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Arnts H, Coolen SE, Fernandes FW, Schuurman R, Krauss JK, Groenewegen HJ, van den Munckhof P. The intralaminar thalamus: a review of its role as a target in functional neurosurgery. Brain Commun 2023; 5:fcad003. [PMID: 37292456 PMCID: PMC10244065 DOI: 10.1093/braincomms/fcad003] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 10/06/2022] [Accepted: 01/03/2023] [Indexed: 09/29/2023] Open
Abstract
The intralaminar thalamus, in particular the centromedian-parafascicular complex, forms a strategic node between ascending information from the spinal cord and brainstem and forebrain circuitry that involves the cerebral cortex and basal ganglia. A large body of evidence shows that this functionally heterogeneous region regulates information transmission in different cortical circuits, and is involved in a variety of functions, including cognition, arousal, consciousness and processing of pain signals. Not surprisingly, the intralaminar thalamus has been a target area for (radio)surgical ablation and deep brain stimulation (DBS) in different neurological and psychiatric disorders. Historically, ablation and stimulation of the intralaminar thalamus have been explored in patients with pain, epilepsy and Tourette syndrome. Moreover, DBS has been used as an experimental treatment for disorders of consciousness and a variety of movement disorders. In this review, we provide a comprehensive analysis of the underlying mechanisms of stimulation and ablation of the intralaminar nuclei, historical clinical evidence, and more recent (experimental) studies in animals and humans to define the present and future role of the intralaminar thalamus as a target in the treatment of neurological and psychiatric disorders.
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Affiliation(s)
- Hisse Arnts
- Department of Neurosurgery, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stan E Coolen
- Department of Neurosurgery, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | | | - Rick Schuurman
- Department of Neurosurgery, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Henk J Groenewegen
- Department of Anatomy and Neurosciences, Neuroscience Campus Amsterdam, Amsterdam University Medical Centers, location VU University Medical Center, Amsterdam, The Netherlands
| | - Pepijn van den Munckhof
- Department of Neurosurgery, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
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Cui ZQ, Wang J, Mao ZQ, Pan LS, Jiang C, Gao QY, Ling ZP, Xu BN, Yu XG, Zhang JN, Chen T. Long-term efficacy, prognostic factors, and safety of deep brain stimulation in patients with refractory Tourette syndrome: A single center, single target, retrospective study. J Psychiatr Res 2022; 151:523-530. [PMID: 35636027 DOI: 10.1016/j.jpsychires.2022.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/11/2022] [Accepted: 05/19/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND To evaluate the long-term efficacy, prognostic factors, and safety of posteroventral globus pallidus internus deep brain stimulation (DBS) in patients with refractory Tourette syndrome (RTS). METHODS This retrospective study recruited 61 patients with RTS who underwent posteroventral globus pallidus internus (GPi) DBS from January 2010 to December 2020 at the Chinese People's Liberation Army General Hospital. The Yale Global Tic Severity Scale (YGTSS), Yale-Brown Obsessive-Compulsive Scale (YBOCS), Beck Depression Inventory (BDI), Gilles de la Tourette Syndrome Quality-of-Life Scale (GTS-QOL) were used to evaluate the preoperative and postoperative clinical condition in all patients. Prognostic factors and adverse events following surgery were analyzed. RESULTS Patient follow up was conducted for an average of 73.33 ± 28.44 months. The final postoperative YGTSS (32.39 ± 22.34 vs 76.61 ± 17.07), YBOCS (11.26 ± 5.57 vs 18.31 ± 8.55), BDI (14.36 ± 8.16 vs 24.79 ± 11.03) and GTS-QOL (39.69 ± 18.29 vs 78.08 ± 14.52) scores at the end of the follow-up period were significantly lower than those before the surgery (p < 0.05). While age and the duration of follow-up were closely related to prognosis, the disease duration and gender were not. No serious adverse events were observed and only one patient exhibited symptomatic deterioration. CONCLUSIONS Posteroventral-GPI DBS provides long-term effectiveness, acceptable safety and can improve the quality of life in RTS patients. Moreover, DBS is more successful among younger patients and with longer treatment duration.
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Affiliation(s)
- Zhi-Qiang Cui
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, 100853, China
| | - Jian Wang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, 100853, China
| | - Zhi-Qi Mao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, 100853, China
| | - Long-Sheng Pan
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, 100853, China
| | - Chao Jiang
- Hebei Key Laboratory for Chronic Diseases, Tangshan Key Laboratory for Preclinical and Basic Research on Chronic Diseases, School of Basic Medical Sciences, North China University of Science and Technology, Tangshan, Hebei, 063210, China
| | - Qing-Yao Gao
- Hebei Key Laboratory for Chronic Diseases, Tangshan Key Laboratory for Preclinical and Basic Research on Chronic Diseases, School of Basic Medical Sciences, North China University of Science and Technology, Tangshan, Hebei, 063210, China
| | - Zhi-Pei Ling
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, 100853, China
| | - Bai-Nan Xu
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, 100853, China
| | - Xin-Guang Yu
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, 100853, China
| | - Jian-Ning Zhang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, 100853, China
| | - Tong Chen
- Department of Neurology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China.
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Inggas MAM, Dianata DAI, Situmeang RFV, Wahjoepramono EJ, Kaido T. Long-term Outcome of Deep Brain Stimulation in Intralaminar Thalamus for Refractory Tourette Syndrome: A Case Report. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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.
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Szejko N, Worbe Y, Hartmann A, Visser-Vandewalle V, Ackermans L, Ganos C, Porta M, Leentjens AFG, Mehrkens JH, Huys D, Baldermann JC, Kuhn J, Karachi C, Delorme C, Foltynie T, Cavanna AE, Cath D, Müller-Vahl K. European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part IV: deep brain stimulation. Eur Child Adolesc Psychiatry 2022; 31:443-461. [PMID: 34605960 PMCID: PMC8940783 DOI: 10.1007/s00787-021-01881-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 09/15/2021] [Indexed: 12/13/2022]
Abstract
In 2011 the European Society for the Study of Tourette Syndrome (ESSTS) published its first European clinical guidelines for the treatment of Tourette Syndrome (TS) with part IV on deep brain stimulation (DBS). Here, we present a revised version of these guidelines with updated recommendations based on the current literature covering the last decade as well as a survey among ESSTS experts. Currently, data from the International Tourette DBS Registry and Database, two meta-analyses, and eight randomized controlled trials (RCTs) are available. Interpretation of outcomes is limited by small sample sizes and short follow-up periods. Compared to open uncontrolled case studies, RCTs report less favorable outcomes with conflicting results. This could be related to several different aspects including methodological issues, but also substantial placebo effects. These guidelines, therefore, not only present currently available data from open and controlled studies, but also include expert knowledge. Although the overall database has increased in size since 2011, definite conclusions regarding the efficacy and tolerability of DBS in TS are still open to debate. Therefore, we continue to consider DBS for TS as an experimental treatment that should be used only in carefully selected, severely affected and otherwise treatment-resistant patients.
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Affiliation(s)
- Natalia Szejko
- Department of Neurology, Medical University of Warsaw, Banacha 1a, 02-091, Warsaw, Poland.
- Department of Bioethics, Medical University of Warsaw, Banacha 1a, 02-091, Warsaw, Poland.
