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Altamirano JM, Salinas-Barboza K. Pallidal and Thalamic Deep Brain Stimulation in the Treatment of Unilateral Dystonia: A Prospective Assessment. Mov Disord Clin Pract 2024. [PMID: 39092579 DOI: 10.1002/mdc3.14184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 07/07/2024] [Accepted: 07/21/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND The complexities of unilateral dystonia have led to exploring simultaneous (dual) globus pallidus internus (GPi) and motor ventral thalamus (Vim/Vop) deep brain stimulation (DBS), yet detailed assessments are lacking. OBJECTIVES To assess the efficacy of GPi, Vim/Vop, and dual DBS in unilateral dystonia. METHODS Three patients with unilateral dystonia (two idiopathic, one acquired), implanted with two DBS electrodes targeting ipsilateral Vim/Vop and GPi, were included. Three stimulation modalities were assessed. First, one electrode was activated, then the other, and finally, both electrodes were activated simultaneously. RESULTS DBS yielded substantial symptomatic reductions in all three evaluated stimulation modalities. Patients exhibited varying responses regarding quality-of-life and depressive symptoms. Treatment satisfaction didn't align with clinical improvements, potentially affected by unrealistic expectations. CONCLUSIONS This study contributes critical insights into GPi, Vim/Vop and simultaneous stimulation for unilateral dystonia. The safety of the procedure underscores the promise of this approach.
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Xu J, Luo Y, Zhang J, Zhong L, Liu H, Weng A, Yang Z, Zhang Y, Ou Z, Yan Z, Cheng Q, Fan X, Zhang X, Zhang W, Hu Q, Liang D, Peng K, Liu G. Progressive thalamic nuclear atrophy in blepharospasm and blepharospasm-oromandibular dystonia. Brain Commun 2024; 6:fcae117. [PMID: 38638150 PMCID: PMC11025674 DOI: 10.1093/braincomms/fcae117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 01/21/2024] [Accepted: 04/05/2024] [Indexed: 04/20/2024] Open
Abstract
The thalamus is considered a key region in the neuromechanisms of blepharospasm. However, previous studies considered it as a single, homogeneous structure, disregarding potentially useful information about distinct thalamic nuclei. Herein, we aimed to examine (i) whether grey matter volume differs across thalamic subregions/nuclei in patients with blepharospasm and blepharospasm-oromandibular dystonia; (ii) causal relationships among abnormal thalamic nuclei; and (iii) whether these abnormal features can be used as neuroimaging biomarkers to distinguish patients with blepharospasm from blepharospasm-oromandibular dystonia and those with dystonia from healthy controls. Structural MRI data were collected from 56 patients with blepharospasm, 20 with blepharospasm-oromandibular dystonia and 58 healthy controls. Differences in thalamic nuclei volumes between groups and their relationships to clinical information were analysed in patients with dystonia. Granger causality analysis was employed to explore the causal effects among abnormal thalamic nuclei. Support vector machines were used to test whether these abnormal features could distinguish patients with different forms of dystonia and those with dystonia from healthy controls. Compared with healthy controls, patients with blepharospasm exhibited reduced grey matter volume in the lateral geniculate and pulvinar inferior nuclei, whereas those with blepharospasm-oromandibular dystonia showed decreased grey matter volume in the ventral anterior and ventral lateral anterior nuclei. Atrophy in the pulvinar inferior nucleus in blepharospasm patients and in the ventral lateral anterior nucleus in blepharospasm-oromandibular dystonia patients was negatively correlated with clinical severity and disease duration, respectively. The proposed machine learning scheme yielded a high accuracy in distinguishing blepharospasm patients from healthy controls (accuracy: 0.89), blepharospasm-oromandibular dystonia patients from healthy controls (accuracy: 0.82) and blepharospasm from blepharospasm-oromandibular dystonia patients (accuracy: 0.94). Most importantly, Granger causality analysis revealed that a progressive driving pathway from pulvinar inferior nuclear atrophy extends to lateral geniculate nuclear atrophy and then to ventral lateral anterior nuclear atrophy with increasing clinical severity in patients with blepharospasm. These findings suggest that the pulvinar inferior nucleus in the thalamus is the focal origin of blepharospasm, extending to pulvinar inferior nuclear atrophy and subsequently extending to the ventral lateral anterior nucleus causing involuntary lower facial and masticatory movements known as blepharospasm-oromandibular dystonia. Moreover, our results also provide potential targets for neuromodulation especially deep brain stimulation in patients with blepharospasm and blepharospasm-oromandibular dystonia.
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Affiliation(s)
- Jinping Xu
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Yuhan Luo
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou 510080, China
| | - Jiana Zhang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou 510080, China
| | - Linchang Zhong
- Department of Medical Imaging, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Huiming Liu
- Department of Medical Imaging, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Ai Weng
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou 510080, China
| | - Zhengkun Yang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou 510080, China
| | - Yue Zhang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou 510080, China
| | - Zilin Ou
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou 510080, China
| | - Zhicong Yan
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou 510080, China
| | - Qinxiu Cheng
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Xinxin Fan
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Xiaodong Zhang
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Weixi Zhang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou 510080, China
| | - Qingmao Hu
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Dong Liang
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Kangqiang Peng
- Department of Medical Imaging, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Gang Liu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou 510080, China
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Rački V, Hero M, Papić E, Rožmarić G, Čizmarević NS, Chudy D, Peterlin B, Vuletić V. Applicability of clinical genetic testing for deep brain stimulation treatment in monogenic Parkinson's disease and monogenic dystonia: a multidisciplinary team perspective. Front Neurosci 2023; 17:1282267. [PMID: 38027472 PMCID: PMC10667448 DOI: 10.3389/fnins.2023.1282267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
In this perspective article, we highlight the possible applicability of genetic testing in Parkinson's disease and dystonia patients treated with deep brain stimulation (DBS). DBS, a neuromodulatory technique employing electrical stimulation, has historically targeted motor symptoms in advanced PD and dystonia, yet its precise mechanisms remain elusive. Genetic insights have emerged as potential determinants of DBS efficacy. Known PD genes such as GBA, SNCA, LRRK2, and PRKN are most studied, even though further studies are required to make firm conclusions. Variable outcomes depending on genotype is present in genetic dystonia, as DYT-TOR1A, NBIA/DYTPANK2, DYT-SCGE and X-linked dystonia-parkinsonism have demonstrated promising outcomes following GPi-DBS, while varying outcomes have been documented in DYT-THAP1. We present two clinical vignettes that illustrate the applicability of genetics in clinical practice, with one PD patient with compound GBA mutations and one GNAL dystonia patient. Integrating genetic testing into clinical practice is pivotal, particularly with advancements in next-generation sequencing. However, there is a clear need for further research, especially in rarer monogenic forms. Our perspective is that applying genetics in PD and dystonia is possible today, and despite challenges, it has the potential to refine patient selection and enhance treatment outcomes.
