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Liu A, Jiao Y, Zhang S, Kong H. Improved depressive symptoms in patients with refractory Gilles de la Tourette syndrome after deep brain stimulation of posteroventral globus pallidus interna. Brain Behav 2022; 12:e2635. [PMID: 35620847 PMCID: PMC9304849 DOI: 10.1002/brb3.2635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 01/29/2022] [Accepted: 02/12/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Deep brain stimulation (DBS) has been used on drug-resistant Gilles de la Tourette syndrome (GTS) for more than two decades until now, but the stimulating targets are still under exploration until now. In this study, the authors reported the efficacy of the bilateral posteroventral globus pallidus interna (GPi) DBS on tic severity and neuropsychiatry symptoms of seven individuals with GTS. METHOD Seven patients with drug-resistant GTS were enrolled in this study. The severity of these patients was evaluated with Yale Global Tics Severity Scale (YGTSS), Yale Brown Obsessive Compulsive Scale (YBOCS), Hamilton Depression Rating Scale (HAMD), Hamilton Anxiety Rating Scale (HAMA), and Global Assessment of Functioning Scale (GAF). Bilateral posteroventral GPi were selected as the permanent stimulating targets. Follow-up period was at least 5 years after surgery in the enrolled patients. RESULTS After surgery, one patient reported no improvement during the follow-up period, and a device removal surgery was performed. The other six patients reported minor to significant improvement. The overall YGTSS, YBOCS, HAMA HAMD, and GAF scores of these patients were changed positively after surgery, but only the improvement of the motor tic and HAMD scores had a statistical difference. No surgical complication was reported. CONCLUSIONS Bilateral posteroventral GPi DBS could relieve the motor tics and depressive symptoms of the enrolled patients significantly, but the vocal tics and other psychiatric symptoms presented a progression without statistical difference during the follow-up period. The results of this study suggested that bilateral posteroventral GPi are effective targets for the motor tics in GTS patients, especially with prominent depressive symptoms.
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Affiliation(s)
- Aijun Liu
- Department of Neurosurgery, the Chinese PLA General Hospital, Haidian, Beijing, China
| | - Yongcheng Jiao
- Department of Neurosurgery, the Chinese PLA General Hospital, Haidian, Beijing, China
| | - Shaohui Zhang
- Department of Neurosurgery, the Chinese PLA General Hospital, Haidian, Beijing, China
| | - Haibo Kong
- Department of Neurosurgery, the Chinese PLA General Hospital, Haidian, Beijing, China
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Stereotactic Surgery for Treating Intractable Tourette Syndrome: A Single-Center Pilot Study. Brain Sci 2022; 12:brainsci12070838. [PMID: 35884645 PMCID: PMC9313141 DOI: 10.3390/brainsci12070838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/14/2022] [Accepted: 06/14/2022] [Indexed: 11/27/2022] Open
Abstract
To evaluate the potential effect of radiofrequency ablation and deep brain stimulation in patients with treatment-refractory Tourette syndrome (TS), this study enrolled thirteen patients with TS who were admitted to our hospital between August 2002 and September 2018. Four patients received a single- or multi-target radiofrequency ablation after local, potentiated, or general anesthesia; eight patients underwent deep brain stimulation (DBS) surgery; and one patient underwent both ablation and DBS surgery. The severity of tics and obsessive compulsive disorder symptoms and the quality of life were evaluated using the Yale Global Tic Severity Scale (YGTSS), Yale−Brown Obsessive Compulsive Scale (YBOCS), and Gilles de la Tourette Syndrome Quality of Life scale (GTS-QOL), respectively, before surgery, one month after surgery, and at the final follow-up after surgery, which was conducted in December 2018. A paired-sample t test and a multiple linear regression analysis were performed to analyze the data. All patients underwent the operation successfully without any severe complications. Overall, the YGTSS total scores at one month post-surgery (44.1 ± 22.3) and at the final visit (35.1 ± 23.7) were significantly decreased compared with those at baseline (75.1 ± 6.2; both p < 0.05). Additionally, the YBOCS scores at one month post-surgery (16.5 ± 10.1) and at the final visit (12.0 ± 9.5) were significantly decreased compared with those at baseline (22.5 ± 13.1; both p < 0.05). Furthermore, the GTS-QOL scores at one month post-surgery (44.0 ± 12.8) and at the final visit (31.0 ± 17.8) were significantly decreased compared with those at baseline (58.4 ± 14.2; both p < 0.05). Results from a multiple linear regression analysis revealed that the improvement in the YGTSS total score was independently associated with the improvement in the GTS-QOL score at one month post-surgery (standardized β = 0.716, p = 0.023) and at the final visit (standardized β = 1.064, p = 0.000). Conversely, changes in YBOCS scores did not correlate with changes in GTS-QOL scores (p > 0.05). Our results demonstrate that tics, psychiatric symptoms, and the quality of life in patients with intractable TS may be relieved by stereotactic ablation surgery and deep brain stimulation. Furthermore, it appears that the improvement in tics contributes more to the post-operative quality of life of patients than does the improvement in obsessive compulsive symptoms.
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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: 24] [Impact Index Per Article: 12.0] [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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Acevedo N, Bosanac P, Pikoos T, Rossell S, Castle D. Therapeutic Neurostimulation in Obsessive-Compulsive and Related Disorders: A Systematic Review. Brain Sci 2021; 11:brainsci11070948. [PMID: 34356182 PMCID: PMC8307974 DOI: 10.3390/brainsci11070948] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/09/2021] [Accepted: 07/10/2021] [Indexed: 01/16/2023] Open
Abstract
Invasive and noninvasive neurostimulation therapies for obsessive-compulsive and related disorders (OCRD) were systematically reviewed with the aim of assessing clinical characteristics, methodologies, neuroanatomical substrates, and varied stimulation parameters. Previous reviews have focused on a narrow scope, statistical rather than clinical significance, grouped together heterogenous protocols, and proposed inconclusive outcomes and directions. Herein, a comprehensive and transdiagnostic evaluation of all clinically relevant determinants is presented with translational clinical recommendations and novel response rates. Electroconvulsive therapy (ECT) studies were limited in number and quality but demonstrated greater efficacy than previously identified. Targeting the pre-SMA/SMA is recommended for transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS). TMS yielded superior outcomes, although polarity findings were conflicting, and refinement of frontal/cognitive control protocols may optimize outcomes. For both techniques, standardization of polarity, more treatment sessions (>20), and targeting multiple structures are encouraged. A deep brain stimulation (DBS) 'sweet spot' of the striatum for OCD was proposed, and CBT is strongly encouraged. Tourette's patients showed less variance and reliance on treatment optimization. Several DBS targets achieved consistent, rapid, and sustained clinical response. Analysis of fiber connectivity, as opposed to precise neural regions, should be implemented for target selection. Standardization of protocols is necessary to achieve translational outcomes.
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Affiliation(s)
- Nicola Acevedo
- Centre for Mental Health, Swinburne University of Technology, John Street, Melbourne, VIC 3122, Australia; (T.P.); (S.R.)
- Correspondence:
| | - Peter Bosanac
- St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Melbourne, VIC 3065, Australia; (P.B.); (D.C.)