- Department of Neurology, Yale School of Medicine, Yale University, New Haven, USA.
| | - Yulia Worbe
- Department on Neurophysiology, Saint Antoine Hospital, Sorbonne Université, Paris, France
- National Reference Center for Tourette Disorder, Pitié Salpetiere Hospital, Paris, France
| | - Andreas Hartmann
- Department of Neurosurgery, Pitié-Salpetriere Hospital, Sorbonne Université, Paris, France
| | - Veerle Visser-Vandewalle
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Linda Ackermans
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Christos Ganos
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Mauro Porta
- Department of Neurosurgery and Neurology, IRCCS Instituto Ortopedico Galeazzi, Milan, Italy
| | - Albert F G Leentjens
- Department of Psychiatry, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan-Hinnerk Mehrkens
- Department of Neurosurgery, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Daniel Huys
- Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany
| | | | - Jens Kuhn
- Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Johanniter Hospital Oberhausen, Oberhausen, Germany
| | - Carine Karachi
- National Reference Center for Tourette Disorder, Pitié Salpetiere Hospital, Paris, France
- Department of Neurosurgery, Pitié-Salpetriere Hospital, Sorbonne Université, Paris, France
- Department of Neurology, Pitié-Salpetriere Hospital, Sorbonne Université, Paris, France
| | - Cécile Delorme
- Department of Neurosurgery, Pitié-Salpetriere Hospital, Sorbonne Université, Paris, France
| | - Thomas Foltynie
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
| | - Andrea E Cavanna
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Danielle Cath
- Department of Specialist Trainings, GGZ Drenthe Mental Health Institution, Assen, The Netherlands
- Department of Psychiatry, University Medical Center Groningen, Rijks University Groningen, Groningen, The Netherlands
| | - Kirsten Müller-Vahl
- Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
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Wehmeyer L, Schüller T, Kiess J, Heiden P, Visser-Vandewalle V, Baldermann JC, Andrade P. Target-Specific Effects of Deep Brain Stimulation for Tourette Syndrome: A Systematic Review and Meta-Analysis. Front Neurol 2021; 12:769275. [PMID: 34744993 PMCID: PMC8563609 DOI: 10.3389/fneur.2021.769275] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/21/2021] [Indexed: 01/09/2023] Open
Abstract
Background: Extended research has pointed to the efficacy of deep brain stimulation (DBS) in treatment of patients with treatment-refractory Tourette syndrome (TS). The four most commonly used DBS targets for TS include the centromedian nucleus-nucleus ventrooralis internus (CM-Voi) and the centromedian nucleus-parafascicular (CM-Pf) complexes of the thalamus, and the posteroventrolateral (pvIGPi) and the anteromedial portion of the globus pallidus internus (amGPi). Differences and commonalities between those targets need to be compared systematically. Objective: Therefore, we evaluated whether DBS is effective in reducing TS symptoms and target-specific differences. Methods: A PubMed literature search was conducted according to the PRISMA guidelines. Eligible literature was used to conduct a systematic review and meta-analysis. Results: In total, 65 studies with 376 patients were included. Overall, Yale Global Tic Severity Scale (YGTSS) scores were reduced by more than 50 in 69% of the patients. DBS also resulted in significant reductions of secondary outcome measures, including the total YGTSS, modified Rush Video-Based Tic Rating Scale (mRVRS), Yale-Brown Obsessive Compulsive Scale (YBOCS), and Becks Depression Inventory (BDI). All targets resulted in significant reductions of YGTSS scores and, with the exception of the CM-Pf, also in reduced YBOCS scores. Interestingly, DBS of pallidal targets showed increased YGTSS and YBOCS reductions compared to thalamic targets. Also, the meta-analysis including six randomized controlled and double-blinded trials demonstrated clinical efficacy of DBS for TS, that remained significant for GPi but not thalamic stimulation in two separate meta-analyses. Conclusion: We conclude that DBS is a clinically effective treatment option for patients with treatment-refractory TS, with all targets showing comparable improvement rates. Future research might focus on personalized and symptom-specific target selection.
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Affiliation(s)
- Laura Wehmeyer
- Faculty of Medicine and University Hospital Cologne, Department of Stereotactic and Functional Neurosurgery, University of Cologne, Cologne, Germany,*Correspondence: Laura Wehmeyer
| | - Thomas Schüller
- Faculty of Medicine and University Hospital Cologne, Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany
| | - Jana Kiess
- Faculty of Medicine and University Hospital Cologne, Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany
| | - Petra Heiden
- Faculty of Medicine and University Hospital Cologne, Department of Stereotactic and Functional Neurosurgery, University of Cologne, Cologne, Germany
| | - Veerle Visser-Vandewalle
- Faculty of Medicine and University Hospital Cologne, Department of Stereotactic and Functional Neurosurgery, University of Cologne, Cologne, Germany
| | - Juan Carlos Baldermann
- Faculty of Medicine and University Hospital Cologne, Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany,Faculty of Medicine and University Hospital Cologne, Department of Neurology, University of Cologne, Cologne, Germany
| | - Pablo Andrade
- Faculty of Medicine and University Hospital Cologne, Department of Stereotactic and Functional Neurosurgery, University of Cologne, Cologne, Germany
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Mahajan UV, Purger DA, Mantovani A, Williams NR, Espil FM, Han SS, Stein SC, Halpern CH. Deep Brain Stimulation Results in Greater Symptomatic Improvement in Tourette Syndrome than Conservative Measures: A Meta-Analysis. Stereotact Funct Neurosurg 2020; 98:270-277. [PMID: 32434201 DOI: 10.1159/000507059] [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: 09/24/2019] [Accepted: 03/06/2020] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Deep brain stimulation (DBS) has emerged as a safe and effective therapy for refractory Tourette syndrome (TS). Recent studies have identified several neural targets as effective in reducing TS symptoms with DBS, but, to our knowledge, none has compared the effectiveness of DBS with conservative therapy. METHODS A literature review was performed to identify studies investigating adult patient outcomes reported as Yale Global Tic Severity Scale (YGTSS) scores after DBS surgery, pharmacotherapy, and psychotherapy. Data were pooled using a random-effects model of inverse variance-weighted meta-analysis (n = 168 for DBS, n = 131 for medications, and n = 154 for behavioral therapy). RESULTS DBS resulted in a significantly greater reduction in YGTSS total score (49.9 ± 17.5%) than pharmacotherapy (22.5 ± 15.2%, p = 0.001) or psychotherapy (20.0 ± 11.3%, p < 0.001), with a complication (adverse effect) rate of 0.15/case, 1.13/case, and 0.60/case, respectively. CONCLUSION Our data suggest that adult patients with refractory TS undergoing DBS experience greater symptomatic improvement with surprisingly low morbidity than can be obtained with pharmacotherapy or psychotherapy.
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Affiliation(s)
- Uma V Mahajan
- Case Western Reserve University, Cleveland, Ohio, USA
| | - David A Purger
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Alessandra Mantovani
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Nolan R Williams
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Flint M Espil
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Summer S Han
- Neurosurgery and Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California, USA
| | - Sherman C Stein
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA,
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Kaido T, Hirabayashi H, Murase N, Sasaki R, Shimokawara T, Nagata K, Bando C, Aono Y. Deep slow nasal respiration with tight lip closure for immediate attenuation of severe tics. J Clin Neurosci 2020; 77:67-74. [PMID: 32417125 DOI: 10.1016/j.jocn.2020.05.037] [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: 04/10/2020] [Accepted: 05/03/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Severe intractable tics, which are associated with Tourette syndrome and chronic tic disorder (TS/CTD), severely affect the quality of life. Common less-invasive treatments are often unable to attenuate tics with deep brain stimulation currently being the only effective treatment. We aimed to assess the anti-tic effect of deep slow nasal respiration with tight lip closure using patients with TS/CTD. METHODS We retrospectively analyzed 10 consecutive patients (9 men, 1 woman; 23-41 years old). We instructed the patients to perform the procedure for 120 s and to obtain a video recording of before and during the procedure. The videos were used to count tics and determine lip competency or incompetency. The counted tics were rated using the modified Rush Video Rating Scale. RESULTS Compared with before the procedure, there were significantly lower frequencies of motor and phonic tics, as well as video scored, during the procedure. Eight patients presented with lip incompetency before the procedure and none after the procedure (P = 0.041). There were no side effects associated with the procedure. CONCLUSION Our findings indicate that deep slow nasal respiration with tight lip closure ameliorates tics in patients with TS/CTD. In accordance with our results, lip opening and oral breathing could be causes of tics, in addition to heritability. Therefore, this novel procedure could improve tics. Furthermore, our findings could contribute toward the development of tic treatments and elucidate their pathophysiology regarding the reward system, hypersensitivity, autonomic nerves, and nasal airway.
