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Torgerson LN, Munoz K, Kostick K, Zuk P, Blumenthal-Barby J, Storch EA, Lázaro-Muñoz G. Clinical and Psychosocial Factors Considered When Deciding Whether to Offer Deep Brain Stimulation for Childhood Dystonia. Neuromodulation 2023; 26:1646-1652. [PMID: 35088744 DOI: 10.1016/j.neurom.2021.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/20/2021] [Accepted: 10/11/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Childhood dystonia is often nonresponsive to medications, and refractory cases are increasingly being treated with deep brain stimulation (DBS). However, many have noted that there is little consensus about when DBS should be offered, and there has been little examination of clinicians' decision-making process when determining whether to offer DBS for childhood dystonia. OBJECTIVES This study aimed to identify and examine the factors considered by pediatric movement disorder specialists before offering DBS. MATERIALS AND METHODS Semistructured interviews (N = 29) with pediatric dystonia clinicians were conducted, transcribed, and coded. Using thematic content analysis, nine central themes were identified when clinicians were asked about key factors, clinical factors, and psychosocial factors considered before offering pediatric DBS. RESULTS Clinicians identified nine main factors. Five of these were classified primarily as clinical factors: early intervention and younger age (raised by 86% of respondents), disease progression and symptom severity (83%), etiology and genetic status (79%), clinicians' perceived risks and benefits of DBS for the patient (79%), and exhaustion of other treatment options (55%). The remaining four were classified primarily as psychosocial factors: social and family support (raised by 97% of respondents), patient and caregiver expectations about outcomes and understanding of DBS treatment (90%), impact of dystonia on quality of life (69%), and financial resources and access to care (31%). CONCLUSIONS Candidacy determinations, in this context, are complicated by an interrelation of clinical and psychosocial factors that contribute to the decision. There is potential for bias when considering family support and quality of life. Uncertainty of outcomes related to the etiology of dystonia makes candidacy judgments challenging. More systematic examination of the characteristics and criteria used to identify pediatric patients with dystonia who can significantly benefit from DBS is necessary to develop clear guidelines and promote the well-being of these children.
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Affiliation(s)
- Laura N Torgerson
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Katrina Munoz
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Kristin Kostick
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Peter Zuk
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | | | - Eric A Storch
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
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McEvoy SD, Limbrick DD, Raskin JS. Neurosurgical management of non-spastic movement disorders. Childs Nerv Syst 2023; 39:2887-2898. [PMID: 37522933 PMCID: PMC10613137 DOI: 10.1007/s00381-023-06100-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 07/21/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Non-spastic movement disorders in children are common, although true epidemiologic data is difficult to ascertain. Children are more likely than adults to have hyperkinetic movement disorders defined as tics, dystonia, chorea/athetosis, or tremor. These conditions manifest from acquired or heredodegenerative etiologies and often severely limit function despite medical and surgical management paradigms. Neurosurgical management for these conditions is highlighted. METHODS We performed a focused review of the literature by searching PubMed on 16 May 2023 using key terms related to our review. No temporal filter was applied, but only English articles were considered. We searched for the terms (("Pallidotomy"[Mesh]) OR "Rhizotomy"[Mesh]) OR "Deep Brain Stimulation"[Mesh], dystonia, children, adolescent, pediatric, globus pallidus, in combination. All articles were reviewed for inclusion in the final reference list. RESULTS Our search terms returned 37 articles from 2004 to 2023. Articles covering deep brain stimulation were the most common (n = 34) followed by pallidotomy (n = 3); there were no articles on rhizotomy. DISCUSSION Non-spastic movement disorders are common in children and difficult to treat. Most of these patients are referred to neurosurgery for the management of dystonia, with modern neurosurgical management including pallidotomy, rhizotomy, and deep brain stimulation. Historically, pallidotomy has been effective and may still be preferred in subpopulations presenting either in status dystonicus or with high risk for hardware complications. Superiority of DBS over pallidotomy for secondary dystonia has not been determined. Rhizotomy is an underutilized surgical tool and more study characterizing efficacy and risk profile is indicated.
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Affiliation(s)
- Sean D McEvoy
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, Brookings, MO, USA
| | - David D Limbrick
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, Brookings, MO, USA
| | - Jeffrey Steven Raskin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA.
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Vogt LM, Yan H, Santyr B, Breitbart S, Anderson M, Germann J, Lizarraga KJ, Hewitt AL, Fasano A, Ibrahim GM, Gorodetsky C. Deep Brain Stimulation for Refractory Status Dystonicus in Children: Multicenter Case Series and Systematic Review. Ann Neurol 2023. [PMID: 37714824 DOI: 10.1002/ana.26799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/14/2023] [Accepted: 09/14/2023] [Indexed: 09/17/2023]
Abstract
OBJECTIVE We sought to better understand the workflow, outcomes, and complications of deep brain stimulation (DBS) for pediatric status dystonicus (SD). We present a systematic review, alongside a multicenter case series of pediatric patients with SD treated with DBS. METHODS We collected individual data regarding treatment, stimulation parameters, and dystonia severity for a multicenter case series (n = 8) and all previously published cases (n = 77). Data for case series were used to create probabilistic voxelwise maps of stimulated tissue associated with dystonia improvement. RESULTS In our institutional series, DBS was implanted a mean of 25 days after SD onset. Programming began a mean of 1.6 days after surgery. All 8 patients in our case series and 73 of 74 reported patients in the systematic review had resolution of their SD with DBS, most within 2 to 4 weeks of surgery. Mean follow-up for patients in the case series was 16 months. DBS target for all patients in the case series and 68 of 77 in our systematic review was the globus pallidus pars interna (GPi). In our case series, stimulation of the posterior-ventrolateral GPi was associated with improved dystonia. Mean dystonia improvement was 32% and 51% in our institutional series and systematic review, respectively. Mortality was 4% in the review, which is lower than reported for treatment with pharmacotherapy alone (10-12.5%). INTERPRETATION DBS is a feasible intervention with potential to reverse refractory pediatric SD and improve survival. More work is needed to increase awareness of DBS in this setting, so that it can be implemented in a timely manner. ANN NEUROL 2023.
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Affiliation(s)
- Lindsey M Vogt
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Han Yan
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Brendan Santyr
- Krembil Brain Institute, Toronto, Ontario, Canada
- Center for Advancing Neurotechnological Innovation to Application, Toronto, Ontario, Canada
| | - Sara Breitbart
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Melanie Anderson
- Library Services, University Health Network, Toronto, Ontario, Canada
| | - Jürgen Germann
- Krembil Brain Institute, Toronto, Ontario, Canada
- Center for Advancing Neurotechnological Innovation to Application, Toronto, Ontario, Canada
| | - Karlo J Lizarraga
- Motor Physiology and Neuromodulation Program, Division of Movement Disorders, Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Angela L Hewitt
- Motor Physiology and Neuromodulation Program, Division of Movement Disorders, Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
- Division of Child Neurology, Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Alfonso Fasano
- Krembil Brain Institute, Toronto, Ontario, Canada
- Center for Advancing Neurotechnological Innovation to Application, Toronto, Ontario, Canada
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - George M Ibrahim
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Carolina Gorodetsky
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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Kostick-Quenet K, Kalwani L, Torgerson L, Muñoz K, Sanchez C, Storch EA, Blumenthal-Barby J, Lázaro-Muñoz G. Deep Brain Stimulation for Pediatric Dystonia: Clinicians' Perspectives on the Most Pressing Ethical Challenges. Stereotact Funct Neurosurg 2023; 101:301-313. [PMID: 37844562 PMCID: PMC10586720 DOI: 10.1159/000530694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 03/30/2023] [Indexed: 10/18/2023]
Abstract
INTRODUCTION Pediatric deep brain stimulation (pDBS) is commonly used to manage treatment-resistant primary dystonias with favorable results and more frequently used for secondary dystonia to improve quality of life. There has been little systematic empirical neuroethics research to identify ethical challenges and potential solutions to ensure responsible use of DBS in pediatric populations. METHODS Clinicians (n = 29) who care for minors with treatment-resistant dystonia were interviewed for their perspectives on the most pressing ethical issues in pDBS. RESULTS Using thematic content analysis to explore salient themes, clinicians identified four pressing concerns: (1) uncertainty about risks and benefits of pDBS (22/29; 72%) that poses a challenge to informed decision-making; (2) ethically navigating decision-making roles (15/29; 52%), including how best to integrate perspectives from diverse stakeholders (patient, caregiver, clinician) and how to manage surrogate decisions on behalf of pediatric patients with limited capacity to make autonomous decisions; (3) information scarcity effects on informed consent and decision quality (15/29; 52%) in the context of patient and caregivers' expectations for treatment; and (4) narrow regulatory status and access (7/29; 24%) such as the lack of FDA-approved indications that contribute to decision-making uncertainty and liability and potentially limit access to DBS among patients who may benefit from it. CONCLUSION These results suggest that clinicians are primarily concerned about ethical limitations of making difficult decisions in the absence of informational, regulatory, and financial supports. We discuss two solutions already underway, including supported decision-making to address uncertainty and further data sharing to enhance clinical knowledge and discovery.
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Affiliation(s)
- Kristin Kostick-Quenet
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Lavina Kalwani
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Laura Torgerson
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Katrina Muñoz
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Clarissa Sanchez
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Eric A. Storch
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | | | - Gabriel Lázaro-Muñoz
- Center for Bioethics, Harvard Medical School, Cambridge, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
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Badke D’Andrea C, Marek S, Van AN, Miller RL, Earl EA, Stewart SB, Dosenbach NUF, Schlaggar BL, Laumann TO, Fair DA, Gordon EM, Greene DJ. Thalamo-cortical and cerebello-cortical functional connectivity in development. Cereb Cortex 2023; 33:9250-9262. [PMID: 37293735 PMCID: PMC10492576 DOI: 10.1093/cercor/bhad198] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 05/09/2023] [Accepted: 05/17/2023] [Indexed: 06/10/2023] Open
Abstract
The thalamus is a critical relay center for neural pathways involving sensory, motor, and cognitive functions, including cortico-striato-thalamo-cortical and cortico-ponto-cerebello-thalamo-cortical loops. Despite the importance of these circuits, their development has been understudied. One way to investigate these pathways in human development in vivo is with functional connectivity MRI, yet few studies have examined thalamo-cortical and cerebello-cortical functional connectivity in development. Here, we used resting-state functional connectivity to measure functional connectivity in the thalamus and cerebellum with previously defined cortical functional networks in 2 separate data sets of children (7-12 years old) and adults (19-40 years old). In both data sets, we found stronger functional connectivity between the ventral thalamus and the somatomotor face cortical functional network in children compared with adults, extending previous cortico-striatal functional connectivity findings. In addition, there was more cortical network integration (i.e. strongest functional connectivity with multiple networks) in the thalamus in children than in adults. We found no developmental differences in cerebello-cortical functional connectivity. Together, these results suggest different maturation patterns in cortico-striato-thalamo-cortical and cortico-ponto-cerebellar-thalamo-cortical pathways.