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Affiliation(s)
- Valentino Rački
- Department of Neurology, Clinical Hospital Center Rijeka, Rijeka, Croatia
- Department of Neurology, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Mario Hero
- Department of Neurology, Clinical Hospital Center Rijeka, Rijeka, Croatia
- Department of Neurology, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Eliša Papić
- Department of Neurology, Clinical Hospital Center Rijeka, Rijeka, Croatia
- Department of Neurology, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Gloria Rožmarić
- Department of Neurology, Clinical Hospital Center Rijeka, Rijeka, Croatia
| | - Nada Starčević Čizmarević
- Department of Medical Genomics and Biology, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Darko Chudy
- Department of Neurosurgery, Clinical Hospital Dubrava, Zagreb, Croatia
| | - Borut Peterlin
- Clinical Institute of Genomic Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Vladimira Vuletić
- Department of Neurology, Clinical Hospital Center Rijeka, Rijeka, Croatia
- Department of Neurology, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
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Owen RL, Grewal SS, Thompson JM, Hassan A, Lee KH, Klassen BT. Effectiveness of Thalamic Ventralis Oralis Anterior and Posterior Nuclei Deep Brain Stimulation for Posttraumatic Dystonia. Mayo Clin Proc Innov Qual Outcomes 2022; 6:137-142. [PMID: 35243206 PMCID: PMC8866047 DOI: 10.1016/j.mayocpiqo.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Herein we report that the ventralis oralis anterior and posterior (Voa/Vop) nuclei of the thalamus may be effective alternative targets for deep brain stimulation (DBS) to improve posttraumatic dystonia when the globus pallidus interna is traumatically damaged. This patient presented at age 35 years with a clinical diagnosis of posttraumatic cervical and bilateral upper limb acquired dystonia resulting from intracerebral and intraventricular hemorrhage after a motorcycle accident at age 19 years. Due to a right globus pallidus interna traumatic lesion, conventional DBS targeting of the inferior basal ganglia was not possible; thus, the alternative Voa/Vop nuclei target was implanted. The patient realized significant benefit and at last follow-up 3 years postoperatively continued to endorse marked benefit and improvement of dystonia symptoms with minimal adverse effects from bilateral DBS implantation in the alternative targets of the Voa/Vop nuclei of the thalamus.
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Morigaki R, Miyamoto R, Matsuda T, Miyake K, Yamamoto N, Takagi Y. Dystonia and Cerebellum: From Bench to Bedside. Life (Basel) 2021; 11:776. [PMID: 34440520 PMCID: PMC8401781 DOI: 10.3390/life11080776] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/20/2021] [Accepted: 07/29/2021] [Indexed: 12/31/2022] Open
Abstract
Dystonia pathogenesis remains unclear; however, findings from basic and clinical research suggest the importance of the interaction between the basal ganglia and cerebellum. After the discovery of disynaptic pathways between the two, much attention has been paid to the cerebellum. Basic research using various dystonia rodent models and clinical studies in dystonia patients continues to provide new pieces of knowledge regarding the role of the cerebellum in dystonia genesis. Herein, we review basic and clinical articles related to dystonia focusing on the cerebellum, and clarify the current understanding of the role of the cerebellum in dystonia pathogenesis. Given the recent evidence providing new hypotheses regarding dystonia pathogenesis, we discuss how the current evidence answers the unsolved clinical questions.
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Affiliation(s)
- Ryoma Morigaki
- Department of Advanced Brain Research, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima 770-8501, Japan; (N.Y.); (Y.T.)
- Department of Neurosurgery, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima 770-8501, Japan; (T.M.); (K.M.)
| | - Ryosuke Miyamoto
- Department of Neurology, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima 770-8501, Japan;
| | - Taku Matsuda
- Department of Neurosurgery, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima 770-8501, Japan; (T.M.); (K.M.)
| | - Kazuhisa Miyake
- Department of Neurosurgery, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima 770-8501, Japan; (T.M.); (K.M.)
| | - Nobuaki Yamamoto
- Department of Advanced Brain Research, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima 770-8501, Japan; (N.Y.); (Y.T.)
- Department of Neurology, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima 770-8501, Japan;
| | - Yasushi Takagi
- Department of Advanced Brain Research, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima 770-8501, Japan; (N.Y.); (Y.T.)
- Department of Neurosurgery, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima 770-8501, Japan; (T.M.); (K.M.)
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Larsh T, Wu SW, Vadivelu S, Grant GA, O'Malley JA. Deep Brain Stimulation for Pediatric Dystonia. Semin Pediatr Neurol 2021; 38:100896. [PMID: 34183138 DOI: 10.1016/j.spen.2021.100896] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 12/26/2022]
Abstract
Dystonia is one of the most common pediatric movement disorders and can have a profound impact on the lives of children and their caregivers. Response to pharmacologic treatment is often unsatisfactory. Deep brain stimulation (DBS) has emerged as a promising treatment option for children with medically refractory dystonia. In this review we highlight the relevant literature related to DBS for pediatric dystonia, with emphasis on the background, indications, prognostic factors, challenges, and future directions of pediatric DBS.
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Affiliation(s)
- Travis Larsh
- Center for Pediatric Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Steve W Wu
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Sudhakar Vadivelu
- Division of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Gerald A Grant
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Stanford University School of Medicine, Palo Alto, CA
| | - Jennifer A O'Malley
- Department of Neurology, Division of Child Neurology, Stanford University School of Medicine, Palo Alto, CA.