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Affiliation(s)
- Takanobu Kaido
- Department of Neurosurgery, National Hospital Organization Nara Medical Center, Nara, Japan; Anatomy and Physiology Laboratory, Department of Health and Nutrition, Osaka Shoin Women's University, Higashiosaka, Japan.
| | - Hidehiro Hirabayashi
- Department of Neurosurgery, National Hospital Organization Nara Medical Center, Nara, Japan
| | - Nagako Murase
- Department of Neurology, National Hospital Organization Nara Medical Center, Nara, Japan
| | - Ryota Sasaki
- Department of Neurosurgery, National Hospital Organization Nara Medical Center, Nara, Japan
| | - Tatsuo Shimokawara
- Department of Neurosurgery, National Hospital Organization Nara Medical Center, Nara, Japan
| | - Kiyoshi Nagata
- Department of Neurosurgery, National Hospital Organization Nara Medical Center, Nara, Japan
| | - Chiaki Bando
- Department of Internal Medicine, National Hospital Organization Nara Medical Center, Nara, Japan
| | - Yuka Aono
- Anatomy and Physiology Laboratory, Department of Health and Nutrition, Osaka Shoin Women's University, Higashiosaka, Japan
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Xu W, Zhang C, Deeb W, Patel B, Wu Y, Voon V, Okun MS, Sun B. Deep brain stimulation for Tourette's syndrome. Transl Neurodegener 2020; 9:4. [PMID: 31956406 PMCID: PMC6956485 DOI: 10.1186/s40035-020-0183-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 01/05/2020] [Indexed: 01/11/2023] Open
Abstract
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.
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Affiliation(s)
- Wenying Xu
- 1Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, 197 Ruijin Er Road, Shanghai, 200025 China
| | - Chencheng Zhang
- 1Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, 197 Ruijin Er Road, Shanghai, 200025 China
| | - Wissam Deeb
- 2Norman Fixel Institute for Neurological Diseases, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL 32608 USA
| | - Bhavana Patel
- 2Norman Fixel Institute for Neurological Diseases, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL 32608 USA
| | - Yiwen Wu
- 3Department of Neurology & Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Valerie Voon
- 1Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, 197 Ruijin Er Road, Shanghai, 200025 China.,4Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Michael S Okun
- 2Norman Fixel Institute for Neurological Diseases, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL 32608 USA
| | - Bomin Sun
- 1Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, 197 Ruijin Er Road, Shanghai, 200025 China
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Kimura Y, Ikegaya N, Iijima K, Takayama Y, Kaneko Y, Omori M, Kaido T, Kano Y, Iwasaki M. Withdrawal of deep brain stimulation in patients with gilles de la tourette syndrome. Mov Disord 2019; 34:1925-1926. [PMID: 31737941 DOI: 10.1002/mds.27909] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 09/11/2019] [Accepted: 09/27/2019] [Indexed: 11/07/2022] Open
Affiliation(s)
- Yuiko Kimura
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Naoki Ikegaya
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Keiya Iijima
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Yutaro Takayama
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Yuu Kaneko
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Mayu Omori
- Department of Psychiatry, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Takanobu Kaido
- Department of Health and Nutrition, Osaka Shoin Women's University, Higashi-Osaka, Osaka, Japan
| | - Yukiko Kano
- Department of Child Neuropsychiatry, Graduated School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masaki Iwasaki
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
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10
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Pandey S, Dash D. Progress in Pharmacological and Surgical Management of Tourette Syndrome and Other Chronic Tic Disorders. Neurologist 2019; 24:93-108. [DOI: 10.1097/nrl.0000000000000218] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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11
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Casagrande SCB, Cury RG, Alho EJL, Fonoff ET. Deep brain stimulation in Tourette's syndrome: evidence to date. Neuropsychiatr Dis Treat 2019; 15:1061-1075. [PMID: 31114210 PMCID: PMC6497003 DOI: 10.2147/ndt.s139368] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Tourette's syndrome (TS) is a neurodevelopmental disorder that comprises vocal and motor tics associated with a high frequency of psychiatric comorbidities, which has an important impact on quality of life. The onset is mainly in childhood and the symptoms can either fade away or require pharmacological therapies associated with cognitive-behavior therapies. In rare cases, patients experience severe and disabling symptoms refractory to conventional treatments. In these cases, deep brain stimulation (DBS) can be considered as an interesting and effective option for symptomatic control. DBS has been studied in numerous trials as a therapy for movement disorders, and currently positive data supports that DBS is partially effective in reducing the motor and non-motor symptoms of TS. The average response, mostly from case series and prospective cohorts and only a few controlled studies, is around 40% improvement on tic severity scales. The ventromedial thalamus has been the preferred target, but more recently the globus pallidus internus has also gained some notoriety. The mechanism by which DBS is effective on tics and other symptoms in TS is not yet understood. As refractory TS is not common, even reference centers have difficulties in performing large controlled trials. However, studies that reproduce the current results in larger and multicenter randomized controlled trials to improve our knowledge so as to support the best target and stimulation settings are still lacking. This article will discuss the selection of the candidates, DBS targets and mechanisms on TS, and clinical evidence to date reviewing current literature about the use of DBS in the treatment of TS.
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Affiliation(s)
- Sara C B Casagrande
- Department of Neurology, School of Medicine, Movement Disorders Center, University of São Paulo, São Paulo, Brazil
| | - Rubens G Cury
- Department of Neurology, School of Medicine, Movement Disorders Center, University of São Paulo, São Paulo, Brazil
| | - Eduardo J L Alho
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo, Brazil,
| | - Erich Talamoni Fonoff
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo, Brazil,
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Neumann WJ, Turner RS, Blankertz B, Mitchell T, Kühn AA, Richardson RM. Toward Electrophysiology-Based Intelligent Adaptive Deep Brain Stimulation for Movement Disorders. Neurotherapeutics 2019; 16:105-118. [PMID: 30607748 PMCID: PMC6361070 DOI: 10.1007/s13311-018-00705-0] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Deep brain stimulation (DBS) represents one of the major clinical breakthroughs in the age of translational neuroscience. In 1987, Benabid and colleagues demonstrated that high-frequency stimulation can mimic the effects of ablative neurosurgery in Parkinson's disease (PD), while offering two key advantages to previous procedures: adjustability and reversibility. Deep brain stimulation is now an established therapeutic approach that robustly alleviates symptoms in patients with movement disorders, such as Parkinson's disease, essential tremor, and dystonia, who present with inadequate or adverse responses to medication. Currently, stimulation electrodes are implanted in specific target regions of the basal ganglia-thalamic circuit and stimulation pulses are delivered chronically. To achieve optimal therapeutic effect, stimulation frequency, amplitude, and pulse width must be adjusted on a patient-specific basis by a movement disorders specialist. The finding that pathological neural activity can be sampled directly from the target region using the DBS electrode has inspired a novel DBS paradigm: closed-loop adaptive DBS (aDBS). The goal of this strategy is to identify pathological and physiologically normal patterns of neuronal activity that can be used to adapt stimulation parameters to the concurrent therapeutic demand. This review will give detailed insight into potential biomarkers and discuss next-generation strategies, implementing advances in artificial intelligence, to further elevate the therapeutic potential of DBS by capitalizing on its modifiable nature. Development of intelligent aDBS, with an ability to deliver highly personalized treatment regimens and to create symptom-specific therapeutic strategies in real-time, could allow for significant further improvements in the quality of life for movement disorders patients with DBS that ultimately could outperform traditional drug treatment.
