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Vilela-Filho O, Souza JT, Ragazzo PC, Silva DJ, Oliveira PM, Goulart LC, Reis MD, Piedimonte F, Ribeiro TM. Bilateral Globus Pallidus Externus Deep Brain Stimulation for the Treatment of Refractory Tourette Syndrome: An Open Clinical Trial. Neuromodulation 2024; 27:742-758. [PMID: 37294231 DOI: 10.1016/j.neurom.2023.04.473] [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: 01/27/2023] [Revised: 04/24/2023] [Accepted: 04/27/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVES We have previously proposed that Tourette syndrome (TS) is the clinical expression of the hyperactivity of globus pallidus externus (GPe) and various cortical areas. This study was designed to test this hypothesis by verifying the efficacy and safety of bilateral GPe deep brain stimulation (DBS) for treating refractory TS. MATERIALS AND METHODS In this open clinical trial, 13 patients were operated on. Target coordinates (center of GPe) were obtained by direct visualization. Physiological mapping was performed with macrostimulation and microrecording. Primary and secondary outcome measures were, respectively, responder and improvement rates of TS and comorbidities, according to pre- and postoperative scores on the following assessment instruments: Yale Global Tic Severity Scale, Yale-Brown Obsessive Compulsive Scale, Beck Depression Inventory/Hamilton Depression Rating Scale, Beck Anxiety Inventory/Hamilton Anxiety Rating Scale, and Concentrated Attention test. RESULTS Intraoperative stimulation (100 Hz/5.0V) did not produce any adverse effects or impact on tics. Microrecording revealed bursting cells discharging synchronously with tics in the central part of the dorsal half of GPe. Patients were followed up for a mean of 61.46±48.50 months. Responder rates were 76.9%, 75%, 71.4%, 71.4%, and 85.7%, respectively, for TS, obsessive-compulsive disorder (OCD), depression, anxiety, and attention deficit hyperactivity disorder. Mean improvements among responders in TS, OCD, depression, and anxiety were 77.4%, 74.7%, 89%, and 84.8%, respectively. After starting stimulation, tic improvement was usually delayed, taking up to ten days to manifest. Afterward, it increased over time, usually reaching its maximum at approximately one year postoperatively. The best stimulation parameters were 2.3V to 3.0V, 90 to 120 μsec, and 100 to 150 Hz, and the most effective contacts were the two dorsal ones. Two complications were registered: reversible impairment of previous depression and transient unilateral bradykinesia. CONCLUSIONS Bilateral GPe-DBS proved to be low risk and quite effective for treating TS and comorbidities, ratifying the pathophysiological hypothesis that led to this study. Moreover, it compared favorably with DBS of other targets currently in use.
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Affiliation(s)
- Osvaldo Vilela-Filho
- Division of Neurosurgery, Department of Surgery, Medical School, Federal University of Goiás, Goiânia, Goiás, Brazil; Nervous System Unity, Clinics Hospital, Medical School, Federal University of Goiás, Goiânia, Goiás, Brazil; Department of Stereotactic and Functional Neurosurgery, Goiânia Neurological Institute, Goiânia, Goiás, Brazil.
| | - Joaquim T Souza
- Nervous System Unity, Clinics Hospital, Medical School, Federal University of Goiás, Goiânia, Goiás, Brazil
| | - Paulo C Ragazzo
- Department of Neurology, Goiânia Neurological Institute, Goiânia, Goiás, Brazil
| | - Délson J Silva
- Nervous System Unity, Clinics Hospital, Medical School, Federal University of Goiás, Goiânia, Goiás, Brazil
| | - Paulo M Oliveira
- Department of Psychiatry, Medical School, Federal University of Goiás, Goiânia, Goiás, Brazil; Department of Psychiatry, Goiânia Neurological Institute, Goiânia, Goiás, Brazil
| | - Lissa C Goulart
- Nervous System Unity, Clinics Hospital, Medical School, Federal University of Goiás, Goiânia, Goiás, Brazil
| | - Manoel D Reis
- Department of Psychiatry, Goiânia Neurological Institute, Goiânia, Goiás, Brazil
| | - Fabian Piedimonte
- JJ Naon Institute of Morphology, Medical School, University of Buenos Aires, Buenos Aires, Argentina
| | - Telma M Ribeiro
- Department of Psychiatry, Goiânia Neurological Institute, Goiânia, Goiás, Brazil
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2
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Gonzalo-Martín E, Alonso-Martínez C, Sepúlveda LP, Clasca F. Micropopulation mapping of the mouse parafascicular nucleus connections reveals diverse input-output motifs. Front Neuroanat 2024; 17:1305500. [PMID: 38260117 PMCID: PMC10800635 DOI: 10.3389/fnana.2023.1305500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 11/10/2023] [Indexed: 01/24/2024] Open
Abstract
Introduction In primates, including humans, the centromedian/parafascicular (CM-Pf) complex is a key thalamic node of the basal ganglia system. Deep brain stimulation in CM-Pf has been applied for the treatment of motor disorders such as Parkinson's disease or Tourette syndrome. Rodents have become widely used models for the study of the cellular and genetic mechanisms of these and other motor disorders. However, the equivalence between the primate CM-Pf and the nucleus regarded as analogous in rodents (Parafascicular, Pf) remains unclear. Methods Here, we analyzed the neurochemical architecture and carried out a brain-wide mapping of the input-output motifs in the mouse Pf at micropopulation level using anterograde and retrograde labeling methods. Specifically, we mapped and quantified the sources of cortical and subcortical input to different Pf subregions, and mapped and compared the distribution and terminal structure of their axons. Results We found that projections to Pf arise predominantly (>75%) from the cerebral cortex, with an unusually strong (>45%) Layer 5b component, which is, in part, contralateral. The intermediate layers of the superior colliculus are the main subcortical input source to Pf. On its output side, Pf neuron axons predominantly innervate the striatum. In a sparser fashion, they innervate other basal ganglia nuclei, including the subthalamic nucleus (STN), and the cerebral cortex. Differences are evident between the lateral and medial portions of Pf, both in chemoarchitecture and in connectivity. Lateral Pf axons innervate territories of the striatum, STN and cortex involved in the sensorimotor control of different parts of the contralateral hemibody. In contrast, the mediodorsal portion of Pf innervates oculomotor-limbic territories in the above three structures. Discussion Our data thus indicate that the mouse Pf consists of several neurochemically and connectively distinct domains whose global organization bears a marked similarity to that described in the primate CM-Pf complex.
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Affiliation(s)
| | | | | | - Francisco Clasca
- Department of Anatomy and Neuroscience, Autónoma de Madrid University, Madrid, Spain
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Rusheen AE, Rojas-Cabrera J, Goyal A, Shin H, Yuen J, Jang DP, Bennet KE, Blaha CD, Lee KH, Oh Y. Deep brain stimulation alleviates tics in Tourette syndrome via striatal dopamine transmission. Brain 2023; 146:4174-4190. [PMID: 37141283 PMCID: PMC10545518 DOI: 10.1093/brain/awad142] [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: 10/07/2022] [Revised: 03/24/2023] [Accepted: 04/14/2023] [Indexed: 05/05/2023] Open
Abstract
Tourette syndrome is a childhood-onset neuropsychiatric disorder characterized by intrusive motor and vocal tics that can lead to self-injury and deleterious mental health complications. While dysfunction in striatal dopamine neurotransmission has been proposed to underlie tic behaviour, evidence is scarce and inconclusive. Deep brain stimulation (DBS) of the thalamic centromedian parafascicular complex (CMPf), an approved surgical interventive treatment for medical refractory Tourette syndrome, may reduce tics by affecting striatal dopamine release. Here, we use electrophysiology, electrochemistry, optogenetics, pharmacological treatments and behavioural measurements to mechanistically examine how thalamic DBS modulates synaptic and tonic dopamine activity in the dorsomedial striatum. Previous studies demonstrated focal disruption of GABAergic transmission in the dorsolateral striatum of rats led to repetitive motor tics recapitulating the major symptom of Tourette syndrome. We employed this model under light anaesthesia and found CMPf DBS evoked synaptic dopamine release and elevated tonic dopamine levels via striatal cholinergic interneurons while concomitantly reducing motor tic behaviour. The improvement in tic behaviour was found to be mediated by D2 receptor activation as blocking this receptor prevented the therapeutic response. Our results demonstrate that release of striatal dopamine mediates the therapeutic effects of CMPf DBS and points to striatal dopamine dysfunction as a driver for motor tics in the pathoneurophysiology of Tourette syndrome.
