DBS in Dystonia and Other Hyperkinetic Movement Disorders

Subthalamic deep brain stimulation for refractory Gilles de la Tourette's syndrome: clinical outcome and functional connectivity

Background

Deep brain stimulation (DBS) is a promising novel approach for managing refractory Gilles de la Tourette’s syndrome (GTS). The subthalamic nucleus (STN) is the most common DBS target for treating movement disorders, and smaller case studies have reported the efficacy of bilateral STN-DBS treatment for relieving tic symptoms. However, management of GTS and treatment mechanism of STN-DBS in GTS remain to be elucidated.

Methods

Ten patients undergoing STN-DBS were included. Tics severity was evaluated using the Yale Global Tic Severity Scale. The severities of comorbid psychiatric symptoms of obsessive–compulsive behavior (OCB), attention-deficit/hyperactivity disorder, anxiety, and depression; social and occupational functioning; and quality of life were assessed. Volumes of tissue activated were used as seed points for functional connectivity analysis performed using a control dataset.

Results

The overall tics severity significantly reduced, with 62.9% ± 26.2% and 58.8% ± 27.2% improvements at the 6- and 12-months follow-up, respectively. All three patients with comorbid OCB showed improvement in their OCB symptoms at both the follow-ups. STN-DBS treatment was reasonably well tolerated by the patients with GTS. The most commonly reported side effect was light dysarthria. The stimulation effect of STN-DBS might regulate these symptoms through functional connectivity with the thalamus, pallidum, substantia nigra pars reticulata, putamen, insula, and anterior cingulate cortices.

Conclusions

STN-DBS was associated with symptomatic improvement in severe and refractory GTS without significant adverse events. The STN is a promising DBS target by stimulating both sensorimotor and limbic subregions, and specific brain area doses affect treatment outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-022-11266-w.

Long-term Outcome of Deep Brain Stimulation in Intralaminar Thalamus for Refractory Tourette Syndrome: A Case Report

BACKGROUND: Tourette syndrome (TS) is a neurobehavioral disease that has onset at an early age around 5–7 years old. This disease affects 0.3–0.8% of young age population. With criteria diagnosis at least one vocal and two motor tics beginning before 18 years old. The symptoms of tics remain unusual from a social point of view, thus making it difficult for patients to evolve their professional life and education level. We present a case report of a young male patient with refractory TS with a Yale Global Tic Severity Scale (YGTSS) score of 88 out of 100; he has experienced remarkable improvement after undergoing a deep brain stimulation (DBS) procedure. CASE REPORT: A 23-year-old male came to our neurosurgery outpatient clinic who had had a history of TS since 8 years ago. He had facial and jumping-type tics. Lately, his jumping movements cannot be controlled, with increasing frequency and intensity. The maximum tic-free interval is only 30 min. On 1st-time evaluation in the neurosurgery outpatient clinic, he scored 88 out 0f 100 on the YGTSS even after medication treatment, repetitive transcranial magnetic stimulation, and behavioral therapies. The DBS procedure was carried out in November 2018 with targets on the bilateral intralaminar nuclei of thalamus (centromedian nucleus). The result is convincing, with decrease of YGTSS score until 14 after 3 years evaluation postsurgery. CONCLUSION: After performing DBS targeting the bilateral thalamus (central thalamus nucleus), the severity of tic was dramatically reduced. The result is pleasing to the patient as they can resume activity in public and return to college. Case reports regarding the treatment of refractory TS with DBS are still rare in Indonesia. To the best of our knowledge, this is the first such report with long-term follow-up in South East Asia.

Deep brain stimulation for Tourette's syndrome

Tourette syndrome (TS) is a childhood-onset neuropsychiatric disorder characterized by the presence of multiple motor and vocal tics. TS usually co-occurs with one or multiple psychiatric disorders. Although behavioral and pharmacological treatments for TS are available, some patients do not respond to the available treatments. For these patients, TS is a severe, chronic, and disabling disorder. In recent years, deep brain stimulation (DBS) of basal ganglia-thalamocortical networks has emerged as a promising intervention for refractory TS with or without psychiatric comorbidities. Three major challenges need to be addressed to move the field of DBS treatment for TS forward: (1) patient and DBS target selection, (2) ethical concerns with treating pediatric patients, and (3) DBS treatment optimization and improvement of individual patient outcomes (motor and phonic tics, as well as functioning and quality of life). The Tourette Association of America and the American Academy of Neurology have recently released their recommendations regarding surgical treatment for refractory TS. Here, we describe the challenges, advancements, and promises of the use of DBS in the treatment of TS. We summarize the results of clinical studies and discuss the ethical issues involved in treating pediatric patients. Our aim is to provide a better understanding of the feasibility, safety, selection process, and clinical effectiveness of DBS treatment for select cases of severe and medically intractable TS.

Potential indications for deep brain stimulation in neurological disorders: an evolving field

Deep brain stimulation (DBS) is an established therapy for appropriately selected patients with movement disorders and neuropsychiatric conditions. Although the exact mechanisms and biology of DBS are not fully understood, it is a safe and well-tolerated therapy for many refractory cases of neuropsychiatric disease. Increasingly, DBS has been explored in other conditions with encouraging results. In this paper, available data is reviewed and new DBS targets, challenges and future directions in neurological disorders are explored. A detailed search of the medical literature discussing the potential use of DBS for neurological disorders excluding accepted indications was conducted. All reports were analyzed individually for content and redundant articles were excluded by examining individual abstracts. The level of evidence for each indication was summarized. Multiple studies report promising preliminary data regarding the safety and efficacy of DBS for a variety of neurological indications including chronic pain, tinnitus, epilepsy, Tourette syndrome, Huntington's disease, tardive dyskinesia and Alzheimer's disease. The initial results of DBS studies for diverse neurological disorders are encouraging but larger, controlled, prospective, homogeneous clinical trials are necessary to establish long-term safety and effectiveness. The field of neuromodulation continues to evolve and advances in DBS technology, stereotactic techniques, neuroimaging and DBS programming capabilities are shaping the present and future of DBS research and use in practice.