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Gonzalez-Baez Ardisana P, Solís-Mata JS, Carrillo-Ruiz JD. Neurosurgical therapy possibilities in treatment of Huntington disease: An update. Parkinsonism Relat Disord 2024; 125:107048. [PMID: 38959686 DOI: 10.1016/j.parkreldis.2024.107048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 06/03/2024] [Accepted: 06/24/2024] [Indexed: 07/05/2024]
Abstract
INTRODUCTION Huntington's disease (HD) is a hereditary condition caused by the expansion of the CAG trinucleotide in the huntingtin gene on chromosome 4, resulting in motor, cognitive, and psychiatric disorders that significantly impact patients' quality of life. Despite the lack of effective treatments for the disease, various surgical strategies have been explored to alleviate symptoms and slow its progression. METHODOLOGY A comprehensive systematic literature review was conducted, including MeSH terms, yielding only 38 articles that were categorized based on the surgical procedure. The study aimed to describe the types of surgeries performed and their efficacy in HD patients. RESULTS Deep brain stimulation (DBS) involved 41 predominantly male patients with bilateral implantation in the globus pallidus, showing a preoperative Unified Huntington's Disease Rating Scale (UHDRS) score of 60.25 ± 16.13 and a marked postoperative value of 48.54 ± 13.93 with a p < 0.018 at one year and p < 0.040 at three years. Patients experienced improvement in hyperkinesia but worsening of bradykinesia. Additionally, cell transplantation in 119 patients resulted in a lower preoperative UHDRS score of 34.61 ± 14.61 and a significant postoperative difference of 32.93 ± 15.87 (p < 0.016), respectively, in the first to third years of following. Some now, less used procedures were crucial for understanding brain function, such as pallidotomies in 3 patients, showing only a 25 % difference from their baseline. CONCLUSION Despite advancements in technology, there is still no curative treatment, only palliative options. Promising treatments like trophic factor implantation offer new prospects for the future.
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Affiliation(s)
- Patricio Gonzalez-Baez Ardisana
- Center of Research in Science of Health (CICSA), Faculty of Science of Health of Anahuac University, Huixquilucan, México State, Mexico
| | - Juan Sebastián Solís-Mata
- Center of Research in Science of Health (CICSA), Faculty of Science of Health of Anahuac University, Huixquilucan, México State, Mexico
| | - José Damián Carrillo-Ruiz
- Stereotactic and Functional Neurosurgery and Radiosurgery at Hospital General de Mexico & Research Direction at Hospital General de Mexico, México City, Mexico; Neuroscience Coordination, Psychology Faculty of Anahuac University, Huixquilucan, México State, Mexico.
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Rissardo JP, Vora NM, Tariq I, Mujtaba A, Caprara ALF. Deep Brain Stimulation for the Management of Refractory Neurological Disorders: A Comprehensive Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1991. [PMID: 38004040 PMCID: PMC10673515 DOI: 10.3390/medicina59111991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/04/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023]
Abstract
In recent decades, deep brain stimulation (DBS) has been extensively studied due to its reversibility and significantly fewer side effects. DBS is mainly a symptomatic therapy, but the stimulation of subcortical areas by DBS is believed to affect the cytoarchitecture of the brain, leading to adaptability and neurogenesis. The neurological disorders most commonly studied with DBS were Parkinson's disease, essential tremor, obsessive-compulsive disorder, and major depressive disorder. The most precise approach to evaluating the location of the leads still relies on the stimulus-induced side effects reported by the patients. Moreover, the adequate voltage and DBS current field could correlate with the patient's symptoms. Implantable pulse generators are the main parts of the DBS, and their main characteristics, such as rechargeable capability, magnetic resonance imaging (MRI) safety, and device size, should always be discussed with patients. The safety of MRI will depend on several parameters: the part of the body where the device is implanted, the part of the body scanned, and the MRI-tesla magnetic field. It is worth mentioning that drug-resistant individuals may have different pathophysiological explanations for their resistance to medications, which could affect the efficacy of DBS therapy. Therefore, this could explain the significant difference in the outcomes of studies with DBS in individuals with drug-resistant neurological conditions.
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Affiliation(s)
| | - Nilofar Murtaza Vora
- Medicine Department, Terna Speciality Hospital and Research Centre, Navi Mumbai 400706, India;
| | - Irra Tariq
- Medicine Department, United Medical & Dental College, Karachi 75600, Pakistan;
| | - Amna Mujtaba
- Medicine Department, Karachi Medical & Dental College, Karachi 74700, Pakistan;
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Kinfe T, Del Vecchio A, Nüssel M, Zhao Y, Stadlbauer A, Buchfelder M. Deep brain stimulation and stereotactic-assisted brain graft injection targeting fronto-striatal circuits for Huntington's disease: an update. Expert Rev Neurother 2022; 22:781-788. [PMID: 35766355 DOI: 10.1080/14737175.2022.2091988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Huntington's Disease as progressive neurological disorders associated with motor, behavioral, and cognitive impairment poses a therapeutic challenge in case of limited responsiveness to established therapeutics. Pallidal deep brain stimulation and neurorestorative strategies (brain grafts) scoping to modulate fronto-striatal circuits have gained increased recognition for the treatment of refractory Huntington's disease (HD). AREAS COVERED A review (2000-2022) was performed in PubMed, Embase, and Cochrane Library covering clinical trials conceptualized to determine the efficacy and safety of invasive, stereotactic-guided deep-brain stimulation and intracranial brain-graft injection targeting the globus pallidus and adjunct structures (striatum). EXPERT OPINION Stereotactic brain-grafting strategies were performed in few HD patients with inconsistent findings and mild-to-moderate clinical responsiveness with a recently published large, randomized-controlled trial (NCT00190450) yielding negative results. We identified 19 in-human DBS trials (uncontrolled) targeting the globus pallidus internus/externus along with randomized-controlled trial pending report (NCT02535884). We did not detect any significant changes in the UHDRS total score after restorative injections, while in contrast, the use of deep-brain stimulation resulted in a significant reduction of chorea. GPi-DBS should be considered in cases where selective chorea is present. However, both invasive therapies remain experimental and are not ready for the implementation in clinical use.
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Affiliation(s)
- Thomas Kinfe
- Division of Functional Neurosurgery and Stereotaxy, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Germany.,Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Germany
| | - Alessandro Del Vecchio
- Department of Artificial Intelligence in Biomedical Engineering (AIBE), Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Martin Nüssel
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Germany
| | - Yining Zhao
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Germany
| | - Andreas Stadlbauer
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Germany
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Bonomo R, Elia AE, Bonomo G, Romito LM, Mariotti C, Devigili G, Cilia R, Giossi R, Eleopra R. Deep brain stimulation in Huntington's disease: a literature review. Neurol Sci 2021; 42:4447-4457. [PMID: 34471947 DOI: 10.1007/s10072-021-05527-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/25/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Huntington's disease (HD) is a neurodegenerative disorder characterized by involuntary movements, cognitive decline, and behavioral changes. The complex constellation of clinical symptoms still makes the therapeutic management challenging. In the new era of functional neurosurgery, deep brain stimulation (DBS) may represent a promising therapeutic approach in selected HD patients. METHODS Articles describing the effect of DBS in patients affected by HD were selected from Medline and PubMed by the association of text words with MeSH terms as follows: "Deep brain stimulation," "DBS," and "HD," "Huntington's disease," and "Huntington." Details on repeat expansion, age at operation, target of operation, duration of follow-up, stimulation parameters, adverse events, and outcome measures were collected. RESULTS Twenty eligible studies, assessing 42 patients with HD, were identified. The effect of globus pallidus internus (GPi) DBS on Unified Huntington's Disease Rating Scale (UHDRS) total score revealed in 10 studies an improvement of total score from 5.4 to 34.5%, and in 4 studies, an increase of motor score from 3.8 to 97.8%. Bilateral GPi-DBS was reported to be effective in reducing Chorea subscore in all studies, with a mean percentage reduction from 21.4 to 73.6%. CONCLUSIONS HD patients with predominant choreic symptoms may be the best candidates for surgery, but the role of other clinical features and of disease progression should be elucidated. For this reason, there is a need for more reliable criteria that may guide the selection of HD patients suitable for DBS. Accordingly, further studies including functional outcomes as primary endpoints are needed.