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Affiliation(s)
- Aaron E Rusheen
- Medical Scientist Training Program, Mayo Clinic, Rochester, MN 55902, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55902, USA
| | - Juan Rojas-Cabrera
- Medical Scientist Training Program, Mayo Clinic, Rochester, MN 55902, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55902, USA
| | - Abhinav Goyal
- Medical Scientist Training Program, Mayo Clinic, Rochester, MN 55902, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55902, USA
| | - Hojin Shin
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55902, USA
- Department of Biomedical Engineering, Mayo Clinic, Rochester, MN 55902, USA
| | - Jason Yuen
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55902, USA
- IMPACT—the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Barwon Health, Geelong, VIC 3216, Australia
| | - Dong-Pyo Jang
- Department of Biomedical Engineering, Hanyang University, Seoul 04763, South Korea
| | - Keven E Bennet
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55902, USA
- Division of Engineering, Mayo Clinic, Rochester, MN 55902, USA
| | - Charles D Blaha
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55902, USA
| | - Kendall H Lee
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55902, USA
- Department of Biomedical Engineering, Mayo Clinic, Rochester, MN 55902, USA
| | - Yoonbae Oh
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55902, USA
- Department of Biomedical Engineering, Mayo Clinic, Rochester, MN 55902, USA
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Kumar VJ, Scheffler K, Grodd W. The structural connectivity mapping of the intralaminar thalamic nuclei. Sci Rep 2023; 13:11938. [PMID: 37488187 PMCID: PMC10366221 DOI: 10.1038/s41598-023-38967-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/18/2023] [Indexed: 07/26/2023] Open
Abstract
The intralaminar nuclei of the thalamus play a pivotal role in awareness, conscious experience, arousal, sleep, vigilance, as well as in cognitive, sensory, and sexual processing. Nonetheless, in humans, little is known about the direct involvement of these nuclei in such multifaceted functions and their structural connections in the brain. Thus, examining the versatility of structural connectivity of the intralaminar nuclei with the rest of the brain seems reasonable. Herein, we attempt to show the direct structural connectivity of the intralaminar nuclei to diencephalic, mesencephalic, and cortical areas using probabilistic tracking of the diffusion data from the human connectome project. The intralaminar nuclei fiber distributions span a wide range of subcortical and cortical areas. Moreover, the central medial and parafascicular nucleus reveal similar connectivity to the temporal, visual, and frontal cortices with only slight variability. The central lateral nucleus displays a refined projection to the superior colliculus and fornix. The centromedian nucleus seems to be an essential component of the subcortical somatosensory system, as it mainly displays connectivity via the medial and superior cerebellar peduncle to the brainstem and the cerebellar lobules. The subparafascicular nucleus projects to the somatosensory processing areas. It is interesting to note that all intralaminar nuclei have connections to the brainstem. In brief, the structural connectivity of the intralaminar nuclei aligns with the structural core of various functional demands for arousal, emotion, cognition, sensory, vision, and motor processing. This study sheds light on our understanding of the structural connectivity of the intralaminar nuclei with cortical and subcortical structures, which is of great interest to a broader audience in clinical and neuroscience research.
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Affiliation(s)
| | - Klaus Scheffler
- Max Planck Institute for Biological Cybernetics, Tübingen, Germany
- Department of Biomedical Magnetic Resonance, University Clinic Tübingen, Tübingen, Germany
| | - Wolfgang Grodd
- Max Planck Institute for Biological Cybernetics, Tübingen, Germany
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5
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Benarroch E. What Is the Role of the Intralaminar Thalamic Input to the Striatum and Its Potential Implications in Parkinson Disease? Neurology 2023; 101:118-123. [PMID: 37460225 DOI: 10.1212/wnl.0000000000207610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/11/2023] [Indexed: 07/20/2023] Open
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Yang JC, Bullinger KL, Isbaine F, Alwaki A, Opri E, Willie JT, Gross RE. Centromedian thalamic deep brain stimulation for drug-resistant epilepsy: single-center experience. J Neurosurg 2022; 137:1591-1600. [PMID: 35395630 DOI: 10.3171/2022.2.jns212237] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 02/07/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Neuromodulation of the centromedian nucleus of the thalamus (CM) has unclear effectiveness in the treatment of drug-resistant epilepsy. Prior reports suggest that it may be more effective in the generalized epilepsies such as Lennox-Gastaut syndrome (LGS). The objective of this study was to determine the outcome of CM deep brain stimulation (DBS) at the authors' institution. METHODS Retrospective chart review was performed for all patients who underwent CM DBS at Emory University, which occurred between December 2018 and May 2021. CM DBS electrodes were implanted using three different surgical methods, including frame-based, robot-assisted, and direct MRI-guided. Seizure frequency, stimulation parameters, and adverse events were recorded from subsequent clinical follow-up visits. RESULTS Fourteen patients underwent CM DBS: 9 had symptomatic generalized epilepsy (including 5 with LGS), 3 had primary or idiopathic generalized epilepsy, and 2 had bifrontal focal epilepsy. At last follow-up (mean [± SEM] 19 ± 5 months, range 4.1-33 months, ≥ 6 months in 11 patients), the median seizure frequency reduction was 91%. Twelve patients (86%) were considered responders (≥ 50% decrease in seizure frequency), including 10 of 12 with generalized epilepsy and both patients with bifrontal epilepsy. Surgical adverse events were rare and included 1 patient with hardware breakage, 1 with a postoperative aspiration event, and 1 with a nonclinically significant intracranial hemorrhage. CONCLUSIONS CM DBS was an effective treatment for drug-resistant generalized and bifrontal epilepsies. Additional studies and analyses may investigate whether CM DBS is best suited for specific epilepsy types, and the relationship of lead location to outcome in different epilepsies.
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Affiliation(s)
| | - Katie L Bullinger
- 2Neurology, Emory University School of Medicine, Atlanta, Georgia; and
| | | | | | - Enrico Opri
- 2Neurology, Emory University School of Medicine, Atlanta, Georgia; and
| | - Jon T Willie
- 3Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Robert E Gross
- Departments of1Neurosurgery and.,2Neurology, Emory University School of Medicine, Atlanta, Georgia; and
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7
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Hanini-Daoud M, Jaouen F, Salin P, Kerkerian-Le Goff L, Maurice N. Processing of information from the parafascicular nucleus of the thalamus through the basal ganglia. J Neurosci Res 2022; 100:1370-1385. [PMID: 35355316 DOI: 10.1002/jnr.25046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 03/08/2022] [Accepted: 03/15/2022] [Indexed: 11/11/2022]
Abstract
Accumulating evidence implicates the parafascicular nucleus of the thalamus (Pf) in basal ganglia (BG)-related functions and pathologies. Despite Pf connectivity with all BG components, most attention is focused on the thalamostriatal system and an integrated view of thalamic information processing in this network is still lacking. Here, we addressed this question by recording the responses elicited by Pf activation in single neurons of the substantia nigra pars reticulata (SNr), the main BG output structure in rodents, in anesthetized mice. We performed optogenetic activation of Pf neurons innervating the striatum, the subthalamic nucleus (STN), or the SNr using virally mediated transcellular delivery of Cre from injection in either target in Rosa26-LoxP-stop-ChR2-EYFP mice to drive channelrhodopsin expression. Photoactivation of Pf neurons connecting the striatum evoked an inhibition often followed by an excitation, likely resulting from the activation of the trans-striatal direct and indirect pathways, respectively. Photoactivation of Pf neurons connecting the SNr or the STN triggered one or two early excitations, suggesting partial functional overlap of trans-subthalamic and direct thalamonigral projections. Excitations were followed in about half of the cases by an inhibition that might reflect recruitment of intranigral inhibitory loops. Finally, global Pf stimulation, electrical or optogenetic, elicited similar complex responses comprising up to four components: one or two short-latency excitations, an inhibition, and a late excitation. These data provide evidence for functional connections between the Pf and different BG components and for convergence of the information processed through these pathways in single SNr neurons, stressing their importance in regulating BG outflow.