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Affiliation(s)
- Carolina Badke D’Andrea
- Department of Cognitive Science, University of California San Diego, La Jolla, CA 92093, United States
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, United States
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, United States
| | - Scott Marek
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, United States
| | - Andrew N Van
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, United States
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO 63130, United States
| | - Ryland L Miller
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, United States
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, United States
| | - Eric A Earl
- Data Science and Sharing Team, National Institute of Mental Health, NIH, DHHS, Bethesda, MD 20899, United States
| | - Stephanie B Stewart
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO 80045, United States
| | - Nico U F Dosenbach
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, United States
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, United States
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO 63130, United States
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63110, United States
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO 63110, United States
| | | | - Timothy O Laumann
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, United States
| | - Damien A Fair
- Institute of Child Development, College of Education and Human Development, University of Minnesota, Minneapolis, MN 55455, United States
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN 55455, United States
- Masonic Institute for the Developing Brain, University of Minnesota, Minneapolis, MN 55455, United States
| | - Evan M Gordon
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, United States
| | - Deanna J Greene
- Department of Cognitive Science, University of California San Diego, La Jolla, CA 92093, United States
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Al-Fatly B, Giesler SJ, Oxenford S, Li N, Dembek TA, Achtzehn J, Krause P, Visser-Vandewalle V, Krauss JK, Runge J, Tadic V, Bäumer T, Schnitzler A, Vesper J, Wirths J, Timmermann L, Kühn AA, Koy A. Neuroimaging-based analysis of DBS outcomes in pediatric dystonia: Insights from the GEPESTIM registry. Neuroimage Clin 2023; 39:103449. [PMID: 37321142 PMCID: PMC10275720 DOI: 10.1016/j.nicl.2023.103449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/16/2023] [Accepted: 06/02/2023] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Deep brain stimulation (DBS) is an established treatment in patients of various ages with pharmaco-resistant neurological disorders. Surgical targeting and postoperative programming of DBS depend on the spatial location of the stimulating electrodes in relation to the surrounding anatomical structures, and on electrode connectivity to a specific distribution pattern within brain networks. Such information is usually collected using group-level analysis, which relies on the availability of normative imaging resources (atlases and connectomes). Analysis of DBS data in children with debilitating neurological disorders such as dystonia would benefit from such resources, especially given the developmental differences in neuroimaging data between adults and children. We assembled pediatric normative neuroimaging resources from open-access datasets in order to comply with age-related anatomical and functional differences in pediatric DBS populations. We illustrated their utility in a cohort of children with dystonia treated with pallidal DBS. We aimed to derive a local pallidal sweetspot and explore a connectivity fingerprint associated with pallidal stimulation to exemplify the utility of the assembled imaging resources. METHODS An average pediatric brain template (the MNI brain template 4.5-18.5 years) was implemented and used to localize the DBS electrodes in 20 patients from the GEPESTIM registry cohort. A pediatric subcortical atlas, analogous to the DISTAL atlas known in DBS research, was also employed to highlight the anatomical structures of interest. A local pallidal sweetspot was modeled, and its degree of overlap with stimulation volumes was calculated as a correlate of individual clinical outcomes. Additionally, a pediatric functional connectome of 100 neurotypical subjects from the Consortium for Reliability and Reproducibility was built to allow network-based analyses and decipher a connectivity fingerprint responsible for the clinical improvements in our cohort. RESULTS We successfully implemented a pediatric neuroimaging dataset that will be made available for public use as a tool for DBS analyses. Overlap of stimulation volumes with the identified DBS-sweetspot model correlated significantly with improvement on a local spatial level (R = 0.46, permuted p = 0.019). The functional connectivity fingerprint of DBS outcomes was determined to be a network correlate of therapeutic pallidal stimulation in children with dystonia (R = 0.30, permuted p = 0.003). CONCLUSIONS Local sweetspot and distributed network models provide neuroanatomical substrates for DBS-associated clinical outcomes in dystonia using pediatric neuroimaging surrogate data. Implementation of this pediatric neuroimaging dataset might help to improve the practice and pave the road towards a personalized DBS-neuroimaging analyses in pediatric patients.
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Affiliation(s)
- Bassam Al-Fatly
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology, Berlin, Germany.
| | - Sabina J Giesler
- Department of Pediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Simon Oxenford
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology, Berlin, Germany
| | - Ningfei Li
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology, Berlin, Germany
| | - Till A Dembek
- Department of Neurology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Johannes Achtzehn
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology, Berlin, Germany
| | - Patricia Krause
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology, Berlin, Germany
| | - Veerle Visser-Vandewalle
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Joachim Runge
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Vera Tadic
- Department of Neurology, University Medical Center Schleswig Holstein, Lübeck Campus, Lübeck, Germany
| | - Tobias Bäumer
- Institute of System Motor Science, University Medical Center Schleswig Holstein, Lübeck Campus, Lübeck, Germany
| | - Alfons Schnitzler
- Department of Neurology, Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Jan Vesper
- Department of Neurology, Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Jochen Wirths
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lars Timmermann
- Department of Neurology, University Hospital of Marburg, Marburg, Germany
| | - Andrea A Kühn
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology, Berlin, Germany.
| | - Anne Koy
- Department of Pediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Rare Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Tai CH, Chou SC, Lin CH, Lee WT, Wu RM, Tseng SH. Long-Term Outcomes of Idiopathic and Acquired Dystonia After Pallidal Deep Brain Stimulation: A Case Series. World Neurosurg 2022; 167:e575-e582. [PMID: 35995355 DOI: 10.1016/j.wneu.2022.08.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/10/2022] [Accepted: 08/10/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Among dystonia patients receiving globus pallidus internus (GPi) deep brain stimulation (DBS), long-term outcomes remain to be established. To report the long-term outcomes of GPi DBS in a patient cohort with idiopathic and acquired dystonia. METHODS In this long-term follow-up cohort, there were 4 patients with idiopathic dystonia and 2 patients with acquired dystonia. The Burke-Fahn-Marsden Dystonia Rating Scale was used to evaluate 6 consecutive patients preoperatively and at 6 months, 12 months, and the last follow-up. The relationship between etiology and clinical improvement was analyzed. Stimulation parameters were evaluated for similarities and differences among these patients. RESULTS The mean follow-up of our cohort was 65.3 months (median 40.5 months). The average improvement in the Burke-Fahn-Marsden Dystonia Rating Scale (mean ± SEM) were 56% ± 7.6, 67% ± 6.8 and 66% ± 9.7 at 6 months, 12 months, and the last follow-up, respectively. There was greater improvement during the long-term follow-up in the 4 patients with idiopathic dystonia than in the 2 patients with acquired dystonia. The 2 most ventral electrodes (contact 0 and 1) were activated in all 11 leads in this cohort. The average stimulation intensity, pulse width and frequency were 2.0 ± 0.24 mA, 252 ± 43 μs, and 99 ± 6.0 Hz, respectively. CONCLUSIONS Isolated dystonia, either monogenic or idiopathic, usually responds better to GPi DBS than to acquired dystonia. Selection of patients by dystonia etiology, accurate placement of DBS leads in GPi targets, and proper stimulation programming are crucial to achieve better long-term outcomes.
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Affiliation(s)
- Chun-Hwei Tai
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Sheng-Che Chou
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chin-Hsien Lin
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Wang-Tso Lee
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ruey-Meei Wu
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Sheng-Hong Tseng
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.
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Bohn E, Goren K, Switzer L, Falck‐Ytter Y, Fehlings D. Pharmacological and neurosurgical interventions for individuals with cerebral palsy and dystonia: a systematic review update and meta-analysis. Dev Med Child Neurol 2021; 63:1038-1050. [PMID: 33772789 PMCID: PMC8451898 DOI: 10.1111/dmcn.14874] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 12/30/2022]
Abstract
AIM To update a systematic review of evidence published up to December 2015 for pharmacological/neurosurgical interventions among individuals with cerebral palsy (CP) and dystonia. METHOD Searches were updated (January 2016 to May 2020) for oral baclofen, trihexyphenidyl, benzodiazepines, clonidine, gabapentin, levodopa, botulinum neurotoxin (BoNT), intrathecal baclofen (ITB), and deep brain stimulation (DBS), and from database inception for medical cannabis. Eligible studies included at least five individuals with CP and dystonia and reported on dystonia, goal achievement, motor function, pain/comfort, ease of caregiving, quality of life (QoL), or adverse events. Evidence certainty was evaluated using GRADE. RESULTS Nineteen new studies met inclusion criteria (two trihexyphenidyl, one clonidine, two BoNT, nine ITB, six DBS), giving a total of 46 studies (four randomized, 42 non-randomized) comprising 915 participants when combined with those from the original systematic review. Very low certainty evidence supported improved dystonia (clonidine, ITB, DBS) and goal achievement (clonidine, BoNT, ITB, DBS). Low to very low certainty evidence supported improved motor function (DBS), pain/comfort (clonidine, BoNT, ITB, DBS), ease of caregiving (clonidine, BoNT, ITB), and QoL (ITB, DBS). Trihexyphenidyl, clonidine, BoNT, ITB, and DBS may increase adverse events. No studies were identified for benzodiazepines, gabapentin, oral baclofen, and medical cannabis. INTERPRETATION Evidence evaluating the use of pharmacological and neurosurgical management options for individuals with CP and dystonia is limited to between low and very low certainty. What this paper adds Meta-analysis suggests that intrathecal baclofen (ITB) and deep brain stimulation (DBS) may improve dystonia and pain. Meta-analysis suggests that DBS may improve motor function. Clonidine, botulinum neurotoxin, ITB, and DBS may improve achievement of individualized goals. ITB and DBS may improve quality of life. No direct evidence is available for oral baclofen, benzodiazepines, gabapentin, or medical cannabis.
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Affiliation(s)
- Emma Bohn
- Holland Bloorview Kids Rehabilitation HospitalTorontoOntarioCanada,Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
| | - Katherine Goren
- Holland Bloorview Kids Rehabilitation HospitalTorontoOntarioCanada,Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
| | - Lauren Switzer
- Holland Bloorview Kids Rehabilitation HospitalTorontoOntarioCanada,Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
| | - Yngve Falck‐Ytter
- Division of Gastroenterology and HepatologyVeteran Affairs North East Ohio Health Care SystemCase Western Reserve UniversityClevelandOHUSA
| | - Darcy Fehlings
- Holland Bloorview Kids Rehabilitation HospitalTorontoOntarioCanada,Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
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Ozturk S, Temel Y, Aygun D, Kocabicak E. Deep Brain Stimulation of the Globus Pallidus Internus for Secondary Dystonia: Clinical Cases and Systematic Review of the Literature Regarding the Effectiveness of Globus Pallidus Internus versus Subthalamic Nucleus. World Neurosurg 2021; 154:e495-e508. [PMID: 34303854 DOI: 10.1016/j.wneu.2021.07.070] [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: 05/27/2021] [Revised: 07/14/2021] [Accepted: 07/15/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) is a frequently applied therapy in primary dystonia. For secondary dystonia, the effects can be less favorable. We share our long-term findings in 9 patients with severe secondary dystonia and discuss these findings in the light of the literature. METHODS Patients who had undergone globus pallidus internus (GPi)-DBS for secondary dystonia were included. Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) scores, clinical improvement rates, follow-up periods, stimulation parameters and the need for internal pulse generator replacements were analyzed. The PubMed and Google Scholar databases were searched for articles describing GPi-DBS and subthalamic nucleus (STN)-DBS only for secondary dystonia cases. Keywords were "dystonia," "deep brain stimulation," "GPi," "dystonia," "deep brain stimulation," and "STN." RESULTS A total of 9 secondary dystonia patients (5 male, 4 female) had undergone GPi-DBS with microelectrode recording in our units. The mean follow-up period was 29 months. The average BFMDRS score was 58.2 before the surgery, whereas the mean value was 36.5 at the last follow-up of the patients (mean improvement, 39%; minimum, 9%; maximum, 63%). In the literature review, we identified 264 GPi-DBS cases (mean follow-up, 19 months) in 72 different articles about secondary dystonia. The mean BFMDRS improvement rate was 52%. In 146 secondary dystonia cases, reported in 19 articles, STN-DBS was performed. The average follow-up period was 20 months and the improvement in BFMDRS score was 66%. CONCLUSIONS Although GPi-DBS has favorable long-term efficacy and safety in the treatment of patients with secondary dystonia, STN seems a promising target for stimulation in patients with secondary dystonia. Further studies including a large number of patients, longer follow-up periods, and more homogenous patients are necessary to establish the optimal target for DBS in the management of secondary dystonias.
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Affiliation(s)
- Sait Ozturk
- Department of Neurosurgery, School of Medicine, Fırat University, Elazig, Turkey.