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Affiliation(s)
- Roberta Bonomo
- Department of Clinical Neurosciences, Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, Italy
- Experimental Neurology Unit, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Antonio E Elia
- Department of Clinical Neurosciences, Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, Italy.
| | - Giulio Bonomo
- Neurosurgery Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Luigi M Romito
- Department of Clinical Neurosciences, Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, Italy
| | - Caterina Mariotti
- Unit of Medical Genetics, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Grazia Devigili
- Department of Clinical Neurosciences, Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, Italy
| | - Roberto Cilia
- Department of Clinical Neurosciences, Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, Italy
| | - Riccardo Giossi
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Department of Oncology and Onco-Hematology, Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, Milan, Italy
| | - Roberto Eleopra
- Department of Clinical Neurosciences, Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, Italy
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Kim A, Lalonde K, Truesdell A, Gomes Welter P, Brocardo PS, Rosenstock TR, Gil-Mohapel J. New Avenues for the Treatment of Huntington's Disease. Int J Mol Sci 2021; 22:ijms22168363. [PMID: 34445070 PMCID: PMC8394361 DOI: 10.3390/ijms22168363] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 12/11/2022] Open
Abstract
Huntington’s disease (HD) is a neurodegenerative disorder caused by a CAG expansion in the HD gene. The disease is characterized by neurodegeneration, particularly in the striatum and cortex. The first symptoms usually appear in mid-life and include cognitive deficits and motor disturbances that progress over time. Despite being a genetic disorder with a known cause, several mechanisms are thought to contribute to neurodegeneration in HD, and numerous pre-clinical and clinical studies have been conducted and are currently underway to test the efficacy of therapeutic approaches targeting some of these mechanisms with varying degrees of success. Although current clinical trials may lead to the identification or refinement of treatments that are likely to improve the quality of life of those living with HD, major efforts continue to be invested at the pre-clinical level, with numerous studies testing novel approaches that show promise as disease-modifying strategies. This review offers a detailed overview of the currently approved treatment options for HD and the clinical trials for this neurodegenerative disorder that are underway and concludes by discussing potential disease-modifying treatments that have shown promise in pre-clinical studies, including increasing neurotropic support, modulating autophagy, epigenetic and genetic manipulations, and the use of nanocarriers and stem cells.
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Affiliation(s)
- Amy Kim
- Island Medical Program and Faculty of Medicine, University of British Columbia, Victoria, BC V8P 5C2, Canada; (A.K.); (K.L.)
| | - Kathryn Lalonde
- Island Medical Program and Faculty of Medicine, University of British Columbia, Victoria, BC V8P 5C2, Canada; (A.K.); (K.L.)
| | - Aaron Truesdell
- Division of Medical Sciences, University of Victoria, Victoria, BC V8P 5C2, Canada;
- Schulich School of Medicine and Dentistry, Western University, London, ON N6A 5C1, Canada
| | - Priscilla Gomes Welter
- Neuroscience Graduate Program, Federal University of Santa Catarina, Florianópolis 88040-900, Brazil; (P.G.W.); (P.S.B.)
| | - Patricia S. Brocardo
- Neuroscience Graduate Program, Federal University of Santa Catarina, Florianópolis 88040-900, Brazil; (P.G.W.); (P.S.B.)
| | - Tatiana R. Rosenstock
- Institute of Cancer and Genomic Science, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK;
- Department of Pharmacology, University of São Paulo, São Paulo 05508-000, Brazil
| | - Joana Gil-Mohapel
- Island Medical Program and Faculty of Medicine, University of British Columbia, Victoria, BC V8P 5C2, Canada; (A.K.); (K.L.)
- Division of Medical Sciences, University of Victoria, Victoria, BC V8P 5C2, Canada;
- Correspondence: ; Tel.: +1-250-472-4597; Fax: +1-250-472-5505
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Dash D, Mestre TA. Therapeutic Update on Huntington's Disease: Symptomatic Treatments and Emerging Disease-Modifying Therapies. Neurotherapeutics 2020; 17:1645-1659. [PMID: 32705582 PMCID: PMC7851270 DOI: 10.1007/s13311-020-00891-w] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Huntington's disease (HD) is a monogenic neurodegenerative disorder that presents with progressive motor, behavior, and cognitive symptoms leading to early disability and mortality. HD is caused by an expanded CAG repeats in exon 1 of the huntingtin (HTT) gene. The corresponding genetic test allows a clinical, definite diagnosis in life and the identification of a fully penetrant mutation carrier in a premanifest stage. In addition to the development of symptomatic treatments that attempt to address unmet care needs such as apathy, irritability, and cognition, novel therapies that target pathways specific to HD biology are being developed with the intent of slowing disease progression. Among these approaches, HTT protein lowering therapies hold great promise. There are currently active programs using antisense oligonucleotides (ASOs), RNA interference, small-molecule splicing modulators, and zinc-finger protein transcription factor. Except for ASOs and RNA interference approaches, the remaining therapeutic strategies are at a preclinical stage of development. While the current therapeutic landscape in HD may bring an unparalleled change in the lives of people with HD and their families with the first-ever disease-modifying therapy, the evaluation of these therapies requires novel tools that enable a more efficient and expedited discovery and evaluative process. Examples are biomarkers targeting the HTT protein to measure target engagement or disease progression and rating scales more sensitive to the earliest clinical changes. These tools will be instrumental in the next phase of disease-modifying clinical trials in HD likely to target the phenoconversion period of the disease, including the prodromal HD stage.
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Affiliation(s)
- Deepa Dash
- Brain and Mind Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Parkinson Disease and Movement Disorders Centre, Division of Neurology, Department of Medicine, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | - Tiago A Mestre
- Brain and Mind Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
- Parkinson Disease and Movement Disorders Centre, Division of Neurology, Department of Medicine, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada.
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Does pallidal neuromodulation influence cognitive decline in Huntington's disease? J Neurol 2020; 268:613-622. [PMID: 32886253 DOI: 10.1007/s00415-020-10206-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/28/2020] [Accepted: 08/31/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Huntington's disease (HD) is an autosomal dominant neurodegenerative disorder associated with motor, psychiatric and cognitive deterioration over time. To date, Continuous Electrical Neuromodulation (CEN) of the globus pallidus internus (GPi) has been reported to improve chorea but little is known about cognitive progression in these patients. We propose to examine CEN impact on expected cognitive decline throughout long-term neuropsychological assessment of a cohort of HD patients. METHOD 13 consecutive HD patients underwent GPi neuromodulation between January 2008 and February 2019. Over a 5-year follow-up period, they received systematic pre- and post-operative assessment according to the existing protocol in our unit. The main outcome measure was the total score obtained on the Mattis Dementia Rating Scale (MDRS) as an indicator of global cognitive function. RESULTS Chorea decreased in all patients postoperatively with a mean improvement of 56% despite disease progression over time, according to previous studies. Moreover we found that the global cognitive profile of HD patients treated with CEN was stable during the first 3 years of treatment. CONCLUSION We report an unexpected positive influence of GPi continuous electrical neuromodulation on the progression of global cognitive functioning in operated HD patients. This is the most important group of patients treated with this method to our knowledge whatever the sample size remains small. This result provides promising evidence of GPi-CEN efficacy not only in reducing chorea, but also in delaying cognitive decline in HD patients operated at an early stage of the disease.
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Deb A, Frank S, Testa CM. New symptomatic therapies for Huntington disease. HANDBOOK OF CLINICAL NEUROLOGY 2017; 144:199-207. [PMID: 28947118 DOI: 10.1016/b978-0-12-801893-4.00017-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Huntington disease (HD), an inherited neurodegenerative disease, results from a CAG repeat expansion creating mutant huntingtin protein and widespread neuronal damage. Motor symptoms such as chorea are often preceded by cognitive and behavioral changes. Tetrabenazine and deutetrabebenazine are the two drugs approved by the Federal Food and Drug Administrationfor HD symptoms, is an effective therapy for chorea. However, there is still a large need for other symptomatic therapies impacting functional issues, including impaired gait, behavioral, and cognitive symptoms. A number of pharmacologic agents are under investigation. Additionally, other mechanisms are being targeted in motor symptom drug development, including phosphodiesterase 10 enzyme inhibition, dopamine modulation, and inhibition of deacetylation. There is perhaps the greatest unmet need in treating nonmotor effects, such as cognition and change in disease course. PBT2, a metal chaperone, and latrepirdine, a mitochondrial stabilizer, are under investigation specifically for the possibility of cognitive benefit. Unfortunately, there is a lack of HD-specific evidence on effective treatments for behavioral and psychiatric symptoms. Further investigation of nonmedication interventions such as physical therapy is necessary. As our understanding of molecular and cellular mechanisms underlying HD broadens, a new set of mechanistic targets will become the focus of HD symptomatic therapies.