- Department of Psychiatry, University of Melbourne, Melbourne, VIC 3010, Australia
| | - Toni Pikoos
- Centre for Mental Health, Swinburne University of Technology, John Street, Melbourne, VIC 3122, Australia; (T.P.); (S.R.)
| | - Susan Rossell
- Centre for Mental Health, Swinburne University of Technology, John Street, Melbourne, VIC 3122, Australia; (T.P.); (S.R.)
- St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Melbourne, VIC 3065, Australia; (P.B.); (D.C.)
| | - David Castle
- St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Melbourne, VIC 3065, Australia; (P.B.); (D.C.)
- Department of Psychiatry, University of Melbourne, Melbourne, VIC 3010, Australia
- Centre for Addiction and Mental Health, 252 College Street, Toronto, ON M5T 1R7, Canada
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Cagle JN, Eisinger RS, Holland MT, Foote KD, Okun MS, Gunduz A. A novel local field potential-based functional approach for targeting the centromedian-parafascicular complex for deep brain stimulation. Neuroimage Clin 2021; 30:102644. [PMID: 33845353 PMCID: PMC8064020 DOI: 10.1016/j.nicl.2021.102644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 02/18/2021] [Accepted: 03/22/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND The centromedian-parafascicular (Cm-Pf) complex of the thalamus is a common deep brain stimulation (DBS) target for treatment of Tourette syndrome (TS). Currently, there are no standardized functional intraoperative neurosurgical targeting approaches. Collectively, these issues have led to variability in DBS lead placement. Therefore, more defined methods are needed to improve targeting accuracy. OBJECTIVE The objective of this observational study was to develop and to verify a functional mapping task capable of differentiating the Cm-Pf region from the nearby ventral intermediate (Vim) nucleus region of the thalamus. The overarching goal was to improve the reproducibility of DBS targeting in the Cm-Pf region. METHODS Seven TS patients completed a modified Go/NoGo task (five in the post-operative setting and two in the intra-operative setting). Post-operative neural signals from Cm-Pf region were collected using sensing-enabled implanted neural stimulators, and intraoperative neural signals from the Cm-Pf region were collected using an external amplifier. Event-related potential (ERP) features were identified by using the grand-average of stimulus onset signals derived from the postoperative participants. These features were correlated with anatomical locations for the specific electrode recordings. The same features were extracted from the intraoperative patients in order to verify electrode positions in the operating room environment. RESULTS Two features - a positive and a negative deflection - were identified in the average ERP from the post-operative participants. The peak amplitudes of both features were significantly correlated with the electrode depth position (p = 0.025 for positive deflection and p = 0.039 for negative deflection). The same result was reproduced intra-operatively in the two most recent patients, where more ventral electrode contacts revealed stronger peak amplitudes in comparison to the dorsal electrode contacts. CONCLUSION This process was used to physiologically confirm accurate lead placement in the operating room setting. The modified Go/NoGo task elicited robust neural responses in the Cm-Pf region however the signal was not present in the Vim nucleus region of thalamus along the DBS electrode trajectory. We conclude that the differences in ERP responses may be a potentially novel LFP based functional approach for future targeting of the Cm-Pf complex for TS DBS.
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Affiliation(s)
- Jackson N Cagle
- J. Crayton Pruitt Department of Biomedical Engineering, University of Florida, Gainesville FL, United States
| | - Robert S Eisinger
- Department of Neuroscience, University of Florida, Gainesville, FL, United States
| | - Marshall T Holland
- Department of Neurosurgery, University of Florida Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States; Department of Neurosurgery, University of Iowa, Iowa City, IA, United States
| | - Kelly D Foote
- Department of Neurosurgery, University of Florida Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
| | - Michael S Okun
- Department of Neuroscience, University of Florida, Gainesville, FL, United States; Department of Neurology, University of Florida Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
| | - Aysegul Gunduz
- J. Crayton Pruitt Department of Biomedical Engineering, University of Florida, Gainesville FL, United States
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Lead Repositioning Guided by Both Physiology and Atlas Based Targeting in Tourette Deep Brain Stimulation. Tremor Other Hyperkinet Mov (N Y) 2020; 10:18. [PMID: 32775032 PMCID: PMC7394226 DOI: 10.5334/tohm.140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: The centromedian (CM) region of the thalamus is a common target for deep brain stimulation (DBS) treatment for Tourette Syndrome (TS). However, there are currently no standard microelectrode recording or macrostimulation methods to differentiate CM thalamus from other nearby structures and nuclei. Case Report: Here we present a case of failed conventional stereotactic targeting in TS DBS. Postoperative local field potential recordings (LFPs) showed features including beta power desynchronization during voluntary movement and thalamo-cortical phase amplitude coupling at rest. These findings suggested that the DBS lead was suboptimally placed in the ventral intermediate (VIM) nucleus of the thalamus rather than the intended CM region. Due to a lack of clinical improvement in tic severity scales three months following the initial surgery, the patient underwent lead revision surgery. Slight repositioning of the DBS leads resulted in a remarkably different clinical outcome. Afterwards, LFPs revealed less beta desynchronization and disappearance of the thalamo-cortical phase amplitude coupling. Follow-up clinical visits documented improvement of the patient’s global tic scores. Discussion: This case provides preliminary evidence that combining physiology with atlas based targeting may possibly enhance outcomes in some cases of Tourette DBS. A larger prospective study will be required to confirm these findings. Highlight: This report demonstrates a case of failed centromedian nucleus region deep brain stimulation (DBS). We observed suboptimal tic improvement several months following DBS surgery and subsequent lead revision improved the outcome. The neurophysiology provided an important clue suggesting the possibility of suboptimally placed DBS leads. Repeat LFPs during lead revision revealed less beta desynchronization and disappearance of the thalamo-cortical phase amplitude coupling. There was improvement in tic outcome following slight repositioning during bilateral DBS lead revision. This case provides preliminary evidence supporting the use of physiology to augment the atlas based targeting of Tourette DBS cases.
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Deeb W, Malaty I. Deep Brain Stimulation for Tourette Syndrome: Potential Role in the Pediatric Population. J Child Neurol 2020; 35:155-165. [PMID: 31526168 DOI: 10.1177/0883073819872620] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Tourette syndrome (TS) is a complex neuropsychiatric disorder. Despite an expected natural history of improvement with age, many individuals continue to have severe tics and remain refractory to the current best pharmacologic and nonpharmacologic treatments. Deep brain stimulation (DBS) has emerged as a potential treatment option. This article reviews the published reports on the use of deep brain stimulation in Tourette syndrome revealing that 2 anatomical targets have been most commonly used: the centromedian thalamus and the globus pallidus internus. The evidence supports a significant clinical improvement of tics with deep brain stimulation, though the data are limited by the small number of patients and variable methodology employed. To bridge these limitations, the international Tourette syndrome deep brain stimulation database and registry have been created, fostering collaboration among multiple centers from 10 countries. By standardizing data collection, the database and registry are providing valuable insights into deep brain stimulation for Tourette syndrome. In conclusion, deep brain stimulation offers significant promise for the management of tics.