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands; Department of Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dursun Aygun
- Department of Neurology, Ondokuz Mayıs University, Samsun, Turkey
| | - Ersoy Kocabicak
- Department of Neurosurgery, Ondokuz Mayıs University, Samsun, Turkey; Neuromodulation Center, Ondokuz Mayıs University, Samsun, Turkey
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10
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Larsh T, Wu SW, Vadivelu S, Grant GA, O'Malley JA. Deep Brain Stimulation for Pediatric Dystonia. Semin Pediatr Neurol 2021; 38:100896. [PMID: 34183138 DOI: 10.1016/j.spen.2021.100896] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 12/26/2022]
Abstract
Dystonia is one of the most common pediatric movement disorders and can have a profound impact on the lives of children and their caregivers. Response to pharmacologic treatment is often unsatisfactory. Deep brain stimulation (DBS) has emerged as a promising treatment option for children with medically refractory dystonia. In this review we highlight the relevant literature related to DBS for pediatric dystonia, with emphasis on the background, indications, prognostic factors, challenges, and future directions of pediatric DBS.
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Affiliation(s)
- Travis Larsh
- Center for Pediatric Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Steve W Wu
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Sudhakar Vadivelu
- Division of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Gerald A Grant
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Stanford University School of Medicine, Palo Alto, CA
| | - Jennifer A O'Malley
- Department of Neurology, Division of Child Neurology, Stanford University School of Medicine, Palo Alto, CA.
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11
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Deep Brain Stimulation and Hypoxemic Perinatal Encephalopathy: State of Art and Perspectives. Life (Basel) 2021; 11:life11060481. [PMID: 34070634 PMCID: PMC8227328 DOI: 10.3390/life11060481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/20/2021] [Accepted: 05/24/2021] [Indexed: 12/12/2022] Open
Abstract
Cerebral palsy (CP) is a heterogeneous group of non-progressive syndromes with lots of clinical variations due to the extent of brain damages and etiologies. CP is majorly defined by dystonia and spasticity. The treatment of acquired dystonia in CP is very difficult. Many pharmacological treatments have been tried and surgical treatment consists of deep brain stimulation (continuous electrical neuromodulation) of internal globus pallidus (GPi). A peculiar cause of CP is neonatal encephalopathy due to an anoxic event in the perinatal period. Many studies showed an improvement of dystonia in CP patients with bilateral GPi DBS. However, it remains a variability in the range of 1% to 50%. Published case-series concerned mainly small population with a majority of adult patients. Selection of patients according to the clinical pattern, to the brain lesions observed on classical imaging and to DTI is the key of a high success rate of DBS in children with perinatal hypoxemic encephalopathy. Only a large retrospective study with a high number of patients in a homogeneous pediatric population with a long-term follow-up or a prospective multicenter trial investigation could answer with a high degree of certitude of the real interest of this therapeutic in children with hypoxemic perinatal encephalopathy.
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12
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Coblentz A, Elias GJB, Boutet A, Germann J, Algarni M, Oliveira LM, Neudorfer C, Widjaja E, Ibrahim GM, Kalia SK, Jain M, Lozano AM, Fasano A. Mapping efficacious deep brain stimulation for pediatric dystonia. J Neurosurg Pediatr 2021; 27:346-356. [PMID: 33385998 DOI: 10.3171/2020.7.peds20322] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to report the authors' experience with deep brain stimulation (DBS) of the internal globus pallidus (GPi) as a treatment for pediatric dystonia, and to elucidate substrates underlying clinical outcome using state-of-the-art neuroimaging techniques. METHODS A retrospective analysis was conducted in 11 pediatric patients (6 girls and 5 boys, mean age 12 ± 4 years) with medically refractory dystonia who underwent GPi-DBS implantation between June 2009 and September 2017. Using pre- and postoperative MRI, volumes of tissue activated were modeled and weighted by clinical outcome to identify brain regions associated with clinical outcome. Functional and structural networks associated with clinical benefits were also determined using large-scale normative data sets. RESULTS A total of 21 implanted leads were analyzed in 11 patients. The average follow-up duration was 19 ± 20 months (median 5 months). Using a 7-point clinical rating scale, 10 patients showed response to treatment, as defined by scores < 3. The mean improvement in the Burke-Fahn-Marsden Dystonia Rating Scale motor score was 40% ± 23%. The probabilistic map of efficacy showed that the voxel cluster most associated with clinical improvement was located at the posterior aspect of the GPi, comparatively posterior and superior to the coordinates of the classic GPi target. Strong functional and structural connectivity was evident between the probabilistic map and areas such as the precentral and postcentral gyri, parietooccipital cortex, and brainstem. CONCLUSIONS This study reported on a series of pediatric patients with dystonia in whom GPi-DBS resulted in variable clinical benefit and described a clinically favorable stimulation site for this cohort, as well as its structural and functional connectivity. This information could be valuable for improving surgical planning, simplifying programming, and further informing disease pathophysiology.
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Affiliation(s)
- Ailish Coblentz
- 1Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto
| | | | - Alexandre Boutet
- 2University Health Network, Toronto
- 3Joint Department of Medical Imaging, University of Toronto
| | | | - Musleh Algarni
- 4Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Division of Neurology, University of Toronto
| | - Lais M Oliveira
- 4Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Division of Neurology, University of Toronto
| | | | - Elysa Widjaja
- 1Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto
| | - George M Ibrahim
- 5Department of Neurosurgery, The Hospital for Sick Children, Toronto
| | - Suneil K Kalia
- 3Joint Department of Medical Imaging, University of Toronto
- 7Krembil Brain Institute, Toronto; and
- 8Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Ontario, Canada
| | - Mehr Jain
- 6Faculty of Medicine, University of Ottawa
| | | | - Alfonso Fasano
- 4Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Division of Neurology, University of Toronto
- 7Krembil Brain Institute, Toronto; and
- 8Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Ontario, Canada
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Luciano MS, Robichaux-Viehoever A, Dodenhoff KA, Gittings M, Viser AC, Racine CA, Bledsoe IO, Pereira C, Wang S, Starr PA, Ostrem JL. Thalamic deep brain stimulation for acquired dystonia in children and young adults: a phase 1 clinical trial. J Neurosurg Pediatr 2021; 27:203-212. [PMID: 33254134 PMCID: PMC8155109 DOI: 10.3171/2020.7.peds20348] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/07/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the feasibility and preliminary efficacy and safety of combined bilateral ventralis oralis posterior/ventralis intermedius (Vop/Vim) deep brain stimulation (DBS) for the treatment of acquired dystonia in children and young adults. Pallidal DBS is efficacious for severe, medication-refractory isolated dystonia, providing 50%-60% long-term improvement. Unfortunately, pallidal stimulation response rates in acquired dystonia are modest and unpredictable, with frequent nonresponders. Acquired dystonia, most commonly caused by cerebral palsy, is more common than isolated dystonia in pediatric populations and is more recalcitrant to standard treatments. Given the limitations of pallidal DBS in acquired dystonia, there is a need to explore alternative brain targets. Preliminary evidence has suggested that thalamic stimulation may be efficacious for acquired dystonia. METHODS Four participants, 3 with perinatal brain injuries and 1 with postencephalitic symptomatic dystonia, underwent bilateral Vop/Vim DBS and bimonthly evaluations for 12 months. The primary efficacy outcome was the change in Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) and Barry-Albright Dystonia Scale (BADS) scores between the baseline and 12-month assessments. Video documentation was used for blinded ratings. Secondary outcomes included evaluation of spasticity (Modified Ashworth Scale score), quality of life (Pediatric Quality of Life Inventory [PedsQL] and modified Unified Parkinson's Disease Rating Scale Part II [UPDRS-II] scores), and neuropsychological assessments. Adverse events were monitored for safety. RESULTS All participants tolerated the procedure well, and there were no safety concerns or serious adverse events. There was an average improvement of 21.5% in the BFMDRS motor subscale score, but the improvement was only 1.6% according to the BADS score. Following blinded video review, dystonia severity ratings were even more modest. Secondary outcomes, however, were more encouraging, with the BFMDRS disability subscale score improving by 15.7%, the PedsQL total score by 27%, and the modified UPDRS-II score by 19.3%. Neuropsychological assessment findings were unchanged 1 year after surgery. CONCLUSIONS Bilateral thalamic neuromodulation by DBS for severe, medication-refractory acquired dystonia was well tolerated. Primary and secondary outcomes showed highly variable treatment effect sizes comparable to those of pallidal stimulation in this population. As previously described, improvements in quality of life and disability were not reflected in dystonia severity scales, suggesting a need for the development of scales specifically for acquired dystonia.Clinical trial registration no.: NCT03078816 (clinicaltrials.gov).
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Affiliation(s)
- Marta San Luciano
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Amy Robichaux-Viehoever
- Department of Neurology, Division of Child Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Kristen A Dodenhoff
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Melissa Gittings
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Aaron C Viser
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Caroline A Racine
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Ian O Bledsoe
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Christa Pereira
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Sarah Wang
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Philip A Starr
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Jill L Ostrem
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
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14
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Kantzanou M, Korfias S, Panourias I, Sakas DE, Karalexi MA. Deep Brain Stimulation-Related Surgical Site Infections: A Systematic Review and Meta-Analysis. Neuromodulation 2021; 24:197-211. [PMID: 33462954 DOI: 10.1111/ner.13354] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/23/2020] [Accepted: 12/14/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Over the last decades, the increased use of deep brain stimulation (DBS) has raised concerns about the potential adverse health effects of the treatment. Surgical site infections (SSIs) following an elective surgery remain a major challenge for neurosurgeons. Few studies have examined the prevalence and risk factors of DBS-related complications, particularly focusing on SSIs. OBJECTIVES We systematically searched published literature, up to June 2020, with no language restrictions. MATERIALS AND METHODS Eligible were studies that examined the prevalence of DBS-related SSIs, as well as studies that examined risk and preventive factors in relation to SSIs. We extracted information on study characteristics, follow-up, exposure and outcome assessment, effect estimate and sample size. Summary odds ratios (sOR) and 95% confidence intervals (CI) were calculated from random-effects meta-analyses; heterogeneity and small-study effects were also assessed. RESULTS We identified 66 eligible studies that included 12,258 participants from 27 countries. The summary prevalence of SSIs was estimated at 5.0% (95% CI: 4.0%-6.0%) with higher rates for dystonia (6.5%), as well as for newer indications of DBS, such as epilepsy (9.5%), Tourette syndrome (5.9%) and OCD (4.5%). Similar prevalence rates were found between early-onset and late-onset hardware infections. Among risk and preventive factors, the perioperative implementation of intra-wound vancomycin was associated with statistically significantly lower risk of SSIs (sOR: 0.26, 95% CI: 0.09-0.74). Heterogeneity was nonsignificant in most meta-analyses. CONCLUSION The present study confirms the still high prevalence of SSIs, especially for newer indications of DBS and provides evidence that preventive measures, such as the implementation of topical vancomycin, seem promising in reducing the risk of DBS-related SSIs. Large clinical trials are needed to confirm the efficacy and safety of such measures.
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Affiliation(s)
- Maria Kantzanou
- Department of Hygiene, Epidemiology & Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Stefanos Korfias
- Department of Neurosurgery, School of Medicine Evangelismos Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Panourias
- Department of Neurosurgery, Korgialenio and Mpenakio General Hospital of Athens, Red Cross, Athens, Greece
| | - Damianos E Sakas
- Department of Neurosurgery, School of Medicine Evangelismos Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria A Karalexi
- Department of Hygiene, Epidemiology & Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Jiang H, Wang R, Zheng Z, Zhu J. Deep brain stimulation for the treatment of cerebral palsy: A review. BRAIN SCIENCE ADVANCES 2020. [DOI: 10.26599/bsa.2020.9050002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Deep brain stimulation (DBS) has been used as a safe and effective neuromodulation technique for treatment of various diseases. A large number of patients suffering from movement disorders such as dyskinesia may benefit from DBS. Cerebral palsy (CP) is a group of permanent disorders mainly involving motor impairment, and medical interventions are usually unsatisfactory or temporarily active, especially for dyskinetic CP. DBS may be another approach to the treatment of CP. In this review we discuss the targets for DBS and the mechanisms of action for the treatment of CP, and focus on presurgical assessment, efficacy for dystonia and other symptoms, safety, and risks.