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Affiliation(s)
- Anindita Deb
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, United States
| | - Samuel Frank
- Beth Israel Deaconess Medical Center/Harvard Medical School in Boston, MA, United States.
| | - Claudia M Testa
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States
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Wojtecki L, Groiss SJ, Hartmann CJ, Elben S, Omlor S, Schnitzler A, Vesper J. Deep Brain Stimulation in Huntington's Disease-Preliminary Evidence on Pathophysiology, Efficacy and Safety. Brain Sci 2016; 6:brainsci6030038. [PMID: 27589813 PMCID: PMC5039467 DOI: 10.3390/brainsci6030038] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 08/18/2016] [Accepted: 08/22/2016] [Indexed: 12/29/2022] Open
Abstract
Huntington's disease (HD) is one of the most disabling degenerative movement disorders, as it not only affects the motor system but also leads to cognitive disabilities and psychiatric symptoms. Deep brain stimulation (DBS) of the pallidum is a promising symptomatic treatment targeting the core motor symptom: chorea. This article gives an overview of preliminary evidence on pathophysiology, safety and efficacy of DBS in HD.
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Affiliation(s)
- Lars Wojtecki
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
| | - Stefan Jun Groiss
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
| | - Christian Johannes Hartmann
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
| | - Saskia Elben
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
| | - Sonja Omlor
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany
| | - Alfons Schnitzler
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
| | - Jan Vesper
- Department of Functional Neurosurgery and Stereotaxy, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
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Estévez-Fraga C, Avilés Olmos I, Mañanes Barral V, López-Sendón Moreno JL. Therapeutic advances in Huntington’s disease. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1196128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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di Biase L, Munhoz RP. Deep brain stimulation for the treatment of hyperkinetic movement disorders. Expert Rev Neurother 2016; 16:1067-78. [DOI: 10.1080/14737175.2016.1196139] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Hartmann CJ, Groiss SJ, Vesper J, Schnitzler A, Wojtecki L. Brain stimulation in Huntington's disease. Neurodegener Dis Manag 2016; 6:223-36. [DOI: 10.2217/nmt-2016-0007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Huntington's disease (HD) is a hereditary neurodegenerative disorder which is associated with severe disturbances of motor function, especially choreatic movements, cognitive decline and psychiatric symptoms. Various brain stimulation methods have been used to study brain function in patients with HD. Moreover, brain stimulation has evolved as an alternative or additive treatment option, besides current symptomatic medical treatment. This article summarizes the results of brain stimulation to better understand the characteristics of cortical excitability and plasticity in HD and gives a perspective on the therapeutic role for noninvasive and invasive neuromodulatory brain stimulation methods.
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Affiliation(s)
- Christian Johannes Hartmann
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany
| | - Stefan Jun Groiss
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany
| | - Jan Vesper
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany
| | - Alfons Schnitzler
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany
| | - Lars Wojtecki
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany
- Institute of Clinical Neuroscience & Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany
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Mason SL, Barker RA. Novel targets for Huntington's disease: future prospects. Degener Neurol Neuromuscul Dis 2016; 6:25-36. [PMID: 30050366 PMCID: PMC6053088 DOI: 10.2147/dnnd.s83808] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Huntington's disease (HD) is an incurable, inherited, progressive, neurodegenerative disorder that is characterized by a triad of motor, cognitive, and psychiatric problems. Despite the noticeable increase in therapeutic trials in HD in the last 20 years, there have, to date, been very few significant advances. The main hope for new and emerging therapeutics for HD is to develop a neuroprotective compound capable of slowing down or even stopping the progression of the disease and ultimately prevent the subtle early signs from developing into manifest disease. Recently, there has been a noticeable shift away from symptomatic therapies in favor of more mechanistic-based interventions, a change driven by a better understanding of the pathogenesis of this disorder. In this review, we discuss the status of, and supporting evidence for, potential novel treatments of HD that are currently under development or have reached the level of early Phase I/II clinical trials.
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Affiliation(s)
| | - Roger A Barker
- John van Geest Centre for Brain Repair, .,Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK
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Vedam-Mai V, Martinez-Ramirez D, Hilliard JD, Carbunaru S, Yachnis AT, Bloom J, Keeling P, Awe L, Foote KD, Okun MS. Post-mortem Findings in Huntington's Deep Brain Stimulation: A Moving Target Due to Atrophy. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2016; 6:372. [PMID: 27127722 PMCID: PMC4848757 DOI: 10.7916/d8zp462h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 04/04/2016] [Indexed: 12/03/2022]
Abstract
Background Deep brain stimulation (DBS) has been shown to be effective for Parkinson’s disease, essential tremor, and primary dystonia. However, mixed results have been reported in Huntington’s disease (HD). Case Report A single case of HD DBS was identified from the University of Florida DBS Brain Tissue Network. The clinical presentation, evolution, surgical planning, DBS parameters, clinical outcomes, and brain pathological changes are summarized. Discussion This case of HD DBS revealed that chorea may improve and be sustained. Minimal histopathological changes were noted around the DBS leads. Severe atrophy due to HD likely changed the DBS lead position relative to the internal capsule.
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Affiliation(s)
- Vinata Vedam-Mai
- Department of Neurosurgery, University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Daniel Martinez-Ramirez
- Department of Neurology, University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Justin D Hilliard
- Department of Neurosurgery, University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Samuel Carbunaru
- Department of Neurology, University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Anthony T Yachnis
- Department of Pathology, University of Florida, Gainesville, FL, USA
| | - Joshua Bloom
- Department of Neurology, University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Peyton Keeling
- Department of Neurology, University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Lisa Awe
- Department of Neurology, University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Kelly D Foote
- Department of Neurosurgery, University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Michael S Okun
- Department of Neurosurgery, University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA; Department of Neurology, University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
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15
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Delorme C, Rogers A, Lau B, Francisque H, Welter ML, Vidal SF, Yelnik J, Durr A, Grabli D, Karachi C. Deep brain stimulation of the internal pallidum in Huntington's disease patients: clinical outcome and neuronal firing patterns. J Neurol 2015; 263:290-298. [PMID: 26568561 DOI: 10.1007/s00415-015-7968-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 10/30/2015] [Accepted: 11/01/2015] [Indexed: 12/31/2022]
Abstract
Deep brain stimulation (DBS) of the internal globus pallidus (GPi) could treat chorea in Huntington's disease patients. The objectives of this study were to evaluate the efficacy of GPi-DBS to reduce abnormal movements of three patients with Huntington's disease and assess tolerability. Three non-demented patients with severe pharmacoresistant chorea underwent bilateral GPi-DBS and were followed for 30, 24, and 12 months, respectively. Primary outcome measure was the change of the chorea and total motor scores of the Unified Huntington's Disease Rating Scale between pre- and last postoperative assessments. Secondary outcome measures were motor changes between ventral versus dorsal and between on- and off- GPi-DBS. GPi neuronal activities were analyzed and compared to those obtained in patients with Parkinson's disease. No adverse effects occurred. Chorea decreased in all patients (13, 67 and 29%) postoperatively. Total motor score decreased in patient 2 (19.6%) and moderately increased in patients 1 and 3 (17.5 and 1.7%), due to increased bradykinesia and dysarthria. Ventral was superior to dorsal GPi-DBS to control chorea. Total motor score increased dramatically off-stimulation compared to ventral GPi-DBS (70, 63 and 19%). Cognitive and psychic functions were overall unchanged. Lower mean rate and less frequent bursting activity were found in Huntington's disease compared to Parkinson's disease patients. Ventral GPi-DBS sustainably reduced chorea, but worsened bradykinesia and dysarthria. Based on these results and previous published reports, we propose to select non-demented HD patients with severe chorea, and a short disease evolution as the best candidates for GPi-DBS.
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Affiliation(s)
- Cécile Delorme
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, 47 boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne Université, UPMC Univ Paris 06, UMR S 1127, CNRS UMR 7225, ICM, 75013, Paris, France
| | - Alister Rogers
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, 47 boulevard de l'Hôpital, 75013, Paris, France. .,Sorbonne Université, UPMC Univ Paris 06, UMR S 1127, CNRS UMR 7225, ICM, 75013, Paris, France. .,Neurosurgery department, Groupe Hospitalier Pitié-Salpêtrière, Brain and Spine Institute, CHU Pitié-Salpêtrière, 47, Bd de L'Hôpital, 75651, Paris Cedex 13, France.