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Affiliation(s)
- Wissam Deeb
- University of Florida, Fixel Institute for Neurologic Disease, Gainesville, FL, USA
| | - Irene Malaty
- University of Florida, Fixel Institute for Neurologic Disease, Gainesville, FL, USA
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9
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Pourfar MH, Mogilner AY. Gilles de la Tourette Syndrome: Deep Brain Stimulation. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Pastor J, Vega-Zelaya L. A new potential specifically marks the sensory thalamus in anaesthetised patients. Clin Neurophysiol 2019; 130:1926-1936. [DOI: 10.1016/j.clinph.2019.07.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 07/02/2019] [Accepted: 07/16/2019] [Indexed: 11/30/2022]
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11
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Johnson KA, Fletcher PT, Servello D, Bona A, Porta M, Ostrem JL, Bardinet E, Welter ML, Lozano AM, Baldermann JC, Kuhn J, Huys D, Foltynie T, Hariz M, Joyce EM, Zrinzo L, Kefalopoulou Z, Zhang JG, Meng FG, Zhang C, Ling Z, Xu X, Yu X, Smeets AY, Ackermans L, Visser-Vandewalle V, Mogilner AY, Pourfar MH, Almeida L, Gunduz A, Hu W, Foote KD, Okun MS, Butson CR. Image-based analysis and long-term clinical outcomes of deep brain stimulation for Tourette syndrome: a multisite study. J Neurol Neurosurg Psychiatry 2019; 90:1078-1090. [PMID: 31129620 PMCID: PMC6744301 DOI: 10.1136/jnnp-2019-320379] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/11/2019] [Accepted: 04/12/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) can be an effective therapy for tics and comorbidities in select cases of severe, treatment-refractory Tourette syndrome (TS). Clinical responses remain variable across patients, which may be attributed to differences in the location of the neuroanatomical regions being stimulated. We evaluated active contact locations and regions of stimulation across a large cohort of patients with TS in an effort to guide future targeting. METHODS We collected retrospective clinical data and imaging from 13 international sites on 123 patients. We assessed the effects of DBS over time in 110 patients who were implanted in the centromedial (CM) thalamus (n=51), globus pallidus internus (GPi) (n=47), nucleus accumbens/anterior limb of the internal capsule (n=4) or a combination of targets (n=8). Contact locations (n=70 patients) and volumes of tissue activated (n=63 patients) were coregistered to create probabilistic stimulation atlases. RESULTS Tics and obsessive-compulsive behaviour (OCB) significantly improved over time (p<0.01), and there were no significant differences across brain targets (p>0.05). The median time was 13 months to reach a 40% improvement in tics, and there were no significant differences across targets (p=0.84), presence of OCB (p=0.09) or age at implantation (p=0.08). Active contacts were generally clustered near the target nuclei, with some variability that may reflect differences in targeting protocols, lead models and contact configurations. There were regions within and surrounding GPi and CM thalamus that improved tics for some patients but were ineffective for others. Regions within, superior or medial to GPi were associated with a greater improvement in OCB than regions inferior to GPi. CONCLUSION The results collectively indicate that DBS may improve tics and OCB, the effects may develop over several months, and stimulation locations relative to structural anatomy alone may not predict response. This study was the first to visualise and evaluate the regions of stimulation across a large cohort of patients with TS to generate new hypotheses about potential targets for improving tics and comorbidities.
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Affiliation(s)
- Kara A Johnson
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, Utah, USA.,Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
| | - P Thomas Fletcher
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, Utah, USA.,School of Computing, University of Utah, Salt Lake City, Utah, USA
| | - Domenico Servello
- Neurosurgical Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Lombardia, Italy
| | - Alberto Bona
- Neurosurgical Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Lombardia, Italy
| | - Mauro Porta
- Tourette's Syndrome and Movement Disorders Center, IRCCS Istituto Ortopedico Galeazzi, Milan, Lombardia, Italy
| | - Jill L Ostrem
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Eric Bardinet
- Institut du Cerveau et de la Moelle Epiniere, Paris, Île-de-France, France
| | - Marie-Laure Welter
- Sorbonne Universités, University of Pierre and Marie Curie University of Paris, the French National Institute of Health and Medical Research U 1127, the National Center for Scientific Research 7225, Paris, France
| | - Andres M Lozano
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Juan Carlos Baldermann
- Department of Psychiatry and Psychotherapy, University of Cologne, Koln, Nordrhein-Westfalen, Germany
| | - Jens Kuhn
- Department of Psychiatry and Psychotherapy, University of Cologne, Koln, Nordrhein-Westfalen, Germany
| | - Daniel Huys
- Department of Psychiatry and Psychotherapy, University of Cologne, Koln, Nordrhein-Westfalen, Germany
| | - Thomas Foltynie
- Queen Square, Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience, University College London Institute of Neurology, London, UK
| | - Marwan Hariz
- Queen Square, Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience, University College London Institute of Neurology, London, UK
| | - Eileen M Joyce
- Queen Square, Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience, University College London Institute of Neurology, London, UK
| | - Ludvic Zrinzo
- Queen Square, Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience, University College London Institute of Neurology, London, UK
| | - Zinovia Kefalopoulou
- Queen Square, Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience, University College London Institute of Neurology, London, UK
| | - Jian-Guo Zhang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Fan-Gang Meng
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - ChenCheng Zhang
- Department of Functional Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhipei Ling
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Xin Xu
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Xinguang Yu
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Anouk Yjm Smeets
- Department of Neurosurgery, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands
| | - Linda Ackermans
- Department of Neurosurgery, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands
| | - Veerle Visser-Vandewalle
- Department of Stereotaxy and Functional Neurosurgery, University Hospital Cologne, Koln, Nordrhein-Westfalen, Germany
| | - Alon Y Mogilner
- Center for Neuromodulation, Departments of Neurology and Neurosurgery, New York University Medical Center, New York, New York, USA
| | - Michael H Pourfar
- Center for Neuromodulation, Departments of Neurology and Neurosurgery, New York University Medical Center, New York, New York, USA
| | - Leonardo Almeida
- Fixel Institute for Neurological Diseases, Program for Movement Disorders and Neurorestoration, Departments of Neurology and Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Aysegul Gunduz
- Fixel Institute for Neurological Diseases, Program for Movement Disorders and Neurorestoration, Departments of Neurology and Neurosurgery, University of Florida, Gainesville, Florida, USA.,J Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, Florida, USA
| | - Wei Hu
- Fixel Institute for Neurological Diseases, Program for Movement Disorders and Neurorestoration, Departments of Neurology and Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Kelly D Foote
- Fixel Institute for Neurological Diseases, Program for Movement Disorders and Neurorestoration, Departments of Neurology and Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Michael S Okun
- Fixel Institute for Neurological Diseases, Program for Movement Disorders and Neurorestoration, Departments of Neurology and Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Christopher R Butson
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, Utah, USA .,Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA.,Departments of Neurology, Neurosurgery, and Psychiatry, University of Utah, Salt Lake City, Utah, USA
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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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13
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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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Neudorfer C, El Majdoub F, Hunsche S, Richter K, Sturm V, Maarouf M. Deep Brain Stimulation of the H Fields of Forel Alleviates Tics in Tourette Syndrome. Front Hum Neurosci 2017; 11:308. [PMID: 28659777 PMCID: PMC5468420 DOI: 10.3389/fnhum.2017.00308] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 05/29/2017] [Indexed: 12/29/2022] Open
Abstract
The current rationale for target selection in Tourette syndrome revolves around the notion of cortico-basal ganglia circuit involvement in the pathophysiology of the disease. However, despite extensive research, the ideal target for deep brain stimulation (DBS) is still under debate, with many structures being neglected and underexplored. Based on clinical observations and taking into account the prevailing hypotheses of network processing in Tourette syndrome, we chose the fields of Forel, namely field H1, as a target for DBS. The fields of Forel constitute the main link between the striatopallidal system and the thalamocortical network, relaying pallidothalamic projections from core anatomical structures to the thalamic ventral nuclear group. In a retrospective study we investigated two patients suffering from chronic, medically intractable Tourette syndrome who underwent bilateral lead implantation in field H1 of Forel. Clinical scales revealed significant alleviation of tics and comorbid symptoms, namely depression and anxiety, in the postoperative course in both patients.