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Affiliation(s)
- Hongjie Jiang
- Department of Neurosurgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Rui Wang
- Department of Neurosurgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Zhe Zheng
- Department of Neurosurgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Junming Zhu
- Department of Neurosurgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
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16
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Abstract
This article overviews the surgical options for hypertonia management in cerebral palsy, both spasticity and dystonia. We review the history and use of intrathecal baclofen. We contrast its use with the indications for selective dorsal rhizotomy and review how it is the optimal technique to lower tone in the ambulatory spastic diplegic patient with cerebral palsy. This article reviews the advent of deep brain stimulation, with an emphasis on selection criteria and expected outcomes in this population. The article reviews the principles and use of selective peripheral neurotomy as it is applied to focal spasticity not requiring systemic tone reduction.
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Affiliation(s)
- Sruthi P Thomas
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, 6701 Fannin Street, Suite 1280, Houston, TX 77030, USA; Department of Neurosurgery, Section of Pediatric Neurosurgery, Baylor College of Medicine, 6701 Fannin Street, Suite 1230, Houston, TX 77030, USA. https://twitter.com/ThomasMDPhD
| | - Angela P Addison
- Department of Neurosurgery, Section of Pediatric Neurosurgery, Baylor College of Medicine, 6701 Fannin Street, Suite 1230, Houston, TX 77030, USA
| | - Daniel J Curry
- Department of Neurosurgery, Section of Pediatric Neurosurgery, Baylor College of Medicine, 6701 Fannin Street, Suite 1230, Houston, TX 77030, USA.
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17
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Badhiwala JH, Karmur B, Elkaim LM, Alotaibi NM, Morgan BR, Lipsman N, De Vloo P, Kalia SK, Lozano AM, Ibrahim GM. Clinical phenotypes associated with outcomes following deep brain stimulation for childhood dystonia. J Neurosurg Pediatr 2019; 24:442-450. [PMID: 31299640 DOI: 10.3171/2019.5.peds1973] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/08/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although deep brain stimulation (DBS) is an accepted treatment for childhood dystonia, there is significant heterogeneity in treatment response and few data are available to identify ideal surgical candidates. METHODS Data were derived from a systematic review and individual patient data meta-analysis of DBS for dystonia in children that was previously published. Outcomes were assessed using the Burke-Fahn-Marsden Dystonia Rating Scale for movement (BFMDRS-M) and for disability (BFMDRS-D). The authors used partial least squares, bootstrapping, and permutation statistics to extract patterns of contributions of specific preoperative characteristics to relationship with distinct outcomes, in all patients and in patients with primary and secondary dystonia separately. RESULTS Of 301 children undergoing DBS for dystonia, 167 had primary dystonia, 125 secondary dystonia, and 9 myoclonus dystonia. Three dissociable preoperative phenotypes (latent variables) were identified and associated with the following: 1) BFMDRS-M at last follow-up; 2) relative change in BFMDRS-M score; and 3) relative change in BFMDRS-D score. The phenotype of patients with secondary dystonia, with a high BFMDRS-M score and truncal involvement, undergoing DBS at a younger age, was associated with a worse postoperative BFMDRS-M score. Children with primary dystonia involving the trunk had greater improvement in BFMDRS-M and -D scores. Those with primary dystonia of shorter duration and proportion of life with disease, undergoing globus pallidus DBS, had greater improvements in BFMDRS-D scores at long-term follow-up. CONCLUSIONS In a comprehensive, data-driven, multivariate analysis of DBS for childhood dystonia, the authors identified novel and dissociable patient phenotypes associated with distinct outcomes. The findings of this report may inform surgical candidacy for DBS.
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Affiliation(s)
| | - Brij Karmur
- 2Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - Lior M Elkaim
- 3Faculty of Medicine, Université de Montréal, Montréal, Québec
| | | | | | - Nir Lipsman
- 1Division of Neurosurgery, Department of Surgery, and
- 4Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Philippe De Vloo
- 1Division of Neurosurgery, Department of Surgery, and
- 5Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario; and
| | - Suneil K Kalia
- 1Division of Neurosurgery, Department of Surgery, and
- 5Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario; and
| | - Andres M Lozano
- 1Division of Neurosurgery, Department of Surgery, and
- 5Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario; and
| | - George M Ibrahim
- 1Division of Neurosurgery, Department of Surgery, and
- 6Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
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Koy A, Bockhorn N, Kühn A, Schneider GH, Krause P, Lauritsch K, Witt K, Paschen S, Deuschl G, Krauss J, Saryyeva A, Runge J, Borggraefe I, Mehrkens J, Horn A, Vesper J, Schnitzler A, Siegert S, Freilinger M, Eckenweiler M, Coenen V, Tadic V, Voges J, Pauls K, Wirths J, Timmermann L, Hellmich M, Abdallat M, Ascencao LC, Grünwald S, Wloch A, Schrader C, Groiss SJ, Wojtecki L. Adverse events associated with deep brain stimulation in patients with childhood-onset dystonia. Brain Stimul 2019; 12:1111-1120. [DOI: 10.1016/j.brs.2019.04.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/15/2019] [Accepted: 04/02/2019] [Indexed: 11/29/2022] Open
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19
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Tustin K, Elze MC, Lumsden DE, Gimeno H, Kaminska M, Lin JP. Gross motor function outcomes following deep brain stimulation for childhood-onset dystonia: A descriptive report. Eur J Paediatr Neurol 2019; 23:473-483. [PMID: 30846371 DOI: 10.1016/j.ejpn.2019.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 01/30/2019] [Accepted: 02/17/2019] [Indexed: 12/20/2022]
Abstract
AIM To examine the impact of deep brain stimulation (DBS) on gross motor function in children with dystonic movement disorders. METHOD Prospective audit involving children implanted 2007-2015, followed for up to two years. Outcomes were evaluated across aetiological sub-groups (inherited, acquired, idiopathic) using the GMFM-88 and BFMDRS movement scale (BFM-M). The predictive value of proportion of life lived with dystonia (PLD) and baseline motor capacity were evaluated. RESULTS Data was available for 60 children (median surgery age 10y11mo). Inherited monogenetic dystonias demonstrated a median increase in GMFM-88 scores of 6.9% (p = 0.021) and 14.5% (p = 0.116) at one and two years. Heredodegenerative and idiopathic dystonias showed disparate responses, with non-significant changes seen in GMFM-88 and BFM-M scores, with the exception of improved one-year BFM-M scores in the idiopathic group [median change 5.5, p = 0.021]. Median GMFM-88 and BFM-M change scores were near zero for acquired dystonias, though improvement was noted in 9/18 CP cases with one-year GMFM-88 data. No significant relationship was found between PLD, or baseline GMFM-88, and GMFM-88 change following DBS. CONCLUSION Gross motor response to DBS is similar in profile to literature reporting results using impairment-based dystonia rating scales. Relatively consistent improvements were seen in inherited monogenetic ("primary") dystonias, while highly variable, often disappointing, gross motor responses were found in acquired, heredodegenerative, and idiopathic dystonias. In view of such response variability, alternatives to mean group studies, such as single case experimental designs with multiple replications, are needed to determine the efficacy of DBS in childhood-onset dystonias. Ongoing research is needed to identify factors that predict treatment response.
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Affiliation(s)
- Kylee Tustin
- Complex Motor Disorder Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Floor 2 Beckett House, Lambeth Palace Road, London, SE1 7EU, United Kingdom.
| | | | - Daniel E Lumsden
- Complex Motor Disorder Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Floor 2 Beckett House, Lambeth Palace Road, London, SE1 7EU, United Kingdom
| | - Hortensia Gimeno
- Complex Motor Disorder Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Floor 2 Beckett House, Lambeth Palace Road, London, SE1 7EU, United Kingdom; King's College London, Institute of Psychiatry, Psychology and Neurosciences, Psychology Department, London, SE5 8AF, United Kingdom
| | - Margaret Kaminska
- Complex Motor Disorder Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Floor 2 Beckett House, Lambeth Palace Road, London, SE1 7EU, United Kingdom
| | - Jean-Pierre Lin
- Complex Motor Disorder Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Floor 2 Beckett House, Lambeth Palace Road, London, SE1 7EU, United Kingdom
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McNish RN, Chembrammel P, Speidel NC, Lin JJ, López-Ortiz C. Rehabilitation for Children With Dystonic Cerebral Palsy Using Haptic Feedback in Virtual Reality: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2019; 8:e11470. [PMID: 31344678 PMCID: PMC6682270 DOI: 10.2196/11470] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 10/26/2018] [Accepted: 11/01/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cerebral palsy (CP) is the most common developmental motor disorder in children. Individuals with CP demonstrate abnormal muscle tone and motor control. Within the population of children with CP, between 4% and 17% present dystonic symptoms that may manifest as large errors in movement tasks, high variability in movement trajectories, and undesired movements at rest. These symptoms of dystonia typically worsen with physical intervention exercises. OBJECTIVE The aim of this study is to establish the effect of haptic feedback in a virtual reality (VR) game intervention on movement outcomes of children with dystonic CP. METHODS The protocol describes a randomized controlled trial that uses a VR game-based intervention incorporating fully automated robotic haptic feedback. The study consists of face-to-face assessments of movement before, after, and 1 month following the completion of the 6-session game-based intervention. Children with dystonic CP, aged between 7 and 17 years, will be recruited for this study through posted fliers and laboratory websites along with a group of typically developing (TD) children in the same age range. We anticipate to recruit a total of 68 participants, 34 each with CP and TD. Both groups of children will be randomly allocated into an intervention or control group using a blocked randomization method. The primary outcome measure will be the smoothness index of the interaction force with the robot and of the accelerometry signals of sensors placed on the upper limb segments. Secondary outcomes include a battery of clinical tests and a quantitative measure of spasticity. Assessors administering clinical measures will be blinded. All sessions will be administered on-site by research personnel. RESULTS The trial has not started and is pending local institutional review board approval. CONCLUSIONS Movement outcomes will be examined for changes in muscle activation and clinical measures in children with dystonic CP and TD children. Paired t tests will be conducted on movement outcomes for both groups of children independently. Positive and negative results will be reported and addressed. TRIAL REGISTRATION ClinicalTrials.gov NCT03744884; https://clinicaltrials.gov/ct2/show/NCT03744884 (Archived by WebCite at http://www.webcitation.org/74RSvmbZP). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/11470.
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Affiliation(s)
- Reika Nicole McNish
- Department of Kinesiology and Community Health, Neuroscience Program, Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Chamapign, Urbana, IL, United States
| | - Pramod Chembrammel
- Health Care Engineering Systems Center, College of Engineering, University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | | | - Julian Jwchun Lin
- Children's Hospital of Illinois, OSF Saint Francis Medical Center, OSF Illinois Neurological Institute, Peoria, IL, United States
| | - Citlali López-Ortiz
- Department of Kinesiology and Community Health, Department of Dance, Neuroscience Program, Illinois Informatics Institute, Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, IL, United States
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Anderson BL, Ziechmann R, Huang X, McInerney J. Long-term Outcome of Globus Pallidus Internus Stimulation for Pisa Syndrome. Cureus 2019; 11:e3838. [PMID: 30891379 PMCID: PMC6411340 DOI: 10.7759/cureus.3838] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Pisa syndrome, defined as dystonia leading to lateral flexion of the spine, is an increasingly recognized complicating factor in the treatment of Parkinson’s disease (PD). Symptoms may persist despite medical therapy, or medical therapy may not be tolerated due to adverse effects. Here, we demonstrate the long-term efficacy of deep brain stimulation (DBS) at the globus pallidus internus (GPi) for the treatment of Pisa syndrome. One patient with Pisa syndrome and Parkinson disease underwent bilateral GPi DBS with computed tomography (CT)-and microelectrode-based guidance. Follow-up with neurosurgery and neurology was done over a four-year period. The patient’s axial deformity decreased from approximately 45 to 25 degrees, and he reported significant relief from back pain. Bilateral GPi DBS is a safe and effective option for Pisa syndrome in patients with PD.