| | - Brian Lau
- Sorbonne Université, UPMC Univ Paris 06, UMR S 1127, CNRS UMR 7225, ICM, 75013, Paris, France
| | - Hélène Francisque
- Sorbonne Université, UPMC Univ Paris 06, UMR S 1127, CNRS UMR 7225, ICM, 75013, Paris, France
| | - Marie-Laure Welter
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, 47 boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne Université, UPMC Univ Paris 06, UMR S 1127, CNRS UMR 7225, ICM, 75013, Paris, France
| | - Sara Fernandez Vidal
- Sorbonne Université, UPMC Univ Paris 06, UMR S 1127, CNRS UMR 7225, ICM, 75013, Paris, France.,Centre de Neuroimagerie de Recherche, Institut du Cerveau et de la Moelle épinière, 75013, Paris, France
| | - Jérôme Yelnik
- Sorbonne Université, UPMC Univ Paris 06, UMR S 1127, CNRS UMR 7225, ICM, 75013, Paris, France
| | - Alexandra Durr
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, 47 boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne Université, UPMC Univ Paris 06, UMR S 1127, CNRS UMR 7225, ICM, 75013, Paris, France
| | - David Grabli
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, 47 boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne Université, UPMC Univ Paris 06, UMR S 1127, CNRS UMR 7225, ICM, 75013, Paris, France
| | - Carine Karachi
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, 47 boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne Université, UPMC Univ Paris 06, UMR S 1127, CNRS UMR 7225, ICM, 75013, Paris, France.,Neurosurgery department, Groupe Hospitalier Pitié-Salpêtrière, Brain and Spine Institute, CHU Pitié-Salpêtrière, 47, Bd de L'Hôpital, 75651, Paris Cedex 13, France
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16
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Cislaghi G, Capiluppi E, Saleh C, Romano L, Servello D, Mariani C, Porto M. Bilateral globus pallidus stimulation in Westphal variant of huntington disease. Neuromodulation 2015; 17:502-5. [PMID: 24024832 DOI: 10.1111/ner.12098] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Giuliana Cislaghi
- Department of Clinical Sciences, L. Sacco Hospital, Università degli Studi di Milano, Milano, Italy
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17
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Wojtecki L, Groiss SJ, Ferrea S, Elben S, Hartmann CJ, Dunnett SB, Rosser A, Saft C, Südmeyer M, Ohmann C, Schnitzler A, Vesper J. A Prospective Pilot Trial for Pallidal Deep Brain Stimulation in Huntington's Disease. Front Neurol 2015; 6:177. [PMID: 26347707 PMCID: PMC4539552 DOI: 10.3389/fneur.2015.00177] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 07/27/2015] [Indexed: 11/28/2022] Open
Abstract
Background Movement disorders in Huntington’s disease are often medically refractive. The aim of the trial was assessment of procedure safety of deep brain stimulation, equality of internal- and external-pallidal stimulation and efficacy followed-up for 6 months in a prospective pilot trial. Methods In a controlled double-blind phase six patients (four chorea-dominant, two Westphal-variant) with predominant movement disorder were randomly assigned to either the sequence of 6-week internal- or 6-week external-pallidal stimulation, or vice versa, followed by further 3 months chronic pallidal stimulation at the target with best effect-side-effect ratio. Primary endpoints were changes in the Unified Huntington’s Disease Rating Scale motor-score, chorea subscore, and total motor-score 4 (blinded-video ratings), comparing internal- versus external-pallidal stimulation, and 6 months versus baseline. Secondary endpoints assessed scores on dystonia, hypokinesia, cognition, mood, functionality/disability, and quality-of-life. Results Intention-to-treat analysis of all patients (n = 3 in each treatment sequence): Both targets were equal in terms of efficacy. Chorea subscores decreased significantly over 6 months (−5.3 (60.2%), p = 0.037). Effects on dystonia were not significant over the group due to it consisting of three responders (>50% improvement) and three non-responders. Westphal patients did not improve. Cognition was stable. Mood and some functionality/disability and quality-of-life scores improved significantly. Eight adverse events and two additional serious adverse events – mostly internal-pallidal stimulation-related – resolved without sequalae. No procedure-related complications occurred. Conclusion Pallidal deep brain stimulation was demonstrated to be a safe treatment option for the reduction of chorea in Huntington’s disease. Their effects on chorea and dystonia and on quality-of-life should be examined in larger controlled trials.
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Affiliation(s)
- Lars Wojtecki
- Department of Neurology, Centre for Movement Disorders and Neuromodulation, Medical Faculty, Heinrich-Heine-University Düsseldorf , Düsseldorf , Germany ; Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich- Heine-University Düsseldorf , Düsseldorf , Germany
| | - Stefan J Groiss
- Department of Neurology, Centre for Movement Disorders and Neuromodulation, Medical Faculty, Heinrich-Heine-University Düsseldorf , Düsseldorf , Germany ; Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich- Heine-University Düsseldorf , Düsseldorf , Germany
| | - Stefano Ferrea
- Department of Neurology, Centre for Movement Disorders and Neuromodulation, Medical Faculty, Heinrich-Heine-University Düsseldorf , Düsseldorf , Germany ; Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich- Heine-University Düsseldorf , Düsseldorf , Germany
| | - Saskia Elben
- Department of Neurology, Centre for Movement Disorders and Neuromodulation, Medical Faculty, Heinrich-Heine-University Düsseldorf , Düsseldorf , Germany ; Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich- Heine-University Düsseldorf , Düsseldorf , Germany
| | - Christian J Hartmann
- Department of Neurology, Centre for Movement Disorders and Neuromodulation, Medical Faculty, Heinrich-Heine-University Düsseldorf , Düsseldorf , Germany ; Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich- Heine-University Düsseldorf , Düsseldorf , Germany
| | - Stephen B Dunnett
- Brain Repair Group, School of Biosciences, Cardiff University , Cardiff , UK
| | - Anne Rosser
- Brain Repair Group, School of Biosciences, Cardiff University , Cardiff , UK
| | - Carsten Saft
- Department of Neurology, St. Josef-Hospital, Ruhr University , Bochum , Germany
| | - Martin Südmeyer
- Department of Neurology, Centre for Movement Disorders and Neuromodulation, Medical Faculty, Heinrich-Heine-University Düsseldorf , Düsseldorf , Germany ; Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich- Heine-University Düsseldorf , Düsseldorf , Germany
| | - Christian Ohmann
- Coordinating Centre for Clinical Trials, Heinrich-Heine-University Düsseldorf , Düsseldorf , Germany
| | - Alfons Schnitzler
- Department of Neurology, Centre for Movement Disorders and Neuromodulation, Medical Faculty, Heinrich-Heine-University Düsseldorf , Düsseldorf , Germany ; Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich- Heine-University Düsseldorf , Düsseldorf , Germany
| | - Jan Vesper
- Department of Stereotactic and Functional Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf , Düsseldorf , Germany
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18
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Nagel SJ, Machado AG, Gale JT, Lobel DA, Pandya M. Preserving cortico-striatal function: deep brain stimulation in Huntington's disease. Front Syst Neurosci 2015; 9:32. [PMID: 25814939 PMCID: PMC4356075 DOI: 10.3389/fnsys.2015.00032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 02/18/2015] [Indexed: 11/13/2022] Open
Abstract
Huntington's disease (HD) is an incurable neurodegenerative disease characterized by the triad of chorea, cognitive dysfunction and psychiatric disturbances. Since the discovery of the HD gene, the pathogenesis has been outlined, but to date a cure has not been found. Disease modifying therapies are needed desperately to improve function, alleviate suffering, and provide hope for symptomatic patients. Deep brain stimulation (DBS), a proven therapy for managing the symptoms of some neurodegenerative movement disorders, including Parkinson's disease, has been reported as a palliative treatment in select cases of HD with debilitating chorea with variable success. New insights into the mechanism of action of DBS suggest it may have the potential to circumvent other manifestations of HD including cognitive deterioration. Furthermore, because DBS is already widely used, reversible, and has a risk profile that is relatively low, new studies can be initiated. In this article we contend that new clinical trials be considered to test the effects of DBS for HD.
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Affiliation(s)
- Sean J Nagel
- Cleveland Clinic, Neurologic Institute, Center for Neurological Restoration Cleveland, Ohio, USA ; Department of Neurosurgery, Cleveland Clinic, Neurologic Institute Cleveland, Ohio, USA
| | - Andre G Machado
- Cleveland Clinic, Neurologic Institute, Center for Neurological Restoration Cleveland, Ohio, USA ; Department of Neurosurgery, Cleveland Clinic, Neurologic Institute Cleveland, Ohio, USA
| | - John T Gale
- Cleveland Clinic, Neurologic Institute, Center for Neurological Restoration Cleveland, Ohio, USA ; Department of Neuroscience, Cleveland Clinic, Lerner Research Institute Cleveland, Ohio, USA
| | - Darlene A Lobel
- Cleveland Clinic, Neurologic Institute, Center for Neurological Restoration Cleveland, Ohio, USA ; Department of Neurosurgery, Cleveland Clinic, Neurologic Institute Cleveland, Ohio, USA
| | - Mayur Pandya
- Cleveland Clinic, Neurologic Institute, Center for Neurological Restoration Cleveland, Ohio, USA ; Department of Psychiatry, Cleveland Clinic, Neurologic Institute Cleveland, Ohio, USA
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19
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Sharma M, Deogaonkar M. Deep brain stimulation in Huntington's disease: assessment of potential targets. J Clin Neurosci 2015; 22:812-7. [PMID: 25698541 DOI: 10.1016/j.jocn.2014.11.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 11/02/2014] [Indexed: 01/17/2023]
Abstract
Huntington's disease (HD) is an autosomal-dominant neurodegenerative disorder that has very few effective therapeutic interventions. Since the disease has a defined neural circuitry abnormality, neuromodulation could be an option. Case reports, original research, and animal model studies were selected from the databases of Medline and PubMed. All related studies published up to July 2014 were included in this review. The following search terms were used: "Deep brain stimulation," "DBS," "thalamotomy," "pallidal stimulation," and "Huntington's Disease," "HD," "chorea," or "hyperkinetic movement disorders." This review examines potential nodes in the HD circuitry that could be modulated using deep brain stimulation (DBS) therapy. With rapid evolution of imaging and ability to reach difficult targets in the brain with refined DBS technology, some phenotypes of HD could potentially be treated with DBS in the near future. Further clinical studies are warranted to validate the efficacy of neuromodulation and to determine the most optimal target for HD.