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Affiliation(s)
- Clemens Neudorfer
- Department of Stereotaxy and Functional Neurosurgery, Cologne-Merheim Medical Center, Witten/Herdecke UniversityCologne, Germany
| | - Faycal El Majdoub
- Department of Stereotaxy and Functional Neurosurgery, Cologne-Merheim Medical Center, Witten/Herdecke UniversityCologne, Germany
| | - Stefan Hunsche
- Department of Stereotaxy and Functional Neurosurgery, Cologne-Merheim Medical Center, Witten/Herdecke UniversityCologne, Germany
| | - Klaus Richter
- Department of Psychiatry and Psychotherapy, LVR Clinics CologneCologne, Germany
| | - Volker Sturm
- Department of Neurosurgery, University Hospital of WürzburgWürzburg, Germany
| | - Mohammad Maarouf
- Department of Stereotaxy and Functional Neurosurgery, Cologne-Merheim Medical Center, Witten/Herdecke UniversityCologne, Germany
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15
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Zhang XH, Li JY, Zhang YQ, Li YJ. Deep Brain Stimulation of the Globus Pallidus Internus in Patients with Intractable Tourette Syndrome: A 1-year Follow-up Study. Chin Med J (Engl) 2017; 129:1022-7. [PMID: 27098785 PMCID: PMC4852667 DOI: 10.4103/0366-6999.180512] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Deep brain stimulation (DBS) has been a promising treatment for patients with refractory Tourette syndrome (TS) for more than a decade. Despite successful DBS treatment of TS in more than 100 patients worldwide, studies with a large patient sample and long-term follow-up assessments are still scarce. Accordingly, we investigated the clinical efficacy and safety of globus pallidus internus (GPi) DBS in the treatment of intractable TS in 24 patients with a 1-year follow-up assessment. Methods: Bilateral/unilateral GPi-DBS was performed in 24 patients with TS. We evaluated symptoms of tics and obsessive-compulsive disorder (OCD) through the Yale Global Tic Severity Scale (YGTSS) and Yale-Brown Obsessive-compulsive Scale (Y-BOCS). We used the Wechsler Adult Intelligence Scale-Revised in China (WAIS-RC) to evaluate the safety of the treatment. We conducted follow-up assessments of all patients for at least 12 months (12–99 months). Results: Symptoms of tics and OCD were significantly relieved at a 12-month follow-up assessment. The mean YGTSS score was 74.04 ± 11.52, 49.83 ± 10.91, 32.58 ± 7.97, and 31.21 ± 8.87 at baseline, 3, 6, and 12 months, respectively. The mean YGTSS scores obtained at the follow-up assessments were significantly different from the baseline (P < 0.05). The improvement in motor tics was superior to that in phonic tics. The mean Y-BOCS scores were 21.61 ± 4.97, 18 ± 4.58, 14.39 ± 3.99, and 13.78 ± 4.56 at baseline, 3, 6, and 12 months, respectively (P < 0.05). We observed a remarkable improvement in psychiatric comorbidities, such as OCD and attention-deficit hyperactivity disorder, after the procedure. WAIS-RC scores were comparable before and after the operation. There were no severe postoperative complications. Conclusion: GPi-DBS appears to comprehensively alleviate tic symptoms and psychiatric comorbidities in patients with TS, thus significantly improving patients’ quality of life.
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Affiliation(s)
| | | | | | - Yong-Jie Li
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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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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Servello D, Zekaj E, Saleh C, Lange N, Porta M. Deep Brain Stimulation in Gilles de la Tourette Syndrome: What Does the Future Hold? A Cohort of 48 Patients. Neurosurgery 2016; 78:91-100. [PMID: 26348012 DOI: 10.1227/neu.0000000000001004] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Gilles de la Tourette syndrome (GTS) is a severe neuropsychiatric disorder with childhood onset, characterized by disabling motor and vocal tics lasting for more than 1 year and associated with a wide range of psychiatric comorbidities. Pharmacological treatment is indicated for moderate to severe GTS patients. However, when GTS is refractory to conventional medical and behavioral treatments, deep brain stimulation (DBS) can be considered as a last resort therapeutic avenue. OBJECTIVE To evaluate the efficacy of DBS and its comorbidities in the largest pool of GTS patients to date. METHODS Our cohort study was based on 48 patients' refractory to conventional treatment who underwent DBS for GTS at Galeazzi Institute, Milan, Italy. An exhaustive preoperative and a follow-up battery of tests was performed including the Yale Global Tic Severity Rating Scale, the Yale-Brown Obsessive Compulsive Scale, the Beck Depression Inventory, the State Trait Anxiety Inventory, and the Subjective Social Impairment on a 10-point Visual Analogue Scale tests. RESULTS Eleven patients in whom the device was removed for inflammatory complications or for poor compliance were excluded from final analysis. Twenty-seven of the remaining 37 patients had a Yale Global Tic Severity Rating Scale score at the last follow-up that was less than 35. Of the 37 patients, in 29 cases (78%) a reduction of more than 50% of the Yale Global Tic Severity Rating Scale score was observed. CONCLUSION The clinical efficacy of DBS in GTS is promising. Although DBS is associated with risks, as is any surgical intervention, DBS should be considered as a last resort therapeutic option in carefully selected GTS patients.
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Affiliation(s)
- Domenico Servello
- *Departments of Neurosurgery and Neurology, IRCCS Galeazzi, Milan, Italy;‡Department of Psychiatry, Harvard Medical School, Neurostatistics Laboratory, Belmont, Massachusetts
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DBS in Tourette syndrome: where are we standing now? J Neural Transm (Vienna) 2016; 123:791-796. [DOI: 10.1007/s00702-016-1569-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 05/01/2016] [Indexed: 11/25/2022]
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20
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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: 135] [Impact Index Per Article: 15.0] [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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Fraint A, Pal G. Deep Brain Stimulation in Tourette's Syndrome. Front Neurol 2015; 6:170. [PMID: 26300844 PMCID: PMC4523794 DOI: 10.3389/fneur.2015.00170] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 07/20/2015] [Indexed: 11/13/2022] Open
Abstract
Objective Tourette’s syndrome (TS) is defined by 1 year of persistent motor and vocal tics. Often, the tics are refractory to conventional pharmacologic and psychobehavioral interventions. In these patients, deep brain stimulation (DBS) may be an appropriate intervention. This paper reviews different DBS targets in TS, discusses existing evidence on the efficacy of DBS in TS, highlights adverse effects of the procedure, discusses indications and patient selection as well as future directions for DBS in TS. Methods A literature review searching PubMed database entries between 2000 and 2015. Search terms included “DBS in Tourette Syndrome”, “Deep brain stimulation in Tourette syndrome,” and “Surgical management of Tourette Syndrome.” Results Though there are no universally accepted guidelines defining ideal DBS candidates for TS, age, tic severity, and treatment refractoriness are important factors to consider in patient selection. A variety of targets exist for DBS in TS, but thalamic targets and GPi are the most widely studied. Psychiatric side effects that are target specific should be monitored closely and it is possible that these adverse effects may be resolved with programing. Small randomized controlled trials support the efficacy of DBS in TS. Conclusion DBS for TS is safe and feasible, but large multi-center clinical trials are needed to determine the ideal target and optimal location within a particular target.
