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Mohamed AA, Faragalla S, Khan A, Flynn G, Rainone G, Johansen PM, Lucke-Wold B. Neurosurgical and pharmacological management of dystonia. World J Psychiatry 2024; 14:624-634. [PMID: 38808085 PMCID: PMC11129150 DOI: 10.5498/wjp.v14.i5.624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 04/20/2024] [Accepted: 04/26/2024] [Indexed: 05/16/2024] Open
Abstract
Dystonia characterizes a group of neurological movement disorders characterized by abnormal muscle movements, often with repetitive or sustained contraction resulting in abnormal posturing. Different types of dystonia present based on the affected body regions and play a prominent role in determining the potential efficacy of a given intervention. For most patients afflicted with these disorders, an exact cause is rarely identified, so treatment mainly focuses on symptomatic alleviation. Pharmacological agents, such as oral anticholinergic administration and botulinum toxin injection, play a major role in the initial treatment of patients. In more severe and/or refractory cases, focal areas for neurosurgical intervention are identified and targeted to improve quality of life. Deep brain stimulation (DBS) targets these anatomical locations to minimize dystonia symptoms. Surgical ablation procedures and peripheral denervation surgeries also offer potential treatment to patients who do not respond to DBS. These management options grant providers and patients the ability to weigh the benefits and risks for each individual patient profile. This review article explores these pharmacological and neurosurgical management modalities for dystonia, providing a comprehensive assessment of each of their benefits and shortcomings.
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Affiliation(s)
- Ali Ahmed Mohamed
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Steven Faragalla
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Asad Khan
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Garrett Flynn
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Gersham Rainone
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL 33606, United States
| | - Phillip Mitchell Johansen
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL 33606, United States
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32611, United States
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Alamri A, Breitbart S, Warsi N, Rayco E, Ibrahim G, Fasano A, Gorodetsky C. Deep Brain Stimulation of the Globus Pallidus Internus in a Child with Refractory Dystonia due to L2-Hydroxyglutaric Aciduria. Stereotact Funct Neurosurg 2024:1-8. [PMID: 38714179 DOI: 10.1159/000538418] [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: 11/01/2023] [Accepted: 03/14/2024] [Indexed: 05/09/2024]
Abstract
INTRODUCTION L-2-hydroxyglutaric aciduria (L2HGA) is a rare neurometabolic disorder marked by progressive and debilitating psychomotor deficits. Here, we report the first patient with L2HGA-related refractory dystonia that was managed with deep brain stimulation to the bilateral globus pallidus internus (GPi-DBS). CASE PRESENTATION We present a 17-year-old female with progressive decline in cognitive function, motor skills, and language ability which significantly impaired activities of daily living. Neurological exam revealed generalized dystonia, significant choreic movements in the upper extremities, slurred speech, bilateral dysmetria, and a wide-based gait. Brisk deep tendon reflexes, clonus, and bilateral Babinski signs were present. Urine 2-OH-glutaric acid level was significantly elevated. Brain MRI showed extensive supratentorial subcortical white matter signal abnormalities predominantly involving the U fibers and bilateral basal ganglia. Genetic testing identified a homozygous pathogenic mutation in the L-2-hydroxyglutarate dehydrogenase gene c. 164G>A (p. Gly55Asp). Following minimal response to pharmacotherapy, GPi-DBS was performed. Significant increases in mobility and decrease in dystonia were observed at 3 weeks, 6 months, and 12 months postoperatively. CONCLUSION This is the first utilization of DBS as treatment for L2HGA-related dystonia. The resulting significant improvements indicate that pallidal neuromodulation may be a viable option for pharmaco-resistant cases, and possibly in other secondary metabolic dystonias.