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Affiliation(s)
- Mayur Sharma
- Department of Neurosurgery, Center of Neuromodulation, Wexner Medical Center, The Ohio State University, 480 Medical Center Drive, Columbus, OH 43210, USA
| | - Milind Deogaonkar
- Department of Neurosurgery, Center of Neuromodulation, Wexner Medical Center, The Ohio State University, 480 Medical Center Drive, Columbus, OH 43210, USA.
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20
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Smith KM, Spindler MA. Uncommon applications of deep brain stimulation in hyperkinetic movement disorders. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2015; 5:278. [PMID: 25713746 PMCID: PMC4314611 DOI: 10.7916/d84x56hp] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 11/20/2014] [Indexed: 12/12/2022]
Abstract
Background In addition to the established indications of tremor and dystonia, deep brain stimulation (DBS) has been utilized less commonly for several hyperkinetic movement disorders, including medication-refractory myoclonus, ballism, chorea, and Gilles de la Tourette (GTS) and tardive syndromes. Given the lack of adequate controlled trials, it is difficult to translate published reports into clinical use. We summarize the literature, draw conclusions regarding efficacy when possible, and highlight concerns and areas for future study. Methods A Pubmed search was performed for English-language articles between January 1980 and June 2014. Studies were selected if they focused primarily on DBS to treat the conditions of focus. Results We identified 49 cases of DBS for myoclonus-dystonia, 21 for Huntington's disease, 15 for choreacanthocytosis, 129 for GTS, and 73 for tardive syndromes. Bilateral globus pallidus interna (GPi) DBS was the most frequently utilized procedure for all conditions except GTS, in which medial thalamic DBS was more common. While the majority of cases demonstrate some improvement, there are also reports of no improvement or even worsening of symptoms in each condition. The few studies including functional or quality of life outcomes suggest benefit. A limited number of studies included blinded on/off testing. There have been two double-blind controlled trials performed in GTS and a single prospective double-blind, uncontrolled trial in tardive syndromes. Patient characteristics, surgical target, stimulation parameters, and duration of follow-up varied among studies. Discussion Despite these extensive limitations, the literature overall supports the efficacy of DBS in these conditions, in particular GTS and tardive syndromes. For other conditions, the preliminary evidence from small studies is promising and encourages further study.
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Affiliation(s)
- Kara M Smith
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Meredith A Spindler
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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21
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Kocabicak E, Temel Y, Höllig A, Falkenburger B, Tan SK. Current perspectives on deep brain stimulation for severe neurological and psychiatric disorders. Neuropsychiatr Dis Treat 2015; 11:1051-66. [PMID: 25914538 PMCID: PMC4399519 DOI: 10.2147/ndt.s46583] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Deep brain stimulation (DBS) has become a well-accepted therapy to treat movement disorders, including Parkinson's disease, essential tremor, and dystonia. Long-term follow-up studies have demonstrated sustained improvement in motor symptoms and quality of life. DBS offers the opportunity to selectively modulate the targeted brain regions and related networks. Moreover, stimulation can be adjusted according to individual patients' demands, and stimulation is reversible. This has led to the introduction of DBS as a treatment for further neurological and psychiatric disorders and many clinical studies investigating the efficacy of stimulating various brain regions in order to alleviate severe neurological or psychiatric disorders including epilepsy, major depression, and obsessive-compulsive disorder. In this review, we provide an overview of accepted and experimental indications for DBS therapy and the corresponding anatomical targets.
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Affiliation(s)
- Ersoy Kocabicak
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, the Netherlands ; Department of Neuroscience, Maastricht University, Maastricht, the Netherlands ; Department of Neurosurgery, Ondokuz Mayıs University, Samsun, Turkey
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, the Netherlands ; Department of Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Anke Höllig
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | | | - Sonny Kh Tan
- Department of Neuroscience, Maastricht University, Maastricht, the Netherlands ; Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
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22
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Abstract
Deep brain stimulation (DBS) has provided remarkable therapeutic benefits for people with a variety of neurological disorders. Despite the uncertainty of the precise mechanisms underlying its efficacy, DBS is clinically effective in improving motor function of essential tremor, Parkinson's disease and primary dystonia and in relieving obsessive-compulsive disorder. Recently, this surgical technique has continued to expand to other numerous neurological diseases with encouraging results. This review highlighted the current and potential future clinical applications of DBS.
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Affiliation(s)
- X L Chen
- Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Y Y Xiong
- Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - G L Xu
- Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - X F Liu
- Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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Zibly Z, Shaw A, Harnof S, Sharma M, Graves C, Deogaonkar M, Rezai A. Modulation of mind: therapeutic neuromodulation for cognitive disability. J Clin Neurosci 2014; 21:1473-7. [DOI: 10.1016/j.jocn.2013.11.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 11/07/2013] [Accepted: 11/13/2013] [Indexed: 12/20/2022]
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Gonzalez V, Cif L, Biolsi B, Garcia-Ptacek S, Seychelles A, Sanrey E, Descours I, Coubes C, de Moura AMR, Corlobe A, James S, Roujeau T, Coubes P. Deep brain stimulation for Huntington's disease: long-term results of a prospective open-label study. J Neurosurg 2014; 121:114-22. [PMID: 24702329 DOI: 10.3171/2014.2.jns131722] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED OBJECT.: To date, experience of globus pallidus internus (GPi) deep brain stimulation (DBS) in the treatment of Huntington's disease (HD) has been limited to a small number of case reports. The aim of this study was to analyze long-term motor outcome of a cohort of HD patients treated with GPi DBS. METHODS Seven patients with pharmacologically resistant chorea and functional impairment were included in a prospective open-label study from 2008 to 2011. The main outcome measure was the motor section of the Unified Huntington's Disease Rating Scale. The primary end point was reduction of chorea. RESULTS Patients underwent MRI-guided bilateral GPi implantation. The median duration of follow-up was 3 years. A significant reduction of chorea was observed in all patients, with sustained therapeutic effect; the mean improvement on the chorea subscore was 58.34% at the 12-month follow-up visit (p = 0.018) and 59.8% at the 3-year visit (p = 0.040). Bradykinesia and dystonia showed a nonsignificant trend toward progressive worsening related to disease evolution and partly to DBS. The frequency of stimulation was 130 Hz for all patients. DBS-induced bradykinesia was managed by pulse-width reduction or bipolar settings. Levodopa mildly improved bradykinesia in 4 patients. Regular off-stimulation tests confirmed a persistent therapeutic effect of DBS on chorea. CONCLUSIONS GPi DBS may provide sustained chorea improvement in selected HD patients with pharmacologically resistant chorea, with transient benefit in physical aspects of quality of life before progression of behavioral and cognitive disorders. DBS therapy did not improve dystonia or bradykinesia. Further studies including quality of life measures are needed to evaluate the impact of DBS in the long-term outcome of HD.
