V. Bilateral pallidotomy for acquired or heredodegenerative generalized dystonia in children. Neurosurg Focus 2022; 53:E12. [DOI: 10.3171/2022.7.focus22332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/18/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE
Dystonias are relatively rare disorders characterized by sustained or intermittent muscle contractions causing abnormal movements or postures. Generalized dystonia is a therapeutic challenge because medications are unable to control dystonia adequately in most patients. These patients may be candidates for surgical therapy. The commonly used surgical procedures in these patients are pallidotomy and deep brain stimulation. Limited studies are available on the role of pallidotomy in children with acquired/heredodegenerative generalized dystonia. The objective of this study was to describe the authors’ experience with bilateral pallidotomy in this group of patients.
METHODS
The authors retrospectively reviewed all pediatric patients (less than 18 years of age) with acquired/heredodegenerative generalized dystonia who underwent bilateral simultaneous pallidotomy at their center between January 2014 and January 2021. Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) scores before and after surgery were recorded. Complications arising after the procedure were recorded as well.
RESULTS
Ten patients (8 male and 2 female) with a mean (range) age of 11.1 (5–17) years were included in this study. The mean duration between disease onset and surgical intervention was 3.9 years. Two patients presented in status dystonicus. The mean ± SD (range) preoperative BFMDRS score of the patients without status dystonicus (n = 8) was 80 ± 18.9 (59.5–108). The mean ± SD BFMDRS score at the time of discharge from the hospital after surgery was 58.8 ± 37.9. Three patients had more than 20% change in BFMDRS score at the time of discharge from the hospital. The mean improvement was 25.5% at the end of 1 year. Of 5 surviving patients in the non–status dystonicus group, 3 patients had more than 40% change in BFMDRS score while the other 2 patients developed recurrence at the last follow-up (4.5 years). Status dystonicus abated after bilateral pallidotomy in both patients. Permanent bulbar complications were seen in 2 patients.
CONCLUSIONS
Bilateral pallidotomy may result in clinically significant improvement in children with acquired/heredodegenerative generalized dystonia, although the benefits should be closely weighed against the risk of irreversible bulbar dysfunction. It is a viable option for children in resource-limited settings.
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Affiliation(s)
- Kanwaljeet Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi
| | - Manmohan Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi
| | - Raghu Samala
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi
| | - Roopa Rajan
- Department of Neurology, All India Institute of Medical Sciences, New Delhi; and
| | - Sheffali Gulati
- Division of Child Neurology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Vinay Goyal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi; and
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11
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di Biase L, Di Santo A, Caminiti ML, Pecoraro PM, Carbone SP, Di Lazzaro V. Dystonia Diagnosis: Clinical Neurophysiology and Genetics. J Clin Med 2022; 11:jcm11144184. [PMID: 35887948 PMCID: PMC9320296 DOI: 10.3390/jcm11144184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/16/2022] [Indexed: 12/12/2022] Open
Abstract
Dystonia diagnosis is based on clinical examination performed by a neurologist with expertise in movement disorders. Clues that indicate the diagnosis of a movement disorder such as dystonia are dystonic movements, dystonic postures, and three additional physical signs (mirror dystonia, overflow dystonia, and geste antagonists/sensory tricks). Despite advances in research, there is no diagnostic test with a high level of accuracy for the dystonia diagnosis. Clinical neurophysiology and genetics might support the clinician in the diagnostic process. Neurophysiology played a role in untangling dystonia pathophysiology, demonstrating characteristic reduction in inhibition of central motor circuits and alterations in the somatosensory system. The neurophysiologic measure with the greatest evidence in identifying patients affected by dystonia is the somatosensory temporal discrimination threshold (STDT). Other parameters need further confirmations and more solid evidence to be considered as support for the dystonia diagnosis. Genetic testing should be guided by characteristics such as age at onset, body distribution, associated features, and coexistence of other movement disorders (parkinsonism, myoclonus, and other hyperkinesia). The aim of the present review is to summarize the state of the art regarding dystonia diagnosis focusing on the role of neurophysiology and genetic testing.