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Affiliation(s)
| | | | - Pascal Salin
- Aix Marseille Univ, CNRS, IBDM, Marseille, France
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8
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Yan H, Siegel L, Breitbart S, Gorodetsky C, Fasano A, Rahim A, Loh A, Kulkarni AV, Ibrahim GM. An open-label prospective pilot trial of nucleus accumbens deep brain stimulation for children with autism spectrum disorder and severe, refractory self-injurious behavior: study protocol. Pilot Feasibility Stud 2022; 8:24. [PMID: 35109924 PMCID: PMC8808966 DOI: 10.1186/s40814-022-00988-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 01/20/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Children and youth with autism spectrum disorder (ASD) may manifest self-injurious behaviors (SIB) that may become severe and refractory with limited pharmacologic or behavioral treatment options. Here, we present the protocol of a prospective, mixed-methods study to assess the safety and efficacy of deep brain stimulation (DBS) of the nucleus accumbens (NAcc) for children and youth with ASD and severe, refractory SIB. METHODS This is a prospective, single-center, single-cohort, open-label, non-randomized pilot trial of 6 patients. Participants will be recruited through specialized behavioral clinics with persistent severe and refractory SIB following standard and intensive interventions. Following NAcc-DBS, participants will be enrolled in the study for 12 months. The primary objectives of the study are safety and feasibility, assessed by rate of recruitment and identification of factors impacting adherence to follow-up and study protocol. Potential treatment efficacy will be assessed by changes in the Children's Yale-Brown Obsessive-Compulsive Scale in ASD (CYBOCS-ASD), the Behavior Problems Index (BPI), the Inventory of Statements about Self-Injury (ISAS) and the Repetitive Behavior Scale-Revised (RBS-R) questionnaires. Additional clinical outcomes will be assessed, including measures of participant and caregiver quality of life, actigraph measurements, and positron emission tomography (PET) changes following DBS. DISCUSSION This study will be the first to evaluate the effect of DBS of the NAcc on a pediatric population in a controlled, prospective trial. Secondary outcomes will improve the understanding of behavioral, neuro-imaging, and electrophysiologic changes in children with ASD and SIB treated with DBS. This trial will provide an estimated effect size of NAcc-DBS for severe refractory SIB in children with ASD in preparation for future comparative trials. TRIAL REGISTRATION Registration on ClinicalTrials.gov was completed on 12 June 2019 with the Identifier: NCT03982888 .
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Affiliation(s)
- Han Yan
- Division of Neurosurgery, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada.,Institute of Health of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Lauren Siegel
- Neurosciences and Mental Health Program, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada
| | - Sara Breitbart
- Division of Neurosurgery, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada.,Neurosciences and Mental Health Program, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada
| | | | - Alfonso Fasano
- Division of Neurology, The Hospital for Sick Children, Toronto, Canada.,Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, Ontario, Canada. Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Brain Institute, Toronto, Ontario, Canada.,CenteR for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, ON, Canada
| | - Aliya Rahim
- Neurosciences and Mental Health Program, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada.,Surrey Place, Toronto, Ontario, Canada
| | - Alvin Loh
- Surrey Place, Toronto, Ontario, Canada.,Division of Developmental Paediatrics, Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Abhaya V Kulkarni
- Division of Neurosurgery, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada.,Institute of Health of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - George M Ibrahim
- Division of Neurosurgery, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada. .,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada. .,Institute of Biomedical Engineering, University of Toronto, Toronto, Canada. .,Institute of Medical Science, University of Toronto, Toronto, Canada.
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9
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Szejko N, Worbe Y, Hartmann A, Visser-Vandewalle V, Ackermans L, Ganos C, Porta M, Leentjens AFG, Mehrkens JH, Huys D, Baldermann JC, Kuhn J, Karachi C, Delorme C, Foltynie T, Cavanna AE, Cath D, Müller-Vahl K. European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part IV: deep brain stimulation. Eur Child Adolesc Psychiatry 2022; 31:443-461. [PMID: 34605960 PMCID: PMC8940783 DOI: 10.1007/s00787-021-01881-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 09/15/2021] [Indexed: 12/13/2022]
Abstract
In 2011 the European Society for the Study of Tourette Syndrome (ESSTS) published its first European clinical guidelines for the treatment of Tourette Syndrome (TS) with part IV on deep brain stimulation (DBS). Here, we present a revised version of these guidelines with updated recommendations based on the current literature covering the last decade as well as a survey among ESSTS experts. Currently, data from the International Tourette DBS Registry and Database, two meta-analyses, and eight randomized controlled trials (RCTs) are available. Interpretation of outcomes is limited by small sample sizes and short follow-up periods. Compared to open uncontrolled case studies, RCTs report less favorable outcomes with conflicting results. This could be related to several different aspects including methodological issues, but also substantial placebo effects. These guidelines, therefore, not only present currently available data from open and controlled studies, but also include expert knowledge. Although the overall database has increased in size since 2011, definite conclusions regarding the efficacy and tolerability of DBS in TS are still open to debate. Therefore, we continue to consider DBS for TS as an experimental treatment that should be used only in carefully selected, severely affected and otherwise treatment-resistant patients.
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Affiliation(s)
- Natalia Szejko
- Department of Neurology, Medical University of Warsaw, Banacha 1a, 02-091, Warsaw, Poland.
- Department of Bioethics, Medical University of Warsaw, Banacha 1a, 02-091, Warsaw, Poland.
- Department of Neurology, Yale School of Medicine, Yale University, New Haven, USA.