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Tisch S, Kumar KR. Pallidal Deep Brain Stimulation for Monogenic Dystonia: The Effect of Gene on Outcome. Front Neurol 2021; 11:630391. [PMID: 33488508 PMCID: PMC7820073 DOI: 10.3389/fneur.2020.630391] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 12/09/2020] [Indexed: 11/13/2022] Open
Abstract
Globus pallidus internus deep brain stimulation (GPi DBS) is the most effective intervention for medically refractory segmental and generalized dystonia in both children and adults. Predictive factors for the degree of improvement after GPi DBS include shorter disease duration and dystonia subtype with idiopathic isolated dystonia usually responding better than acquired combined dystonias. Other factors contributing to variability in outcome may include body distribution, pattern of dystonia and DBS related factors such as lead placement and stimulation parameters. The responsiveness to DBS appears to vary between different monogenic forms of dystonia, with some improving more than others. The first observation in this regard was reports of superior DBS outcomes in DYT-TOR1A (DYT1) dystonia, although other studies have found no difference. Recently a subgroup with young onset DYT-TOR1A, more rapid progression and secondary worsening after effective GPi DBS, has been described. Myoclonus dystonia due to DYT-SCGE (DYT11) usually responds well to GPi DBS. Good outcomes following GPi DBS have also been documented in X-linked dystonia Parkinsonism (DYT3). In contrast, poorer, more variable DBS outcomes have been reported in DYT-THAP1 (DYT6) including a recent larger series. The outcome of GPi DBS in other monogenic isolated and combined dystonias including DYT-GNAL (DYT25), DYT-KMT2B (DYT28), DYT-ATP1A3 (DYT12), and DYT-ANO3 (DYT24) have been reported with varying results in smaller numbers of patients. In this article the available evidence for long term GPi DBS outcome between different genetic dystonias is reviewed to reappraise popular perceptions of expected outcomes and revisit whether genetic diagnosis may assist in predicting DBS outcome.
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Affiliation(s)
- Stephen Tisch
- Department of Neurology, St Vincent's Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Kishore Raj Kumar
- Molecular Medicine Laboratory and Neurology Department, Concord Clinical School, Concord Repatriation General Hospital, The University of Sydney, Sydney, NSW, Australia
- Kinghorn Centre for Clinical Genomics, Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
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Evidente VGH, Ponce FA, Evidente MH, Lambert M, Garrett R, Sugumaran M, Lott DG. Adductor Spasmodic Dysphonia Improves with Bilateral Thalamic Deep Brain Stimulation: Report of 3 Cases Done Asleep and Review of Literature. Tremor Other Hyperkinet Mov (N Y) 2020; 10:60. [PMID: 33505767 PMCID: PMC7792454 DOI: 10.5334/tohm.575] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/12/2020] [Indexed: 11/24/2022] Open
Abstract
Background To date, there are only six published reports of adductor spasmodic dysphonia (SD) responding to awake thalamic deep brain stimulation (DBS). Methods We retrospectively reviewed cases of Essential Tremor (ET) with SD that were seen in our center from 2012 to 2020. We further identified those that have undergone thalamic DBS, and had a blinded laryngologist rate first the audio voice recordings before and after DBS using the Unified Spasmodic Dysphonia Rating Scale (USDRS), and the video recordings last to rate the related movements and facial grimacing. Results We identified three cases of adductor SD with ET that had undergone bilateral ventralis intermedius (VIM) DBS under general anesthesia. All patients noted improvement of their limb and voice tremor, as well as their SD post-DBS. Although improvement of tremor was observed even with initial programming in all three, improvement of SD was noted only upon reaching higher amplitudes or wider pulse widths. Blinded voice assessments showed improvement of USDRS scores post-DBS compared to pre-DBS, and with stimulator on compared to stimulator off. Discussion We report the first three cases of SD responding favorably to bilateral VIM asleep DBS and summarize the nine cases so far of SD who have undergone thalamic DBS.
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Affiliation(s)
| | | | | | | | - Robin Garrett
- Movement Disorders Center of Arizona, Scottsdale, Arizona, US
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Finger ME, Siddiqui MS, Morris AK, Ruckart KW, Wright SC, Haq IU, Madden LL. Auditory-Perceptual Evaluation of Deep Brain Stimulation on Voice and Speech in Patients With Dystonia. J Voice 2020; 34:636-644. [PMID: 30879706 PMCID: PMC6745002 DOI: 10.1016/j.jvoice.2019.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 02/15/2019] [Accepted: 02/19/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine the effects of globus pallidus interna (GPi) deep brain stimulation (DBS) on speech and voice quality of patients with primary, medically refractory dystonia. METHODS Voices of 14 patients aged ≥18 years (males = 7 and females = 7) with primary dystonia (DYT1 gene mutation dystonia = 4, cervical dystonia = 6, and generalized dystonia = 4) with bilateral GPi DBS were assessed. Five blinded raters (two fellowship-trained laryngologists and three speech/language pathologists) evaluated audio recordings of each patient pre- and post-DBS. Perceptual voice quality was rated using the Grade, Roughness, Breathiness, Asthenia, and Strain scale and changes in speech intelligibility were assessed with the Clinical Global Impression scale of Severity instrument. Inter-rater and intrarater reliability rates for perceptual voice ratings were assessed using the kappa coefficient. RESULTS Voice quality parameters showed mean improvements in Grade (P < 0.0001), Roughness (P = 0.0043), and Strain (P < 0.0001) 12 months post-DBS. Asthenia increased from baseline to 6 months (P = 0.0022) and declined significantly from 6 to 12 months (P = 0.0170). Breathiness did not change significantly over time. Speech intelligibility also improved from 6 to 12 months (P = 0.0202) and from pre-DBS to 12 months post-DBS (P = 0.0022). Grade and Strain ratings had nearly perfect and substantial inter-rater agreement (0.84 and 0.71, respectively). CONCLUSIONS Voice and speech intelligibility improved after bilateral GPi DBS for dystonia. GPi DBS may emerge as a potential treatment option for patients with medically refractory laryngeal dystonia.