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Affiliation(s)
- Abdullah Alamri
- Department of Pediatrics, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Sara Breitbart
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nebras Warsi
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Eriberto Rayco
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - George Ibrahim
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Alfonso Fasano
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, Ontario, Canada
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada
- Krembil Brain Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Ontario, Canada
| | - Carolina Gorodetsky
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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Duga V, Giossi R, Romito LM, Stanziano M, Levi V, Panteghini C, Zorzi G, Nardocci N. Long-Term Globus Pallidus Internus Deep Brain Stimulation in Pediatric Non-Degenerative Dystonia: A Cohort Study and a Meta-Analysis. Mov Disord 2024. [PMID: 38646731 DOI: 10.1002/mds.29815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 03/24/2024] [Accepted: 03/27/2024] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND The evidence in the effectiveness of deep brain stimulation in children with medication-refractory non-degenerative monogenic dystonia is heterogeneous and long-term results are sparse. OBJECTIVES The objective is to describe long-term outcomes in a single-center cohort and compare our results with a meta-analysis cohort form literature. METHODS We performed a retrospective single-center cohort study including consecutive pediatric patients with non-degenerative genetic or idiopathic dystonia treated with globus pallidus internus deep brain stimulation at our center and a systematic review and individual-patient data meta-analysis with the same inclusion criteria. The primary outcome was the change from baseline in the Burke-Fahn-Marsden Dystonia Rating Scale-movement (BFMDRS-M) score. RESULTS The clinical cohort included 25 patients with a mean study follow-up of 11.4 years. The meta-analysis cohort included 224 patients with a mean follow-up of 3 years. Overall, the BFMDRS-M mean improvements at 1 year and at last follow-up were 41% and 33% in the clinical cohort and 58.9% and 57.2% in the meta-analysis cohort, respectively. TOR1A-dystonia showed the greatest and most stable BFMDRS-M improvement in both cohorts at 1 year and at last follow-up (76.3% and 74.3% in the clinical cohort; 69.6% and 67.3% in the meta-analysis cohort), followed by SGCE-dystonia (63% and 63.9% in the meta-analysis cohort). THAP1-dystonia (70.1% and 29.8% in the clinical cohort; 52.3% and 42.0% in the meta-analysis cohort) and KMT2B-dystonia (33.3% and 41.3% in the clinical cohort; 38.0% and 26.7% in the meta-analysis cohort) showed a less pronounced or sustained response. CONCLUSION Globus pallidus deep brain stimulation long-term treatment seems effective with a possible gene-specific differential effect. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Valentina Duga
- Child Neuropsychiatry Unit, Department of Pediatric Neuroscience, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
- Child and Adolescent Neuropsychiatric Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Riccardo Giossi
- Poison Control Center and Clinical Pharmacology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
- Department of Research and Clinical Development, Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Luigi Michele Romito
- Movement Disorders Unit, Neurology Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Mario Stanziano
- Neuroradiology Unit, Department of Technology and Diagnosis, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Vincenzo Levi
- Functional Neurosurgery Unit, Neurosurgery Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Celeste Panteghini
- Molecular Neurogenetics Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Giovanna Zorzi
- Child Neuropsychiatry Unit, Department of Pediatric Neuroscience, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Nardo Nardocci
- Child Neuropsychiatry Unit, Department of Pediatric Neuroscience, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
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Gelineau-Morel R, Dlamini N, Bruss J, Cohen AL, Robertson A, Alexopoulos D, Smyser CD, Boes AD. Network localization of pediatric lesion-induced dystonia. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.06.24305421. [PMID: 38645071 PMCID: PMC11030491 DOI: 10.1101/2024.04.06.24305421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Objective Dystonia is a movement disorder defined by involuntary muscle contractions leading to abnormal postures or twisting and repetitive movements. Classically dystonia has been thought of as a disorder of the basal ganglia, but newer results in idiopathic dystonia and lesion-induced dystonia in adults point to broader motor network dysfunction spanning the basal ganglia, cerebellum, premotor cortex, sensorimotor, and frontoparietal regions. It is unclear whether a similar network is shared between different etiologies of pediatric lesion-induced dystonia. Methods Three cohorts of pediatric patients with lesion-induced dystonia were identified. The lesion etiologies included hypoxia, kernicterus, and stroke versus comparison subjects with acquired lesions not associated with dystonia. Multivariate lesion-symptom mapping and lesion network mapping were used to evaluate the anatomy and networks associated with dystonia. Results Multivariate lesion-symptom mapping showed that lesions of the putamen (stroke: r = 0.50, p <0.01; hypoxia, r = 0.64, p <0.001) and globus pallidus (kernicterus, r = 0.61, p <0.01) were associated with dystonia. Lesion network mapping using normative connectome data from healthy children demonstrated that these regional findings occurred within a common brain-wide network that involves the basal ganglia, anterior and medial cerebellum, and cortical regions that overlap the cingulo-opercular and somato-cognitive-action networks. Interpretation We interpret these findings as novel evidence for a unified dystonia brain network that involves the somato-cognitive-action network, which is involved in higher order coordination of movement. Elucidation of this network gives insight into the functional origins of dystonia and provides novel targets to investigate for therapeutic intervention.