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Affiliation(s)
- Wolf-Julian Neumann
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité - Universitätsmedizin Berlin, Campus Charite Mitte, Chariteplatz 1, 10117, Berlin, Germany.
| | - Robert S Turner
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Benjamin Blankertz
- Department of Computer Science, Technische Universität Berlin, Berlin, Germany
| | - Tom Mitchell
- Machine Learning Department, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Andrea A Kühn
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité - Universitätsmedizin Berlin, Campus Charite Mitte, Chariteplatz 1, 10117, Berlin, Germany
- Berlin School of Mind and Brain, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Neurocure, Centre of Excellence, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - R Mark Richardson
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Coulombe MA, Elkaim LM, Alotaibi NM, Gorman DA, Weil AG, Fallah A, Kalia SK, Lipsman N, Lozano AM, Ibrahim GM. Deep brain stimulation for Gilles de la Tourette syndrome in children and youth: a meta-analysis with individual participant data. J Neurosurg Pediatr 2018; 23:236-246. [PMID: 30497215 DOI: 10.3171/2018.7.peds18300] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 07/25/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Gilles de la Tourette syndrome (GTS) is a disorder characterized by motor and vocal tics. Although by definition the onset of GTS is before age 18 years, clinical trials of deep brain stimulation (DBS) have been conducted only in adults. Using individual participant data (IPD) meta-analysis methodology, the current study investigated the safety and efficacy of DBS as a treatment for GTS in children and youth. METHODS A systematic review with no date or language restrictions was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Three electronic databases were searched: PubMed, EMBASE, and Web of Science. From 843 articles screened, the IPD of 58 children and youth (ages 12–21 years) extracted from 21 articles were collected and analyzed. A mixed-effects univariable analysis followed by multivariable hierarchical regression was performed using change in the Yale Global Tic Severity Scale (YGTSS) score as the primary outcome and reported measures of comorbidities as secondary outcomes. RESULTS The authors’ results showed an average improvement of 57.5% ± 24.6% across studies on the YGTSS. They also found that comorbid depression and stimulation pulse width each correlated negatively with outcome (p < 0.05). In patients with less severe GTS, greater improvements were evident following thalamic stimulation. More than one-quarter (n = 16, 27.6%) of participants experienced side effects, the majority of which were minor. CONCLUSIONS DBS in the pediatric population may be an effective option with a moderate safety profile for treatment of GTS in carefully selected children and youth. Large, prospective studies with long-term follow-up are necessary to understand how DBS influences tic symptoms and may alter the natural course of GTS in children.
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Affiliation(s)
| | | | - Naif M Alotaibi
- Department of Surgery, University of Toronto.,Division of Neurosurgery, Toronto Western Hospital, Krembil Neuroscience Institute, Toronto; and
| | - Daniel A Gorman
- Department of Psychiatry, The Hospital for Sick Children, University of Toronto, Ontario
| | - Alexander G Weil
- Faculty of Medicine, Université de Montréal, Quebec.,Division of Neurosurgery, Sainte Justine Hospital, Montreal, Quebec, Canada
| | - Aria Fallah
- Department of Neurosurgery, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Suneil K Kalia
- Department of Surgery, University of Toronto.,Division of Neurosurgery, Toronto Western Hospital, Krembil Neuroscience Institute, Toronto; and
| | - Nir Lipsman
- Department of Surgery, University of Toronto.,Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto; and
| | - Andres M Lozano
- Department of Surgery, University of Toronto.,Division of Neurosurgery, Toronto Western Hospital, Krembil Neuroscience Institute, Toronto; and
| | - George M Ibrahim
- Department of Surgery, University of Toronto.,Division of Neurosurgery, The Hospital for Sick Children, The Hospital for Sick Children Research Institute, Program in Neuroscience and Mental Health, Toronto, Ontario, Canada
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Kano Y, Matsuda N, Nonaka M, Fujio M, Kono T, Kaido T. Sensory phenomena and obsessive-compulsive symptoms in Tourette syndrome following deep brain stimulation: Two case reports. J Clin Neurosci 2018; 56:199-201. [DOI: 10.1016/j.jocn.2018.06.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 06/25/2018] [Indexed: 11/26/2022]
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Ethics of Deep Brain Stimulation in Adolescent Patients with Refractory Tourette Syndrome: a Systematic Review and Two Case Discussions. NEUROETHICS-NETH 2018; 11:143-155. [PMID: 29937946 PMCID: PMC5978799 DOI: 10.1007/s12152-018-9359-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 03/13/2018] [Indexed: 12/15/2022]
Abstract
Introduction Tourette Syndrome (TS) is a childhood onset disorder characterized by vocal and motor tics and often remits spontaneously during adolescence. For treatment refractory patients, Deep Brain Stimulation (DBS) may be considered. Methods and Results We discuss ethical problems encountered in two adolescent TS patients treated with DBS and systematically review the literature on the topic. Following surgery one patient experienced side effects without sufficient therapeutic effects and the stimulator was turned off. After a second series of behavioural treatment, he experienced a tic reduction of more than 50%. The second patient went through a period of behavioural disturbances that interfered with optimal programming, but eventually experienced a 70% tic reduction. Sixteen DBS surgeries in adolescent TS patients have been reported, none of which pays attention to ethical aspects. Discussion Specific ethical issues arise in adolescent TS patients undergoing DBS relating both to clinical practice as well as to research. Attention should be paid to selecting patients fairly, thorough examination and weighing of risks and benefits, protecting the health of children and adolescents receiving DBS, special issues concerning patient's autonomy, and the normative impact of quality of life. In research, registration of all TS cases in a central database covering a range of standardized information will facilitate further development of DBS for this indication. Conclusion Clinical practice should be accompanied by ongoing ethical reflection, preferably covering not only theoretical thought but providing also insights in the views and perspectives of those concerned, that is patients, family members and professionals.
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Saleh C, Hasler G. Deep brain stimulation for psychiatric disorders: Is there an impact on social functioning? Surg Neurol Int 2017; 8:134. [PMID: 28781911 PMCID: PMC5523473 DOI: 10.4103/sni.sni_15_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 05/06/2017] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) for refractory psychiatric disorders shows promising effects on symptom-reduction, however, little is known regarding the effects of DBS on social outcome. METHODS A PubMed search based on original studies of DBS for psychiatric disorders [treatment resistant depression (TRD), Gilles de la Tourette's syndrome (GTS), and obsessive compulsive disorder (OCD)] was conducted. Data on social outcome following surgery were extracted and analyzed. RESULTS Social functioning was not a primary outcome measure in the reviewed article. The literature is incomplete and inconclusive on this variable, however from the reported data, there is some evidence that DBS has the potential to improve social functioning. CONCLUSIONS More systematic and detailed data gathering and reporting on social outcome with longer follow-ups are needed to evaluate more exhaustively the role of DBS in refractory psychiatric disorders.
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Affiliation(s)
- Christian Saleh
- Division of Molecular Psychiatry, Translational Research Center, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Gregor Hasler
- Division of Molecular Psychiatry, Translational Research Center, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
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Dowd RS, Pourfar M, Mogilner AY. Deep brain stimulation for Tourette syndrome: a single-center series. J Neurosurg 2017; 128:596-604. [PMID: 28387621 DOI: 10.3171/2016.10.jns161573] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Tourette syndrome (TS) is a complex neuropsychiatric disorder characterized by multiple motor and phonic tics. While pharmacological and behavioral therapy can be effective in most patients, a subset of patients remains refractory to treatment. Increasing clinical evidence from multiple centers suggests that deep brain stimulation (DBS) of the medial thalamus can be effective in many cases of refractory TS. METHODS The authors retrospectively reviewed outcomes in 13 patients with refractory TS who underwent medial thalamic DBS performed by their team over a 7-year period. Patients were evaluated by a multidisciplinary team, and preoperative objective assessments were performed using the Yale Global Tic Severity Scale (YGTSS) and Yale-Brown Obsessive Compulsive Scale. YGTSS scores were calculated at visits immediately postoperatively and at the most recent follow-up in patients with a minimum of 6 months of postoperative follow-up. Coordinates of the active DBS contacts were calculated and projected onto each patient's pre- and postoperative images. RESULTS Patients showed an average decrease of 37% (p = 0.0063) in the total tic severity at their first postoperative visit. At their latest visit, their scores achieved significance, decreasing from preoperative scores by an average of 50% (p = 0.0014). The average position of the active contact was noted to be at the junction of the posterior ventralis oralis internus/centromedian-parafascicular nuclei. Device-related complications occurred in 2 patients, necessitating additional surgeries. All patients continued to use the system at last follow-up. CONCLUSIONS The authors' data are consistent with the small but growing body of literature supporting DBS of the ventralis oralis internus/centromedian-parafascicular thalamus as an effective and relatively safe treatment for severe, refractory TS.