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Quadruple deep brain stimulation in Huntington's disease, targeting pallidum and subthalamic nucleus: case report and review of the literature. J Neural Transm (Vienna) 2014; 121:1303-12. [PMID: 24699718 DOI: 10.1007/s00702-014-1201-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Accepted: 03/18/2014] [Indexed: 10/25/2022]
Abstract
Deep brain stimulation (DBS) represents an established treatment option in a growing number of movement disorders. Recent case reports suggest beneficial effect of globus pallidus internus (GPi)-DBS in selected patients suffering from Huntington's disease with marked disabling chorea. We present a 41-year-old man with genetically confirmed HD following quadruple GPi- and subthalamic nucleus (STN)-DBS. Motor function was assessed by Abnormal Involuntary Movement Scale (AIMS) and by Unified Huntington Disease Rating Scale (UHDRS) presurgery and postsurgery for up to 4 years. Furthermore, cognitive, neuropsychiatric state and quality of life (QoL) including life satisfaction (QLS) were annually evaluated. Chorea assessed by AIMS and UHDRS subscores improved by 52 and 55 %, 45 and 60 %, 35 and 45 % and 55-66 % at 1-4 years, respectively, compared to presurgical state following GPi-STN-DBS. During these time periods bradykinesia did not increase following separate STN- and combined GPi-STN-DBS compared to presurgical state. Mood, QoL and QLS were ameliorated. However, dysexecutive symptoms increased at 4 years postsurgery. The present case report suggests that bilateral GPi- and STN-DBS may represent a new treatment avenue in selected HD patients. Clinically, GPi-DBS attenuated chorea and was associated with a larger effect-adverse effect window compared to STN-DBS. However, GPi-DBS-induced bradykinesia may emerge as one main limitation of GPi-DBS in HD. Thus, quadruple GPi-STN-DBS may be indicated, if separate GPi-DBS does not result in sufficient control of motor symptoms. Future controlled studies need to confirm if the present anecdotal observation of additive beneficial effects of GPi- and STN-DBS in a HD patient with severe generalized chorea and relatively intact cognitive and affective functions indeed represents a new therapeutic option.
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Abstract
The term hyperkinetic movement disorder encompasses dystonia, tremor, chorea, myoclon and tics. These symptoms are all caused by dysfunctional neural networks including the basal ganglia loop and can be accompanied by other neurological or psychiatric symptoms. Deep brain stimulation (DBS) is an important extension of therapeutic options for this group of patients in whom drug therapy is limited. Permanent electrodes are implanted in various subcortical brain areas in order to achieve an improvement in motor symptoms by high frequency stimulation. Already established indications include primary generalized or segmental dystonia and essential tremor but an increasingly better understanding of systemic pathophysiology has allowed DBS to be explored as a treatment for other disorders of the hyperkinetic spectrum. This article provides an overview of common hyperkinetic movement disorders from the viewpoint of recent advances in neurostimulation therapy.
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Lim TT, Fernandez HH, Cooper S, Wilson KMK, Machado AG. Successful deep brain stimulation surgery with intraoperative magnetic resonance imaging on a difficult neuroacanthocytosis case: case report. Neurosurgery 2014; 73:E184-7; discussion E188. [PMID: 23615095 DOI: 10.1227/01.neu.0000429852.45073.73] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Chorea acanthocytosis is a progressive hereditary neurodegenerative disorder characterized by hyperkinetic movements, seizures, and acanthocytosis in the absence of any lipid abnormality. Medical treatment is typically limited and disappointing. CLINICAL PRESENTATION We report on a 32-year-old patient with chorea acanthocytosis with a failed attempt at awake deep brain stimulation (DBS) surgery due to intraoperative seizures and postoperative intracranial hematoma. He then underwent a second DBS operation, but under general anesthesia and with intraoperative magnetic resonance imaging guidance. Marked improvement in his dystonia, chorea, and overall quality of life was noted 2 and 8 months postoperatively. CONCLUSION DBS surgery of the bilateral globus pallidus pars interna may be useful in controlling the hyperkinetic movements in neuroacanthocytosis. Because of the high propensity for seizures in this disorder, DBS performed under general anesthesia, with intraoperative magnetic resonance imaging guidance, may allow successful implantation while maintaining accurate target localization.
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Affiliation(s)
- Thien Thien Lim
- Center of Neurological Restoration, Neurological Institute, Cleveland Clinic, Ohio, USA.
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Abstract
The field of functional neurosurgery has developed a number of recent innovative neuromodulatory approaches to treat disease that remains resistant to the best medical therapy. These include novel surgical techniques to intervene in motor and cognitive sequelae of refractory epilepsy, neurodegenerative disease, and certain psychiatric conditions. To a large extent, much of the innovation in our field continues to be driven by a systems-level understanding of the impact of disease on the brain. For example, several groups have exploited findings from neuroimaging work to identify a number of new potential neuromodulatory targets for the treatment of refractory depression. Ongoing discoveries at the cellular and molecular level promise targeted gene or drug delivery aimed at curing disease. Neurosurgeons will certainly remain at the forefront of translating these strategies into practical clinical applications. Several randomized trials are now underway to assess the safety and efficacy of a number of new approaches, and we will continue to acquire better knowledge of optimal patient selection, identification of the most effective neuromodulatory targets, and recognition of adverse effects as these studies progress.
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Woopen C, Pauls KAM, Koy A, Moro E, Timmermann L. Early application of deep brain stimulation: Clinical and ethical aspects. Prog Neurobiol 2013; 110:74-88. [DOI: 10.1016/j.pneurobio.2013.04.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 04/10/2013] [Accepted: 04/16/2013] [Indexed: 11/25/2022]
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Velez-Lago FM, Thompson A, Oyama G, Hardwick A, Sporrer JM, Zeilman P, Foote KD, Bowers D, Ward HE, Sanchez-Ramos J, Okun MS. Differential and better response to deep brain stimulation of chorea compared to dystonia in Huntington's disease. Stereotact Funct Neurosurg 2013; 91:129-33. [PMID: 23343665 DOI: 10.1159/000341070] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 06/10/2012] [Indexed: 11/19/2022]
Abstract
Huntington's disease (HD) is an autosomal dominant and progressive neurodegenerative syndrome characterized by motor, cognitive and psychiatric manifestations. Chorea and dystonia are features that may be troublesome to some patients and may potentially prove unresponsive to pharmacological treatments. There are several reports on the results of globus pallidus internus deep brain stimulation (DBS) surgery for HD. In these published cases, DBS was utilized mainly to treat disabling chorea. We report our experience with 2 HD cases treated with DBS. The cases illustrate a differential response with a better outcome in the choreic presentation compared to the dystonic presentation. Additionally, DBS worsened gait features in both cases.
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Affiliation(s)
- Frances M Velez-Lago
- Departments of Neurology and Neurosurgery, University of Florida, Gainesville, FL 32607, USA
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Abstract
Deep brain stimulation (DBS) is a well established treatment for essential tremor and for the tremor associated with Parkinson's disease. The efficacy of DBS in these common tremors has led some investigators to apply the technique to rarer tremors such as such as Holmes' tremor, posttraumatic tremor, orthostatic tremor, and the tremor associated with multiple sclerosis. Likewise, DBS of the thalamus and globus pallidus directly suppresses levodopa-induced dyskinesias in Parkinson's disease, suggesting the application of DBS to other hyperkinetic states such as Huntington's disease, tardive dyskinesia, and hemiballism. Myoclonus has also been treated with DBS, especially in cases where it is associated with dystonia. This chapter reviews the reported results of DBS for these conditions. Due to the rarity of these indications, most of the literature reviewed takes the form of case reports or small single-center case series.
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Affiliation(s)
- Philip A Starr
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.
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Metabolic and electrophysiological changes in the basal ganglia of transgenic Huntington's disease rats. Neurobiol Dis 2012; 48:488-94. [DOI: 10.1016/j.nbd.2012.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 06/30/2012] [Accepted: 07/09/2012] [Indexed: 01/01/2023] Open
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Oluigbo CO, Salma A, Rezai AR. Deep Brain Stimulation for Neurological Disorders. IEEE Rev Biomed Eng 2012; 5:88-99. [DOI: 10.1109/rbme.2012.2197745] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Bronte-Stewart H, Taira T, Valldeoriola F, Merello M, Marks WJ, Albanese A, Bressman S, Moro E. Inclusion and exclusion criteria for DBS in dystonia. Mov Disord 2011; 26 Suppl 1:S5-16. [PMID: 21692112 DOI: 10.1002/mds.23482] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
When considering a patient with dystonia for deep brain stimulation (DBS) surgery several factors need to be considered. Level B evidence has shown that all motor features and associated pain in primary generalized and segmental dystonia are potentially responsive to globus pallidus internus (GPi) DBS. However, improvements in clinical series of ≥ 90% may reflect methods that need improvement, and larger prospective studies are needed to address these factors. Nevertheless, to date the selection criteria for DBS-specifically in terms of patient features (severity and nature of symptoms, age, time of evolution, or any other demographic or disease aspects)--have not been assessed in a systematic fashion. In general, dystonia patients are not considered for DBS unless medical therapies have been previously and extensively tested. The vast majority of reported patients have had DBS surgery when the disease was provoking important disability, with loss of independence and impaired quality of life. There does not appear to be an upper age limit or a minimum age limit, although there are no published data regarding the outcome of GPi DBS for dystonia in children younger than 7 years of age. There is currently no enough evidence to prove that subjects with primary--generalized dystonia who undergo DBS at an early age and sooner rather than later after disease onset may gain more benefit from DBS than those undergoing DBS after the development of fixed skeletal deformities. There is no enough evidence to refuse or support consideration of DBS in patients with previous ablative procedures.