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Affiliation(s)
- Rose Gelineau-Morel
- Division of Neurology, Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri, USA
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Nomazulu Dlamini
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Joel Bruss
- Department of Pediatrics, University of Iowa Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Department of Neurology, University of Iowa Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Alexander Li Cohen
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Amanda Robertson
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
| | | | - Christopher D. Smyser
- Department of Neurology, Washington University, St Louis, Missouri, USA
- Department of Pediatrics, Washington University, St Louis, Missouri, USA
- Mallinckrodt Institute of Radiology, Washington University, St Louis, Missouri, USA
| | - Aaron D. Boes
- Department of Pediatrics, University of Iowa Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Department of Neurology, University of Iowa Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa, USA Characters in title: 57, Characters in running head: 31
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Kahlon S, Barton CR, Abu Libdeh A, O'Malley JA, Pearson T, Waugh JL, Wu SW, Zea Vera AG, Kruer MC. Emerging Subspecialties: Pediatric Movement Disorders Neurology. Neurology 2024; 102:e208050. [PMID: 38165345 DOI: 10.1212/wnl.0000000000208050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Pediatric movement disorders (PMD) neurologists care for infants, children, and adolescents with conditions that disrupt typical movement; serving as important subspecialist child neurologists in both academic and private practice settings. In contrast to adult movement disorders neurologists whose "bread and butter" is hypokinetic Parkinson disease, PMD subspecialty practice is often dominated by hyperkinetic movement disorders including tics, dystonia, chorea, tremor, and myoclonus. PMD neurology practice intersects with a variety of subspecialties, including neonatology, developmental pediatrics, rehabilitation medicine, epilepsy, child & adolescent psychiatry, psychology, orthopedics, genetics & metabolism, and neurosurgery. Over the past several decades, significant advancements in the PMD field have included operationalizing definitions for distinct movement disorders, recognizing the spectrum of clinical phenotypes, expanding research on genetic and neuroimmunologic causes of movement disorders, and advancing available treatments. Subspecialty training in PMD provides trainees with advanced clinical, diagnostic, procedural, and management skills that reflect the complexities of contemporary practice. The child neurologist who is fascinated by the intricacies of child motor development, appreciates the power of observation skills coupled with a thoughtful physical examination, and is excited by the challenge of the unknown may be well-suited to a career as a PMD specialist.
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Affiliation(s)
- Simran Kahlon
- From the Pediatric Movement Disorders Program (M.C.K.), Division of Neurology (S.K.), Barrow Neurological Institute, Phoenix Children's Hospital, AZ; Division of Neurology (C.R.B.), Norton Children's Hospital, University of Louisville, KY; Department of Pediatrics (A.A.L.), Al-Balqa Applied University, Salt, Jordan; Department of Neurology (A.A.L.), University of Virginia, Charlottesville; Department of Neurology (J.A.O.M.), Stanford University School of Medicine, Palo Alto, CA; Division of Neurology (T.P.), Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; Division of Pediatric Neurology (J.L.W.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Division of Neurology (S.W.W.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, OH; Department of Neurology (A.G.Z.V.), Children's National Hospital; Department of Neurology and Pediatrics (A.G.Z.V.), George Washington University School of Medicine & Health Sciences, Washington, DC; Department of Child Health, Genetics, Neurology, and Cellular and Molecular Medicine (M.C.K.), University of Arizona College of Medicine, Phoenix, AZ; and Programs in Biomedical Informatics, Molecular & Cellular Biology and Neuroscience (M.C.K.), Arizona State University
| | - Christopher R Barton
- From the Pediatric Movement Disorders Program (M.C.K.), Division of Neurology (S.K.), Barrow Neurological Institute, Phoenix Children's Hospital, AZ; Division of Neurology (C.R.B.), Norton Children's Hospital, University of Louisville, KY; Department of Pediatrics (A.A.L.), Al-Balqa Applied University, Salt, Jordan; Department of Neurology (A.A.L.), University of Virginia, Charlottesville; Department of Neurology (J.A.O.M.), Stanford University School of Medicine, Palo Alto, CA; Division of Neurology (T.P.), Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; Division of Pediatric Neurology (J.L.W.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Division of Neurology (S.W.W.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, OH; Department of Neurology (A.G.Z.V.), Children's National Hospital; Department of Neurology and Pediatrics (A.G.Z.V.), George Washington University School of Medicine & Health Sciences, Washington, DC; Department of Child Health, Genetics, Neurology, and Cellular and Molecular Medicine (M.C.K.), University of Arizona College of Medicine, Phoenix, AZ; and Programs in Biomedical Informatics, Molecular & Cellular Biology and Neuroscience (M.C.K.), Arizona State University