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Affiliation(s)
- Richard S Dowd
- 1Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts; and
| | - Michael Pourfar
- 2Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Alon Y Mogilner
- 2Department of Neurosurgery, New York University Langone Medical Center, New York, New York
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Caligiore D, Mannella F, Arbib MA, Baldassarre G. Dysfunctions of the basal ganglia-cerebellar-thalamo-cortical system produce motor tics in Tourette syndrome. PLoS Comput Biol 2017; 13:e1005395. [PMID: 28358814 PMCID: PMC5373520 DOI: 10.1371/journal.pcbi.1005395] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 02/01/2017] [Indexed: 12/24/2022] Open
Abstract
Motor tics are a cardinal feature of Tourette syndrome and are traditionally associated with an excess of striatal dopamine in the basal ganglia. Recent evidence increasingly supports a more articulated view where cerebellum and cortex, working closely in concert with basal ganglia, are also involved in tic production. Building on such evidence, this article proposes a computational model of the basal ganglia-cerebellar-thalamo-cortical system to study how motor tics are generated in Tourette syndrome. In particular, the model: (i) reproduces the main results of recent experiments about the involvement of the basal ganglia-cerebellar-thalamo-cortical system in tic generation; (ii) suggests an explanation of the system-level mechanisms underlying motor tic production: in this respect, the model predicts that the interplay between dopaminergic signal and cortical activity contributes to triggering the tic event and that the recently discovered basal ganglia-cerebellar anatomical pathway may support the involvement of the cerebellum in tic production; (iii) furnishes predictions on the amount of tics generated when striatal dopamine increases and when the cortex is externally stimulated. These predictions could be important in identifying new brain target areas for future therapies. Finally, the model represents the first computational attempt to study the role of the recently discovered basal ganglia-cerebellar anatomical links. Studying this non-cortex-mediated basal ganglia-cerebellar interaction could radically change our perspective about how these areas interact with each other and with the cortex. Overall, the model also shows the utility of casting Tourette syndrome within a system-level perspective rather than viewing it as related to the dysfunction of a single brain area. Tourette syndrome is a neuropsychiatric disorder characterized by vocal and motor tics. Tics represent a cardinal symptom traditionally associated with a dysfunction of the basal ganglia leading to an excess of the dopamine neurotransmitter. This view gives a restricted clinical picture and limits therapeutic approaches because it ignores the influence of altered interactions between the basal ganglia and other brain areas. In this respect, recent evidence supports a more articulated framework where cerebellum and cortex are also involved in tic production. Building on these data, we propose a computational model of the basal ganglia-cerebellar-thalamo-cortical network to investigate the specific mechanisms underlying motor tic production. The model reproduces the results of recent experiments and suggests an explanation of the system-level processes underlying tic production. Moreover, it furnishes predictions related to the amount of tics generated when there are dysfunctions in the basal ganglia-cerebellar-thalamo-cortical circuits. These predictions could be important in identifying new brain target areas for future therapies based on a system-level view of Tourette syndrome.
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Affiliation(s)
- Daniele Caligiore
- Laboratory of Computational Embodied Neuroscience, Institute of Cognitive Sciences and Technologies, National Research Council (CNR-ISTC-LOCEN), Roma, Italy
- * E-mail:
| | - Francesco Mannella
- Laboratory of Computational Embodied Neuroscience, Institute of Cognitive Sciences and Technologies, National Research Council (CNR-ISTC-LOCEN), Roma, Italy
| | - Michael A. Arbib
- Neuroscience Program, USC Brain Project, Computer Science Department, University of Southern California, Los Angeles, California, United States of America
| | - Gianluca Baldassarre
- Laboratory of Computational Embodied Neuroscience, Institute of Cognitive Sciences and Technologies, National Research Council (CNR-ISTC-LOCEN), Roma, Italy
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Testini P, Min HK, Bashir A, Lee KH. Deep Brain Stimulation for Tourette's Syndrome: The Case for Targeting the Thalamic Centromedian-Parafascicular Complex. Front Neurol 2016; 7:193. [PMID: 27891112 PMCID: PMC5102892 DOI: 10.3389/fneur.2016.00193] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 10/24/2016] [Indexed: 12/13/2022] Open
Abstract
Tourette’s syndrome (TS) is a neurologic condition characterized by both motor and phonic tics and is typically associated with psychiatric comorbidities, including obsessive-compulsive disorder/behavior and attention-deficit hyperactivity disorder, and can be psychologically and socially debilitating. It is considered a disorder of the cortico–striato–thalamo–cortical circuitry, as suggested by pathophysiology studies and therapeutic options. Among these, deep brain stimulation (DBS) of the centromedian–parafascicular nucleus (CM-Pf) of the thalamus is emerging as a valuable treatment modality for patients affected by severe, treatment-resistant TS. Here, we review the most recent experimental evidence for the pivotal role of CM-Pf in the pathophysiology of TS, discuss potential mechanisms of action that may mediate the effects of CM-Pf DBS in TS, and summarize its clinical efficacy.
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Affiliation(s)
- Paola Testini
- Department of Neurosurgery, Mayo Clinic , Rochester, MN , USA
| | - Hoon-Ki Min
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA; Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA; Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Asif Bashir
- Department of Neurosurgery, JFK New Jersey Neuroscience Institute , Edison, NJ , USA
| | - Kendall H Lee
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA; Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
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Akbarian-Tefaghi L, Zrinzo L, Foltynie T. The Use of Deep Brain Stimulation in Tourette Syndrome. Brain Sci 2016; 6:brainsci6030035. [PMID: 27548235 PMCID: PMC5039464 DOI: 10.3390/brainsci6030035] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/13/2016] [Accepted: 08/15/2016] [Indexed: 12/16/2022] Open
Abstract
Tourette syndrome (TS) is a childhood neurobehavioural disorder, characterised by the presence of motor and vocal tics, typically starting in childhood but persisting in around 20% of patients into adulthood. In those patients who do not respond to pharmacological or behavioural therapy, deep brain stimulation (DBS) may be a suitable option for potential symptom improvement. This manuscript attempts to summarise the outcomes of DBS at different targets, explore the possible mechanisms of action of DBS in TS, as well as the potential of adaptive DBS. There will also be a focus on the future challenges faced in designing optimized trials.
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Affiliation(s)
- Ladan Akbarian-Tefaghi
- Institute of Neurology, University College London (UCL), Queen Square, London WC1N 3BG, UK.
| | - Ludvic Zrinzo
- Sobell Department of Motor Neuroscience, University College London (UCL) Institute of Neurology, London WC1N 3BG, UK.
| | - Thomas Foltynie
- Sobell Department of Motor Neuroscience, University College London (UCL) Institute of Neurology, London WC1N 3BG, UK.
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Testini P, Zhao CZ, Stead M, Duffy PS, Klassen BT, Lee KH. Centromedian-Parafascicular Complex Deep Brain Stimulation for Tourette Syndrome: A Retrospective Study. Mayo Clin Proc 2016; 91:218-25. [PMID: 26848003 PMCID: PMC4765735 DOI: 10.1016/j.mayocp.2015.11.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 11/24/2015] [Accepted: 11/25/2015] [Indexed: 12/24/2022]
Abstract
Deep brain stimulation (DBS) of the thalamic centromedian/parafascicular (CM-Pf) complex has been reported as a promising treatment for patients with severe, treatment-resistant Tourette syndrome (TS). In this study, safety and clinical outcomes of bilateral thalamic CM-Pf DBS were reviewed in a series of 12 consecutive patients with medically refractory TS, 11 of whom met the criteria of postsurgical follow-up at our institution for at least 2 months. Five patients were followed for a year or longer. Consistent with many patients with TS, all patients had psychiatric comorbidities. Tic severity and frequency were measured by using the Yale Global Tic Severity Scale (YGTSS) over time (average, 26 months) in 10 subjects. One patient was tested at 2-week follow-up only and thus was excluded from group YGTSS analysis. Final YGTSS scores differed significantly from the preoperative baseline score. The average (n=10) improvement relative to baseline in the total score was 54% (95% CI, 37-70); average improvement relative to baseline in the YGTSS Motor tic, Phonic tic, and Impairment subtests was 46% (95% CI, 34-64), 52% (95% CI, 34-72), and 59% (95% CI, 39-78), respectively. There were no intraoperative complications. After surgery, 1 subject underwent wound revision because of a scalp erosion and wound infection; the implanted DBS system was successfully salvaged with surgical revision and combined antibiotic therapy. Stimulation-induced adverse effects did not prevent the use of the DBS system, although 1 subject is undergoing a trial period with the stimulator off. This surgical series adds to the literature on CM-Pf DBS and supports its use as an effective and safe therapeutic option for severe refractory TS.