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Affiliation(s)
- Mary E Finger
- Departments of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Departments of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Mustafa S Siddiqui
- Departments of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Amy K Morris
- Departments of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kathryn W Ruckart
- Departments of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - S Carter Wright
- Departments of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ihtsham U Haq
- Departments of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Lyndsay L Madden
- Departments of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina.
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Macerollo A, Sajin V, Bonello M, Barghava D, Alusi SH, Eldridge PR, Osman-Farah J. Deep brain stimulation in dystonia: State of art and future directions. J Neurosci Methods 2020; 340:108750. [DOI: 10.1016/j.jneumeth.2020.108750] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 04/19/2020] [Accepted: 04/20/2020] [Indexed: 01/03/2023]
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11
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Krüger MT, Hu A, Honey CR. Deep Brain Stimulation for Spasmodic Dysphonia: A Blinded Comparison of Unilateral and Bilateral Stimulation in Two Patients. Stereotact Funct Neurosurg 2020; 98:200-205. [PMID: 32316007 DOI: 10.1159/000507058] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 03/06/2020] [Indexed: 11/19/2022]
Abstract
Deep brain stimulation (DBS) is a promising new therapy for patients with spasmodic dysphonia (SD). The preliminary results from our randomized controlled trial showed good clinical effects with unilateral left thalamic stimulation in 6 right- handed patients. This suggests that the pathological process underpinning SD may have a "hemisphere dominant" pathway. We describe 2 patients with concurrent essential tremor and SD who had previously undergone bilateral thalamic DBS for their limb tremor. Both patients experienced an unanticipated improvement of their SD symptoms. One patient was right-handed, and the other was mixed left-handed. To investigate the amount of SD improvement following DBS therapy in each hemisphere, 4 different settings were tested: both sides on, left side on, right side on, and both sides off. Both patients most improved following bilateral stimulation. There was, however, a powerful unilateral benefit in both patients with only a small additional benefit from bilateral stimulation. The right-handed patient improved most with left-hemisphere stimulation whereas the mixed left-handed patient improved most with right hemisphere stimulation. There was some discrepancy between the two tests applied in the second patient reflecting the known difficulties to evaluate vocal symptom improvement in SD. We discuss the possible correlation of handedness and speech hemisphere dominance as well as the need for more reliable tests to measure SD severity. Ultimately, we recommend a bilateral approach for future studies, using a patient perception test as the primary outcome and functional imaging to further investigate the correlation of handedness and the amount of hemisphere dominance in SD.
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Affiliation(s)
- Marie T Krüger
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada, .,Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland, .,Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany,
| | - Amanda Hu
- Division of Otolaryngology, Head and Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher R Honey
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
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Badhiwala JH, Karmur B, Elkaim LM, Alotaibi NM, Morgan BR, Lipsman N, De Vloo P, Kalia SK, Lozano AM, Ibrahim GM. Clinical phenotypes associated with outcomes following deep brain stimulation for childhood dystonia. J Neurosurg Pediatr 2019; 24:442-450. [PMID: 31299640 DOI: 10.3171/2019.5.peds1973] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/08/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although deep brain stimulation (DBS) is an accepted treatment for childhood dystonia, there is significant heterogeneity in treatment response and few data are available to identify ideal surgical candidates. METHODS Data were derived from a systematic review and individual patient data meta-analysis of DBS for dystonia in children that was previously published. Outcomes were assessed using the Burke-Fahn-Marsden Dystonia Rating Scale for movement (BFMDRS-M) and for disability (BFMDRS-D). The authors used partial least squares, bootstrapping, and permutation statistics to extract patterns of contributions of specific preoperative characteristics to relationship with distinct outcomes, in all patients and in patients with primary and secondary dystonia separately. RESULTS Of 301 children undergoing DBS for dystonia, 167 had primary dystonia, 125 secondary dystonia, and 9 myoclonus dystonia. Three dissociable preoperative phenotypes (latent variables) were identified and associated with the following: 1) BFMDRS-M at last follow-up; 2) relative change in BFMDRS-M score; and 3) relative change in BFMDRS-D score. The phenotype of patients with secondary dystonia, with a high BFMDRS-M score and truncal involvement, undergoing DBS at a younger age, was associated with a worse postoperative BFMDRS-M score. Children with primary dystonia involving the trunk had greater improvement in BFMDRS-M and -D scores. Those with primary dystonia of shorter duration and proportion of life with disease, undergoing globus pallidus DBS, had greater improvements in BFMDRS-D scores at long-term follow-up. CONCLUSIONS In a comprehensive, data-driven, multivariate analysis of DBS for childhood dystonia, the authors identified novel and dissociable patient phenotypes associated with distinct outcomes. The findings of this report may inform surgical candidacy for DBS.
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Affiliation(s)
| | - Brij Karmur
- 2Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - Lior M Elkaim
- 3Faculty of Medicine, Université de Montréal, Montréal, Québec
| | | | | | - Nir Lipsman
- 1Division of Neurosurgery, Department of Surgery, and
- 4Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Philippe De Vloo
- 1Division of Neurosurgery, Department of Surgery, and
- 5Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario; and
| | - Suneil K Kalia
- 1Division of Neurosurgery, Department of Surgery, and
- 5Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario; and
| | - Andres M Lozano
- 1Division of Neurosurgery, Department of Surgery, and
- 5Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario; and
| | - George M Ibrahim
- 1Division of Neurosurgery, Department of Surgery, and
- 6Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
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13
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Wen Y, Yang H, Bao X. Deep brain stimulation for early-onset dystonia. BRAIN SCIENCE ADVANCES 2019. [DOI: 10.26599/bsa.2019.9050004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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14
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Abstract
Deep brain stimulation (DBS) is considered as a treatment option for many neurological diseases. Many patients with movement disorders exhibit remarkable improvement after DBS. Owing to its minimally invasive nature, reversibility, and adjustability, DBS has been increasingly used over the past several decades. Dystonia is one of the most common movement disorders among children, and there is no effective treatment. Recently, some surgeon groups have performed DBS surgery for children. However, the outcomes of DBS in children are not well characterized. Here we mainly discuss the efficacy of DBS against childhood-onset dystonia and introduce the main procedure of pediatric DBS based on our own experience.