| | - Yulia Worbe
- Department on Neurophysiology, Saint Antoine Hospital, Sorbonne Université, Paris, France
- National Reference Center for Tourette Disorder, Pitié Salpetiere Hospital, Paris, France
| | - Andreas Hartmann
- Department of Neurosurgery, Pitié-Salpetriere Hospital, Sorbonne Université, Paris, France
| | - Veerle Visser-Vandewalle
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Linda Ackermans
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Christos Ganos
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Mauro Porta
- Department of Neurosurgery and Neurology, IRCCS Instituto Ortopedico Galeazzi, Milan, Italy
| | - Albert F G Leentjens
- Department of Psychiatry, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan-Hinnerk Mehrkens
- Department of Neurosurgery, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Daniel Huys
- Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany
| | | | - Jens Kuhn
- Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Johanniter Hospital Oberhausen, Oberhausen, Germany
| | - Carine Karachi
- National Reference Center for Tourette Disorder, Pitié Salpetiere Hospital, Paris, France
- Department of Neurosurgery, Pitié-Salpetriere Hospital, Sorbonne Université, Paris, France
- Department of Neurology, Pitié-Salpetriere Hospital, Sorbonne Université, Paris, France
| | - Cécile Delorme
- Department of Neurosurgery, Pitié-Salpetriere Hospital, Sorbonne Université, Paris, France
| | - Thomas Foltynie
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
| | - Andrea E Cavanna
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Danielle Cath
- Department of Specialist Trainings, GGZ Drenthe Mental Health Institution, Assen, The Netherlands
- Department of Psychiatry, University Medical Center Groningen, Rijks University Groningen, Groningen, The Netherlands
| | - Kirsten Müller-Vahl
- Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
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10
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Torres Diaz CV, González-Escamilla G, Ciolac D, Navas García M, Pulido Rivas P, Sola RG, Barbosa A, Pastor J, Vega-Zelaya L, Groppa S. Network Substrates of Centromedian Nucleus Deep Brain Stimulation in Generalized Pharmacoresistant Epilepsy. Neurotherapeutics 2021; 18:1665-1677. [PMID: 33904113 PMCID: PMC8608991 DOI: 10.1007/s13311-021-01057-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2021] [Indexed: 02/04/2023] Open
Abstract
Deep brain stimulation (DBS), specifically thalamic DBS, has achieved promising results to reduce seizure severity and frequency in pharmacoresistant epilepsies, thereby establishing it for clinical use. The mechanisms of action are, however, still unknown. We evidenced the brain networks directly modulated by centromedian (CM) nucleus-DBS and responsible for clinical outcomes in a cohort of patients uniquely diagnosed with generalized pharmacoresistant epilepsy. Preoperative imaging and long-term (2-11 years) clinical data from ten generalized pharmacoresistant epilepsy patients (mean age at surgery = 30.8 ± 5.9 years, 4 female) were evaluated. Volume of tissue activated (VTA) was included as seeds to reconstruct the targeted network to thalamic DBS from diffusion and functional imaging data. CM-DBS clinical outcome improvement (> 50%) appeared in 80% of patients and was tightly related to VTAs interconnected with a reticular system network encompassing sensorimotor and supplementary motor cortices, together with cerebellum/brainstem. Despite methodological differences, both structural and functional connectomes revealed the same targeted network. Our results demonstrate that CM-DBS outcome in generalized pharmacoresistant epilepsy is highly dependent on the individual connectivity profile, involving the cerebello-thalamo-cortical circuits. The proposed framework could be implemented in future studies to refine stereotactic implantation or the parameters for individualized neuromodulation.
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Affiliation(s)
| | - Gabriel González-Escamilla
- Movement Disorders and Neurostimulation, Department of Neurology, Focus Program Translational Neuroscience (FTN), University Medical Center of the Johannes Gutenberg University Mainz, Rhine Main Neuroscience Network (rmn2), Mainz, Germany.
| | - Dumitru Ciolac
- Movement Disorders and Neurostimulation, Department of Neurology, Focus Program Translational Neuroscience (FTN), University Medical Center of the Johannes Gutenberg University Mainz, Rhine Main Neuroscience Network (rmn2), Mainz, Germany
- Laboratory of Neurobiology and Medical Genetics, Nicolae Testemitanu, State University of Medicine and Pharmacy, Chisinau, Republic of Moldova
- Department of Neurology, Institute of Emergency Medicine, Chisinau, Republic of Moldova
| | - Marta Navas García
- Department of Neurosurgery, University Hospital La Princesa, Madrid, Spain
| | | | - Rafael G Sola
- Department of Neurosurgery, University Hospital La Princesa, Madrid, Spain
| | - Antonio Barbosa
- Department of Neuroradiology, University Hospital La Princesa, Madrid, Spain
| | - Jesús Pastor
- Department of Clinical, Neurophysiology University Hospital La Princesa, Madrid, Spain
| | - Lorena Vega-Zelaya
- Department of Clinical, Neurophysiology University Hospital La Princesa, Madrid, Spain
| | - Sergiu Groppa
- Movement Disorders and Neurostimulation, Department of Neurology, Focus Program Translational Neuroscience (FTN), University Medical Center of the Johannes Gutenberg University Mainz, Rhine Main Neuroscience Network (rmn2), Mainz, Germany
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11
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Price JB, Rusheen AE, Barath AS, Rojas Cabrera JM, Shin H, Chang SY, Kimble CJ, Bennet KE, Blaha CD, Lee KH, Oh Y. Clinical applications of neurochemical and electrophysiological measurements for closed-loop neurostimulation. Neurosurg Focus 2021; 49:E6. [PMID: 32610297 DOI: 10.3171/2020.4.focus20167] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 04/16/2020] [Indexed: 12/21/2022]
Abstract
The development of closed-loop deep brain stimulation (DBS) systems represents a significant opportunity for innovation in the clinical application of neurostimulation therapies. Despite the highly dynamic nature of neurological diseases, open-loop DBS applications are incapable of modifying parameters in real time to react to fluctuations in disease states. Thus, current practice for the designation of stimulation parameters, such as duration, amplitude, and pulse frequency, is an algorithmic process. Ideal stimulation parameters are highly individualized and must reflect both the specific disease presentation and the unique pathophysiology presented by the individual. Stimulation parameters currently require a lengthy trial-and-error process to achieve the maximal therapeutic effect and can only be modified during clinical visits. The major impediment to the development of automated, adaptive closed-loop systems involves the selection of highly specific disease-related biomarkers to provide feedback for the stimulation platform. This review explores the disease relevance of neurochemical and electrophysiological biomarkers for the development of closed-loop neurostimulation technologies. Electrophysiological biomarkers, such as local field potentials, have been used to monitor disease states. Real-time measurement of neurochemical substances may be similarly useful for disease characterization. Thus, the introduction of measurable neurochemical analytes has significantly expanded biomarker options for feedback-sensitive neuromodulation systems. The potential use of biomarker monitoring to advance neurostimulation approaches for treatment of Parkinson's disease, essential tremor, epilepsy, Tourette syndrome, obsessive-compulsive disorder, chronic pain, and depression is examined. Further, challenges and advances in the development of closed-loop neurostimulation technology are reviewed, as well as opportunities for next-generation closed-loop platforms.
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Affiliation(s)
| | - Aaron E Rusheen
- 1Department of Neurologic Surgery.,2Medical Scientist Training Program
| | | | | | | | | | | | - Kevin E Bennet
- 1Department of Neurologic Surgery.,3Division of Engineering, and
| | | | - Kendall H Lee
- 1Department of Neurologic Surgery.,4Department of Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
| | - Yoonbae Oh
- 1Department of Neurologic Surgery.,4Department of Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
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12
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Camprodon JA, Chou T, Testo AA, Deckersbach T, Scharf JM, Dougherty DD. Case Report: Deep Brain Stimulation to the Ventral Internal Capsule/Ventral Striatum Induces Repeated Transient Episodes of Voltage-Dependent Tourette-Like Behaviors. Front Hum Neurosci 2021; 14:590379. [PMID: 33568978 PMCID: PMC7869408 DOI: 10.3389/fnhum.2020.590379] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 12/15/2020] [Indexed: 11/26/2022] Open
Abstract
Deep Brain Stimulation (DBS) is an invasive device-based neuromodulation technique that allows the therapeutic direct stimulation of subcortical and deep cortical structures following the surgical placement of stimulating electrodes. DBS is approved by the U.S. Federal Drug Administration for the treatment of movement disorders and obsessive-compulsive disorder, while new indications, including Major Depressive Disorder (MDD), are in experimental development. We report the case of a patient with MDD who received DBS to the ventral internal capsule and ventral striatum bilaterally and presented with 2 weeks of voltage-dependent Tourette-like symptoms including brief transient episodes of abrupt-onset and progressively louder coprolalia and stuttered speech; tic-like motor behavior in his right arm and leg; rushes of anxiety, angry prosody, angry affect; and moderate amnesia without confusion. We describe the results of the inpatient neuropsychiatric workup leading to the diagnosis of iatrogenic voltage-dependent activation of cortico-subcortical circuits and discuss insights into the pathophysiology of Tourette as well as safety considerations raised by the case.