| | - Amal Abu Libdeh
- From the Pediatric Movement Disorders Program (M.C.K.), Division of Neurology (S.K.), Barrow Neurological Institute, Phoenix Children's Hospital, AZ; Division of Neurology (C.R.B.), Norton Children's Hospital, University of Louisville, KY; Department of Pediatrics (A.A.L.), Al-Balqa Applied University, Salt, Jordan; Department of Neurology (A.A.L.), University of Virginia, Charlottesville; Department of Neurology (J.A.O.M.), Stanford University School of Medicine, Palo Alto, CA; Division of Neurology (T.P.), Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; Division of Pediatric Neurology (J.L.W.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Division of Neurology (S.W.W.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, OH; Department of Neurology (A.G.Z.V.), Children's National Hospital; Department of Neurology and Pediatrics (A.G.Z.V.), George Washington University School of Medicine & Health Sciences, Washington, DC; Department of Child Health, Genetics, Neurology, and Cellular and Molecular Medicine (M.C.K.), University of Arizona College of Medicine, Phoenix, AZ; and Programs in Biomedical Informatics, Molecular & Cellular Biology and Neuroscience (M.C.K.), Arizona State University
| | - Jennifer A O'Malley
- From the Pediatric Movement Disorders Program (M.C.K.), Division of Neurology (S.K.), Barrow Neurological Institute, Phoenix Children's Hospital, AZ; Division of Neurology (C.R.B.), Norton Children's Hospital, University of Louisville, KY; Department of Pediatrics (A.A.L.), Al-Balqa Applied University, Salt, Jordan; Department of Neurology (A.A.L.), University of Virginia, Charlottesville; Department of Neurology (J.A.O.M.), Stanford University School of Medicine, Palo Alto, CA; Division of Neurology (T.P.), Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; Division of Pediatric Neurology (J.L.W.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Division of Neurology (S.W.W.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, OH; Department of Neurology (A.G.Z.V.), Children's National Hospital; Department of Neurology and Pediatrics (A.G.Z.V.), George Washington University School of Medicine & Health Sciences, Washington, DC; Department of Child Health, Genetics, Neurology, and Cellular and Molecular Medicine (M.C.K.), University of Arizona College of Medicine, Phoenix, AZ; and Programs in Biomedical Informatics, Molecular & Cellular Biology and Neuroscience (M.C.K.), Arizona State University
| | - Toni Pearson
- From the Pediatric Movement Disorders Program (M.C.K.), Division of Neurology (S.K.), Barrow Neurological Institute, Phoenix Children's Hospital, AZ; Division of Neurology (C.R.B.), Norton Children's Hospital, University of Louisville, KY; Department of Pediatrics (A.A.L.), Al-Balqa Applied University, Salt, Jordan; Department of Neurology (A.A.L.), University of Virginia, Charlottesville; Department of Neurology (J.A.O.M.), Stanford University School of Medicine, Palo Alto, CA; Division of Neurology (T.P.), Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; Division of Pediatric Neurology (J.L.W.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Division of Neurology (S.W.W.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, OH; Department of Neurology (A.G.Z.V.), Children's National Hospital; Department of Neurology and Pediatrics (A.G.Z.V.), George Washington University School of Medicine & Health Sciences, Washington, DC; Department of Child Health, Genetics, Neurology, and Cellular and Molecular Medicine (M.C.K.), University of Arizona College of Medicine, Phoenix, AZ; and Programs in Biomedical Informatics, Molecular & Cellular Biology and Neuroscience (M.C.K.), Arizona State University
| | - Jeff L Waugh
- From the Pediatric Movement Disorders Program (M.C.K.), Division of Neurology (S.K.), Barrow Neurological Institute, Phoenix Children's Hospital, AZ; Division of Neurology (C.R.B.), Norton Children's Hospital, University of Louisville, KY; Department of Pediatrics (A.A.L.), Al-Balqa Applied University, Salt, Jordan; Department of Neurology (A.A.L.), University of Virginia, Charlottesville; Department of Neurology (J.A.O.M.), Stanford University School of Medicine, Palo Alto, CA; Division of Neurology (T.P.), Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; Division of Pediatric Neurology (J.L.W.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Division of Neurology (S.W.W.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, OH; Department of Neurology (A.G.Z.V.), Children's National Hospital; Department of Neurology and Pediatrics (A.G.Z.V.), George Washington University School of Medicine & Health Sciences, Washington, DC; Department of Child Health, Genetics, Neurology, and Cellular and Molecular Medicine (M.C.K.), University of Arizona College of Medicine, Phoenix, AZ; and Programs in Biomedical Informatics, Molecular & Cellular Biology and Neuroscience (M.C.K.), Arizona State University
| | - Steve W Wu