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Affiliation(s)
- Brian L Anderson
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | | | - Xuemei Huang
- Neurology, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - James McInerney
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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22
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Elkaim LM, Alotaibi NM, Sigal A, Alotaibi HM, Lipsman N, Kalia SK, Fehlings DL, Lozano AM, Ibrahim GM. Deep brain stimulation for pediatric dystonia: a meta-analysis with individual participant data. Dev Med Child Neurol 2019; 61:49-56. [PMID: 30320439 DOI: 10.1111/dmcn.14063] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/28/2018] [Indexed: 12/31/2022]
Abstract
AIM We performed a meta-analysis with individual participant data of deep brain stimulation (DBS) for dystonia in children and young people. METHOD Three databases (PubMed, Embase, and Web of Science) were queried from January 1999 to August 2017 with no language restrictions to identify case studies and cohort studies reporting on pediatric patients (age ≤21y) with dystonia. The primary outcomes were changes in Burke-Fahn-Marsden (BFM) or Barry-Albright Dystonia Scale scores. A mixed-effects regression was used to identify associations between clinical covariates and outcomes. RESULTS Of 2509 citations reviewed, 72 articles (321 children) were eligible. At last follow-up (median 12mo, 25th centile=9.0; 75th centile=32.2), 277 (86.3%) patients showed improvement in dystonia, while 66.1 percent showed clinically significant (>20%) BFM Dystonia Rating Scale-motor improvement. On multivariable hierarchical regression, older age at dystonia onset, inherited dystonia without nervous system pathology and idiopathic dystonia (vs inherited with nervous system pathology or acquired dystonia), and truncal involvement indicated a better outcome (p<0.05). INTERPRETATION The data suggest that DBS is effective and should be considered in selected children with inherited or idiopathic dystonia. WHAT THIS PAPER ADDS Deep brain stimulation is effective in selected children with inherited or idiopathic dystonia.
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Affiliation(s)
- Lior M Elkaim
- Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Naif M Alotaibi
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Alissa Sigal
- Faculty of Medicine, Université de Montréal, Montreal, Canada
| | | | - Nir Lipsman
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada.,Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Suneil K Kalia
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada.,Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, Toronto, Canada
| | - Darcy L Fehlings
- Child Development Program, Holland Bloorview Rehabilitation Hospital, University of Toronto, Toronto, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada.,Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, Toronto, Canada
| | - George M Ibrahim
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada.,Division of Neurosurgery, The Hospital for Sick Children, Program in Neuroscience and Mental Health, The Hospital for Sick Children Research Institute, Toronto, Canada.,Department of Surgery, Institute of Biomaterials and Biomedical Engineering, Institute of Medical Science, University of Toronto, Toronto, Canada
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23
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Deep brain stimulation in pediatric dystonia: a systematic review. Neurosurg Rev 2018; 43:873-880. [PMID: 30397842 DOI: 10.1007/s10143-018-1047-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 10/21/2018] [Accepted: 10/29/2018] [Indexed: 01/12/2023]
Abstract
While deep brain stimulation (DBS) treatment is relatively rare in children, it may have a role in dystonia to reduce motor symptoms and disability. Pediatric DBS studies are sparse and limited by small sample size, and thus, outcomes are poorly understood. Thus, we performed a systematic review of the literature including studies of DBS for pediatric (age < 21) dystonia. Patient demographics, disease causes and characteristics, motor scores, and disability scores were recorded at baseline and at last post-operative follow-up. We identified 19 studies reporting DBS outcomes in 76 children with dystonia. Age at surgery was 13.8 ± 3.9 (mean ± SD) years, and 58% of individuals were male. Post-operative follow-up duration was 2.8 ± 2.8 years. Sixty-eight percent of patients had primary dystonia (PD), of whom 56% had a pathological mutation in DYT1 (DYT1+). Across all patients, regardless of dystonia type, 43.8 ± 36% improvement was seen in Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) motor (-M) scores after DBS, while 43.7 ± 31% improvement was observed in BFMDRS disability (-D) scores. Patients with PD were more likely to experience ≥ 50% improvement (56%) in BFMDRS-M scores compared to patients with secondary causes of dystonia (21%, p = 0.004). DYT1+ patients were more likely to achieve ≥ 50% improvement (65%) in BFMDRS-D than DTY1- individuals (29%, p = 0.02), although there was no difference in BFMDRS-M ≥ 50% improvement rates between DYT1+ (66%) or DYT1- (43%) children (p = 0.11). While DBS is less common in pediatric patients, individuals with severe dystonia may receive worthwhile benefit with neuromodulation treatment.
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Candela S, Vanegas MI, Darling A, Ortigoza-Escobar JD, Alamar M, Muchart J, Climent A, Ferrer E, Rumià J, Pérez-Dueñas B. Frameless robot-assisted pallidal deep brain stimulation surgery in pediatric patients with movement disorders: precision and short-term clinical results. J Neurosurg Pediatr 2018; 22:416-425. [PMID: 30028274 DOI: 10.3171/2018.5.peds1814] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The purpose of this study was to verify the safety and accuracy of the Neuromate stereotactic robot for use in deep brain stimulation (DBS) electrode implantation for the treatment of hyperkinetic movement disorders in childhood and describe the authors' initial clinical results. METHODS A prospective evaluation of pediatric patients with dystonia and other hyperkinetic movement disorders was carried out during the 1st year after the start-up of a pediatric DBS unit in Barcelona. Electrodes were implanted bilaterally in the globus pallidus internus (GPi) using the Neuromate robot without the stereotactic frame. The authors calculated the distances between the electrodes and their respective planned trajectories, merging the postoperative CT with the preoperative plan using VoXim software. Clinical outcome was monitored using validated scales for dystonia and myoclonus preoperatively and at 1 month and 6 months postoperatively and by means of a quality-of-life questionnaire for children, administered before surgery and at 6 months' follow-up. We also recorded complications derived from the implantation technique, "hardware," and stimulation. RESULTS Six patients aged 7 to 16 years and diagnosed with isolated dystonia ( DYT1 negative) (3 patients), choreo-dystonia related to PDE2A mutation (1 patient), or myoclonus-dystonia syndrome SGCE mutations (2 patients) were evaluated during a period of 6 to 19 months. The average accuracy in the placement of the electrodes was 1.24 mm at the target point. At the 6-month follow-up, patients showed an improvement in the motor (65%) and functional (48%) components of the Burke-Fahn-Marsden Dystonia Rating Scale. Patients with myoclonus and SGCE mutations also showed an improvement in action myoclonus (95%-100%) and in functional tests (50%-75%) according to the Unified Motor-Rating Scale. The Neuro-QOL score revealed inconsistent results, with improvement in motor function and social relationships but worsening in anxiety, cognitive function, and pain. The only surgical complication was medial displacement of the first electrode, which limited intensity of stimulation in the lower contacts, in one case. CONCLUSIONS The Neuromate stereotactic robot is an accurate and safe tool for the placement of GPi electrodes in children with hyperkinetic movement disorders.
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Affiliation(s)
- Santiago Candela
- Departments of1Neurosurgery.,6Pediatric Movement Disorders Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona
| | - María Isabel Vanegas
- 2Neuropediatrics, and.,6Pediatric Movement Disorders Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona.,7Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Alejandra Darling
- 2Neuropediatrics, and.,6Pediatric Movement Disorders Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona
| | - Juan Darío Ortigoza-Escobar
- 2Neuropediatrics, and.,6Pediatric Movement Disorders Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona
| | - Mariana Alamar
- Departments of1Neurosurgery.,6Pediatric Movement Disorders Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona
| | - Jordi Muchart
- 3Diagnostic Imaging.,6Pediatric Movement Disorders Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona
| | - Alejandra Climent
- Departments of1Neurosurgery.,2Neuropediatrics, and.,4Intraoperative Neurophysiology Unit, and.,6Pediatric Movement Disorders Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona
| | - Enrique Ferrer
- Departments of1Neurosurgery.,5Department of Neurosurgery, Hospital Clinic de Barcelona, Universitat de Barcelona; and.,6Pediatric Movement Disorders Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona
| | - Jordi Rumià
- Departments of1Neurosurgery.,5Department of Neurosurgery, Hospital Clinic de Barcelona, Universitat de Barcelona; and.,6Pediatric Movement Disorders Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona
| | - Belén Pérez-Dueñas
- 2Neuropediatrics, and.,6Pediatric Movement Disorders Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona.,7Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
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25
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Sanger TD, Robison A, Arguelles E, Ferman D, Liker M. Case Report: Targeting for Deep Brain Stimulation Surgery Using Chronic Recording and Stimulation in an Inpatient Neuromodulation Monitoring Unit, With Implantation of Electrodes in GPi and Vim in a 7-Year-Old Child With Progressive Generalized Dystonia. J Child Neurol 2018; 33:776-783. [PMID: 30066598 DOI: 10.1177/0883073818787741] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Deep brain stimulation for secondary dystonia has been limited by unknown optimal targets for individual children. OBJECTIVES We report the first case of a 7-year-old girl with severe generalized dystonia due to acquired striatal necrosis in whom we used a new method for identifying targets for deep brain stimulation. METHODS We implanted temporary depth electrodes in 5 different nuclei bilaterally in the basal ganglia and thalamus, with test stimulation and recording during 1 week while the child was an inpatient in a neuromodulation monitoring unit. RESULTS Single-unit activity in ventral intermedius Vim, internal globus pallidus (GPi), and subthalamic (STN) nuclei occurred during dystonic spasms and correlated with electromyography. Stimulation in Vim eliminated dystonic spasms. Subsequent implantation of 4 permanent deep brain stimulation electrodes in bilateral Vim and Gpi nuclei resolved dystonic spasms. CONCLUSION The use of temporary stimulation and recording electrodes to identify deep brain stimulation targets is a promising new technique that could improve outcomes in children with acquired dystonia.
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Affiliation(s)
- Terence D Sanger
- 1 Department of Neurology, Children's Hospital Los Angeles, Los Angeles, CA, USA.,2 Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, USA
| | - Aaron Robison
- 3 Department of Neurosurgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Enrique Arguelles
- 2 Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, USA
| | - Diana Ferman
- 1 Department of Neurology, Children's Hospital Los Angeles, Los Angeles, CA, USA.,2 Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, USA
| | - Mark Liker
- 3 Department of Neurosurgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
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Elkaim LM, De Vloo P, Kalia SK, Lozano AM, Ibrahim GM. Deep brain stimulation for childhood dystonia: current evidence and emerging practice. Expert Rev Neurother 2018; 18:773-784. [DOI: 10.1080/14737175.2018.1523721] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Lior M. Elkaim
- Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Phillippe De Vloo
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
| | - Suneil K. Kalia
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, Toronto, Canada
| | - Andres M. Lozano
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, Toronto, Canada
| | - George M. Ibrahim
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
- Division of Neurosurgery, The Hospital for Sick Children, Program in Neuroscience and Mental Health, The Hospital for Sick Children Research Institute, Toronto, Canada
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27
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Sanger TD. A Computational Model of Deep-Brain Stimulation for Acquired Dystonia in Children. Front Comput Neurosci 2018; 12:77. [PMID: 30294268 PMCID: PMC6158364 DOI: 10.3389/fncom.2018.00077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 08/28/2018] [Indexed: 11/13/2022] Open
Abstract
The mechanism by which deep brain stimulation (DBS) improves dystonia is not understood, partly heterogeneity of the underlying disorders leads to differing effects of stimulation in different locations. Similarity between the effects of DBS and the effects of lesions has led to biophysical models of blockade or reduced transmission of involuntary activity in individual cells in the pathways responsible for dystonia. Here, we expand these theories by modeling the effect of DBS on populations of neurons. We emphasize the important observation that the DBS signal itself causes surprisingly few side effects and does not normally appear in the electromyographic signal. We hypothesize that, at the population level, massively synchronous rhythmic firing caused by DBS is only poorly transmitted through downstream populations. However, the high frequency of stimulation overwhelms incoming dystonic activity, thereby substituting an ineffectively transmitted exogenous signal for the endogenous abnormal signal. Changes in sensitivity can occur not only at the site of stimulation, but also at downstream sites due to synaptic and homeostatic plasticity mechanisms. The mechanism is predicted to depend strongly on the stimulation frequency. We provide preliminary data from simultaneous multichannel recordings in basal ganglia and thalamus in children with secondary dystonia. We also provide illustrative simulations of the effect of stimulation frequency on the transmission of the DBS pulses through sequential populations of neurons in the dystonia pathway. Our experimental results and model provide a new hypothesis and computational framework consistent with the clinical features of DBS in childhood acquired dystonia.