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Affiliation(s)
- Joan A Camprodon
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Tina Chou
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Abigail A Testo
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Thilo Deckersbach
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Jeremiah M Scharf
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Darin D Dougherty
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
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13
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Zhou B, Kuang W, Huang H, Zhu Y, Chen X, Li L, Yang P. Successful Treatment of Psychiatric Symptoms after Traumatic Brain Injury Using Deep Brain Stimulation to the Anterior Limb of Internal Capsule-Nucleus Accumbens. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE : THE OFFICIAL SCIENTIFIC JOURNAL OF THE KOREAN COLLEGE OF NEUROPSYCHOPHARMACOLOGY 2020; 18:636-640. [PMID: 33124598 PMCID: PMC7609219 DOI: 10.9758/cpn.2020.18.4.636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/06/2019] [Accepted: 07/29/2019] [Indexed: 11/23/2022]
Abstract
Psychiatric symptoms are common after traumatic brain injury (TBI), and some patients have poor drug therapeutic efficacy. We report a successfully treated case of psychiatric symptoms after TBI using deep brain stimulation (DBS) to the anterior limb of internal capsule (ALIC)-nucleus accumbens (NAc) in a 76-year-old woman. The patient suffered from auditory hallucination, mood changes, and insomnia caused by TBI. Psychological test assessment showed the scores of Hamilton Anxiety Scale, Hamilton Depression Scale and Positive and Negative Syndrome Scale were 30, 35, and 96 respectively. Head magnetic resonance imaging scan showed right temporal lobe encephalomalacia. Head magnetic resonance spectroscopy (MRS) showed bilateral basal ganglia choline increased relatively. After DBS to the ALIC-NAc, the target parameters were adjusted. The psychiatric symptoms were completely improved and the result of head MRS was normal in the end. The current report declares that DBS is reversible, adjustable and safe in the treatment of psychiatric symptoms caused by TBI. DBS to the ALIC-NAc should be considered as a possible treatment choice once a patient showed psychiatric symptoms after TBI.
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Affiliation(s)
- Bin Zhou
- Department of Neurosurgery, Brain Hospital of Hunan Province, Clinical Medical School of Hunan University of Chinese Medicine, China
| | - Weiping Kuang
- Department of Neurosurgery, Brain Hospital of Hunan Province, Clinical Medical School of Hunan University of Chinese Medicine, China
| | - Hongxing Huang
- Department of Neurosurgery, Brain Hospital of Hunan Province, Clinical Medical School of Hunan University of Chinese Medicine, China
| | - Yong Zhu
- Department of Neurosurgery, Brain Hospital of Hunan Province, Clinical Medical School of Hunan University of Chinese Medicine, China
| | - Xiaofeng Chen
- Department of Neurosurgery, Brain Hospital of Hunan Province, Clinical Medical School of Hunan University of Chinese Medicine, China
| | - Liang Li
- Provincial Key Laboratory of TCM Diagnostics, Hunan University of Chinese Medicine, Changsha, Hunan Province, China
| | - Ping Yang
- Department of Neurosurgery, Brain Hospital of Hunan Province, Clinical Medical School of Hunan University of Chinese Medicine, China
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14
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Abstract
Background:Tics, defined as quick, rapid, sudden, recurrent, non-rhythmic motor movements or vocalizations are required components of Tourette Syndrome (TS) - a complex disorder characterized by the presence of fluctuating, chronic motor and vocal tics, and the presence of co-existing neuropsychological problems. Despite many advances, the underlying pathophysiology of tics/TS remains unknown.Objective:To address a variety of controversies surrounding the pathophysiology of TS. More specifically: 1) the configuration of circuits likely involved; 2) the role of inhibitory influences on motor control; 3) the classification of tics as either goal-directed or habitual behaviors; 4) the potential anatomical site of origin, e.g. cortex, striatum, thalamus, cerebellum, or other(s); and 5) the role of specific neurotransmitters (dopamine, glutamate, GABA, and others) as possible mechanisms (Abstract figure).Methods:Existing evidence from current clinical, basic science, and animal model studies are reviewed to provide: 1) an expanded understanding of individual components and the complex integration of the Cortico-Basal Ganglia-Thalamo-Cortical (CBGTC) circuit - the pathway involved with motor control; and 2) scientific data directly addressing each of the aforementioned controversies regarding pathways, inhibition, classification, anatomy, and neurotransmitters.Conclusion:Until a definitive pathophysiological mechanism is identified, one functional approach is to consider that a disruption anywhere within CBGTC circuitry, or a brain region inputting to the motor circuit, can lead to an aberrant message arriving at the primary motor cortex and enabling a tic. Pharmacologic modulation may be therapeutically beneficial, even though it might not be directed toward the primary abnormality.
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Affiliation(s)
- Harvey S. Singer
- Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Farhan Augustine
- Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, United States
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15
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Deeb W, Malaty I. Deep Brain Stimulation for Tourette Syndrome: Potential Role in the Pediatric Population. J Child Neurol 2020; 35:155-165. [PMID: 31526168 DOI: 10.1177/0883073819872620] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Tourette syndrome (TS) is a complex neuropsychiatric disorder. Despite an expected natural history of improvement with age, many individuals continue to have severe tics and remain refractory to the current best pharmacologic and nonpharmacologic treatments. Deep brain stimulation (DBS) has emerged as a potential treatment option. This article reviews the published reports on the use of deep brain stimulation in Tourette syndrome revealing that 2 anatomical targets have been most commonly used: the centromedian thalamus and the globus pallidus internus. The evidence supports a significant clinical improvement of tics with deep brain stimulation, though the data are limited by the small number of patients and variable methodology employed. To bridge these limitations, the international Tourette syndrome deep brain stimulation database and registry have been created, fostering collaboration among multiple centers from 10 countries. By standardizing data collection, the database and registry are providing valuable insights into deep brain stimulation for Tourette syndrome. In conclusion, deep brain stimulation offers significant promise for the management of tics.
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Affiliation(s)
- Wissam Deeb
- University of Florida, Fixel Institute for Neurologic Disease, Gainesville, FL, USA
| | - Irene Malaty
- University of Florida, Fixel Institute for Neurologic Disease, Gainesville, FL, USA
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16
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Xu W, Zhang C, Deeb W, Patel B, Wu Y, Voon V, Okun MS, Sun B. Deep brain stimulation for Tourette's syndrome. Transl Neurodegener 2020; 9:4. [PMID: 31956406 PMCID: PMC6956485 DOI: 10.1186/s40035-020-0183-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 01/05/2020] [Indexed: 01/11/2023] Open
Abstract
Tourette syndrome (TS) is a childhood-onset neuropsychiatric disorder characterized by the presence of multiple motor and vocal tics. TS usually co-occurs with one or multiple psychiatric disorders. Although behavioral and pharmacological treatments for TS are available, some patients do not respond to the available treatments. For these patients, TS is a severe, chronic, and disabling disorder. In recent years, deep brain stimulation (DBS) of basal ganglia-thalamocortical networks has emerged as a promising intervention for refractory TS with or without psychiatric comorbidities. Three major challenges need to be addressed to move the field of DBS treatment for TS forward: (1) patient and DBS target selection, (2) ethical concerns with treating pediatric patients, and (3) DBS treatment optimization and improvement of individual patient outcomes (motor and phonic tics, as well as functioning and quality of life). The Tourette Association of America and the American Academy of Neurology have recently released their recommendations regarding surgical treatment for refractory TS. Here, we describe the challenges, advancements, and promises of the use of DBS in the treatment of TS. We summarize the results of clinical studies and discuss the ethical issues involved in treating pediatric patients. Our aim is to provide a better understanding of the feasibility, safety, selection process, and clinical effectiveness of DBS treatment for select cases of severe and medically intractable TS.