- From the Pediatric Movement Disorders Program (M.C.K.), Division of Neurology (S.K.), Barrow Neurological Institute, Phoenix Children's Hospital, AZ; Division of Neurology (C.R.B.), Norton Children's Hospital, University of Louisville, KY; Department of Pediatrics (A.A.L.), Al-Balqa Applied University, Salt, Jordan; Department of Neurology (A.A.L.), University of Virginia, Charlottesville; Department of Neurology (J.A.O.M.), Stanford University School of Medicine, Palo Alto, CA; Division of Neurology (T.P.), Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; Division of Pediatric Neurology (J.L.W.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Division of Neurology (S.W.W.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, OH; Department of Neurology (A.G.Z.V.), Children's National Hospital; Department of Neurology and Pediatrics (A.G.Z.V.), George Washington University School of Medicine & Health Sciences, Washington, DC; Department of Child Health, Genetics, Neurology, and Cellular and Molecular Medicine (M.C.K.), University of Arizona College of Medicine, Phoenix, AZ; and Programs in Biomedical Informatics, Molecular & Cellular Biology and Neuroscience (M.C.K.), Arizona State University
| | - Alonso G Zea Vera
- From the Pediatric Movement Disorders Program (M.C.K.), Division of Neurology (S.K.), Barrow Neurological Institute, Phoenix Children's Hospital, AZ; Division of Neurology (C.R.B.), Norton Children's Hospital, University of Louisville, KY; Department of Pediatrics (A.A.L.), Al-Balqa Applied University, Salt, Jordan; Department of Neurology (A.A.L.), University of Virginia, Charlottesville; Department of Neurology (J.A.O.M.), Stanford University School of Medicine, Palo Alto, CA; Division of Neurology (T.P.), Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; Division of Pediatric Neurology (J.L.W.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Division of Neurology (S.W.W.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, OH; Department of Neurology (A.G.Z.V.), Children's National Hospital; Department of Neurology and Pediatrics (A.G.Z.V.), George Washington University School of Medicine & Health Sciences, Washington, DC; Department of Child Health, Genetics, Neurology, and Cellular and Molecular Medicine (M.C.K.), University of Arizona College of Medicine, Phoenix, AZ; and Programs in Biomedical Informatics, Molecular & Cellular Biology and Neuroscience (M.C.K.), Arizona State University
| | - Michael C Kruer
- From the Pediatric Movement Disorders Program (M.C.K.), Division of Neurology (S.K.), Barrow Neurological Institute, Phoenix Children's Hospital, AZ; Division of Neurology (C.R.B.), Norton Children's Hospital, University of Louisville, KY; Department of Pediatrics (A.A.L.), Al-Balqa Applied University, Salt, Jordan; Department of Neurology (A.A.L.), University of Virginia, Charlottesville; Department of Neurology (J.A.O.M.), Stanford University School of Medicine, Palo Alto, CA; Division of Neurology (T.P.), Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; Division of Pediatric Neurology (J.L.W.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Division of Neurology (S.W.W.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, OH; Department of Neurology (A.G.Z.V.), Children's National Hospital; Department of Neurology and Pediatrics (A.G.Z.V.), George Washington University School of Medicine & Health Sciences, Washington, DC; Department of Child Health, Genetics, Neurology, and Cellular and Molecular Medicine (M.C.K.), University of Arizona College of Medicine, Phoenix, AZ; and Programs in Biomedical Informatics, Molecular & Cellular Biology and Neuroscience (M.C.K.), Arizona State University
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Gelineau-Morel R, Smyser C, Leeder JS. Identifying Effective Treatments for Dystonia in Patients With Cerebral Palsy: A Precision Therapeutics Approach. Neurology 2023; 101:752-759. [PMID: 37463749 PMCID: PMC10624496 DOI: 10.1212/wnl.0000000000207593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 05/12/2023] [Indexed: 07/20/2023] Open
Abstract
Recent focus on improving the recognition of dystonia in cerebral palsy (DCP) has highlighted the need for more effective treatments. Evidence supports improved functional outcomes with early interventions for patients with cerebral palsy, but it is not known which interventions are most effective for DCP. Current pharmacologic recommendations for DCP are based largely on anecdotal evidence, with medications demonstrating minimal to moderate improvements in dystonia and variable efficacy between patients. Patients, families, and clinicians have identified the need for new and improved treatments in DCP, naming this as the top research theme in a recent Neurology® publication. Precision therapeutics focuses on providing early effective interventions that are individualized to every patient and can guide research priorities to improve treatments for DCP. This commentary outlines current obstacles to improving treatment of DCP and addresses how precision therapeutics can address each of these obstacles through 4 key components: (1) identification of predictive biomarkers to select patients likely to develop DCP in the future and for whom early intervention may be appropriate to delay or prevent full manifestation of dystonia, (2) stratification of patients with DCP into subgroups according to shared features (clinical, functional, biochemical, etc) to provide a targeted intervention based on those shared features, (3) administration of an individualized dose of an effective intervention to ensure adequate concentrations of the therapeutic entity at the site of action, and (4) monitoring of objective biomarkers of response to intervention. With implementation of each of these components of precision therapeutics, new and more effective treatments for every person with DCP can be realized.