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Affiliation(s)
- Avram Fraint
- Department of Neurological Sciences, Rush University Medical Center , Chicago, IL , USA
| | - Gian Pal
- Department of Neurological Sciences, Rush University Medical Center , Chicago, IL , USA
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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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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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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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Kocabicak E, Temel Y, Höllig A, Falkenburger B, Tan SK. Current perspectives on deep brain stimulation for severe neurological and psychiatric disorders. Neuropsychiatr Dis Treat 2015; 11:1051-66. [PMID: 25914538 PMCID: PMC4399519 DOI: 10.2147/ndt.s46583] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Deep brain stimulation (DBS) has become a well-accepted therapy to treat movement disorders, including Parkinson's disease, essential tremor, and dystonia. Long-term follow-up studies have demonstrated sustained improvement in motor symptoms and quality of life. DBS offers the opportunity to selectively modulate the targeted brain regions and related networks. Moreover, stimulation can be adjusted according to individual patients' demands, and stimulation is reversible. This has led to the introduction of DBS as a treatment for further neurological and psychiatric disorders and many clinical studies investigating the efficacy of stimulating various brain regions in order to alleviate severe neurological or psychiatric disorders including epilepsy, major depression, and obsessive-compulsive disorder. In this review, we provide an overview of accepted and experimental indications for DBS therapy and the corresponding anatomical targets.
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Affiliation(s)
- Ersoy Kocabicak
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, the Netherlands ; Department of Neuroscience, Maastricht University, Maastricht, the Netherlands ; Department of Neurosurgery, Ondokuz Mayıs University, Samsun, Turkey
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, the Netherlands ; Department of Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Anke Höllig
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | | | - Sonny Kh Tan
- Department of Neuroscience, Maastricht University, Maastricht, the Netherlands ; Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
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Malaty IA, Akbar U. Updates in medical and surgical therapies for Tourette syndrome. Curr Neurol Neurosci Rep 2014; 14:458. [PMID: 24871966 DOI: 10.1007/s11910-014-0458-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tourette syndrome is a complex neurobehavioral disorder defined by multiple motor and at least 1 vocal tic, persisting over 1 year, waxing and waning in severity, and not explained by another condition. The condition may range from mild nuisance to debilitating and disabling in severity. Management includes counseling and reassurance, behavioral interventions, pharmacologic, and rarely, surgical interventions. Traditionally, alpha-2 agonists and dopamine receptor antagonists have been utilized. In addition, a number of different pharmacotherapies have been implemented in the search for improved management of tics with better tolerability. In rare, severely disabling cases, neuromodulation with deep brain stimulation may be indicated. Optimal brain targets and candidate selection are still in evolution. This article will review the evidence for current medical and surgical therapies with a focus on recent updates.
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Affiliation(s)
- Irene A Malaty
- Department of Neurology, University of Florida, UF Center for Movement Disorders and Neurorestoration, P.O. Box 100236, Gainesville, FL, 32610, 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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Bour LJ, Ackermans L, Foncke EMJ, Cath D, van der Linden C, Visser Vandewalle V, Tijssen MA. Tic related local field potentials in the thalamus and the effect of deep brain stimulation in Tourette syndrome: Report of three cases. Clin Neurophysiol 2014; 126:1578-88. [PMID: 25435514 DOI: 10.1016/j.clinph.2014.10.217] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 10/14/2014] [Accepted: 10/31/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Three patients with intractable Tourette syndrome (TS) underwent thalamic deep brain stimulation (DBS). To investigate the role of thalamic electrical activity in tic generation, local field potentials (LFP), EEG and EMG simultaneously were recorded. METHODS Event related potentials and event related spectral perturbations of EEG and LFP, event related cross-coherences between EEG/LFP and LFP/LFP were analyzed. As time locking events, the tic onsets were used. Spontaneous tics were compared to voluntary tic mimicking. The effect of tic suppression and DBS on thalamic LFPs was evaluated. RESULTS All three patients showed time-locked and prior to onset of spontaneous motor tics thalamic synchronization and thalamo-cortical cross-coherence. Also in three patients, not time-locked to motor tics, increased intra-thalamic coherences in the 1-8Hz frequency band were found. In one patient it was demonstrated that voluntary mimicked tics were preceded by premotor cortical and thalamic potentials. In this patient unilateral thalamic DBS contralaterally decreased the background thalamic activity. CONCLUSIONS The present study in three cases with TS shows that spontaneous tics in TS are preceded by repetitive coherent thalamo-cortical discharges, indicating that preceding a tic the basal ganglia circuits are "charged up", ultimately leading to a motor tic. SIGNIFICANCE Thalamic LFP recording may lead to more insight in underlying pathophysiological mechanisms in TS.
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Affiliation(s)
- L J Bour
- Department of Neurology and Clinical Neurophysiology of the Academic Medical Center, University of Amsterdam, The Netherlands.
| | - L Ackermans
- Department of Neurosurgery, Maastricht University Medical Center, The Netherlands; MIND (Maastricht Institute for Neuromodulative Development), The Netherlands
| | - E M J Foncke
- Department of Neurology of the Free University of Amsterdam, The Netherlands
| | - D Cath
- Department of Clinical and Health Psychology, Utrecht University/Altrecht, Anxiety Outpatient Program, Utrecht, The Netherlands
| | - C van der Linden
- Center for Movement Disorders, St. Lucas Hospital Ghent, Ghent, Belgium
| | - V Visser Vandewalle
- Department of Stereotactic and Functional Neurosurgery, University of Cologne, Germany
| | - M A Tijssen
- Department of Neurology, University of Groningen, The Netherlands
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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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Smith Y, Galvan A, Ellender TJ, Doig N, Villalba RM, Huerta-Ocampo I, Wichmann T, Bolam JP. The thalamostriatal system in normal and diseased states. Front Syst Neurosci 2014; 8:5. [PMID: 24523677 PMCID: PMC3906602 DOI: 10.3389/fnsys.2014.00005] [Citation(s) in RCA: 150] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 01/11/2014] [Indexed: 11/13/2022] Open
Abstract
Because of our limited knowledge of the functional role of the thalamostriatal system, this massive network is often ignored in models of the pathophysiology of brain disorders of basal ganglia origin, such as Parkinson's disease (PD). However, over the past decade, significant advances have led to a deeper understanding of the anatomical, electrophysiological, behavioral and pathological aspects of the thalamostriatal system. The cloning of the vesicular glutamate transporters 1 and 2 (vGluT1 and vGluT2) has provided powerful tools to differentiate thalamostriatal from corticostriatal glutamatergic terminals, allowing us to carry out comparative studies of the synaptology and plasticity of these two systems in normal and pathological conditions. Findings from these studies have led to the recognition of two thalamostriatal systems, based on their differential origin from the caudal intralaminar nuclear group, the center median/parafascicular (CM/Pf) complex, or other thalamic nuclei. The recent use of optogenetic methods supports this model of the organization of the thalamostriatal systems, showing differences in functionality and glutamate receptor localization at thalamostriatal synapses from Pf and other thalamic nuclei. At the functional level, evidence largely gathered from thalamic recordings in awake monkeys strongly suggests that the thalamostriatal system from the CM/Pf is involved in regulating alertness and switching behaviors. Importantly, there is evidence that the caudal intralaminar nuclei and their axonal projections to the striatum partly degenerate in PD and that CM/Pf deep brain stimulation (DBS) may be therapeutically useful in several movement disorders.