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Affiliation(s)
- Wenying Xu
- 1Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, 197 Ruijin Er Road, Shanghai, 200025 China
| | - Chencheng Zhang
- 1Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, 197 Ruijin Er Road, Shanghai, 200025 China
| | - Wissam Deeb
- 2Norman Fixel Institute for Neurological Diseases, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL 32608 USA
| | - Bhavana Patel
- 2Norman Fixel Institute for Neurological Diseases, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL 32608 USA
| | - Yiwen Wu
- 3Department of Neurology & Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Valerie Voon
- 1Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, 197 Ruijin Er Road, Shanghai, 200025 China.,4Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Michael S Okun
- 2Norman Fixel Institute for Neurological Diseases, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL 32608 USA
| | - Bomin Sun
- 1Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, 197 Ruijin Er Road, Shanghai, 200025 China
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17
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Li J, Li Y, Gutierrez L, Xu W, Wu Y, Liu C, Li D, Sun B, Zhang C, Wei H. Imaging the Centromedian Thalamic Nucleus Using Quantitative Susceptibility Mapping. Front Hum Neurosci 2020; 13:447. [PMID: 31998098 PMCID: PMC6962173 DOI: 10.3389/fnhum.2019.00447] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/05/2019] [Indexed: 11/13/2022] Open
Abstract
The centromedian (CM) nucleus is an intralaminar thalamic nucleus that is considered as a potentially effective target of deep brain stimulation (DBS) and ablative surgeries for the treatment of multiple neurological and psychiatric disorders. However, the structure of CM is invisible on the standard T1- and T2-weighted (T1w and T2w) magnetic resonance images, which hamper it as a direct DBS target for clinical applications. The purpose of the current study is to demonstrate the use of quantitative susceptibility mapping (QSM) technique to image the CM within the thalamic region. Twelve patients with Parkinson's disease, dystonia, or schizophrenia were included in this study. A 3D multi-echo gradient recalled echo (GRE) sequence was acquired together with T1w and T2w images on a 3-T MR scanner. The QSM image was reconstructed from the GRE phase data. Direct visual inspection of the CM was made on T1w, T2w, and QSM images. Furthermore, the contrast-to-noise ratios (CNRs) of the CM to the adjacent posterior part of thalamus on T1w, T2w, and QSM images were compared using the one-way analysis of variance (ANOVA) test. QSM dramatically improved the visualization of the CM nucleus. Clear delineation of CM compared to the surroundings was observed on QSM but not on T1w and T2w images. Statistical analysis showed that the CNR on QSM was significantly higher than those on T1w and T2w images. Taken together, our results indicate that QSM is a promising technique for improving the visualization of CM as a direct targeting for DBS surgery.
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Affiliation(s)
- Jun Li
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yufei Li
- Institute for Medical Imaging Technology, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Lorenzo Gutierrez
- Institute for Medical Imaging Technology, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Wenying Xu
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yiwen Wu
- Department of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chunlei Liu
- Department of Electrical Engineering and Computer Sciences, University of California, Berkeley, Berkeley, CA, United States.,Helen Wills Neuroscience Institute, University of California, Berkeley, Berkeley, CA, United States
| | - Dianyou Li
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bomin Sun
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chencheng Zhang
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongjiang Wei
- Institute for Medical Imaging Technology, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
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18
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Elle T, Alam M, Voigt C, Krauss JK, John N, Schwabe K. Deep brain stimulation of the thalamic centromedian-parafascicular nucleus improves behavioural and neuronal traits in a rat model of Tourette. Behav Brain Res 2020; 378:112251. [DOI: 10.1016/j.bbr.2019.112251] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 09/17/2019] [Accepted: 09/17/2019] [Indexed: 01/23/2023]
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19
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Mandelbaum G, Taranda J, Haynes TM, Hochbaum DR, Huang KW, Hyun M, Umadevi Venkataraju K, Straub C, Wang W, Robertson K, Osten P, Sabatini BL. Distinct Cortical-Thalamic-Striatal Circuits through the Parafascicular Nucleus. Neuron 2019; 102:636-652.e7. [PMID: 30905392 DOI: 10.1016/j.neuron.2019.02.035] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 01/03/2019] [Accepted: 02/20/2019] [Indexed: 01/08/2023]
Abstract
The thalamic parafascicular nucleus (PF), an excitatory input to the basal ganglia, is targeted with deep-brain stimulation to alleviate a range of neuropsychiatric symptoms. Furthermore, PF lesions disrupt the execution of correct motor actions in uncertain environments. Nevertheless, the circuitry of the PF and its contribution to action selection are poorly understood. We find that, in mice, PF has the highest density of striatum-projecting neurons among all sub-cortical structures. This projection arises from transcriptionally and physiologically distinct classes of PF neurons that are also reciprocally connected with functionally distinct cortical regions, differentially innervate striatal neurons, and are not synaptically connected in PF. Thus, mouse PF contains heterogeneous neurons that are organized into parallel and independent associative, limbic, and somatosensory circuits. Furthermore, these subcircuits share motifs of cortical-PF-cortical and cortical-PF-striatum organization that allow each PF subregion, via its precise connectivity with cortex, to coordinate diverse inputs to striatum.
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Affiliation(s)
- Gil Mandelbaum
- Howard Hughes Medical Institute, Department of Neurobiology, Harvard Medical School, Boston, MA 02115, USA
| | - Julian Taranda
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724, USA
| | - Trevor M Haynes
- Howard Hughes Medical Institute, Department of Neurobiology, Harvard Medical School, Boston, MA 02115, USA
| | - Daniel R Hochbaum
- Howard Hughes Medical Institute, Department of Neurobiology, Harvard Medical School, Boston, MA 02115, USA; Society of Fellows, Harvard University, Cambridge, MA 02138, USA
| | - Kee Wui Huang
- Howard Hughes Medical Institute, Department of Neurobiology, Harvard Medical School, Boston, MA 02115, USA
| | - Minsuk Hyun
- Howard Hughes Medical Institute, Department of Neurobiology, Harvard Medical School, Boston, MA 02115, USA
| | | | - Christoph Straub
- Howard Hughes Medical Institute, Department of Neurobiology, Harvard Medical School, Boston, MA 02115, USA
| | - Wengang Wang
- Howard Hughes Medical Institute, Department of Neurobiology, Harvard Medical School, Boston, MA 02115, USA
| | - Keiramarie Robertson
- Howard Hughes Medical Institute, Department of Neurobiology, Harvard Medical School, Boston, MA 02115, USA
| | - Pavel Osten
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724, USA
| | - Bernardo L Sabatini
- Howard Hughes Medical Institute, Department of Neurobiology, Harvard Medical School, Boston, MA 02115, USA.
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20
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Ilyas A, Pizarro D, Romeo AK, Riley KO, Pati S. The centromedian nucleus: Anatomy, physiology, and clinical implications. J Clin Neurosci 2019; 63:1-7. [PMID: 30827880 DOI: 10.1016/j.jocn.2019.01.050] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 01/30/2019] [Indexed: 02/02/2023]
Abstract
Of all the truncothalamic nuclei, the centromedian-parafascicular nuclei complex (CM-Pf) is the largest and is considered the prototypic thalamic projection system. Located among the caudal intralaminar thalamic nuclei, the CM-Pf been described by Jones as "the forgotten components of the great loop of connections joining the cerebral cortex via the basal ganglia". The CM, located lateral relative to the Pf, is a major source of direct input to the striatum and also has connections to other, distinct region of the basal ganglia as well as the brainstem and cortex. Functionally, the CM participates in sensorimotor coordination, cognition (e.g. attention, arousal), and pain processing. The role of CM as 'gate control' function by propagating only salient stimuli during attention-demanding tasks has been proposed. Given its rich connectivity and diverse physiologic role, recent studies have explored the CM as potential target for neuromodulation therapy for Tourette syndrome, Parkinson's disease, generalized epilepsy, intractable neuropathic pain, and in restoring consciousness. This comprehensive review summarizes the structural and functional anatomy of the CM and its physiologic role with a focus on clinical implications.