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Affiliation(s)
- Rose Gelineau-Morel
- From the Division of Neurology (R.G.-M.), Children's Mercy Kansas City; School of Medicine (R.G.-M., J.S.L.), University of Missouri-Kansas City; Department of Pediatrics (R.G.-M., J.S.L.), University of Kansas Medical Center, Kansas City; Department of Pediatrics (C.S.), Department of Neurology (C.S.), and Mallinckrodt Institute of Radiology (C.S.), Washington University in St. Louis; and Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation (J.S.L.), Children's Mercy Kansas City, MO.
| | - Christopher Smyser
- From the Division of Neurology (R.G.-M.), Children's Mercy Kansas City; School of Medicine (R.G.-M., J.S.L.), University of Missouri-Kansas City; Department of Pediatrics (R.G.-M., J.S.L.), University of Kansas Medical Center, Kansas City; Department of Pediatrics (C.S.), Department of Neurology (C.S.), and Mallinckrodt Institute of Radiology (C.S.), Washington University in St. Louis; and Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation (J.S.L.), Children's Mercy Kansas City, MO
| | - J Steven Leeder
- From the Division of Neurology (R.G.-M.), Children's Mercy Kansas City; School of Medicine (R.G.-M., J.S.L.), University of Missouri-Kansas City; Department of Pediatrics (R.G.-M., J.S.L.), University of Kansas Medical Center, Kansas City; Department of Pediatrics (C.S.), Department of Neurology (C.S.), and Mallinckrodt Institute of Radiology (C.S.), Washington University in St. Louis; and Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation (J.S.L.), Children's Mercy Kansas City, MO
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MacLean JA, Nataraj J, Davies J, Zakharova A, Kurtz J, Liker MA, Olaya J, Sanger TD. Novel utilization of deep brain stimulation in the pedunculopontine nucleus with globus pallidus internus for treatment of childhood-onset dystonia. Front Hum Neurosci 2023; 17:1270430. [PMID: 37929227 PMCID: PMC10625402 DOI: 10.3389/fnhum.2023.1270430] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/28/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction Deep brain stimulation (DBS) is a well-documented therapy for dystonia utilized in many adult and pediatric movement disorders. Pedunculopontine nucleus (PPN) has been investigated as a DBS target primarily in adult patients with dystonia or dyskinesias from Parkinson's disease, showing improvement in postural instability and gait dysfunction. Due to the difficulty in targeting PPN using standard techniques, it is not commonly chosen as a target for adult or pediatric pathology. There is no current literature describing the targeting of PPN in DBS for childhood-onset dystonia. Methods Two pediatric and one young adult patient with childhood-onset dystonia who underwent DBS implantation at our institution were identified. Patient 1 has Mitochondrial Enoyl CoA Reductase Protein-Associated Neurodegeneration (MEPAN) syndrome. Patient 2 has Glutaric Aciduria Type 1 (GA1). Patient 3 has atypical pantothenate kinase-associated neurodegeneration (PKAN). PPN was identified as a potential target for these patients due to axial or orofacial dystonia. Pre- and post-operative videos taken as part of routine clinical assessments were evaluated and scored on the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) and Barry-Albright Dystonia Scale (BADS). All patients had permanent electrodes placed bilaterally in PPN and globus pallidus internus (GPi). A Likert scale on quality of life was also obtained from the patient/parents as applicable. Results Significant programming was necessary over the first 3-12 months to optimize patients' response to stimulation. All patients experienced at least a 34% improvement in the BFMDRS score. Patients 2 and 3 also experienced an over 30% improvement in BADS score. All patients/parents appreciated improvement in quality of life postoperatively. Discussion Deep brain stimulation in PPN was safely and successfully used in two pediatric patients and one young adult patient with childhood-onset dystonia. These patients showed clinically significant improvements in BFMDRS scoring post operatively. This represents the first reported DBS targeting of PPN in pediatric patients, and suggests that PPN is a possible target for pediatric-onset dystonia with axial and orofacial symptoms that may be refractory to traditional pallidal stimulation alone.