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Affiliation(s)
- Yongxin Wen
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
- These authors contributed equally to this work
| | - Haibo Yang
- Department of Pediatric Surgery, Peking University First Hospital, Beijing 100034, China
- These authors contributed equally to this work
| | - Xinhua Bao
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
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15
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Zhang YQ, Wang JW, Wang YP, Zhang XH, Li JP. Thalamus Stimulation for Myoclonus Dystonia Syndrome: Five Cases and Long-Term Follow-up. World Neurosurg 2018; 122:e933-e939. [PMID: 30419400 DOI: 10.1016/j.wneu.2018.10.177] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 10/24/2018] [Accepted: 10/26/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Myoclonic dystonia syndrome (MDS) is a rare inherited movement disorder characterized by the coexistence of myoclonic jerks and dystonia. Deep brain stimulation (DBS) is a promising treatment for patients with MDS that targets the globus pallidus internus or ventral intermediate nucleus (Vim) of the thalamus. However, there are few studies regarding the long-term effects of Vim DBS in patients with MDS and even fewer in those without gene mutations. METHODS Two positive and three negative SGCE mutation patients presenting with predominant myoclonus underwent Vim DBS. The Unified Myoclonus Rating Scale and the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) were assessed pre- and postoperation. RESULTS Over an average follow-up period of 50 months, the myoclonus improvement rate was 92.7%. The average improvement in the BFMDRS motor score was 71.4% and the average improvement in the BFMDRS disabling score was 75.8%. CONCLUSIONS This study suggests that Vim DBS can be a safe and effective treatment option for patients with MDS. Vim DBS alone may be preferable for patients with myoclonus-dominated MDS regardless of the identification of an SGCE mutation. Additional globus pallidus internus DBS may be used for progressive dystonia after Vim DBS.
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Affiliation(s)
- Yu-Qing Zhang
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jia-Wei Wang
- Department of Neurosurgery, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yun-Peng Wang
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiao-Hua Zhang
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ji-Ping Li
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
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16
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Alterman RL, Filippidis AS. Genetic Subtypes and Deep Brain Stimulation in Dystonia. Mov Disord Clin Pract 2018; 5:357-360. [PMID: 30838292 PMCID: PMC6336377 DOI: 10.1002/mdc3.12660] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 05/28/2018] [Accepted: 06/07/2018] [Indexed: 01/16/2023] Open
Affiliation(s)
- Ron L. Alterman
- Division of NeurosurgeryBeth Israel Deaconess Medical CenterBostonMA
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17
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Miocinovic S, Miller A, Swann NC, Ostrem JL, Starr PA. Chronic deep brain stimulation normalizes scalp EEG activity in isolated dystonia. Clin Neurophysiol 2017; 129:368-376. [PMID: 29288993 DOI: 10.1016/j.clinph.2017.11.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 09/21/2017] [Accepted: 11/21/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate cortical activity using scalp EEG in patients with isolated dystonia treated with chronic deep brain stimulation (DBS), on and off stimulation. METHODS We analyzed 64-channel scalp EEG in 12 isolated dystonia patients treated with chronic DBS (7 generalized, 5 cervical/segmental; 7 globus pallidus (GP), 5 subthalamic nucleus (STN)), and 20 healthy age-matched controls. Recordings during rest and movement task, and clinical motor scores, were collected with DBS-on and during a 90-min DBS washout. RESULTS Resting state alpha power in the dominant (or contralateral to more dystonic side) motor cortex channel during DBS was comparable to healthy controls, but it increased when DBS was stopped. Resting state and movement-related alpha coherence between bilateral motor cortex channels was increased off DBS. CONCLUSIONS Chronic DBS reduces exaggerated alpha oscillations and interhemispheric alpha coherence in the motor cortex of patients with isolated dystonia. SIGNIFICANCE These findings complement related studies in Parkinson's disease and support the view that network desynchronization is a prominent mechanism of DBS in movement disorders.
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Affiliation(s)
| | - Andrew Miller
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
| | - Nicole C Swann
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
| | - Jill L Ostrem
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States.
| | - Philip A Starr
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
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18
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Shakkottai VG, Batla A, Bhatia K, Dauer WT, Dresel C, Niethammer M, Eidelberg D, Raike RS, Smith Y, Jinnah HA, Hess EJ, Meunier S, Hallett M, Fremont R, Khodakhah K, LeDoux MS, Popa T, Gallea C, Lehericy S, Bostan AC, Strick PL. Current Opinions and Areas of Consensus on the Role of the Cerebellum in Dystonia. THE CEREBELLUM 2017; 16:577-594. [PMID: 27734238 DOI: 10.1007/s12311-016-0825-6] [Citation(s) in RCA: 163] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A role for the cerebellum in causing ataxia, a disorder characterized by uncoordinated movement, is widely accepted. Recent work has suggested that alterations in activity, connectivity, and structure of the cerebellum are also associated with dystonia, a neurological disorder characterized by abnormal and sustained muscle contractions often leading to abnormal maintained postures. In this manuscript, the authors discuss their views on how the cerebellum may play a role in dystonia. The following topics are discussed: The relationships between neuronal/network dysfunctions and motor abnormalities in rodent models of dystonia. Data about brain structure, cerebellar metabolism, cerebellar connections, and noninvasive cerebellar stimulation that support (or not) a role for the cerebellum in human dystonia. Connections between the cerebellum and motor cortical and sub-cortical structures that could support a role for the cerebellum in dystonia. Overall points of consensus include: Neuronal dysfunction originating in the cerebellum can drive dystonic movements in rodent model systems. Imaging and neurophysiological studies in humans suggest that the cerebellum plays a role in the pathophysiology of dystonia, but do not provide conclusive evidence that the cerebellum is the primary or sole neuroanatomical site of origin.