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Affiliation(s)
- Helen Bronte-Stewart
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California 94305, USA.
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Abstract
The basal ganglia (BG) are a group of subcortical structures involved in diverse functions, such as motor, cognition and emotion. However, the BG do not control these functions directly, but rather modulate functional processes occurring in structures outside the BG. The BG form multiple functional loops, each of which controls different functions with similar architectures. Accordingly, to understand the modulatory role of the BG, it is strategic to uncover the mechanisms of signal processing within specific functional loops that control simple neural circuits outside the BG, and then extend the knowledge to other BG loops. The saccade control system is one of the best-understood neural circuits in the brain. Furthermore, sophisticated saccade paradigms have been used extensively in clinical research in patients with BG disorders as well as in basic research in behaving monkeys. In this review, we describe recent advances of BG research from the viewpoint of saccade control. Specifically, we account for experimental results from neuroimaging and clinical studies in humans based on the updated knowledge of BG functions derived from neurophysiological experiments in behaving monkeys by taking advantage of homologies in saccade behavior. It has become clear that the traditional BG network model for saccade control is too limited to account for recent evidence emerging from the roles of subcortical nuclei not incorporated in the model. Here, we extend the traditional model and propose a new hypothetical framework to facilitate clinical and basic BG research and dialogue in the future.
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Affiliation(s)
- Masayuki Watanabe
- Department of Physiology, Kansai Medical University, Fumizonocho 10-15, Moriguchi, Osaka 570-8506, Japan
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Edwards TC, Zrinzo L, Limousin P, Foltynie T. Deep brain stimulation in the treatment of chorea. Mov Disord 2011; 27:357-63. [PMID: 21997283 DOI: 10.1002/mds.23967] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Deep brain stimulation has been used as a means of reducing dyskinesias in various conditions, including Parkinson's disease and dystonia for many years. Recently, owing to the clinical similarities between L-dopa induced dyskinesia and chorea, deep brain stimulation has now been implemented as a novel treatment method in both Huntington's disease and neuroacanthocytosis, and a paucity of case studies exist reporting its efficacy. This review will summarize the case studies of deep brain stimulation in both Huntington's disease and neuroacanthocytosis, and discuss the possible implications and limitations associated with these reports. As both these disorders are often refractory to medication and difficult to treat, deep brain stimulation may be a useful treatment option in the future.
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Affiliation(s)
- Thomas C Edwards
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK
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Abstract
SUMMARY Huntington’s disease (HD) is an inherited, neurodegenerative disorder characterized by progressive motor dysfunction, abnormal involuntary movements, emotional disturbances and cognitive decline. There is currently no treatment to modify the progression of HD. Until disease modifying agents are established, symptomatic treatment remains the cornerstone of management. Treating chorea and other motor symptoms may improve the quality of life of sufferers. Multiple interventions have been studied for the treatment of chorea, but tetrabenazine is the only US FDA-approved drug indicated for the treatment of chorea associated with HD. In this article, medications available for the treatment of chorea will be summarized and investigational interventions for the management of chorea will also be briefly reviewed. Although chorea only constitutes part of HD, the movements can be disabling, injurious or bothersome.
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Affiliation(s)
- Okeanis Vaou
- Boston Medical Center, 72 East Concord St, C3, Boston, MA 02118, USA
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Abstract
Huntington's disease (HD) is caused by a triplet repeat expansion in the IT15 gene on chromosome 4 encoding huntingtin. Gene mutations are found in about 99% of cases, with symptoms and signs suggestive of HD. This implies the existence of other causes of this syndrome, and, in recent years, several other distinct genetic disorders have been identified that can present with a clinical picture indistinguishable from HD, termed HD-like (HDL) syndromes. So far, four genes associated with HDL syndromes have been identified, including the prion protein gene (HDL1), the junctophilin 3 gene (HDL2) and, the gene encoding the TATA box-binding protein (HDL4). In addition, a single family with a recessively inherited HD phenocopy, the exact genetic basis of which is currently unknown (HDL3), has been described. These disorders, however, account for only a small proportion of HDL cases, and the list of HDL genes and conditions is set to grow. In this article, we review the currently identified HD phenocopy disorders and discuss clinical clues to facilitate further investigations. We will concentrate on the four so-called HDL syndromes mentioned above. Other genetic choreatic syndromes such as dentatorubral-pallidoluysian atrophy, neuroferritinopathy, pantothenate kinase-associated neurodegeneration, and chorea-acanthocytosis are also briefly discussed.
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Affiliation(s)
- Susanne A Schneider
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, UK.
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Abstract
Dystonias can be classified as primary or secondary, as dystonia-plus syndromes, and as heredodegenerative dystonias. Their prevalence is difficult to determine. In our experience 80-90% of all dystonias are primary. About 20-30% of those have a genetic background; 10-20% are secondary, with tardive dystonia and dystonia in cerebral palsy being the most common forms. If dystonia in spastic conditions is accepted as secondary dystonia, this is the most common form of all dystonia. In primary dystonias, the dystonic movements are the only symptoms. In secondary dystonias, dystonic movements result from exogenous processes directly or indirectly affecting brain parenchyma. They may be caused by focal and diffuse brain damage, drugs, chemical agents, physical interactions with the central nervous system, and indirect central nervous system effects. Dystonia-plus syndromes describe brain parenchyma processes producing predominantly dystonia together with other movement disorders. They include dopa-responsive dystonia and myoclonus-dystonia. Heredodegenerative dystonias are dystonic movements occurring in the context of other heredodegenerative disorders. They may be caused by impaired energy metabolism, impaired systemic metabolism, storage of noxious substances, oligonucleotid repeats and other processes. Pseudodystonias mimic dystonia and include psychogenic dystonia and various orthopedic, ophthalmologic, vestibular, and traumatic conditions. Unusual manifestations, unusual age of onset, suspect family history, suspect medical history, and additional signs may indicate nonprimary dystonia. If they are suspected, etiological clarification becomes necessary. Unfortunately, potential etiologies are legion. Diagnostic algorithms can be helpful. Treatment of nonprimary dystonias, with few exceptions, does not differ from treatment of primary dystonias. The most effective treatment for focal and segmental dystonias is local botulinum toxin injections. Deep brain stimulation of the globus pallidus internus is effective for generalized dystonia. Antidystonic drugs, including anticholinergics, tetrabenazine, clozapine, and gamma-aminobutyric acid receptor agonists, are less effective and often produce adverse effects. Dopamine is extremely effective in dopa-responsive dystonia. The Bertrand procedure can be effective in cervical dystonia. Other peripheral surgery, including myotomy, myectomy, neurotomy, rhizotomy, ramizectomy, and accessory nerve neurolysis, has largely been abandoned. Central surgery other than deep brain stimulation is obsolete. Adjuvant therapies, including orthoses, physiotherapy, ergotherapy, behavioral therapy, social support, and support groups, may be helpful. Analgesics should also be considered where appropriate.
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Affiliation(s)
- Dirk Dressler
- Movement Disorders Section, Department of Neurology, Hanover Medical School, Hanover, Germany.
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Abstract
The term "neuroacanthocytosis" describes a heterogeneous group of molecularly-defined disorders which result in progressive neurodegeneration, predominantly of the basal ganglia, and erythrocyte acanthocytosis. The clinical presentation of neuroacanthocytosis syndromes typically involves chorea and dystonia, but a range of other movement disorders may be seen. Psychiatric and cognitive symptoms may be prominent. There can be considerable phenotypic overlap; however, features of inheritance, age of onset, neuroimaging and laboratory findings, in addition to the spectrum of central and peripheral neurological abnormalities and extraneuronal involvement, can help to distinguish the specific syndromes. The two core neuroacanthocytosis syndromes, in which acanthocytosis is a typical, although not invariable finding, are autosomal recessive chorea-acanthocytosis and X-linked McLeod syndrome. Acanthocytes are found in a smaller proportion of patients with Huntington's disease-like 2 and pantothenate kinase-associated neurodegeneration. Additionally, acanthocytosis has been reported in a few patients with other neurological disorders. The causative genes do not appear to be linked by a specific function or pathway, although abnormalities of membrane processing may be implicated. The connection between the erythrocyte membrane abnormality, which results in the characteristic "thorny" protrusions, the vulnerability of the basal ganglia, and the respective genetic mutations, is obscure.