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Affiliation(s)
- Paola Testini
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Cong Z Zhao
- Department of Medicine, University of California San Francisco, Fresno, CA
| | - Matt Stead
- Department of Neurology, Mayo Clinic, Rochester, MN
| | | | | | - Kendall H Lee
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN; Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN.
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Baldermann JC, Schüller T, Huys D, Becker I, Timmermann L, Jessen F, Visser-Vandewalle V, Kuhn J. Deep Brain Stimulation for Tourette-Syndrome: A Systematic Review and Meta-Analysis. Brain Stimul 2015; 9:296-304. [PMID: 26827109 DOI: 10.1016/j.brs.2015.11.005] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 10/15/2015] [Accepted: 11/13/2015] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND A significant proportion of patients with Tourette syndrome (TS) continue to experience symptoms across adulthood that in severe cases fail to respond to standard therapies. For these cases, deep brain stimulation (DBS) is emerging as a promising treatment option. OBJECTIVE We conducted a systematic literature review to evaluate the efficacy of DBS for GTS. METHODS Individual data of case reports and series were pooled; the Yale Global Tic Severity Scale (YGTSS) was chosen as primary outcome parameter. RESULTS In total, 57 studies were eligible, including 156 cases. Overall, DBS resulted in a significant improvement of 52.68% (IQR = 40.74, p < 0.001) in the YGTSS. Analysis of controlled studies significantly favored stimulation versus off stimulation with a standardized mean difference of 0.96 (95% CI: 0.36-1.56). Disentangling different target points revealed significant YGTSS reductions after stimulation of the thalamus, the posteroventrolateral part and the anteromedial part of the globus pallidus internus, the anterior limb of the internal capsule and nucleus accumbens with no significant difference between these targets. A significant negative correlation of preoperative tic scores with the outcome of thalamic stimulation was found. CONCLUSIONS Despite small patient numbers, we conclude that DBS for GTS is a valid option for medically intractable patients. Different brain targets resulted in comparable improvement rates, indicating a modulation of a common network. Future studies might focus on a better characterization of the clinical effects of distinct regions, rather than searching for a unique target.
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Affiliation(s)
- Juan Carlos Baldermann
- Department of Psychiatry and Psychotherapy, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany.
| | - Thomas Schüller
- Department of Psychiatry and Psychotherapy, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany
| | - Daniel Huys
- Department of Psychiatry and Psychotherapy, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany
| | - Ingrid Becker
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany
| | - Lars Timmermann
- Department of Neurology, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany
| | - Frank Jessen
- Department of Psychiatry and Psychotherapy, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany
| | - Veerle Visser-Vandewalle
- Department of Stereotactic and Functional Neurosurgery, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany
| | - Jens Kuhn
- Department of Psychiatry and Psychotherapy, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany
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Israelashvili M, Loewenstern Y, Bar-Gad I. Abnormal neuronal activity in Tourette syndrome and its modulation using deep brain stimulation. J Neurophysiol 2015; 114:6-20. [PMID: 25925326 PMCID: PMC4493664 DOI: 10.1152/jn.00277.2015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 04/29/2015] [Indexed: 12/26/2022] Open
Abstract
Tourette syndrome (TS) is a common childhood-onset disorder characterized by motor and vocal tics that are typically accompanied by a multitude of comorbid symptoms. Pharmacological treatment options are limited, which has led to the exploration of deep brain stimulation (DBS) as a possible treatment for severe cases. Multiple lines of evidence have linked TS with abnormalities in the motor and limbic cortico-basal ganglia (CBG) pathways. Neurophysiological data have only recently started to slowly accumulate from multiple sources: noninvasive imaging and electrophysiological techniques, invasive electrophysiological recordings in TS patients undergoing DBS implantation surgery, and animal models of the disorder. These converging sources point to system-level physiological changes throughout the CBG pathway, including both general altered baseline neuronal activity patterns and specific tic-related activity. DBS has been applied to different regions along the motor and limbic pathways, primarily to the globus pallidus internus, thalamic nuclei, and nucleus accumbens. In line with the findings that also draw on the more abundant application of DBS to Parkinson's disease, this stimulation is assumed to result in changes in the neuronal firing patterns and the passage of information through the stimulated nuclei. We present an overview of recent experimental findings on abnormal neuronal activity associated with TS and the changes in this activity following DBS. These findings are then discussed in the context of current models of CBG function in the normal state, during TS, and finally in the wider context of DBS in CBG-related disorders.
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Affiliation(s)
- Michal Israelashvili
- The Leslie & Susan Goldschmied (Gonda) Multidisciplinary Brain Research Center, Bar-Ilan University, Ramat-Gan, Israel
| | - Yocheved Loewenstern
- The Leslie & Susan Goldschmied (Gonda) Multidisciplinary Brain Research Center, Bar-Ilan University, Ramat-Gan, Israel
| | - Izhar Bar-Gad
- The Leslie & Susan Goldschmied (Gonda) Multidisciplinary Brain Research Center, Bar-Ilan University, Ramat-Gan, Israel
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25
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Cleary DR, Ozpinar A, Raslan AM, Ko AL. Deep brain stimulation for psychiatric disorders: where we are now. Neurosurg Focus 2015; 38:E2. [DOI: 10.3171/2015.3.focus1546] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Fossil records showing trephination in the Stone Age provide evidence that humans have sought to influence the mind through physical means since before the historical record. Attempts to treat psychiatric disease via neurosurgical means in the 20th century provided some intriguing initial results. However, the indiscriminate application of these treatments, lack of rigorous evaluation of the results, and the side effects of ablative, irreversible procedures resulted in a backlash against brain surgery for psychiatric disorders that continues to this day. With the advent of psychotropic medications, interest in invasive procedures for organic brain disease waned.
Diagnosis and classification of psychiatric diseases has improved, due to a better understanding of psychiatric patho-physiology and the development of disease and treatment biomarkers. Meanwhile, a significant percentage of patients remain refractory to multiple modes of treatment, and psychiatric disease remains the number one cause of disability in the world. These data, along with the safe and efficacious application of deep brain stimulation (DBS) for movement disorders, in principle a reversible process, is rekindling interest in the surgical treatment of psychiatric disorders with stimulation of deep brain sites involved in emotional and behavioral circuitry.
This review presents a brief history of psychosurgery and summarizes the development of DBS for psychiatric disease, reviewing the available evidence for the current application of DBS for disorders of the mind.
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Affiliation(s)
- Daniel R. Cleary
- 1Department of Neurology, Yale Medical School, New Haven, Connecticut
| | - Alp Ozpinar
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Ahmed M. Raslan
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Andrew L. Ko
- 3Department of Neurological Surgery, University of Washington, Seattle, Washington
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Abstract
Despite the application of deep brain stimulation (DBS) as an efficient treatment modality for psychiatric disorders, such as obsessive-compulsive disorder (OCD), Gilles de la Tourette Syndrome (GTS), and treatment refractory major depression (TRD), few patients are operated or included in clinical trials, often for fear of the potential risks of an approach deemed too dangerous. To assess the surgical risks, we conducted an analysis of publications on DBS for psychiatric disorders. A PubMed search was conducted on reports on DBS for OCD, GTS, and TRD. Forty-nine articles were included. Only reports on complications related to DBS were selected and analyzed. Two hundred seventy-two patients with a mean follow-up of 22 months were included in our analysis. Surgical mortality was nil. The overall mortality was 1.1 %: two suicides were unrelated to DBS and one death was reported to be unlikely due to DBS. The majority of complications were transient and related to stimulation. Long-term morbidity occurred in 16.5 % of cases. Three patients had permanent neurological complications due to intracerebral hemorrhage (2.2 %). Complications reported in DBS for psychiatric diseases appear to be similar to those reported for DBS in movement disorders. But class I evidence is lacking. Our analysis was based mainly on small non-randomized studies. A significant number of patients (approximately 150 patients) who were treated with DBS for psychiatric diseases had to be excluded from our analysis as no data on complications was available. The exact prevalence of complications of DBS in psychiatric diseases could not be established. DBS for psychiatric diseases is promising, but remains an experimental technique in need of further evaluation. A close surveillance of patients undergoing DBS for psychiatric diseases is mandatory.