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Affiliation(s)
- Yoland Smith
- Yerkes National Primate Research Center, Emory UniversityAtlanta, GA, USA
- Department of Neurology, Emory UniversityAtlanta, GA, USA
- Udall Center of Excellence for Parkinson’s Disease, Emory UniversityAtlanta, GA, USA
| | - Adriana Galvan
- Yerkes National Primate Research Center, Emory UniversityAtlanta, GA, USA
- Department of Neurology, Emory UniversityAtlanta, GA, USA
- Udall Center of Excellence for Parkinson’s Disease, Emory UniversityAtlanta, GA, USA
| | - Tommas J. Ellender
- Department of Pharmacology, MRC Anatomical Neuropharmacology UnitOxford, UK
| | - Natalie Doig
- Department of Pharmacology, MRC Anatomical Neuropharmacology UnitOxford, UK
| | - Rosa M. Villalba
- Yerkes National Primate Research Center, Emory UniversityAtlanta, GA, USA
- Udall Center of Excellence for Parkinson’s Disease, Emory UniversityAtlanta, GA, USA
| | | | - Thomas Wichmann
- Yerkes National Primate Research Center, Emory UniversityAtlanta, GA, USA
- Department of Neurology, Emory UniversityAtlanta, GA, USA
- Udall Center of Excellence for Parkinson’s Disease, Emory UniversityAtlanta, GA, USA
| | - J. Paul Bolam
- Department of Pharmacology, MRC Anatomical Neuropharmacology UnitOxford, UK
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Motlagh MG, Smith ME, Landeros-Weisenberger A, Kobets AJ, King RA, Miravite J, de Lotbinière ACJ, Alterman RL, Mogilner AY, Pourfar MH, Okun MS, Leckman JF. Lessons Learned from Open-label Deep Brain Stimulation for Tourette Syndrome: Eight Cases over 7 Years. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2013; 3. [PMID: 24255802 PMCID: PMC3822402 DOI: 10.7916/d8m32tgm] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 08/23/2013] [Indexed: 12/26/2022]
Abstract
Background Deep brain stimulation (DBS) remains an experimental but promising treatment for patients with severe refractory Gilles de la Tourette syndrome (TS). Controversial issues include the selection of patients (age and clinical presentation), the choice of brain targets to obtain optimal patient-specific outcomes, and the risk of surgery- and stimulation-related serious adverse events. Methods This report describes our open-label experience with eight patients with severe refractory malignant TS treated with DBS. The electrodes were placed in the midline thalamic nuclei or globus pallidus, pars internus, or both. Tics were clinically assessed in all patients pre- and postoperatively using the Modified Rush Video Protocol and the Yale Global Tic Severity Scale (YGTSS). Results Although three patients had marked postoperative improvement in their tics (>50% improvement on the YGTSS), the majority did not reach this level of clinical improvement. Two patients had to have their DBS leads removed (one because of postoperative infection and another because of lack of benefit). Discussion Our clinical experience supports the urgent need for more data and refinements in interventions and outcome measurements for severe, malignant, and medication-refractory TS. Because TS is not an etiologically homogenous clinical entity, the inclusion criteria for DBS patients and the choice of brain targets will require more refinement.
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Affiliation(s)
- Maria G Motlagh
- Child Study Center, Yale University, New Haven, Connecticut, United States of America
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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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35
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Surgery for Psychiatric Disorders. World Neurosurg 2013; 80:S31.e17-28. [DOI: 10.1016/j.wneu.2012.03.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Accepted: 03/28/2012] [Indexed: 12/28/2022]
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Porta M, Servello D, Zanaboni C, Anasetti F, Menghetti C, Sassi M, Robertson MM. Deep brain stimulation for treatment of refractory Tourette syndrome: long-term follow-up. Acta Neurochir (Wien) 2012; 154:2029-41. [PMID: 22961243 DOI: 10.1007/s00701-012-1497-8] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 08/23/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND Eighteen patients with severe and refractory Tourette Syndrome underwent bilateral thalamic deep brain stimulation. The surgical procedures and stimulation processes of the cohort were reported in 2008; the 2 year follow-up was reported in 2009. The aim of the research is the assessment of long-term outcome (5-6 years) on tics, obsessional behaviours, anxiety, mood, and on the overall general health of the patients and their general satisfaction. METHOD In this study, all 18 of the original patients will be discussed, pre- and post-DBS, according to our protocol using standardized objective schedules, as well as the clinical impressions of both clinicians and patients. As there were no substantial nor statistical differences on measures of cognitive functioning between pre-DBS and 2 year follow-up, we decided not to continue this aspect of the formal assessment, particularly as there were also no clinical indications. RESULTS At 5-6 year follow-up, there was a significant reduction in tic severity (p < 0.001), and significant improvements in obsessive compulsive behaviours (p = 0.003), anxiety (p < 0.001) and depressive (p < 0.001) symptoms. Patients, in general, required less medication for tics, co-morbid conditions and/or co-existent psychopathologies. The long-term outcome/satisfaction were not unanimous between patients and the medical team. CONCLUSIONS At long-term follow-up, DBS was very successful in terms of a significant improvement in tics and also a significant reduction in the potentially disabling symptoms of obsessionality, anxiety and depression. However, compared with our more positive overall results at 2 years, these later results demonstrate long-term difficulties as follows: non-compliance, long-term complications , and the differences in the opinions between the (a) medical, (b) the surgical teams and (c) the post-DBS patients as to their outcome/satisfaction with the procedures. Our experience highlights the need for controlled studies, for long-term follow up, and the need to improve the selection of patients for DBS.
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Affiliation(s)
- M Porta
- Tourette Center- IRCCS Galeazzi Hospital, via R. Galeazzi 4, 20161, Milano, Italy.
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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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39
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Surgery for Tourette syndrome. World Neurosurg 2012; 80:S29.e15-22. [PMID: 22722039 DOI: 10.1016/j.wneu.2012.06.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2011] [Revised: 05/07/2012] [Accepted: 06/13/2012] [Indexed: 11/23/2022]
Abstract
Tourette syndrome is a chronic neuropsychiatric disorder characterized by motor and vocal tics. In the majority of cases, tics are associated by behavioral disorders such as obsessive-compulsive behavior. First symptoms typically appear in early childhood. Mostly symptoms disappear when adulthood is reached. Treatment options consist of behavioral therapy and medication. In refractory cases, surgery may be an option. In the past, several attempts have been made to treat therapy-refractory patients through neurosurgical ablative procedures. In 1999, deep brain stimulation was introduced as a novel treatment option for patients with intractable Tourette syndrome. Up until now, five brain areas have been used or suggested as potential target areas for deep brain stimulation in Tourette syndrome. In the majority of the published cases, there is a clear effect on tics but most studies consist of only a limited number of patients. A strict patient selection is absolutely mandatory. There is a need for double-blinded multicenter trials with inclusion of more patients.