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Affiliation(s)
- Terence D Sanger
- Department of Biomedical Engineering, Biokinesiology, and Child Neurology, University of Southern California, Los Angeles, CA, United States
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28
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Abstract
INTRODUCTION DBS is initially used for treatment of essential tremor and Parkinson's disease in adults. In 1996, a child with severe life-threatening dystonia was offered DBS to the internal globus pallidus (GPi) with lasting efficacy at 20 years. Since that time, increasing number of children benefited from DBS. PATIENTS AND METHODS We retrospectively evaluated our database of patients who underwent DBS from 2011 to 2017. All patients ≤ 17 years of age at the time of implantation of DBS were included in this series. Subjective Benefit Rating Scale (SBRS), Hoehn Yahr Scale (HYS), Fahn Marsden Rating Scale (FMRS), Clinical Global Impressions Scales (CGI), and Yale Global Tic Severity Scale (YGT) were used to evaluate clinical outcome. RESULTS Between May 2014 and October 2017, 11 children underwent DBS procedure in our institution. Six of them were female and five of them were male. Mean age at surgery was 11.8 ± 4.06 years (range 5-17 years). In our series, four patients had primary dystonia (PDY) (36.3%), three patients had secondary dystonia (SDY) (27.2%), two patients had JP (18.1%), and two patients had Tourette Syndrome (TS) (18.1%). Two JP patients underwent bilateral STN DBS while the other nine patients underwent bilateral GPi DBS. SBRS scores were 1.75 ± 0.5 for patients with PDY, 3 ± 0 for patients with JP, 2.5 ± 0.7 for patients with TS, and 2 ± 1 for patients with SDY. Mean FMRS reduction rate was 40.5 for patients with dystonia. Significant improvement was also defined in patients with TS and JP after DBS. None of the patients experienced any intracerebral hemorrhage or other serious adverse neurological effect related to the DBS. Wound complications occurred in two patients. CONCLUSION There are many literatures that support DBS as a treatment option for pediatric patients with medically refractory neurological disorders. DBS has replaced ablative procedures as a treatment of choice not only for adult patients, but also for pediatric patients. Wound-related complications still remain the most common problem in pediatric patients. Development of smaller and more flexible hardware will improve quality of children's life and minimize wound-related complications in the future.
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Pediatric Deep Brain Stimulation Using Awake Recording and Stimulation for Target Selection in an Inpatient Neuromodulation Monitoring Unit. Brain Sci 2018; 8:brainsci8070135. [PMID: 30018276 PMCID: PMC6070881 DOI: 10.3390/brainsci8070135] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 07/06/2018] [Accepted: 07/11/2018] [Indexed: 11/17/2022] Open
Abstract
Deep brain stimulation (DBS) for secondary (acquired, combined) dystonia does not reach the high degree of efficacy achieved in primary (genetic, isolated) dystonia. We hypothesize that this may be due to variability in the underlying injury, so that different children may require placement of electrodes in different regions of basal ganglia and thalamus. We describe a new targeting procedure in which temporary depth electrodes are placed at multiple possible targets in basal ganglia and thalamus, and probing for efficacy is performed using test stimulation and recording while children remain for one week in an inpatient Neuromodulation Monitoring Unit (NMU). Nine Children with severe secondary dystonia underwent the NMU targeting procedure. In all cases, 4 electrodes were implanted. We compared the results to 6 children who had previously had 4 electrodes implanted using standard intraoperative microelectrode targeting techniques. Results showed a significant benefit, with 80% of children with NMU targeting achieving greater than 5-point improvement on the Burke–Fahn–Marsden Dystonia Rating Scale (BFMDRS), compared with 50% of children using intraoperative targeting. NMU targeting improved BFMDRS by an average of 17.1 whereas intraoperative targeting improved by an average of 10.3. These preliminary results support the use of test stimulation and recording in a Neuromodulation Monitoring Unit (NMU) as a new technique with the potential to improve outcomes following DBS in children with secondary (acquired) dystonia. A larger sample size will be needed to confirm these results.
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30
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Fehlings D, Brown L, Harvey A, Himmelmann K, Lin JP, Macintosh A, Mink JW, Monbaliu E, Rice J, Silver J, Switzer L, Walters I. Pharmacological and neurosurgical interventions for managing dystonia in cerebral palsy: a systematic review. Dev Med Child Neurol 2018; 60:356-366. [PMID: 29405267 DOI: 10.1111/dmcn.13652] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2017] [Indexed: 12/22/2022]
Abstract
AIM To systematically review evidence for pharmacological/neurosurgical interventions for managing dystonia in individuals with cerebral palsy (CP) to inform a care pathway. METHOD Searches included studies with a minimum of five participants with dystonia in CP receiving oral baclofen, benzodiazepines (clonazepam, diazepam, lorazepam), clonidine, gabapentin, levodopa, trihexyphenidyl, botulinum toxin, intrathecal baclofen (ITB), or deep brain stimulation (DBS). Evidence was classified according to American Academy of Neurology guidelines. RESULTS Twenty-eight articles underwent data extraction: one levodopa, five trihexyphenidyl, three botulinum toxin, six ITB, and 13 DBS studies. No articles for oral baclofen, benzodiazepines, clonidine, or gabapentin met the inclusion criteria. Evidence for reducing dystonia was level C (possibly effective) for ITB and DBS; level C (possibly ineffective) for trihexyphenidyl; and level U (inadequate data) for botulinum toxin. INTERPRETATION For dystonia reduction, ITB and DBS are possibly effective, whereas trihexyphenidyl was possibly ineffective. There is insufficient evidence to support oral medications or botulinum toxin to reduce dystonia. There is insufficient evidence for pharmacological and neurosurgical interventions to improve motor function, decrease pain, and ease caregiving. The majority of the pharmacological and neurosurgical management of dystonia in CP is based on clinical expert opinion. WHAT THIS PAPER ADDS Intrathecal baclofen and deep brain stimulation are possibly effective in reducing dystonia. Current evidence does not support effectiveness of oral medications or botulinum toxin to reduce dystonia. Evidence is inadequate for pharmacological/neurosurgical interventions impact on improving motor function, pain/comfort, and easing caregiving. The majority of the care pathway rests on expert opinion.
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Affiliation(s)
- Darcy Fehlings
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
| | - Leah Brown
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
| | - Adrienne Harvey
- Developmental Disability and Rehabilitation Research, Murdoch Childrens Research Institute, Parkville, Vic, Australia
| | - Kate Himmelmann
- Department of Pediatrics, Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jean-Pierre Lin
- Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's and St Thomas', NHS Foundation Trust, Kings' Health Partners, London, UK
| | - Alexander Macintosh
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
| | - Jonathan W Mink
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | - Elegast Monbaliu
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - James Rice
- Paediatric Rehabilitation Department, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Jessica Silver
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
| | - Lauren Switzer
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
| | - Ilana Walters
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
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Deep brain stimulation for dystonia due to cerebral palsy: A review. Eur J Paediatr Neurol 2018; 22:308-315. [PMID: 29396170 DOI: 10.1016/j.ejpn.2017.12.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/07/2017] [Accepted: 12/07/2017] [Indexed: 01/08/2023]
Abstract
Cerebral palsy (CP) is a heterogeneous group of syndromes that cause a non-progressive disorder of early onset, with abnormal control of movement and posture. Various aetiologies can cause the CP clinical spectrum, but all have a disruption of motor control in common. CP can be divided into four major types based on the motor disability: predominant spastic, dyskinetic, ataxic and mixed form. Dyskinetic CP (DCP) is the most common cause of acquired dystonia in children. The treatment of DCP is challenging because most individuals have mixed degrees of chorea, athetosis and dystonia. Pharmacological treatment is often unsatisfactory. Functional neurosurgery, in particular deep brain stimulation targeting the basal ganglia or the cerebellum, is emerging as a promising therapeutic approach in selected patients with DCP. We evaluated herein the effects of DBS on patients with DCP in a review of published patient data in the largest available studies.
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Somatosensory Evoked Potentials and Central Motor Conduction Times in children with dystonia and their correlation with outcomes from Deep Brain Stimulation of the Globus pallidus internus. Clin Neurophysiol 2017; 129:473-486. [PMID: 29254860 PMCID: PMC5786451 DOI: 10.1016/j.clinph.2017.11.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 11/14/2017] [Accepted: 11/17/2017] [Indexed: 12/13/2022]
Abstract
A high proportion (47%) of children with dystonia have evidence of abnormal sensory pathway function. Central motor conduction times (CMCTs) and somatosensory evoked potentials (SEPs) show a significant relationship with deep brain stimulation (DBS) outcome, independent of aetiology or cranial MRI. CMCTs and SEPs can guide patient selection and help counsel families about potential benefit of DBS.
Objectives To report Somatosensory Evoked Potentials (SEPs) and Central Motor Conduction Times (CMCT) in children with dystonia and to test the hypothesis that these parameters predict outcome from Deep Brain Stimulation (DBS). Methods 180 children with dystonia underwent assessment for Globus pallidus internus (GPi) DBS, mean age 10 years (range 2.5–19). CMCT to each limb was calculated using Transcranial Magnetic Stimulation. Median and posterior tibial nerve SEPs were recorded over contralateral and midline centro-parietal scalp. Structural abnormalities were assessed with cranial MRI. One-year outcome from DBS was assessed as percentage improvement in Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS-m). Results Abnormal CMCTs and SEPs were found in 19% and 47% of children respectively and were observed more frequently in secondary than primary dystonia. Of children proceeding to DBS, better outcome was seen in those with normal (n = 78/89) versus abnormal CMCT (n = 11/89) (p = 0.002) and those with normal (n = 35/51) versus abnormal SEPs (n = 16/51) (p = 0.001). These relationships were independent of dystonia aetiology and cranial MRI findings. Conclusions CMCTs and SEPs provide objective evidence of motor and sensory pathway dysfunction in children with dystonia and relate to DBS outcome. Significance CMCTs and SEPs can contribute to patient selection and counselling of families about potential benefit from neuromodulation for dystonia.
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Johans SJ, Swong KN, Hofler RC, Anderson DE. A Stepwise Approach: Decreasing Infection in Deep Brain Stimulation for Childhood Dystonic Cerebral Palsy. J Child Neurol 2017; 32:871-875. [PMID: 28604158 DOI: 10.1177/0883073817713900] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Dystonia is a movement disorder characterized by involuntary muscle contractions, which cause twisting movements or abnormal postures. Deep brain stimulation has been used to improve the quality of life for secondary dystonia caused by cerebral palsy. Despite being a viable treatment option for childhood dystonic cerebral palsy, deep brain stimulation is associated with a high rate of infection in children. The authors present a small series of patients with dystonic cerebral palsy who underwent a stepwise approach for bilateral globus pallidus interna deep brain stimulation placement in order to decrease the rate of infection. Four children with dystonic cerebral palsy who underwent a total of 13 surgical procedures (electrode and battery placement) were identified via a retrospective review. There were zero postoperative infections. Using a multistaged surgical plan for pediatric patients with dystonic cerebral palsy undergoing deep brain stimulation may help to reduce the risk of infection.