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Sugiyama K, Nozaki T, Asakawa T, Koizumi S, Saitoh O, Namba H. The present indication and future of deep brain stimulation. Neurol Med Chir (Tokyo) 2015; 55:416-21. [PMID: 25925757 PMCID: PMC4628169 DOI: 10.2176/nmc.ra.2014-0394] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
The use of electrical stimulation to treat pain in human disease dates back to ancient Rome or Greece. Modern deep brain stimulation (DBS) was initially applied for pain treatment in the 1960s, and was later used to treat movement disorders in the 1990s. After recognition of DBS as a therapy for central nervous system (CNS) circuit disorders, DBS use showed drastic increase in terms of adaptability to disease and the patient’s population. More than 100,000 patients have received DBS therapy worldwide. The established indications for DBS are Parkinson’s disease, tremor, and dystonia, whereas global indications of DBS expanded to other neuronal diseases or disorders such as neuropathic pain, epilepsy, and tinnitus. DBS is also experimentally used to manage cognitive disorders and psychiatric diseases such as major depression, obsessive-compulsive disorder (OCD), Tourette’s syndrome, and eating disorders. The importance of ethics and conflicts surrounding the regulation and freedom of choice associated with the application of DBS therapy for new diseases or disorders is increasing. These debates are centered on the use of DBS to treat new diseases and disorders as well as its potential to enhance ability in normal healthy individuals. Here we present three issues that need to be addressed in the future: (1) elucidation of the mechanisms of DBS, (2) development of new DBS methods, and (3) miniaturization of the DBS system. With the use of DBS, functional neurosurgery entered into the new era that man can manage and control the brain circuit to treat intractable neuronal diseases and disorders.
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Affiliation(s)
- Kenji Sugiyama
- Department of Neurosurgery, Hamamatsu University School of Medicine
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Almeida L, Martinez-Ramirez D, Rossi PJ, Peng Z, Gunduz A, Okun MS. Chasing tics in the human brain: development of open, scheduled and closed loop responsive approaches to deep brain stimulation for tourette syndrome. J Clin Neurol 2015; 11:122-31. [PMID: 25851890 PMCID: PMC4387477 DOI: 10.3988/jcn.2015.11.2.122] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 12/10/2014] [Accepted: 12/12/2014] [Indexed: 11/30/2022] Open
Abstract
Tourette syndrome is a childhood-onset disorder characterized by a combination of motor and vocal tics, often associated with psychiatric comorbidities including attention deficit and hyperactivity disorder and obsessive-compulsive disorder. Despite an onset early in life, half of patients may present symptoms in adulthood, with variable degrees of severity. In select cases, the syndrome may lead to significant physical and social impairment, and a worrisome risk for self injury. Evolving research has provided evidence supporting the idea that the pathophysiology of Tourette syndrome is directly related to a disrupted circuit involving the cortex and subcortical structures, including the basal ganglia, nucleus accumbens, and the amygdala. There has also been a notion that a dysfunctional group of neurons in the putamen contributes to an abnormal facilitation of competing motor responses in basal ganglia structures ultimately underpinning the generation of tics. Surgical therapies for Tourette syndrome have been reserved for a small group of patients not responding to behavioral and pharmacological therapies, and these therapies have been directed at modulating the underlying pathophysiology. Lesion therapy as well as deep brain stimulation has been observed to suppress tics in at least some of these cases. In this article, we will review the clinical aspects of Tourette syndrome, as well as the evolution of surgical approaches and we will discuss the evidence and clinical responses to deep brain stimulation in various brain targets. We will also discuss ongoing research and future directions as well as approaches for open, scheduled and closed loop feedback-driven electrical stimulation for the treatment of Tourette syndrome.
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Affiliation(s)
- Leonardo Almeida
- Department of Neurology, Division of Movement Disorders, University of Florida at Gainesville, Gainesville, FL, USA.
| | - Daniel Martinez-Ramirez
- Department of Neurology, Division of Movement Disorders, University of Florida at Gainesville, Gainesville, FL, USA
| | - Peter J Rossi
- Department of Biomedical Engineering, University of Florida at Gainesville, Gainesville, FL, USA
| | - Zhongxing Peng
- Department of Neurology, Division of Movement Disorders, University of Florida at Gainesville, Gainesville, FL, USA
| | - Aysegul Gunduz
- Department of Biomedical Engineering, University of Florida at Gainesville, Gainesville, FL, USA
| | - Michael S Okun
- Department of Neurology, Division of Movement Disorders, University of Florida at Gainesville, Gainesville, FL, USA
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Smith KM, Spindler MA. Uncommon applications of deep brain stimulation in hyperkinetic movement disorders. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2015; 5:278. [PMID: 25713746 PMCID: PMC4314611 DOI: 10.7916/d84x56hp] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 11/20/2014] [Indexed: 12/12/2022]
Abstract
Background In addition to the established indications of tremor and dystonia, deep brain stimulation (DBS) has been utilized less commonly for several hyperkinetic movement disorders, including medication-refractory myoclonus, ballism, chorea, and Gilles de la Tourette (GTS) and tardive syndromes. Given the lack of adequate controlled trials, it is difficult to translate published reports into clinical use. We summarize the literature, draw conclusions regarding efficacy when possible, and highlight concerns and areas for future study. Methods A Pubmed search was performed for English-language articles between January 1980 and June 2014. Studies were selected if they focused primarily on DBS to treat the conditions of focus. Results We identified 49 cases of DBS for myoclonus-dystonia, 21 for Huntington's disease, 15 for choreacanthocytosis, 129 for GTS, and 73 for tardive syndromes. Bilateral globus pallidus interna (GPi) DBS was the most frequently utilized procedure for all conditions except GTS, in which medial thalamic DBS was more common. While the majority of cases demonstrate some improvement, there are also reports of no improvement or even worsening of symptoms in each condition. The few studies including functional or quality of life outcomes suggest benefit. A limited number of studies included blinded on/off testing. There have been two double-blind controlled trials performed in GTS and a single prospective double-blind, uncontrolled trial in tardive syndromes. Patient characteristics, surgical target, stimulation parameters, and duration of follow-up varied among studies. Discussion Despite these extensive limitations, the literature overall supports the efficacy of DBS in these conditions, in particular GTS and tardive syndromes. For other conditions, the preliminary evidence from small studies is promising and encourages further study.
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Affiliation(s)
- Kara M Smith
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Meredith A Spindler
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Schrock LE, Mink JW, Woods DW, Porta M, Servello D, Visser-Vandewalle V, Silburn PA, Foltynie T, Walker HC, Shahed-Jimenez J, Savica R, Klassen BT, Machado AG, Foote KD, Zhang JG, Hu W, Ackermans L, Temel Y, Mari Z, Changizi BK, Lozano A, Auyeung M, Kaido T, Agid Y, Welter ML, Khandhar SM, Mogilner AY, Pourfar MH, Walter BL, Juncos JL, Gross RE, Kuhn J, Leckman JF, Neimat JA, Okun MS. Tourette syndrome deep brain stimulation: a review and updated recommendations. Mov Disord 2014; 30:448-71. [PMID: 25476818 DOI: 10.1002/mds.26094] [Citation(s) in RCA: 174] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 10/06/2014] [Accepted: 10/08/2014] [Indexed: 12/16/2022] Open
Abstract
Deep brain stimulation (DBS) may improve disabling tics in severely affected medication and behaviorally resistant Tourette syndrome (TS). Here we review all reported cases of TS DBS and provide updated recommendations for selection, assessment, and management of potential TS DBS cases based on the literature and implantation experience. Candidates should have a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V) diagnosis of TS with severe motor and vocal tics, which despite exhaustive medical and behavioral treatment trials result in significant impairment. Deep brain stimulation should be offered to patients only by experienced DBS centers after evaluation by a multidisciplinary team. Rigorous preoperative and postoperative outcome measures of tics and associated comorbidities should be used. Tics and comorbid neuropsychiatric conditions should be optimally treated per current expert standards, and tics should be the major cause of disability. Psychogenic tics, embellishment, and malingering should be recognized and addressed. We have removed the previously suggested 25-year-old age limit, with the specification that a multidisciplinary team approach for screening is employed. A local ethics committee or institutional review board should be consulted for consideration of cases involving persons younger than 18 years of age, as well as in cases with urgent indications. Tourette syndrome patients represent a unique and complex population, and studies reveal a higher risk for post-DBS complications. Successes and failures have been reported for multiple brain targets; however, the optimal surgical approach remains unknown. Tourette syndrome DBS, though still evolving, is a promising approach for a subset of medication refractory and severely affected patients.