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Affiliation(s)
- Ruth H Walker
- Department of Neurology, James J. Peters Veterans Affairs Medical Center, Bronx and Department of Neurology, Mount Sinai School of Medicine, New York, NY, USA
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Demeestere J, Vandenberghe W. Experimental surgical therapies for Huntington's disease. CNS Neurosci Ther 2010; 17:705-13. [PMID: 21199443 DOI: 10.1111/j.1755-5949.2010.00209.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Huntington's disease (HD) is an autosomal dominant neurodegenerative disorder characterized by abnormal movement, cognitive decline, and psychiatric disturbance. HD is caused by a trinucleotide repeat expansion in the HTT gene and a corresponding neurotoxic polyglutamine expansion in the huntingtin protein. There is currently no therapy to modify the progressive course of the disease, and symptomatic treatment options are limited. In this review we describe a diverse set of emerging experimental therapeutic strategies for HD: deep brain stimulation; delivery of neurotrophic factors; cell transplantation; HTT gene silencing using RNA interference or antisense oligonucleotides; and delivery of intrabodies. The common feature of these experimental therapies is that they all require a neurosurgical intervention, either for implantation of an electrode or for brain delivery of molecules, viruses or cells that do not cross the blood-brain barrier upon oral or intravenous administration. We summarize available data on the rationale, safety, efficacy, and intrinsic limitations of each of these approaches, focusing mainly on studies in HD patients and genetic animal models of HD. Although each of these strategies holds significant promise, their efficacy remains to be proven in HD patients.
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Affiliation(s)
- Jelle Demeestere
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
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43
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Prakash KM. An Overview of Surgical Therapy for Movement Disorders. PROCEEDINGS OF SINGAPORE HEALTHCARE 2010. [DOI: 10.1177/201010581001900405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Surgical treatments are an important consideration in the management of many movement disorders, particularly for patients refractory to medications. Increasing number of published reports have demonstrated an overall improvement in motor function, activities of daily living and quality of life particularly with deep brain stimulation. In addition the procedure is also relatively safe. In this article, we review the various types of movement disorders that may benefit from surgical intervention.
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Affiliation(s)
- Kumar M Prakash
- Department of Neurology, National Neuroscience Institute (Singapore General Hospital Campus), Singapore
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Gubellini P, Salin P, Kerkerian-Le Goff L, Baunez C. Deep brain stimulation in neurological diseases and experimental models: From molecule to complex behavior. Prog Neurobiol 2009; 89:79-123. [DOI: 10.1016/j.pneurobio.2009.06.003] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 04/28/2009] [Accepted: 06/18/2009] [Indexed: 11/30/2022]
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45
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Martinez-Torres I, Limousin P, Tisch S, Page R, Pinto A, Foltynie T, Bhatia KP, Hariz MI, Zrinzo L. Early and marked benefit with GPi DBS for Lubag syndrome presenting with rapidly progressive life-threatening dystonia. Mov Disord 2009; 24:1710-2. [DOI: 10.1002/mds.22656] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Sato K, Nakagawa E, Saito Y, Komaki H, Sakuma H, Sugai K, Sasaki M, Kaido T, Nakama H, Otsuki T. Hyperkinetic movement disorder in a child treated by globus pallidus stimulation. Brain Dev 2009; 31:452-5. [PMID: 18801630 DOI: 10.1016/j.braindev.2008.08.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2008] [Revised: 07/26/2008] [Accepted: 08/02/2008] [Indexed: 10/21/2022]
Abstract
We report herein the case of a 9-year-old girl with life-threatening hyperkinetic involuntary movement of unknown etiology. Medical treatment was ineffective for her stereotypy and choreoathetotic/ballistic movements, but bilateral stimulation of the globus pallidus immediately alleviated these symptoms. Pallidal deep-brain stimulation may be considered the therapy of choice for children with intractable hyperkinetic movement disorders.
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Affiliation(s)
- Ken Sato
- Department of Child Neurology, National Center Hospital of Neurology and Psychiatry, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo, Japan
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48
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Fasano A, Mazzone P, Piano C, Quaranta D, Soleti F, Bentivoglio AR. GPi-DBS in Huntington's disease: results on motor function and cognition in a 72-year-old case. Mov Disord 2009; 23:1289-92. [PMID: 18512756 DOI: 10.1002/mds.22116] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Huntington's disease (HD) produces debilitating motor abnormalities that are poorly responsive to medical therapy. Deep brain stimulation (DBS) of the posteroventral globus pallidus internus (GPi) may offer a treatment option for patients with diskinetic phenotype and minimal cognitive impairment, but its role in the management of HD remains unclear and to date only two cases have been reported. We report the outcome of GPi-DBS in a 72-year-old man with HD. Stimulation at 130 Hz caused a rapid amelioration of chorea producing the worsening of bradykinesia, whereas 40 Hz stimulation (maintaining constant the total electrical energy delivered) improved chorea while preserving the ability to walk. At 1-year follow-up, chorea has completely disappeared; however, the patient was unable to stand and walk. The cognitive profile showed a progressive deterioration, with an extension of deficit from the mainly dysexecutive alterations at baseline to a more diffused cognitive deterioration.
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Affiliation(s)
- Alfonso Fasano
- Istituto di Neurologia, Università Cattolica del Sacro Cuore, Roma, Italia.
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49
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Biolsi B, Cif L, Fertit HE, Robles SG, Coubes P. Long-term follow-up of Huntington disease treated by bilateral deep brain stimulation of the internal globus pallidus. J Neurosurg 2008; 109:130-2. [DOI: 10.3171/jns/2008/109/7/0130] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Deep brain stimulation is now accepted as a safe and efficient treatment for movement disorders including selected types of dystonia and dyskinesia. Very little, however, is known about its effect on other movement disorders, particularly for “choreic” movements. Huntington disease is a fatal autosomal-dominant neurodegenerative disorder characterized by movement disorders, progressive cognitive impairment, and psychiatric symptoms. Bilateral chronic stimulation of the internal globus pallidus was performed to control choreic movements in a 60-year-old man with a 10-year history of Huntington disease. Chronic deep brain stimulation resulted in remarkable improvement of choreic movements. Postoperative improvement was sustained after 4 years of follow-up with a marked improvement in daily quality of life.
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Affiliation(s)
- Brigitte Biolsi
- 1Department of Neurosurgery, University Hospital Guy de Chauliac; and
| | - Laura Cif
- 1Department of Neurosurgery, University Hospital Guy de Chauliac; and
- 2Research Unit on Movement Disorder, Institut National de la Santé et de la Recherche Médicale U661, Centre National de la Recherche Scientifique UMR 5203, Montpellier, France
| | - Hassan El Fertit
- 1Department of Neurosurgery, University Hospital Guy de Chauliac; and
| | | | - Philippe Coubes
- 1Department of Neurosurgery, University Hospital Guy de Chauliac; and
- 2Research Unit on Movement Disorder, Institut National de la Santé et de la Recherche Médicale U661, Centre National de la Recherche Scientifique UMR 5203, Montpellier, France
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Starr PA, Kang GA, Heath S, Shimamoto S, Turner RS. Pallidal neuronal discharge in Huntington's disease: support for selective loss of striatal cells originating the indirect pathway. Exp Neurol 2008; 211:227-33. [PMID: 18342309 PMCID: PMC3673313 DOI: 10.1016/j.expneurol.2008.01.023] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Revised: 01/24/2008] [Accepted: 01/27/2008] [Indexed: 10/22/2022]
Abstract
Chorea is the predominant motor manifestation in the early symptomatic phase of adult onset Huntington's disease (HD). Pathologically, this stage is marked by differential loss of striatal neurons contributing to the indirect pathway. This pattern of neuronal loss predicts decreased neuronal firing rates in GPi and increased firing rates in GPe, the opposite of the changes in firing rate known to occur in Parkinson's disease (PD). We present single-unit discharge characteristics (33 neurons) observed in an awake patient with HD (41 CAG repeats) undergoing microelectrode guided surgery for pallidal deep brain stimulation. Pallidal single-unit activity at "rest" and during voluntary movement was discriminated off line by principal component analysis and evaluated with respect to discharge rate, bursting, and oscillatory activity in the 0-200 Hz range. 24 GPi and 9 GPe units were studied, and compared with 132 GPi and 50 GPe units from 14 patients with PD. The mean (+/-SEM) spontaneous discharge rate for HD was 58+/-4 for GPi and 73+/-5 for GPe. This contrasted with discharge rates in PD of 95+/-2 for GPi and 57+/-3 for GPe. HD GPi units showed more bursting than PD GPi units but much less oscillatory activity in the 2-35 Hz frequency range at rest. These findings are consistent with selective early loss of striatal cells originating the indirect pathway.
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Affiliation(s)
- Philip A Starr
- Department of Neurosurgery, University of California, San Francisco, San Francisco CA 94143, USA.
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