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Affiliation(s)
- Stephen J Johans
- 1 Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Kevin N Swong
- 1 Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Ryan C Hofler
- 1 Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Douglas E Anderson
- 1 Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, USA
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Koy A, Timmermann L. Deep brain stimulation in cerebral palsy: Challenges and opportunities. Eur J Paediatr Neurol 2017; 21:118-121. [PMID: 27289260 DOI: 10.1016/j.ejpn.2016.05.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 05/18/2016] [Accepted: 05/22/2016] [Indexed: 12/31/2022]
Abstract
Cerebral palsy (CP) is the most common cause for acquired dystonia in childhood. Pharmacological treatment is often unsatisfactory and side effects are frequently dose-limiting. Data on outcome of DBS in paediatric patients with dyskinetic CP is very limited and heterogeneous. Reasons for the variability in responses are not entirely known yet. Interestingly, some CP-patients seem to improve subjectively on pallidal stimulation but without measurable changes in impairment scales. Besides dystonia scales, the use of sensitive age-dependent assessments tools is therefore reasonable to capture the full effect. As the course of disease duration as well as the age at operation seem to correlate with DBS outcome in patients with dystonia, DBS at an early stage of development might be beneficial for some of these patients. For the future, well-conducted trials as well as data collection in the international registry is of major importance to increase knowledge about DBS in CP patients, especially those implanted at a young age. Furthermore, selection criteria and guidelines or treatment standards are needed to improve the service for children with dyskinetic CP - especially in light of unsatisfactory medical treatment options.
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Affiliation(s)
- Anne Koy
- Department of Neurology, University Hospital of Cologne, Germany; Department of Paediatrics, University Hospital of Cologne, Germany.
| | - Lars Timmermann
- Department of Neurology, University Hospital of Cologne, Germany
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Kaminska M, Perides S, Lumsden DE, Nakou V, Selway R, Ashkan K, Lin JP. Complications of Deep Brain Stimulation (DBS) for dystonia in children - The challenges and 10 year experience in a large paediatric cohort. Eur J Paediatr Neurol 2017; 21:168-175. [PMID: 27567277 DOI: 10.1016/j.ejpn.2016.07.024] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 07/20/2016] [Accepted: 07/25/2016] [Indexed: 12/20/2022]
Abstract
Deep brain stimulation (DBS) has been increasingly used for primary and secondary movement disorders in children and young people. Reports of hardware related complications have been sparse for this population and from small cohorts of patients. We report DBS complications from a single large DBS centre with 10 year experience. Data was collected as a prospective audit and additionally from a questionnaire on recharging of the stimulators. 129 patients with a minimum 6 months follow up were identified, mean age10.8 y (range 3.0-18.75), mean follow up 3.3y (range 0.5-10.3), weight 10.4-94.2 kg, 126 new implants (92 Activa RC) and 69 revisions for reasons other than infection. 26 patients were 7y or younger. Surgical site infections (SSI) rates were 10.3% for new implants and revisions, lower 8.6% for new Activa RC and even lower, 4.7%, for new Activa RC in patients under 7y (1/21). SSI occurred within first 6 months and necessitated total system removal in 86% of those infected. Electrode/extension problems were recorded in 18.4% of patients, fracture in 4.6% malfunction in 7.7%, short extension 3.8% and electrode migration in 2.3%. Other complications involved clinically silent intracranial bleed in 1 patient, skin erosions (2.3%), unexpected switching off in 18.7% of Soletra/Kinetra and 3.4% of Activa RC, transient seroma at IPG site in postoperative period (8%). Of the 48 returned recharging questionnaires, 38% of families required recharger replacement and 23% experienced frequent problems maintaining connection during recharging. However, 83% of responders considered recharging not at all or only a little care burden. We identified lower than previously reported DBS infection rates particularly for patients under 7 years, but relatively high incidence of technical problems with electrodes, extensions and in particular recharging. This has to be considered when offering DBS for children with movement disorders.
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Affiliation(s)
- Margaret Kaminska
- Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Sarah Perides
- Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Daniel E Lumsden
- Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Vasiliki Nakou
- Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Richard Selway
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Keyoumars Ashkan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Jean-Pierre Lin
- Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Koy A, Weinsheimer M, Pauls KAM, Kühn AA, Krause P, Huebl J, Schneider GH, Deuschl G, Erasmi R, Falk D, Krauss JK, Lütjens G, Schnitzler A, Wojtecki L, Vesper J, Korinthenberg R, Coenen VA, Visser-Vandewalle V, Hellmich M, Timmermann L. German registry of paediatric deep brain stimulation in patients with childhood-onset dystonia (GEPESTIM). Eur J Paediatr Neurol 2017; 21:136-146. [PMID: 27424797 DOI: 10.1016/j.ejpn.2016.05.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 05/22/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Data on paediatric deep brain stimulation (DBS) is limited, especially for long-term outcomes, because of small numbers in single center series and lack of systematic multi-center trials. OBJECTIVES We seek to systematically evaluate the clinical outcome of paediatric patients undergoing DBS. METHODS A German registry on paediatric DBS (GEPESTIM) was created to collect data of patients with dystonia undergoing DBS up to the age of 18 years. Patients were divided into three groups according to etiology (group 1 inherited, group 2 acquired, and group 3 idiopathic dystonia). RESULTS Data of 44 patients with a mean age of 12.8 years at time of operation provided by 6 German centers could be documented in the registry so far (group 1 n = 18, group 2 n = 16, group 3 n = 10). Average absolute improvement after implantation was 15.5 ± 18.0 for 27 patients with pre- and postoperative Burke-Fahn-Marsden Dystonia Rating scale movement scores available (p < 0.001) (group 1: 19.6 ± 19.7, n = 12; group 2: 7.0 ± 8.9, n = 8; group 3: 19.2 ± 20.7, n = 7). Infection was the main reason for hardware removal (n = 6). 20 IPG replacements due to battery expiry were necessary in 15 patients at 3.7 ± 1.8 years after last implantation. DISCUSSION Pre- and postoperative data on paediatric DBS are very heterogeneous and incomplete but corroborate the positive effects of DBS on inherited and acquired dystonia. Adverse events including relatively frequent IPG replacements due to battery expiry seem to be a prominent feature of children with dystonia undergoing DBS. The registry enables collaborative research on DBS treatment in the paediatric population and to create standardized management algorithms in the future.
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Affiliation(s)
- A Koy
- Department of Neurology, University Hospital of Cologne, Germany; Department of Paediatrics, University Hospital of Cologne, Germany.
| | - M Weinsheimer
- Department of Neurology, University Hospital of Cologne, Germany
| | - K A M Pauls
- Department of Neurology, University Hospital of Cologne, Germany
| | - A A Kühn
- Department of Neurology, Charité University Medicine Berlin, Germany
| | - P Krause
- Department of Neurology, Charité University Medicine Berlin, Germany
| | - J Huebl
- Department of Neurology, Charité University Medicine Berlin, Germany
| | - G-H Schneider
- Department of Neurosurgery, Charité University Medicine Berlin, Germany
| | - G Deuschl
- Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
| | - R Erasmi
- Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
| | - D Falk
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
| | - J K Krauss
- Department of Neurosurgery, Medical School, MHH, Hannover, Germany
| | - G Lütjens
- Department of Neurosurgery, Medical School, MHH, Hannover, Germany
| | - A Schnitzler
- Department of Neurology, University Hospital of Düsseldorf, Germany
| | - L Wojtecki
- Department of Neurology, University Hospital of Düsseldorf, Germany
| | - J Vesper
- Department of Stereotactic and Functional Neurosurgery, University Hospital of Düsseldorf, Germany
| | - R Korinthenberg
- Department of Paediatrics, Freiburg University Medical Centre, Germany
| | - V A Coenen
- Department Stereotactic and Functional Neurosurgery, Freiburg University Medical Centre, Germany
| | - V Visser-Vandewalle
- Department of Stereotactic and Functional Neurosurgery, University Hospital of Cologne, Germany
| | - M Hellmich
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Germany
| | - L Timmermann
- Department of Neurology, University Hospital of Cologne, Germany.
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Beaulieu-Boire I, Aquino CC, Fasano A, Poon YY, Fallis M, Lang AE, Hodaie M, Kalia SK, Lozano A, Moro E. Deep Brain Stimulation in Rare Inherited Dystonias. Brain Stimul 2016; 9:905-910. [PMID: 27743838 DOI: 10.1016/j.brs.2016.07.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 07/01/2016] [Accepted: 07/21/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Rare causes of inherited movement disorders often present with a debilitating phenotype of dystonia, sometimes combined with parkinsonism and other neurological signs. Since these disorders are often resistant to medications, DBS may be considered as a possible treatment. METHODS Patients with identified genetic diseases (ataxia-telangiectasia, chorea-achantocytosis, dopa-responsive dystonia, congenital nemaline myopathy, methylmalonic aciduria, neuronal ceroid lipofuscinosis, spinocerebellar ataxia types 2 and 3, Wilson's disease, Woodhouse-Sakati syndrome, methylmalonic aciduria, and X trisomy) and disabling dystonia underwent bilateral GPi DBS (bilateral thalamic Vim nucleus in 1 case). The primary outcome was the difference in the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) between baseline, 1 year and last available follow-up. Preoperative factors such as age at surgery, disease duration at surgery, proportion of life lived with dystonia and severity of dystonia were correlated to the primary outcome. RESULTS Eleven patients were operated between February 2003 and December 2013. Age and duration of disease at time of surgery were 30 ± 19 and 12.5 ± 15.7 years, respectively. DBS effects on dystonia severity were variable but overall marginally effective, with a mean improvement of 7.9% (p = 0.39) at 1-year follow-up and 16.7% (p = 0.46) at last follow-up (mean 47.3 ± 19.9 months after surgery). No preoperative factors were identified to predict the surgical outcome. CONCLUSION Our findings support the current knowledge that DBS is modestly effective in treating rare inherited dystonias with a combined phenotype. However, the BFMDRS might not be the best tool to measure outcome in these severely affected patients.
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Affiliation(s)
- Isabelle Beaulieu-Boire
- Division of Neurology, Centre Hospitalier Universitaire de Sherbrooke, University of Sherbrooke, Sherbrooke, Québec, Canada; Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Camila C Aquino
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Alfonso Fasano
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.
| | - Yu-Yan Poon
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Melanie Fallis
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Antony E Lang
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Mojgan Hodaie
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Suneil K Kalia
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Andres Lozano
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Elena Moro
- Division of Neurology, CHU Grenoble, INSERM U836, Joseph Fourier University, Grenoble, France
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van den Heuvel CNAM, Tijssen MAJ, van de Warrenburg BPC, Delnooz CCS. The Symptomatic Treatment of Acquired Dystonia: A Systematic Review. Mov Disord Clin Pract 2016; 3:548-558. [PMID: 30363468 DOI: 10.1002/mdc3.12400] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/12/2016] [Accepted: 05/23/2016] [Indexed: 12/27/2022] Open
Abstract
Background Acquired dystonia is caused by an acquired or exogenous event. Although the therapeutic armamentarium used in clinical practice is more or less similar to that used for inherited or idiopathic dystonia, formal proof of the efficacy of these interventions in acquired dystonia is lacking. Methods The authors attempt to provide a comprehensive and systematic review of the current evidence for medical and allied health care treatment strategies in acquired dystonias. The PubMed, Cochrane Library, MEDLINE, Web of Science, PiCarta, and PsycINFO databases were searched up to December 2015, including randomized controlled trials, patient-control studies, and case series or single case reports containing a report on clinical outcome. Results There are level 3 practice recommendations for botulinum toxin injections and globus pallidus pars interna deep brain stimulation for tardive dystonia and dystonic cerebral palsy as well as intrathecal baclofen for dystonic cerebral palsy. There are insufficient and conflicting data on the effect (vs. the hazard) of other pharmacological interventions, and limited work has been done on other forms of neurostimulation and allied health care. Because no class A1 or A2 studies were identified, level 1 or 2 practice recommendations could not be deducted for a specific treatment intervention. Conclusions To improve the current medical and allied health care treatment options for patients with acquired dystonia, high-quality trials that examine the efficacy of therapies need to be performed.