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Affiliation(s)
- Lauren E Schrock
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
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Yampolsky C, Bendersky D. [Surgery for behavioral disorders: the state of the art]. Surg Neurol Int 2014; 5:S211-31. [PMID: 25165612 PMCID: PMC4138826 DOI: 10.4103/2152-7806.137936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 08/15/2013] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Surgery for behavioral disorders (SBD) is becoming a more common treatment since the development of neuromodulation techniques. METHODS This article is a non-systematic review of the history, current indications, techniques and surgical targets of SBD. We divide its history into 3 eras: the first era starts in the beginning of psychosurgery and finishes with the development of stereotactic techniques, when the second one starts. It is characterized by the realization of stereotactic lesions. We are traveling through the third era, which begins when deep brain stimulation (DBS) starts to be used for SBD. RESULTS In spite of the serious mistakes committed in the past, nowadays, SBD is reawakening. The psychiatric disorders which are most frequently treated by surgery are: treatment-resistant depression, obsessive-compulsive disorder and Tourette syndrome. Furthermore, some patients with abnormal aggression were surgically treated. There are several stereotactic targets described for these disorders. Vagus nerve stimulation may be also used for depression. CONCLUSION The results of DBS in these disorders seem to be encouraging. However, more randomized trials are needed in order to establish the effectiveness of SBD. It must be taken in mind that a proper patient selection will help us to perform a safer procedure as well as to achieve better surgical results, leading SBD to be more accepted by psychiatrists, patients and their families. Further research is needed in several topics such as: physiopathology of behavioral disorders, indications of SBD and new surgical targets.
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Affiliation(s)
- Claudio Yampolsky
- Servicio de Neurocirugía, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Damián Bendersky
- Servicio de Neurocirugía, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
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Abstract
Tourette's syndrome (TS) is a childhood neuropsychiatric disorder characterized by multiple involuntary motor and vocal tics. It is commonly associated with other behavioral disorders including attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, anxiety, depression, and self-injurious behaviors. Tourette's syndrome can be effectively managed with psychobehavioral and pharmacological treatments, and many patients experience an improvement in tics in adulthood. However, symptoms may persist and cause severe impairment in a small subset of patients despite available therapies. In recent years, deep brain stimulation (DBS) has been shown to be a promising treatment option for such patients. Since the advent of its use in 1999, multiple targets have been identified in DBS for TS, including the medial thalamus, globus pallidus internus, globus pallidus externus, anterior limb of the internal capsule/nucleus accumbens, and subthalamic nucleus. While the medial thalamus is the most commonly reported trajectory, the optimal surgical target for TS is still a topic of much debate. This paper provides a review of the available literature regarding the use of DBS for TS.
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Affiliation(s)
- Janine Rotsides
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
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Abstract
Gilles de la Tourette syndrome is a movement disorder characterized by repetitive stereotyped motor and phonic movements with varying degrees of psychiatric comorbidity. Deep brain stimulation (DBS) has emerged as a novel therapeutic intervention for patients with refractory Tourette syndrome. Since 1999, more than 100 patients have undergone DBS at various targets within the corticostriatothalamocortical network thought to be implicated in the underlying pathophysiology of Tourette syndrome. Future multicenter clinical trials and the use of a centralized online database to compare the results are necessary to determine the efficacy of DBS for Tourette syndrome.
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Affiliation(s)
- Won Kim
- Department of Neurosurgery, University of California, Los Angeles 10945, Le Conte Avenue, Suite 2120, Los Angeles, CA 90095, USA.
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Höflich A, Savli M, Comasco E, Moser U, Novak K, Kasper S, Lanzenberger R. Neuropsychiatric deep brain stimulation for translational neuroimaging. Neuroimage 2013; 79:30-41. [DOI: 10.1016/j.neuroimage.2013.04.065] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 04/13/2013] [Accepted: 04/16/2013] [Indexed: 10/26/2022] Open
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Cognitive Functioning in Psychiatric Disorders Following Deep Brain Stimulation. Brain Stimul 2013; 6:532-7. [DOI: 10.1016/j.brs.2013.01.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 12/18/2012] [Accepted: 01/07/2013] [Indexed: 11/19/2022] Open
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Müller-Vahl KR. Surgical treatment of Tourette syndrome. Neurosci Biobehav Rev 2012; 37:1178-85. [PMID: 23041074 DOI: 10.1016/j.neubiorev.2012.09.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 09/19/2012] [Accepted: 09/26/2012] [Indexed: 11/15/2022]
Abstract
In severely affected, treatment resistant patients with Tourette syndrome (TS) new therapeutic strategies are urgently needed. Since 1999, 34 studies including more than 90 patients have been performed to investigate the efficacy and safety of deep brain stimulation (DBS) in the treatment of tics resulting in the vast majority of patients in an improvement of tics and in some patients even of comorbidities. Both surgery-related (e.g., bleeding, infection) and stimulation-related adverse events (e.g., loss of energy, blurred vision) seem to occur only in a minority of patients and not to cause significant impairment, respectively. Since randomized controlled studies including a larger number of patients are still lacking, up to now, no definite conclusion can be drawn. Therefore, at present time DBS is recommended only in adult, treatment resistant, and severely affected patients. However, most experts have no doubt that DBS is indeed effective in the treatment of tics. Future studies should aim to identify which target in which patient is optimal depending on the individual symptomatology.
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Affiliation(s)
- Kirsten R Müller-Vahl
- Clinic of Psychiatry, Socialpsychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany.
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Saleh C, Gonzalez V, Cif L, Coubes P. Deep brain stimulation of the globus pallidus internus and Gilles de la Tourette syndrome: Toward multiple networks modulation. Surg Neurol Int 2012; 3:S127-42. [PMID: 22826816 PMCID: PMC3400493 DOI: 10.4103/2152-7806.95424] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 03/28/2012] [Indexed: 11/09/2022] Open
Abstract
Background: Gilles de la Tourette's syndrome (GTS) is a complex neuropsychiatric disorder characterized by disabling motor and vocal tics. The pathophysiology of GTS remains poorly understood. Conventional treatment consists in pharmacological and behavioral treatment. For patients suffering severe adverse effects or not responding to pharmacological treatment, deep brain stimulation (DBS) presents an alternative treatment. However, the optimal target choice in DBS for GTS remains a divisive issue. Methods: A PubMed search from 1999 to 2012 was conducted. Thirty-three research articles reporting on DBS in patients with GTS were selected and analyzed. Results: Eighty-eight patients with Tourette's syndrome were treated since 1999 with DBS. The majority of patients received thalamic stimulation. Significantly fewer patients were treated with globus pallidus internus stimulation. Occasionally, the anterior limb of the internal capsule and the nucleus accumbens were implanted. The subthalamic nucleus was selected once. All targets were reported with positive results, but of variable extent. Only 14 patients exhibited level 1 evidence. Conclusion: In light of the wide spectrum of associated behavioral co-morbidities in GTS, multiple networks modulation may result in the most efficacious treatment strategy. The optimal locations for DBS within the cortico-basal ganglia-thalamocortical circuits remain to be established. However, at the current stage, comparison between targets should be done with great caution. Significant disparity between number of patients treated per target, methodological variability, and quality of reporting renders a meaningful comparison between targets difficult. Randomized controlled trials with larger cohorts and standardization of procedures are urgently needed.
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Affiliation(s)
- Christian Saleh
- Department of Neurosurgery, CHRU Montpellier, Montpellier, France
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