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Affiliation(s)
- Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Diana Pizarro
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Andrew K Romeo
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kristen O Riley
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Sandipan Pati
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
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21
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Marano M, Migliore S, Squitieri F, Insola A, Scarnati E, Mazzone P. CM-Pf deep brain stimulation and the long term management of motor and psychiatric symptoms in a case of Tourette syndrome. J Clin Neurosci 2019; 62:269-272. [PMID: 30612913 DOI: 10.1016/j.jocn.2018.12.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 12/23/2018] [Indexed: 11/18/2022]
Abstract
Tourette syndrome is a rare neuropsychiatric disorder affecting the cortico-striato-thalamo-cortical system. The disease manifests in childhood with tics and various psychiatric comorbidities. Cases of refractory Tourette syndrome are valuable candidates for functional neurosurgery. The thalamic centromedian-parafascicular complex is an experimental target that shows a promising role in Tourette syndrome deep brain stimulation, due to pathophysiologic evidences. We have shown on a long term follow-up, that thalamic deep brain stimulation, targeted on the centromedian-parafascicular complex, could modulate motor (i.e. tics) symptoms and owns a putative effect on various psychiatric aspects. Non-responding psychiatric symptoms could be due to the aberrant developmental environment of young Tourette patients more than disease itself. Centromedian-parafascicular complex is intriguingly embedded in motor, associative and limbic pathways and should be further investigated in his role for neuromodulation of human movement and behavior.
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Affiliation(s)
- Massimo Marano
- Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine, Campus Bio-Medico of Rome University, Via Alvaro del Portillo, 21, 00128 Rome, Italy.
| | - Simone Migliore
- Huntington and Rare Diseases Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, Viale Cappuccini, 1, 71013 San Giovanni Rotondo, Italy
| | - Ferdinando Squitieri
- Huntington and Rare Diseases Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, Viale Cappuccini, 1, 71013 San Giovanni Rotondo, Italy
| | | | - Eugenio Scarnati
- Department of Applied Clinical Sciences and Biotechnology, DISCAB, University of l'Aquila, Viale Vetoio Coppito, l'Aquila 67100, Italy
| | - Paolo Mazzone
- Functional Neurosurgery and DBS, Centro Chirurgico Toscano, Via dei Lecci, 22, 52100 Arezzo, Italy
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22
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Coulombe MA, Elkaim LM, Alotaibi NM, Gorman DA, Weil AG, Fallah A, Kalia SK, Lipsman N, Lozano AM, Ibrahim GM. Deep brain stimulation for Gilles de la Tourette syndrome in children and youth: a meta-analysis with individual participant data. J Neurosurg Pediatr 2018; 23:236-246. [PMID: 30497215 DOI: 10.3171/2018.7.peds18300] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 07/25/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Gilles de la Tourette syndrome (GTS) is a disorder characterized by motor and vocal tics. Although by definition the onset of GTS is before age 18 years, clinical trials of deep brain stimulation (DBS) have been conducted only in adults. Using individual participant data (IPD) meta-analysis methodology, the current study investigated the safety and efficacy of DBS as a treatment for GTS in children and youth. METHODS A systematic review with no date or language restrictions was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Three electronic databases were searched: PubMed, EMBASE, and Web of Science. From 843 articles screened, the IPD of 58 children and youth (ages 12–21 years) extracted from 21 articles were collected and analyzed. A mixed-effects univariable analysis followed by multivariable hierarchical regression was performed using change in the Yale Global Tic Severity Scale (YGTSS) score as the primary outcome and reported measures of comorbidities as secondary outcomes. RESULTS The authors’ results showed an average improvement of 57.5% ± 24.6% across studies on the YGTSS. They also found that comorbid depression and stimulation pulse width each correlated negatively with outcome (p < 0.05). In patients with less severe GTS, greater improvements were evident following thalamic stimulation. More than one-quarter (n = 16, 27.6%) of participants experienced side effects, the majority of which were minor. CONCLUSIONS DBS in the pediatric population may be an effective option with a moderate safety profile for treatment of GTS in carefully selected children and youth. Large, prospective studies with long-term follow-up are necessary to understand how DBS influences tic symptoms and may alter the natural course of GTS in children.
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Affiliation(s)
| | | | - Naif M Alotaibi
- Department of Surgery, University of Toronto.,Division of Neurosurgery, Toronto Western Hospital, Krembil Neuroscience Institute, Toronto; and
| | - Daniel A Gorman
- Department of Psychiatry, The Hospital for Sick Children, University of Toronto, Ontario
| | - Alexander G Weil
- Faculty of Medicine, Université de Montréal, Quebec.,Division of Neurosurgery, Sainte Justine Hospital, Montreal, Quebec, Canada
| | - Aria Fallah
- Department of Neurosurgery, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Suneil K Kalia
- Department of Surgery, University of Toronto.,Division of Neurosurgery, Toronto Western Hospital, Krembil Neuroscience Institute, Toronto; and
| | - Nir Lipsman
- Department of Surgery, University of Toronto.,Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto; and
| | - Andres M Lozano
- Department of Surgery, University of Toronto.,Division of Neurosurgery, Toronto Western Hospital, Krembil Neuroscience Institute, Toronto; and
| | - George M Ibrahim
- Department of Surgery, University of Toronto.,Division of Neurosurgery, The Hospital for Sick Children, The Hospital for Sick Children Research Institute, Program in Neuroscience and Mental Health, Toronto, Ontario, Canada
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23
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Schwabe K, Krauss JK. What rodent models of deep brain stimulation can teach us about the neural circuit regulation of prepulse inhibition in neuropsychiatric disorders. Schizophr Res 2018; 198:45-51. [PMID: 28663025 DOI: 10.1016/j.schres.2017.06.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 06/16/2017] [Accepted: 06/19/2017] [Indexed: 11/29/2022]
Abstract
Deep brain stimulation (DBS) is routinely used for treatment of movement disorders and it is also under investigation for neuropsychiatric disorders with deficient sensorimotor gating, such as schizophrenia, Tourette's syndrome and obsessive compulsive disorder. Electrical stimulation induces excitation and inhibition both at the stimulation site and at projection sites, thus modulating synchrony and oscillatory behavior of neuronal networks. We first provide background information on DBS in neuropsychiatric disorders accompanied by deficient sensorimotor gating. We then introduce prepulse inhibition (PPI) as a measure for sensorimotor gating in these disorders. Thereafter, we report on the use of DBS in rat models with deficient PPI induced by pharmacologic, genetic and neurodevelopmental manipulation. These models offer the opportunity to define the neuronal circuit regulation that is of relevance to PPI and its deficits in neuropsychiatric disorders with disturbed sensorimotor gating. Finally, we report on the use of the PPI paradigm in human patients operated for DBS on/off stimulation, which may further elucidate the neuronal network involved in regulation of PPI.
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Affiliation(s)
- Kerstin Schwabe
- Department of Neurosurgery, Medical University Hannover, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany.
| | - Joachim K Krauss
- Department of Neurosurgery, Medical University Hannover, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany.