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Affiliation(s)
- Vikram G Shakkottai
- Department of Neurology, University of Michigan, Room 4009, BSRB, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA. .,Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, 48109-2200, USA.
| | - Amit Batla
- Sobell Department of Motor Neuroscience and Movement Disorders, University College London, London, UK
| | - Kailash Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders, University College London, London, UK
| | - William T Dauer
- Department of Neurology, University of Michigan, Room 4009, BSRB, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA.,Department of Cell and Developmental Biology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Christian Dresel
- Center for Neurosciences, The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Martin Niethammer
- Center for Neurosciences, The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - David Eidelberg
- Center for Neurosciences, The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Robert S Raike
- Global Research Organization, Medtronic Inc. Neuromodulation, Minneapolis, MN, USA
| | - Yoland Smith
- Yerkes National Primate Center and Department of Neurology, Emory University, Atlanta, GA, USA
| | - H A Jinnah
- Department of Neurology, Human Genetics and Pediatrics, Emory University, Atlanta, GA, USA
| | - Ellen J Hess
- Departments of Pharmacology and Neurology, Emory University, Atlanta, GA, USA
| | - Sabine Meunier
- Institut du Cerveau et de la Moelle épinière (ICM), Inserm U 1127, CNRS UMR 7225, Sorbonne Universités, UPMC Univ Paris 06 UMR, S 1127, Paris, France.,Human Motor Control Section, Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Mark Hallett
- Human Motor Control Section, Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Rachel Fremont
- Dominick P. Purpura Department of Neuroscience, Albert Einstein College of Medicine, New York, NY, USA
| | - Kamran Khodakhah
- Dominick P. Purpura Department of Neuroscience, Department of Psychiatry and Behavioral Sciences, and The Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, New York, NY, USA
| | - Mark S LeDoux
- Departments of Neurology, and Anatomy and Neurobiology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Traian Popa
- Inserm U 1127, CNRS UMR 7225, Sorbonne Universités, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, F-75013, Paris, France
| | - Cécile Gallea
- Inserm U 1127, CNRS UMR 7225, Sorbonne Universités, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, F-75013, Paris, France.,Centre de NeuroImagerie de Recherche - CENIR, ICM, F-75013, Paris, France
| | - Stéphane Lehericy
- Inserm U 1127, CNRS UMR 7225, Sorbonne Universités, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, F-75013, Paris, France
| | - Andreea C Bostan
- Systems Neuroscience Institute and Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA, USA
| | - Peter L Strick
- Systems Neuroscience Institute and Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Neurobiology, University of Pittsburgh Brain Institute, University of Pittsburgh, Pittsburgh, PA, USA
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19
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Goulenko V, da Costa Cruz PL, Niemeyer Filho P. Unilateral thalamic and pallidal deep brain stimulation for idiopathic hemidystonia: results of individual and combined stimulations. Case report. Neurosurg Focus 2017; 43:E2. [DOI: 10.3171/2017.4.focus17134] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pallidal stimulation has been the usual surgical treatment for dystonia in the last decades. The continuous investigation of the physiopathology and the motor pathways involved leads to the search for complementary targets to improve results. The authors present the case of a 37-year-old woman who had suffered from idiopathic hemidystonia with hyperkinetic and hypokinetic movements for 11 years, and who was treated with deep brain stimulation. A brief literature review is also provided. The globus pallidus internus and the ventral intermediate/ventral oral posterior complex of the thalamus were stimulated separately and simultaneously for 3 months and compared using the Burke-Fahn-Marsden Dystonia Rating Scale and the Global Dystonia Severity Rating Scale, with a 3.5-year follow-up. The synergism of multiple-target stimulation resulted in a complete improvement of the mixed dystonic symptoms.
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20
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Poologaindran A, Ivanishvili Z, Morrison MD, Rammage LA, Sandhu MK, Polyhronopoulos NE, Honey CR. The effect of unilateral thalamic deep brain stimulation on the vocal dysfunction in a patient with spasmodic dysphonia: interrogating cerebellar and pallidal neural circuits. J Neurosurg 2017; 128:575-582. [PMID: 28304188 DOI: 10.3171/2016.10.jns161025] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Spasmodic dysphonia (SD) is a neurological disorder of the voice where a patient's ability to speak is compromised due to involuntary contractions of the intrinsic laryngeal muscles. Since the 1980s, SD has been treated with botulinum toxin A (BTX) injections into the throat. This therapy is limited by the delayed-onset of benefits, wearing-off effects, and repeated injections required every 3 months. In a patient with essential tremor (ET) and coincident SD, the authors set out to quantify the effects of thalamic deep brain stimulation (DBS) on vocal function while investigating the underlying motor thalamic circuitry. A 79-year-old right-handed woman with ET and coincident adductor SD was referred to our neurosurgical team. While primarily treating her limb tremor, the authors studied the effects of unilateral, thalamic DBS on vocal function using the Unified Spasmodic Dysphonia Rating Scale (USDRS) and voice-related quality of life (VRQOL). Since dystonia is increasingly being considered a multinodal network disorder, an anterior trajectory into the left thalamus was deliberately chosen such that the proximal contacts of the electrode were in the ventral oralis anterior (Voa) nucleus (pallidal outflow) and the distal contacts were in the ventral intermediate (Vim) nucleus (cerebellar outflow). In addition to assessing on/off unilateral thalamic Vim stimulation on voice, the authors experimentally assessed low-voltage unilateral Vim, Voa, or multitarget stimulation in a prospective, randomized, doubled-blinded manner. The evaluators were experienced at rating SD and were familiar with the vocal tremor of ET. A Wilcoxon signed-rank test was used to study the pre- and posttreatment effect of DBS on voice. Unilateral left thalamic Vim stimulation (DBS on) significantly improved SD vocal dysfunction compared with no stimulation (DBS off), as measured by the USDRS (p < 0.01) and VRQOL (p < 0.01). In the experimental interrogation, both low-voltage Vim (p < 0.01) and multitarget Vim + Voa (p < 0.01) stimulation were significantly superior to low-voltage Voa stimulation. For the first time, the effects of high-frequency stimulation of different neural circuits in SD have been quantified. Unexpectedly, focused Voa (pallidal outflow) stimulation was inferior to Vim (cerebellar outflow) stimulation despite the classification of SD as a dystonia. While only a single case, scattered reports exist on the positive effects of thalamic DBS on dysphonia. A Phase 1 pilot trial (DEBUSSY; clinical trial no. NCT02558634, clinicaltrials.gov) is underway at the authors' center to evaluate the safety and preliminary efficacy of DBS in SD. The authors hope that this current report stimulates neurosurgeons to investigate this new indication for DBS.