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Affiliation(s)
- Lazzaro di Biase
- Neurology Unit, Campus Bio-Medico University Hospital Foundation, Via Álvaro del Portillo 200, 00128 Rome, Italy; (A.D.S.); (M.L.C.); (P.M.P.); (S.P.C.); (V.D.L.)
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University of Rome, Via Álvaro del Portillo 21, 00128 Rome, Italy
- Brain Innovations Lab., Campus Bio-Medico University of Rome, Via Álvaro del Portillo 21, 00128 Rome, Italy
- Correspondence: or ; Tel.: +39-062-2541-1220
| | - Alessandro Di Santo
- Neurology Unit, Campus Bio-Medico University Hospital Foundation, Via Álvaro del Portillo 200, 00128 Rome, Italy; (A.D.S.); (M.L.C.); (P.M.P.); (S.P.C.); (V.D.L.)
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University of Rome, Via Álvaro del Portillo 21, 00128 Rome, Italy
| | - Maria Letizia Caminiti
- Neurology Unit, Campus Bio-Medico University Hospital Foundation, Via Álvaro del Portillo 200, 00128 Rome, Italy; (A.D.S.); (M.L.C.); (P.M.P.); (S.P.C.); (V.D.L.)
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University of Rome, Via Álvaro del Portillo 21, 00128 Rome, Italy
| | - Pasquale Maria Pecoraro
- Neurology Unit, Campus Bio-Medico University Hospital Foundation, Via Álvaro del Portillo 200, 00128 Rome, Italy; (A.D.S.); (M.L.C.); (P.M.P.); (S.P.C.); (V.D.L.)
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University of Rome, Via Álvaro del Portillo 21, 00128 Rome, Italy
| | - Simona Paola Carbone
- Neurology Unit, Campus Bio-Medico University Hospital Foundation, Via Álvaro del Portillo 200, 00128 Rome, Italy; (A.D.S.); (M.L.C.); (P.M.P.); (S.P.C.); (V.D.L.)
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University of Rome, Via Álvaro del Portillo 21, 00128 Rome, Italy
| | - Vincenzo Di Lazzaro
- Neurology Unit, Campus Bio-Medico University Hospital Foundation, Via Álvaro del Portillo 200, 00128 Rome, Italy; (A.D.S.); (M.L.C.); (P.M.P.); (S.P.C.); (V.D.L.)
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University of Rome, Via Álvaro del Portillo 21, 00128 Rome, Italy
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Deep brain stimulation in dystonia: factors contributing to variability in outcome in short and long term follow-up. Curr Opin Neurol 2022; 35:510-517. [PMID: 35787538 DOI: 10.1097/wco.0000000000001072] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Deep brain stimulation (DBS) is currently the most effective treatment for medically refractory dystonia with globus pallidus internus (GPi) usually the preferred target. Despite the overall success of DBS in dystonia, there remains variability in treatment outcome in both short and long-term follow-up, due to various factors. Factors contributing to variability in outcome comprise 'Dystonia Related' including dystonia classification, semiology, duration, body distribution, orthopaedic deformity, aetiology and genetic cause. The majority of these factors are identifiable from clinical assessment, brain MRI and genetic testing, and therefore merit careful preoperative consideration. 'DBS related' factors include brain target, accuracy of lead placement, stimulation parameters, time allowed for response, neurostimulation technology employed and DBS induced side-effects. In this review, factors contributing to variability in short and long-term dystonia DBS outcome are reviewed and discussed. RECENT FINDINGS The recognition of differential DBS benefit in monogenic dystonia, increasing experience with subthalamic nucleus (STN) DBS and in DBS for Meige syndrome, elucidation of DBS side effects and novel neurophysiological and imaging techniques to assist in predicting clinical outcome. SUMMARY Improved understanding of factors contributing to variability of DBS outcome in dystonia may assist in patient selection and predicting surgical outcomes.
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Buzo EL, De la Casa-Fages B, Sánchez MG, Sánchez JP, Carballal CF, Vidorreta JG, Sierra OM, Chicote AC, Grandas F. Pallidal deep brain stimulation response in two siblings with atypical adult-onset dystonia related to a KMT2B variant. J Neurol Sci 2022; 438:120295. [DOI: 10.1016/j.jns.2022.120295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/05/2022] [Accepted: 05/18/2022] [Indexed: 11/25/2022]
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