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Viswanathan A, Jimenez-Shahed J, Baizabal Carvallo JF, Jankovic J. Deep brain stimulation for Tourette syndrome: target selection. Stereotact Funct Neurosurg 2012; 90:213-24. [PMID: 22699684 DOI: 10.1159/000337776] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Accepted: 03/03/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Tourette syndrome (TS) is a complex neurological disorder manifested chiefly by motor and phonic tics and a variety of behavioral comorbidities, including attention disorder, obsessive-compulsive disorder and impulse control problems. Surgical treatment is increasingly considered when tics become troublesome or even disabling or self-injurious despite optimal medical therapy. In this review, we describe the surgical techniques, stimulation parameters, outcomes of deep brain stimulation (DBS) in TS, and critically review target choices. METHODS A search of the PubMed database was performed to identify all articles discussing DBS and TS. 'Tourette' and 'Stimulation' were used as MeSH headings. RESULTS Since the first report of thalamic DBS for TS in 1999, follow-up on less than 100 patients has been reported in the literature. Reported targets for DBS include the thalamic centromedian nucleus and substantia periventricularis, posteroventral globus pallidus internus, ventromedial globus pallidus internus, globus pallidus externus, anterior limb of the internal capsule and nucleus accumbens. CONCLUSIONS Determination of the optimal surgical target will require a multicenter, randomized trial, and an expanded understanding of the neurobiology of TS.
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Affiliation(s)
- Ashwin Viswanathan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA.
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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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Pansaon Piedad JC, Rickards HE, Cavanna AE. What Patients With Gilles de la Tourette Syndrome Should Be Treated With Deep Brain Stimulation and What Is the Best Target? Neurosurgery 2012; 71:173-92. [DOI: 10.1227/neu.0b013e3182535a00] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
AbstractBACKGROUND:Gilles de la Tourette syndrome (GTS) is a chronic neurodevelopmental disorder characterized by tics and associated behavioral symptoms. Over the past decade, deep brain stimulation (DBS) has been increasingly advocated as a reversible and controllable procedure for selected cases of GTS.OBJECTIVE:We set out to answer 2 clinically relevant questions: what patients with GTS should be treated with DBS and what is the best target?METHODS:We conducted a systematic literature review of the published studies of DBS in GTS and critically evaluated the current evidence for both patient and target selection.RESULTS:Since 1999, up to 99 cases of DBS in GTS have been reported in the scientific literature, with varying selection criteria, stimulation targets, and assessment protocols. The vast majority of studies published to date are case reports or case series reporting successful outcomes in terms of both tic severity improvement and tolerability. The reviewed studies suggest that the best candidates are patients with significant functional impairment related to the tic symptoms, who did not respond to conventional pharmacological and behavioral interventions. The globus pallidus internus and thalamus appear to be the safest and most effective targets, especially for patients with “pure” GTS and patients with comorbid obsessive-compulsive symptoms, anxiety, and depression.CONCLUSION:DBS is a promising treatment option for severe cases of GTS. There is a need to reach consensus on the definition of “treatment-refractoriness” and to conduct larger double-blind randomized controlled studies on the most promising targets.
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Affiliation(s)
- John Carlo Pansaon Piedad
- Michael Trimble Neuropsychiatry Research Group, Department of Neuropsychiatry, University of Birmingham and BSMHFT, Birmingham, United Kingdom
| | - Hugh Edward Rickards
- Michael Trimble Neuropsychiatry Research Group, Department of Neuropsychiatry, University of Birmingham and BSMHFT, Birmingham, United Kingdom
| | - Andrea Eugenio Cavanna
- Michael Trimble Neuropsychiatry Research Group, Department of Neuropsychiatry, University of Birmingham and BSMHFT, Birmingham, United Kingdom
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology and UCL, London, United Kingdom
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Savica R, Stead M, Mack KJ, Lee KH, Klassen BT. Deep brain stimulation in tourette syndrome: a description of 3 patients with excellent outcome. Mayo Clin Proc 2012; 87:59-62. [PMID: 22212969 PMCID: PMC3538384 DOI: 10.1016/j.mayocp.2011.08.005] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Revised: 08/05/2011] [Accepted: 08/08/2011] [Indexed: 10/14/2022]
Abstract
Tourette syndrome (TS) is a complex neuropsychiatric disorder often starting in childhood and characterized by the presence of multiple motor and vocal tics and psychiatric comorbidities. Patients with TS usually respond to medical treatment, and the condition often improves during adolescence; however, surgery has been considered a possible approach for the subset of patients with ongoing medically refractory disease. Ablative procedures have been associated with unsatisfactory results and major adverse effects, prompting trials of deep brain stimulation (DBS) as an alternative therapy. It remains unclear which of the various nuclear targets is most effective in TS. We describe 3 patients with TS who underwent DBS targeting the bilateral thalamic centromedian/parafascicular complex (CM/Pf) with an excellent clinical outcome. At 1-year follow-up, the mean reduction in the total Yale Global Tic Severity Scale score in the 3 patients was 70% (range, 60%-80%).Our study further supports the role of the CM/Pf DBS target in medically intractable TS.
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Affiliation(s)
| | - Matt Stead
- Department of Neurology, Mayo Clinic, Rochester, MN
| | | | - Kendall H. Lee
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Bryan T. Klassen
- Department of Neurology, Mayo Clinic, Rochester, MN
- Correspondence: Address to Bryan T. Klassen, MD, Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN 55905
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Abstract
Psychiatric disorders are worldwide a common cause of severe and long-term disability and socioeconomic burden. The management of patients with psychiatric disorders consists of drug therapy and/or psychotherapy. However, in some patients, these treatment modalities do not produce sufficient therapeutic effects or induce intolerable side effects. For these patients, neuromodulation has been suggested as a potential treatment modality. Neuromodulation includes deep brain stimulation, vagal nerve stimulation, and transcranial magnetic and electrical stimulation. The rationale for neuromodulation is derived from the research identifying neurobiologically localized substrates for refractory psychiatric symptoms. Here, we review the clinical data on neuromodulation in the major psychiatric disorders. Relevant data from animal models will also be discussed to explain the neurobiological basis of the therapy.