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Affiliation(s)
| | | | - Murray D Morrison
- 2Otolaryngology, The University of British Columbia, Vancouver, British Columbia,Canada
| | - Linda A Rammage
- 2Otolaryngology, The University of British Columbia, Vancouver, British Columbia,Canada
| | - Mini K Sandhu
- Department of Surgery, Divisions of1Neurosurgery and
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21
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Deep brain stimulation for dystonia: a novel perspective on the value of genetic testing. J Neural Transm (Vienna) 2017; 124:417-430. [PMID: 28160152 DOI: 10.1007/s00702-016-1656-9] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 11/16/2016] [Indexed: 10/20/2022]
Abstract
The dystonias are a group of disorders characterized by excessive muscle contractions leading to abnormal movements and postures. There are many different clinical manifestations and underlying causes. Deep brain stimulation (DBS) provides an effect treatment, but outcomes can vary considerably among the different subtypes of dystonia. Several variables are thought to contribute to this variation including age of onset and duration of dystonia, specific characteristics of the dystonic movements, location of stimulation and stimulator settings, and others. The potential contributions of genetic factors have received little attention. In this review, we summarize evidence that some of the variation in DBS outcomes for dystonia is due to genetic factors. The evidence suggests that more methodical genetic testing may provide useful information in the assessment of potential surgical candidates, and in advancing our understanding of the biological mechanisms that influence DBS outcomes.
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22
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Wang JW, Li JP, Wang YP, Zhang XH, Zhang YQ. Deep brain stimulation for myoclonus-dystonia syndrome with double mutations in DYT1 and DYT11. Sci Rep 2017; 7:41042. [PMID: 28102337 PMCID: PMC5244480 DOI: 10.1038/srep41042] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 12/15/2016] [Indexed: 11/16/2022] Open
Abstract
Myoclonus-dystonia syndrome (MDS) is a rare autosomal dominant inherited disorder characterized by the presentation of both myoclonic jerks and dystonia. Evidence is emerging that deep brain stimulation (DBS) may be a promising treatment for MDS. However, there are no studies reporting the effects of DBS on MDS with double mutations in DYT1 and DYT11. Two refractory MDS patients with double mutations were treated between 2011 and 2015 in our center. Genetic testing for DYT1 and DYT11 was performed through polymerase chain reaction amplification and direct sequencing of the specific exons of genes. For the first patient, initial bilateral ventral intermediate thalamus nucleus (Vim) DBS was performed. Because of worsening dystonia after initial improvement in symptoms, subsequent bilateral globus pallidus internus (GPi) DBS was offered at 43 months after initial surgery, which reversed the deterioration and restored the motor function. For the second patient, initial improvement in motor symptoms and quality of life was sustained at the follow-up 6 months after bilateral Vim DBS treatment. Thus, DBS may be an effective therapeutic option for MDS, even in patients with double mutations. Moreover, GPi DBS may be used as a supplementary treatment when initial Vim DBS fails to control MDS symptoms.
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Affiliation(s)
- Jia-Wei Wang
- Beijing Institute of Functional Neurosurgery, Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, P.R. China
| | - Ji-Ping Li
- Beijing Institute of Functional Neurosurgery, Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, P.R. China
| | - Yun-Peng Wang
- Beijing Institute of Functional Neurosurgery, Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, P.R. China
| | - Xiao-Hua Zhang
- Beijing Institute of Functional Neurosurgery, Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, P.R. China
| | - Yu-Qing Zhang
- Beijing Institute of Functional Neurosurgery, Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, P.R. China
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Deep brain stimulation for childhood dystonia: Is 'where' as important as in 'whom'? Eur J Paediatr Neurol 2017; 21:176-184. [PMID: 28220756 DOI: 10.1016/j.ejpn.2016.10.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 10/03/2016] [Indexed: 01/07/2023]
Abstract
Deep brain stimulation (DBS) has become a mainstay of dystonia management in adulthood. Typically targeting electrode placement in the GPi, sustained improvement in dystonic symptoms are anticipated in adults with isolated genetic dystonias. Dystonia in childhood is more commonly a symptomatic condition, with dystonia frequently expressed on the background of a structurally abnormal brain. Outcomes following DBS in this setting are much more variable, the reasons for which have yet to be elucidated. Much of the focus on improving outcomes following DBS in dystonia management has been on the importance of patient selection, with, until recently, little discussion of the choice of target. In this review, we advance the argument that patient selection for DBS in childhood cannot be made separate from the choice of target nuclei. The anatomy of common DBS targets is considered, and factors influencing their choice for electrode insertion are discussed. We propose an "ABC" for DBS in childhood dystonia is proposed: Appropriate Child selected; Best nuclei chosen for electrode insertion; Correct position within that nucleus.
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24
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Cif L, Coubes P. Historical developments in children's deep brain stimulation. Eur J Paediatr Neurol 2017; 21:109-117. [PMID: 27693334 DOI: 10.1016/j.ejpn.2016.08.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 08/19/2016] [Accepted: 08/29/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Heterogeneous by the underlying pathobiology and clinical presentation, childhood onset dystonia is most frequently progressive, with related disability and limitations in functions of daily living. Consequently, there is an obvious need for efficient symptomatic therapies. METHODS AND RESULTS Following lesional surgery to basal ganglia (BG) and thalamus, deep brain stimulation (DBS) is a more conservative and adjustable intervention to and validated for internal segment of the globus pallidus (GPi), highly efficient in treating isolated "primary" dystonia and associated symptoms such as subcortical myoclonus. The role of DBS in acquired, neurometabolic and degenerative disorders with dystonia deserves further exploration to confirm as an efficient and lasting therapy. However, the pathobiological background with distribution of the sequellae over the central nervous system and related clinical features, will limit DBS efficacy in these conditions. Cumulative arguments propose DBS in severe life threatening dystonic conditions called status dystonicus as first line therapy, irrespective of the underlying cause. There are no currently available validated selection criteria for DBS in pediatric dystonia. Concurrent targets such as subthalamic nucleus (STN) and several motor nuclei of the thalamus are under exploration and only little information is available in children. DBS programming in paediatric population was adopted from experience in adults. The choice of neuromodulatory DBS parameters could influence not only the initial therapeutic outcome of dystonic symptoms but also its maintenance over time and potentially the occurrence of DBS related side effects. CONCLUSION DBS allows efficient symptomatic treatment of severe dystonia in children and advances pathophysiological knowledge about local and distributed abnormal neural activity over the motor cortical-subcortical networks in dystonia and other movement disorders.