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Affiliation(s)
- Corina N A M van den Heuvel
- Department of Neurology, Donders Institute for Brain, Cognition, and Behavior Radboud University Medical Center Nijmegen the Netherlands
| | - Marina A J Tijssen
- Department of Neurology University Medical Center Groningen Groningen the Netherlands
| | - Bart P C van de Warrenburg
- Department of Neurology, Donders Institute for Brain, Cognition, and Behavior Radboud University Medical Center Nijmegen the Netherlands
| | - Cathérine C S Delnooz
- Department of Neurology University Medical Center Groningen Groningen the Netherlands
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Dupré DA, Tomycz N, Oh MY, Whiting D. Deep brain stimulation for obesity: past, present, and future targets. Neurosurg Focus 2016; 38:E7. [PMID: 26030707 DOI: 10.3171/2015.3.focus1542] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The authors review the history of deep brain stimulation (DBS) in patients for treating obesity, describe current DBS targets in the brain, and discuss potential DBS targets and nontraditional stimulation parameters that may improve the effectiveness of DBS for ameliorating obesity. Deep brain stimulation for treating obesity has been performed both in animals and in humans with intriguing preliminary results. The brain is an attractive target for addressing obesity because modulating brain activity may permit influencing both sides of the energy equation--caloric intake and energy expenditure.
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Affiliation(s)
- Derrick A Dupré
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Nestor Tomycz
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Michael Y Oh
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Donald Whiting
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
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Abstract
Tone management is one of the primary roles of a pediatric physiatrist. Hypertonicity frequently inhibits normal movement patterns in children with central nervous system lesions but at times can reinforce muscle group firing and be useful for a child's function. Treatment approaches should be individualized based on functional goals, degree of impairment, interference with care, and type and location of hypertonicity. Treatment plans should be created in collaboration with all individuals caring for the child. There are many causes of hypertonicity as well as many nonsurgical and surgical treatments. Historical and current evidence-based treatments are reviewed.
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Affiliation(s)
- Sathya Vadivelu
- Division of Pediatric Rehabilitation Medicine, Department of Pediatrics, Rady Children's Hospital San Diego, University of California San Diego, 3020 Children's Way MC5096, San Diego, CA 92123, USA
| | - Anne Stratton
- Department of Physical Medicine and Rehabilitation, University of Colorado, Denver, CO, USA
| | - Wendy Pierce
- Department of Physical Medicine and Rehabilitation, University of Colorado, 4125 Briargate Parkway, Box 520, Colorado Springs, CO 80920, USA.
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Nam TM, Cho KR, Youn J, Cho JW, Lee JI. Deep brain stimulation in a dentatorubral-pallidoluyisian atrophy patient with myoclonic dystonia. J Clin Neurosci 2015; 22:1976-8. [PMID: 26186965 DOI: 10.1016/j.jocn.2015.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 04/11/2015] [Indexed: 01/26/2023]
Abstract
We describe a patient with myoclonic dystonia caused by dentatorubral-pallidoluyisian atrophy (DRPLA), which was successfully controlled with bilateral deep brain stimulation (DBS) of the globus pallidus internus (GPi). DRPLA is a rare disease which can progressively cause a loss or degeneration of neurons in the globus pallidus, dentate nucleus, subthalamic nucleus, and red nucleus. This observation is another example of secondary dystonia which can be controlled by GPi-DBS in carefully selected patients.
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Affiliation(s)
- Taek Min Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Republic of Korea
| | - Kyung Rae Cho
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Republic of Korea
| | - Jinyoung Youn
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin Whan Cho
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Republic of Korea.
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Bertucco M, Sanger TD. Current and emerging strategies for treatment of childhood dystonia. J Hand Ther 2015; 28:185-93; quiz 194. [PMID: 25835254 PMCID: PMC4424089 DOI: 10.1016/j.jht.2014.11.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 10/29/2014] [Accepted: 11/04/2014] [Indexed: 02/03/2023]
Abstract
Childhood dystonia is a movement disorder characterized by involuntary sustained or intermittent muscle contractions causing twisting and repetitive movements, abnormal postures, or both (Sanger et al, 2003). Dystonia is a devastating neurological condition that prevents the acquisition of normal motor skills during critical periods of development in children. Moreover, it is particularly debilitating in children when dystonia affects the upper extremities such that learning and consolidation of common daily motor actions are impeded. Thus, the treatment and rehabilitation of dystonia is a challenge that continuously requires exploration of novel interventions. This review will initially describe the underlying neurophysiological mechanisms of the motor impairments found in childhood dystonia followed by the clinical measurement tools that are available to document the presence and severity of symptoms. Finally, we will discuss the state-of-the-art of therapeutic options for childhood dystonia, with particular emphasis on emergent and innovative strategies.
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Affiliation(s)
- Matteo Bertucco
- Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, USA
| | - Terence D Sanger
- Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, USA; Department of Child Neurology, University of Southern California, Los Angeles, CA, USA; Department of Biokinesiology, University of Southern California, Los Angeles, CA, USA; Children's Hospital of Los Angeles, Los Angeles, CA, USA.
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Arsenault D, Drouin-Ouellet J, Saint-Pierre M, Petrou P, Dubois M, Kriz J, Barker RA, Cicchetti A, Cicchetti F. A novel combinational approach of microstimulation and bioluminescence imaging to study the mechanisms of action of cerebral electrical stimulation in mice. J Physiol 2015; 593:2257-78. [PMID: 25653107 DOI: 10.1113/jphysiol.2014.287243] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 01/30/2015] [Indexed: 12/12/2022] Open
Abstract
Deep brain stimulation (DBS) is used to treat a number of neurological conditions and is currently being tested to intervene in neuropsychiatric conditions. However, a better understanding of how it works would ensure that side effects could be minimized and benefits optimized. We have thus developed a unique device to perform brain stimulation (BS) in mice and to address fundamental issues related to this methodology in the pre-clinical setting. This new microstimulator prototype was specifically designed to allow simultaneous live bioluminescence imaging of the mouse brain, allowing real time assessment of the impact of stimulation on cerebral tissue. We validated the authenticity of this tool in vivo by analysing the expression of toll-like receptor 2 (TLR2), corresponding to the microglial response, in the stimulated brain regions of TLR2-fluc-GFP transgenic mice, which we further corroborated with post-mortem analyses in these animals as well as in human brains of patients who underwent DBS to treat their Parkinson's disease. In the present study, we report on the development of the first BS device that allows for simultaneous live in vivo imaging in mice. This tool opens up a whole new range of possibilities that allow a better understanding of BS and how to optimize its effects through its use in murine models of disease.
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Affiliation(s)
- Dany Arsenault
- Centre de Recherche du CHU de Québec (CHUQ), Axe Neurosciences, Québec, QC, Canada
| | - Janelle Drouin-Ouellet
- John van Geest Centre for Brain Repair, Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK
| | - Martine Saint-Pierre
- Centre de Recherche du CHU de Québec (CHUQ), Axe Neurosciences, Québec, QC, Canada
| | - Petros Petrou
- Centre de Recherche du CHU de Québec (CHUQ), Axe Neurosciences, Québec, QC, Canada
| | - Marilyn Dubois
- Centre de Recherche du CHU de Québec (CHUQ), Axe Neurosciences, Québec, QC, Canada
| | - Jasna Kriz
- Département de Psychiatrie et Neurosciences, Université Laval, Québec, QC, Canada.,Institut Universitaire en Santé Mentale de Québec, Québec, QC, Canada
| | - Roger A Barker
- John van Geest Centre for Brain Repair, Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK
| | - Antonio Cicchetti
- Centre de Recherche du CHU de Québec (CHUQ), Axe Neurosciences, Québec, QC, Canada
| | - Francesca Cicchetti
- Centre de Recherche du CHU de Québec (CHUQ), Axe Neurosciences, Québec, QC, Canada.,Département de Psychiatrie et Neurosciences, Université Laval, Québec, QC, Canada
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Abstract
On the basis of some research evidence and consensus, identification of acute opsoclonus, ataxia, or myoclonus should prompt consideration of an underlying neuroblastoma. On the basis of some research evidence and consensus, surgical treatment options should be considered for children with dystonia, including secondary dystonias, such as those related to cerebral palsy, and include intrathecal baclofen pumps and deep brain stimulation. On the basis of some research evidence and clinical experience, tetrabenazine may be effective in treating chorea. On the basis of strong research evidence, although seldom inherently dangerous, tics may be uncomfortable for affected children and interfere with academic achievement and social development. On the basis of some research evidence and clinical experience, topiramate may be an effective treatment for tic disorders.
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Affiliation(s)
- Michael C Kruer
- Sanford Children's Pediatric Movement Disorders Clinic, Division of Pediatric Neurology, Sanford Children's Specialty Clinic, Sioux Falls, SD
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Christian E, Melamed E, Peck E, Krieger MD, McComb JG. Does a temporizing measure of cerebrospinal fluid drainage as the initial procedure alter the surgical outcome in premature infants with post-hemorrhagic hydrocephalus? Fluids Barriers CNS 2015. [PMCID: PMC4582318 DOI: 10.1186/2045-8118-12-s1-p8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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Christian E, Jin D, Attenello F, Wen T, Cen S, Mack WJ, Krieger MD, McComb JG. Trends in hospitalization of preterm infants with intraventricular hemorrhage and hydrocephalus in the United States, 2000-2010. Fluids Barriers CNS 2015. [PMCID: PMC4582248 DOI: 10.1186/2045-8118-12-s1-o1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Keen JR, Przekop A, Olaya JE, Zouros A, Hsu FPK. Deep brain stimulation for the treatment of childhood dystonic cerebral palsy. J Neurosurg Pediatr 2014; 14:585-93. [PMID: 25325412 DOI: 10.3171/2014.8.peds141] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECT Deep brain stimulation (DBS) for dystonic cerebral palsy (CP) has rarely been reported, and its efficacy, though modest when compared with that for primary dystonia, remains unclear, especially in the pediatric population. The authors present a small series of children with dystonic CP who underwent bilateral pallidal DBS, to evaluate the treatment's efficacy and safety in the pediatric dystonic CP population. METHODS The authors conducted a retrospective review of patients (under the age of 18 years) with dystonic CP who had undergone DBS of the bilateral globus pallidus internus between 2010 and 2012. Two of the authors independently assessed outcomes using the Barry-Albright Dystonia Scale (BADS) and the Burke-Fahn-Marsden Dystonia Rating Scale-movement (BFMDRS-M). RESULTS Five children were diagnosed with dystonic CP due to insults occurring before the age of 1 year. Mean age at surgery was 11 years (range 8-17 years), and the mean follow-up was 26.6 months (range 2-42 months). The mean target position was 20.6 mm lateral to the midcommissural point. The mean preoperative and postoperative BADS scores were 23.8 ± 4.9 (range 18.5-29.0) and 20.0 ± 5.5 (range 14.5-28.0), respectively, with a mean overall percent improvement of 16.0% (p = 0.14). The mean preoperative and postoperative BFMDRS-M scores were 73.3 ± 26.6 (range 38.5-102.0) and 52.4 ± 21.5 (range 34.0-80.0), respectively, with a mean overall percent improvement of 28.5% (p = 0.10). Those stimulated at least 23 months (4 patients) improved 18.3% (p = 0.14) on the BADS and 30.5% (p = 0.07) on the BFMDRS-M. The percentage improvement per body region yielded conflicting results between rating scales; however, BFMDRS-M scores for speech showed some of the greatest improvements. Two patients required hardware removal (1 complete system, 1 unilateral electrode) within 4 months after implantation because of infections that resolved with antibiotics. CONCLUSIONS All postoperative dystonia rating scale scores improved with pallidal stimulation, and the greatest improvements occurred in those stimulated the longest. The results were modest but comparable to findings in other similar series. Deep brain stimulation remains a viable treatment option for childhood dystonic CP, although young children may have an increased risk of infection. Of particular note, improvements in the BFMDRS-M subscores for speech were comparable to those for other muscle groups, a finding not previously reported.
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