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24
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Cenci MA, Jörntell H, Petersson P. On the neuronal circuitry mediating L-DOPA-induced dyskinesia. J Neural Transm (Vienna) 2018; 125:1157-1169. [PMID: 29704061 PMCID: PMC6060876 DOI: 10.1007/s00702-018-1886-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/17/2018] [Indexed: 11/27/2022]
Abstract
With the advent of rodent models of l-DOPA-induced dyskinesia (LID), a growing literature has linked molecular changes in the striatum to the development and expression of abnormal involuntary movements. Changes in information processing at the striatal level are assumed to impact on the activity of downstream basal ganglia nuclei, which in turn influence brain-wide networks, but very little is actually known about systems-level mechanisms of dyskinesia. As an aid to approach this topic, we here review the anatomical and physiological organisation of cortico-basal ganglia-thalamocortical circuits, and the changes affecting these circuits in animal models of parkinsonism and LID. We then review recent findings indicating that an abnormal cerebellar compensation plays a causal role in LID, and that structures outside of the classical motor circuits are implicated too. In summarizing the available data, we also propose hypotheses and identify important knowledge gaps worthy of further investigation. In addition to informing novel therapeutic approaches, the study of LID can provide new clues about the interplay between different brain circuits in the control of movement.
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Affiliation(s)
- M Angela Cenci
- Basal Ganglia Pathophysiology Unit, Department Experimental Medical Science, Lund University, Lund, Sweden.
| | - Henrik Jörntell
- Neural Basis of Sensorimotor Control, Department Experimental Medical Science, Lund University, Lund, Sweden
| | - Per Petersson
- The Group for Integrative Neurophysiology and Neurotechnology, Neuronano Research Centre, Department Experimental Medical Science, Lund University, Lund, Sweden
- Department of Integrative Medical Biology, Umeå University, Umeå, Sweden
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25
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Fazl A, Fleisher J. Anatomy, Physiology, and Clinical Syndromes of the Basal Ganglia: A Brief Review. Semin Pediatr Neurol 2018; 25:2-9. [PMID: 29735113 PMCID: PMC6039104 DOI: 10.1016/j.spen.2017.12.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Movement disorders typically arise from dysfunction of the basal ganglia (BG), cerebellum, or both. The BG-a group of deep, subcortical structures-form complex circuits that shape motor control and motor learning, as well as limbic and associative functions. In this article, we summarize the anatomy and physiology of the BG and cerebellum, and briefly highlight the clinical syndromes that may arise in the context of their injury or dysfunction.
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Affiliation(s)
- Arash Fazl
- Department of Neurology, Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders at NYU Langone Health, New York University School of Medicine, New York, NY
| | - Jori Fleisher
- Department of Neurology, Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders at NYU Langone Health, New York University School of Medicine, New York, NY; Department of Neurological Sciences, Section of Movement Disorders, Rush Medical College, Rush Medical University, Chicago, IL.
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26
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Jo HJ, McCairn KW, Gibson WS, Testini P, Zhao CZ, Gorny KR, Felmlee JP, Welker KM, Blaha CD, Klassen BT, Min HK, Lee KH. Global network modulation during thalamic stimulation for Tourette syndrome. NEUROIMAGE-CLINICAL 2018; 18:502-509. [PMID: 29560306 PMCID: PMC5857897 DOI: 10.1016/j.nicl.2018.02.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 02/09/2018] [Accepted: 02/18/2018] [Indexed: 12/14/2022]
Abstract
Background and objectives Deep brain stimulation (DBS) of the thalamus is a promising therapeutic alternative for treating medically refractory Tourette syndrome (TS). However, few human studies have examined its mechanism of action. Therefore, the networks that mediate the therapeutic effects of thalamic DBS remain poorly understood. Methods Five participants diagnosed with severe medically refractory TS underwent bilateral thalamic DBS stereotactic surgery. Intraoperative fMRI characterized the blood oxygen level-dependent (BOLD) response evoked by thalamic DBS and determined whether the therapeutic effectiveness of thalamic DBS, as assessed using the Modified Rush Video Rating Scale test, would correlate with evoked BOLD responses in motor and limbic cortical and subcortical regions. Results Our results reveal that thalamic stimulation in TS participants has wide-ranging effects that impact the frontostriatal, limbic, and motor networks. Thalamic stimulation induced suppression of motor and insula networks correlated with motor tic reduction, while suppression of frontal and parietal networks correlated with vocal tic reduction. These regions mapped closely to major regions of interest (ROI) identified in a nonhuman primate model of TS. Conclusions Overall, these findings suggest that a critical factor in TS treatment should involve modulation of both frontostriatal and motor networks, rather than be treated as a focal disorder of the brain. Using the novel combination of DBS-evoked tic reduction and fMRI in human subjects, we provide new insights into the basal ganglia-cerebellar-thalamo-cortical network-level mechanisms that influence the effects of thalamic DBS. Future translational research should identify whether these network changes are cause or effect of TS symptoms.
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Affiliation(s)
- Hang Joon Jo
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
| | - Kevin W McCairn
- Systems Neuroscience Section, Primate Research Institute, Kyoto University, Inuyama, Aichi 484-8506, Japan
| | - William S Gibson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Paola Testini
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Cong Zhi Zhao
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Joel P Felmlee
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA
| | - Kirk M Welker
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA
| | - Charles D Blaha
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Bryan T Klassen
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
| | - Hoon-Ki Min
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN 55905, USA.
| | - Kendall H Lee
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA; Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN 55905, USA.
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27
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Ogundele MO, Ayyash HF. Review of the evidence for the management of co-morbid Tic disorders in children and adolescents with attention deficit hyperactivity disorder. World J Clin Pediatr 2018; 7:36-42. [PMID: 29456930 PMCID: PMC5803563 DOI: 10.5409/wjcp.v7.i1.36] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 11/28/2017] [Accepted: 12/06/2017] [Indexed: 02/06/2023] Open
Abstract
Attention deficit hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder in children and adolescents, with prevalence ranging between 5% and 12% in the developed countries. Tic disorders (TD) are common co-morbidities in paediatric ADHD patients with or without pharmacotherapy treatment. There has been conflicting evidence of the role of psychostimulants in either precipitating or exacerbating TDs in ADHD patients. We carried out a literature review relating to the management of TDs in children and adolescents with ADHD through a comprehensive search of MEDLINE, EMBASE, CINAHL and Cochrane databases. No quantitative synthesis (meta-analysis) was deemed appropriate. Meta-analysis of controlled trials does not support an association between new onset or worsening of tics and normal doses of psychostimulant use. Supratherapeutic doses of dextroamphetamine have been shown to exacerbate TD. Most tics are mild or moderate and respond to psychoeducation and behavioural management. Level A evidence support the use of alpha adrenergic agonists, including Clonidine and Guanfacine, reuptake noradrenenaline inhibitors (Atomoxetine) and stimulants (Methylphenidate and Dexamphetamines) for the treatment of Tics and comorbid ADHD. Priority should be given to the management of co-morbid Tourette’s syndrome (TS) or severely disabling tics in children and adolescents with ADHD. Severe TDs may require antipsychotic treatment. Antipsychotics, especially Aripiprazole, are safe and effective treatment for TS or severe Tics, but they only moderately control the co-occurring ADHD symptomatology. Short vignettes of different common clinical scenarios are presented to help clinicians determine the most appropriate treatment to consider in each patient presenting with ADHD and co-morbid TDs.
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Affiliation(s)
- Michael O Ogundele
- Department of Community Paediatrics, NHS Fife, Glenwood Health Centre, Glenrothes KY6 1HK, United Kingdom
| | - Hani F Ayyash
- Cambridgeshire and Peterborough NHS Foundation Trust, Peterborough Integrated Neurodevelopmental Service, University of Cambridge Health Partners, Cambridge CB21 5EF, United Kingdom
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