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Abstract
OPINION STATEMENT Tics come in a variety of types and frequencies; have a waxing and waning course; are exacerbated by stress, anxiety, and fatigue; and often resolve or improve in the teenage or early adult years. Tourette syndrome requires the presence of chronic, fluctuating motor and phonic tics. In addition to tics, individuals with Tourette syndrome often have a variety of comorbid conditions such as attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder, depression and anxiety, episodic outbursts, and academic difficulties. These conditions often are a greater source of difficulty than the tics themselves. All patients with tics should be evaluated to assure proper diagnosis and to identify any associated psychopathology or academic difficulty. The treatment of tics begins with education of the patient and family, including discussions about the fundamentals of tics: their characteristics, etiology, outcomes, and available treatments. Therapy should be individualized based on the extent of impairment, available support, ability to cope, and the presence of other problems. Indications for the treatment of tics include psychosocial problems (loss of self-esteem, comments from peers, excessive worries about tics, diminished participation in activities), functional difficulties, classroom disruption, and physical discomfort. A variety of behavioral approaches can be used. Recent studies have emphasized the value of comprehensive behavioral intervention for tics (CBIT). Because habit reversal is the major component of CBIT, a cooperative patient, the presence of a premonitory urge, and a committed family are essential ingredients for success. If tic-suppressing medication is required, a two-tier approach and monotherapy are recommended. First-tier medications, notably the α-adrenergic agonists, are recommended for individuals with milder tics, especially persons with both tics and ADHD. Second-tier medications include various typical and atypical neuroleptics. Their sequence of prescription is often based on physician experience; I favor pimozide and fluphenazine. Atypical antipsychotics, such as risperidone and aripiprazole, have some advantages based on their side-effect profile and are particularly beneficial in individuals with significant co-existing behavioral issues. As will become readily apparent, however, few medications have been adequately assessed. Deep brain stimulation is an emerging therapy, but further data are required to optimize the location of electrode placement and stimulation and to determine precise indications for its implementation. Stimulant medication is effective in treating ADHD in children with tics; studies reducing concerns about its use are discussed.
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Abstract
The realization that medications used to treat movement disorders and psychiatric conditions of basal ganglia origin have significant shortcomings, as well as advances in the understanding of the functional organization of the brain, has led to a renaissance in functional neurosurgery, and particularly the use of deep brain stimulation (DBS). Movement disorders are now routinely being treated with DBS of 'motor' portions of the basal ganglia output nuclei, specifically the subthalamic nucleus and the internal pallidal segment. These procedures are highly effective and generally safe. Use of DBS is also being explored in the treatment of neuropsychiatric disorders, with targeting of the 'limbic' basal ganglia-thalamocortical circuitry. The results of these procedures are also encouraging, but many unanswered questions remain in this emerging field. This review summarizes the scientific rationale and practical aspects of using DBS for neurologic and neuropsychiatric disorders.
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Martínez-Fernández R, Zrinzo L, Aviles-Olmos I, Hariz M, Martinez-Torres I, Joyce E, Jahanshahi M, Limousin P, Foltynie T. Deep brain stimulation for Gilles de la Tourette syndrome: a case series targeting subregions of the globus pallidus internus. Mov Disord 2011; 26:1922-30. [PMID: 21538528 DOI: 10.1002/mds.23734] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Revised: 02/07/2011] [Accepted: 03/08/2011] [Indexed: 01/03/2023] Open
Abstract
Deep brain stimulation remains an experimental treatment for patients with Gilles de la Tourette syndrome. Currently, a major controversial issue is the choice of brain target that leads to optimal patient outcomes within a presumed network of basal ganglia and cortical pathways involved in tic pathogenesis. This report describes our experience with patients with severe refractory Gilles de la Tourette syndrome treated with globus pallidus internus deep brain stimulation. Five patients were selected for surgery, 2 targeting the posteroventral globus pallidus internus and 2 targeting the anteromedial region. The remaining patient was first targeted on the posterolateral region, but after 18 months the electrodes were relocated in the anteromedial area. Tics were clinically assessed in all patients pre- and postoperatively using the Modified Rush Video protocol and the Yale Global Tic Severity Scale. Obsessive-compulsive behaviors were quantified with the Yale-Brown Obsessive Compulsive Scale. The Gilles de la Tourette Syndrome-Quality of Life Scale was also completed. All patients experienced improvements in tic severity but to variable extents. More convincing improvements were seen in patients with electrodes sited in the anteromedial region of the globus pallidus internus than in those with posterolateral implants. Mean reduction in the Modified Rush Video Rating scale for each group was 54% and 37%, respectively. Our open-label limited experience supports the use of the anteromedial globus pallidus internus as a promising target for future planned randomized double-blind trials of deep brain stimulation for patients with Gilles de la Tourette syndrome.
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Affiliation(s)
- Raul Martínez-Fernández
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology, Queen Square, London, United Kingdom
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Müller-Vahl KR, Cath DC, Cavanna AE, Dehning S, Porta M, Robertson MM, Visser-Vandewalle V. European clinical guidelines for Tourette syndrome and other tic disorders. Part IV: deep brain stimulation. Eur Child Adolesc Psychiatry 2011; 20:209-17. [PMID: 21445726 DOI: 10.1007/s00787-011-0166-4] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Ten years ago deep brain stimulation (DBS) has been introduced as an alternative and promising treatment option for patients suffering from severe Tourette syndrome (TS). It seemed timely to develop a European guideline on DBS by a working group of the European Society for the Study of Tourette Syndrome (ESSTS). For a narrative review a systematic literature search was conducted and expert opinions of the guidelines group contributed also to the suggestions. Of 63 patients reported so far in the literature 59 had a beneficial outcome following DBS with moderate to marked tic improvement. However, randomized controlled studies including a larger number of patients are still lacking. Although persistent serious adverse effects (AEs) have hardly been reported, surgery-related (e.g., bleeding, infection) as well as stimulation-related AEs (e.g., sedation, anxiety, altered mood, changes in sexual function) may occur. At present time, DBS in TS is still in its infancy. Due to both different legality and practical facilities in different European countries these guidelines, therefore, have to be understood as recommendations of experts. However, among the ESSTS working group on DBS in TS there is general agreement that, at present time, DBS should only be used in adult, treatment resistant, and severely affected patients. It is highly recommended to perform DBS in the context of controlled trials.
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Affiliation(s)
- Kirsten R Müller-Vahl
- Clinic of Psychiatry, Socialpsychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.
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Sassi M, Porta M, Servello D. Deep brain stimulation therapy for treatment-refractory Tourette's syndrome: A review. Acta Neurochir (Wien) 2011; 153:639-45. [PMID: 20853121 DOI: 10.1007/s00701-010-0803-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Accepted: 09/08/2010] [Indexed: 11/24/2022]
Abstract
Tourette's syndrome is a chronic neurobehavioral disorder that can demonstrate refractoriness to conservative treatments, or to invasive nonsurgical treatments such as botulinum toxin infiltration, or to psychobehavioral treatments. In these cases, the surgical option is often proposed, either with lesional interventions, or more recently with deep brain stimulation (DBS). This latter modality is currently preferred because of its reversibility and modularity. Some relevant issues, however, still persist in terms of appropriate indication to treatment, selection of target, and follow-up evaluation.
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Affiliation(s)
- Marco Sassi
- Functional Neurosurgery Unit, IRCCS Galeazzi, Via Galeazzi 4, 20161, Milan, Italy.
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Ackermans L, Duits A, van der Linden C, Tijssen M, Schruers K, Temel Y, Kleijer M, Nederveen P, Bruggeman R, Tromp S, van Kranen-Mastenbroek V, Kingma H, Cath D, Visser-Vandewalle V. Double-blind clinical trial of thalamic stimulation in patients with Tourette syndrome. Brain 2011; 134:832-44. [DOI: 10.1093/brain/awq380] [Citation(s) in RCA: 211] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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