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Affiliation(s)
- Laura Cif
- Unités de Neurochirurgie Fonctionnelle et Pédiatrique, Département de Neurochirurgie, Centre Hospitalier Universitaire Montpellier, France; Unité de Recherche sur les Comportements et Mouvements Anormaux (URCMA), France; Institut de Génomique Fonctionnelle, Centre National de la Recherche Scientifique, Unité Mixte de la Recherche 5203, France; Université Montpellier, 34000, Montpellier, France; Laboratoire de Recherche en Neurosciences Cliniques (LRENC), France.
| | - Philippe Coubes
- Unités de Neurochirurgie Fonctionnelle et Pédiatrique, Département de Neurochirurgie, Centre Hospitalier Universitaire Montpellier, France; Unité de Recherche sur les Comportements et Mouvements Anormaux (URCMA), France; Institut de Génomique Fonctionnelle, Centre National de la Recherche Scientifique, Unité Mixte de la Recherche 5203, France; Université Montpellier, 34000, Montpellier, France
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25
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Vocal Tremor: Novel Therapeutic Target for Deep Brain Stimulation. Brain Sci 2016; 6:brainsci6040048. [PMID: 27735866 PMCID: PMC5187562 DOI: 10.3390/brainsci6040048] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 09/29/2016] [Accepted: 10/03/2016] [Indexed: 01/25/2023] Open
Abstract
Tremulous voice is characteristically associated with essential tremor, and is referred to as essential vocal tremor (EVT). Current estimates suggest that up to 40% of individuals diagnosed with essential tremor also present with EVT, which is associated with an impaired quality of life. Traditional EVT treatments have demonstrated limited success in long-term management of symptoms. However, voice tremor has been noted to decrease in patients receiving deep brain stimulation (DBS) with the targeting of thalamic nuclei. In this study, we describe our multidisciplinary procedure for awake, frameless DBS with optimal stimulation targets as well as acoustic analysis and laryngoscopic assessment to quantify tremor reduction. Finally, we investigate the most recent clinical evidence regarding the procedure.
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Excellent outcome of pallidal deep brain stimulation in DYT6 dystonia: A case report. J Neurol Sci 2016; 366:18-19. [DOI: 10.1016/j.jns.2016.04.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/15/2016] [Accepted: 04/16/2016] [Indexed: 11/21/2022]
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TODA H, SAIKI H, NISHIDA N, IWASAKI K. Update on Deep Brain Stimulation for Dyskinesia and Dystonia: A Literature Review. Neurol Med Chir (Tokyo) 2016; 56:236-48. [PMID: 27053331 PMCID: PMC4870178 DOI: 10.2176/nmc.ra.2016-0002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 03/01/2016] [Indexed: 12/11/2022] Open
Abstract
Deep brain stimulation (DBS) has been an established surgical treatment option for dyskinesia from Parkinson disease and for dystonia. The present article deals with the timing of surgical intervention, selecting an appropriate target, and minimizing adverse effects. We provide an overview of current evidences and issues for dyskinesia and dystonia as well as emerging DBS technology.
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Affiliation(s)
- Hiroki TODA
- Department of Neurosurgery, Tazuke Kofukai Medical Research Institute and Kitano Hospital, Kita, Osaka
| | - Hidemoto SAIKI
- Department of Neurology, Tazuke Kofukai Medical Research Institute and Kitano Hospital, Kita, Osaka
| | - Namiko NISHIDA
- Department of Neurosurgery, Tazuke Kofukai Medical Research Institute and Kitano Hospital, Kita, Osaka
| | - Koichi IWASAKI
- Department of Neurosurgery, Tazuke Kofukai Medical Research Institute and Kitano Hospital, Kita, Osaka
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Albanese A, Romito LM, Calandrella D. Therapeutic advances in dystonia. Mov Disord 2015; 30:1547-56. [DOI: 10.1002/mds.26384] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 07/27/2015] [Accepted: 07/30/2015] [Indexed: 12/15/2022] Open
Affiliation(s)
- Alberto Albanese
- Istituto Clinico Humanitas; Rozzano Milano Italy
- Istituto di Neurologia, Università Cattolica del Sacro Cuore; Milano Italy
| | - Luigi M. Romito
- Neurologia I, Istituto Neurologico Carlo Besta; Milano Italy
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Ho AL, Erickson-Direnzo E, Pendharkar AV, Sung CK, Halpern CH. Deep brain stimulation for vocal tremor: a comprehensive, multidisciplinary methodology. Neurosurg Focus 2015; 38:E6. [DOI: 10.3171/2015.3.focus1537] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Tremulous voice is a characteristic feature of a multitude of movement disorders, but when it occurs in individuals diagnosed with essential tremor, it is referred to as essential vocal tremor (EVT). For individuals with EVT, their tremulous voice is associated with significant social embarrassment and in severe cases may result in the discontinuation of employment and hobbies. Management of EVT is extremely difficult, and current behavioral and medical interventions for vocal tremor result in suboptimal outcomes. Deep brain stimulation (DBS) has been proposed as a potential therapeutic avenue for EVT, but few studies can be identified that have systematically examined improvements in EVT following DBS. The authors describe a case of awake bilateral DBS targeting the ventral intermediate nucleus for a patient suffering from severe voice and arm tremor. They also present their comprehensive, multidisciplinary methodology for definitive treatment of EVT via DBS. To the authors’ knowledge, this is the first time comprehensive intraoperative voice evaluation has been used to guide microelectrode/stimulator placement, as well as the first time that standard pre- and post-DBS assessments have been conducted, demonstrating the efficacy of this tailored DBS approach.
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Affiliation(s)
| | | | | | - Chih-Kwang Sung
- 2Otolaryngology (Head and Neck Surgery), Stanford University School of Medicine, Stanford, California
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