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Affiliation(s)
- Jennifer A. MacLean
- Department of Neurology, Children’s Hospital of Orange County, Orange, CA, United States
- Research Institute, Children’s Hospital of Orange County, Orange, CA, United States
| | - Jaya Nataraj
- Samueli School of Engineering, University of California, Irvine, Irvine, CA, United States
| | - Jordan Davies
- Division of Neurosurgery, Children’s Hospital of Orange County, Orange, CA, United States
- Department of Neurological Surgery, School of Medicine, University of California, Irvine, Irvine, CA, United States
| | - Aleksandra Zakharova
- Department of Neurology, Children’s Hospital of Orange County, Orange, CA, United States
- Unit of Pediatric Neurology, Faculty of Medicine Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile
| | - Joshua Kurtz
- School of Medicine, University of California, Irvine, Irvine, CA, United States
| | - Mark A. Liker
- Division of Neurosurgery, Children’s Hospital of Orange County, Orange, CA, United States
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Joffre Olaya
- Division of Neurosurgery, Children’s Hospital of Orange County, Orange, CA, United States
- Department of Neurological Surgery, School of Medicine, University of California, Irvine, Irvine, CA, United States
| | - Terence D. Sanger
- Department of Neurology, Children’s Hospital of Orange County, Orange, CA, United States
- Research Institute, Children’s Hospital of Orange County, Orange, CA, United States
- Samueli School of Engineering, University of California, Irvine, Irvine, CA, United States
- Department of Pediatrics, School of Medicine, University of California, Irvine, Irvine, CA, United States
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Zea Vera A, Gropman AL. Surgical treatment of movement disorders in neurometabolic conditions. Front Neurol 2023; 14:1205339. [PMID: 37333007 PMCID: PMC10272416 DOI: 10.3389/fneur.2023.1205339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 05/16/2023] [Indexed: 06/20/2023] Open
Abstract
Refractory movement disorders are a common feature of inborn errors of metabolism (IEMs), significantly impacting quality of life and potentially leading to life-threatening complications such as status dystonicus. Surgical techniques, including deep brain stimulation (DBS) and lesioning techniques, represent an additional treatment option. However, the application and benefits of these procedures in neurometabolic conditions is not well understood. This results in challenges selecting surgical candidates and counseling patients preoperatively. In this review, we explore the literature of surgical techniques for the treatment of movement disorders in IEMs. Globus pallidus internus DBS has emerged as a beneficial treatment option for dystonia in Panthotate-Kinase-associated Neurodegeneration. Additionally, several patients with Lesch-Nyhan Disease have shown improvement following pallidal stimulation, with more robust effects on self-injurious behavior than dystonia. Although there are numerous reports describing benefits of DBS for movement disorders in other IEMs, the sample sizes have generally been small, limiting meaningful conclusions. Currently, DBS is preferred to lesioning techniques. However, successful use of pallidotomy and thalamotomy in neurometabolic conditions has been reported and may have a role in selected patients. Surgical techniques have also been used successfully in patients with IEMs to treat status dystonicus. Advancing our knowledge of these treatment options could significantly improve the care for patients with neurometabolic conditions.
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Affiliation(s)
- Alonso Zea Vera
- Division of Neurology, Children’s National Hospital, Washington, DC, United States
- Department of Neurology, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Andrea L. Gropman
- Department of Neurology, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
- Division of Neurogenetics and Neurodevelopmental Pediatrics, Children’s National Hospital, Washington DC, United States
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Hitti FL, Widge AS, Riva-Posse P, Malone DA, Okun MS, Shanechi MM, Foote KD, Lisanby SH, Ankudowich E, Chivukula S, Chang EF, Gunduz A, Hamani C, Feinsinger A, Kubu CS, Chiong W, Chandler JA, Carbunaru R, Cheeran B, Raike RS, Davis RA, Halpern CH, Vanegas-Arroyave N, Markovic D, Bick SK, McIntyre CC, Richardson RM, Dougherty DD, Kopell BH, Sweet JA, Goodman WK, Sheth SA, Pouratian N. Future directions in psychiatric neurosurgery: Proceedings of the 2022 American Society for Stereotactic and Functional Neurosurgery meeting on surgical neuromodulation for psychiatric disorders. Brain Stimul 2023; 16:867-878. [PMID: 37217075 PMCID: PMC11189296 DOI: 10.1016/j.brs.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/10/2023] [Accepted: 05/14/2023] [Indexed: 05/24/2023] Open
Abstract
OBJECTIVE Despite advances in the treatment of psychiatric diseases, currently available therapies do not provide sufficient and durable relief for as many as 30-40% of patients. Neuromodulation, including deep brain stimulation (DBS), has emerged as a potential therapy for persistent disabling disease, however it has not yet gained widespread adoption. In 2016, the American Society for Stereotactic and Functional Neurosurgery (ASSFN) convened a meeting with leaders in the field to discuss a roadmap for the path forward. A follow-up meeting in 2022 aimed to review the current state of the field and to identify critical barriers and milestones for progress. DESIGN The ASSFN convened a meeting on June 3, 2022 in Atlanta, Georgia and included leaders from the fields of neurology, neurosurgery, and psychiatry along with colleagues from industry, government, ethics, and law. The goal was to review the current state of the field, assess for advances or setbacks in the interim six years, and suggest a future path forward. The participants focused on five areas of interest: interdisciplinary engagement, regulatory pathways and trial design, disease biomarkers, ethics of psychiatric surgery, and resource allocation/prioritization. The proceedings are summarized here. CONCLUSION The field of surgical psychiatry has made significant progress since our last expert meeting. Although weakness and threats to the development of novel surgical therapies exist, the identified strengths and opportunities promise to move the field through methodically rigorous and biologically-based approaches. The experts agree that ethics, law, patient engagement, and multidisciplinary teams will be critical to any potential growth in this area.
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Affiliation(s)
- Frederick L Hitti
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Alik S Widge
- Department of Psychiatry and Behavioral Sciences, University of Minnesota-Twin Cities, Minneapolis, MN, USA
| | - Patricio Riva-Posse
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Donald A Malone
- Department of Psychiatry, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Michael S Okun
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, Gainesville, FL, USA
| | - Maryam M Shanechi
- Departments of Electrical and Computer Engineering and Biomedical Engineering, Viterbi School of Engineering, University of Southern California, Los Angeles, CA, USA
| | - Kelly D Foote
- Department of Neurosurgery, Norman Fixel Institute for Neurological Diseases, Gainesville, FL, USA
| | - Sarah H Lisanby
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD, USA
| | - Elizabeth Ankudowich
- Division of Translational Research, National Institute of Mental Health, Bethesda, MD, USA
| | - Srinivas Chivukula
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Edward F Chang
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Aysegul Gunduz
- Department of Biomedical Engineering and Fixel Institute for Neurological Disorders, University of Florida, Gainesville, FL, USA
| | - Clement Hamani
- Sunnybrook Research Institute, Hurvitz Brain Sciences Centre, Harquail Centre for Neuromodulation, Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Ashley Feinsinger
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Cynthia S Kubu
- Department of Neurology, Cleveland Clinic and Case Western Reserve University, School of Medicine, Cleveland, OH, USA
| | - Winston Chiong
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Jennifer A Chandler
- Faculty of Law, University of Ottawa, Ottawa, ON, USA; Affiliate Investigator, Bruyère Research Institute, Ottawa, ON, USA
| | | | | | - Robert S Raike
- Global Research Organization, Medtronic Inc. Neuromodulation, Minneapolis, MN, USA
| | - Rachel A Davis
- Departments of Psychiatry and Neurosurgery, University of Colorado Anschutz, Aurora, CO, USA
| | - Casey H Halpern
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; The Cpl Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | | | - Dejan Markovic
- Department of Electrical Engineering, University of California Los Angeles, Los Angeles, CA, USA
| | - Sarah K Bick
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cameron C McIntyre
- Departments of Biomedical Engineering and Neurosurgery, Duke University, Durham, NC, USA
| | - R Mark Richardson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Darin D Dougherty
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Brian H Kopell
- Department of Neurosurgery, Center for Neuromodulation, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jennifer A Sweet
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Wayne K Goodman
- Department of Psychiatry and Behavior Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Sameer A Sheth
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Nader Pouratian
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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