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Nataraj J, MacLean JA, Davies J, Kurtz J, Salisbury A, Liker MA, Sanger TD, Olaya J. Application of deep brain stimulation for the treatment of childhood-onset dystonia in patients with MEPAN syndrome. Front Neurol 2024; 14:1307595. [PMID: 38328756 PMCID: PMC10847241 DOI: 10.3389/fneur.2023.1307595] [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: 10/04/2023] [Accepted: 12/27/2023] [Indexed: 02/09/2024] Open
Abstract
Introduction Mitochondrial Enoyl CoA Reductase Protein-Associated Neurodegeneration (MEPAN) syndrome is a rare inherited metabolic condition caused by MECR gene mutations. This gene encodes a protein essential for fatty acid synthesis, and defects cause progressively worsening childhood-onset dystonia, optic atrophy, and basal ganglia abnormalities. Deep brain stimulation (DBS) has shown mixed improvement in other childhood-onset dystonia conditions. To the best of our knowledge, DBS has not been investigated as a treatment for dystonia in patients with MEPAN syndrome. Methods Two children with MEPAN were identified as possible DBS candidates due to severe generalized dystonia unresponsive to pharmacotherapy. Temporary depth electrodes were placed in six locations bilaterally and tested during a 6-day hospitalization to determine the best locations for permanent electrode placement. The Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) and Barry-Albright Dystonia Scale (BADS) were used for preoperative and postoperative testing to quantitatively assess dystonia severity changes. Patient 1 had permanent electrodes placed at the globus pallidus internus (GPi) and pedunculopontine nucleus (PPN). Patient 2 had permanent electrodes placed at the GPi and ventralis intermedius nucleus of the thalamus (VIM). Results Both patients successfully underwent DBS placement with no perioperative complications and significant improvement in their BFMDRS score. Patient 2 also demonstrated improvement in the BADS. Discussion We demonstrated a novel application of DBS in MEPAN syndrome patients with childhood-onset dystonia. These patients showed clinically significant improvements in dystonia following DBS, indicating that DBS can be considered for dystonia in patients with rare metabolic disorders that currently have no other proven treatment options.
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Affiliation(s)
- Jaya Nataraj
- Samueli School of Engineering, University of California Irvine, Irvine, CA, United States
- Research Institute, Children’s Hospital of Orange County, Orange, CA, United States
| | - Jennifer A. MacLean
- Research Institute, Children’s Hospital of Orange County, Orange, CA, United States
- Department of Neurology, Children’s Hospital of Orange County, Orange, CA, United States
| | - Jordan Davies
- Division of Neurosurgery, Children’s Hospital of Orange County, Orange, CA, United States
- Department of Neurological Surgery, School of Medicine, University of California Irvine, Irvine, CA, United States
| | - Joshua Kurtz
- School of Medicine, University of California Irvine, Irvine, CA, United States
| | - Amanda Salisbury
- Research Institute, Children’s Hospital of Orange County, Orange, CA, United States
| | - Mark A. Liker
- Division of Neurosurgery, Children’s Hospital of Orange County, Orange, CA, United States
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Terence D. Sanger
- Samueli School of Engineering, University of California Irvine, Irvine, CA, United States
- Research Institute, Children’s Hospital of Orange County, Orange, CA, United States
- Department of Neurology, Children’s Hospital of Orange County, Orange, CA, United States
- Department of Pediatrics, School of Medicine, University of California Irvine, Irvine, CA, United States
| | - Joffre Olaya
- Division of Neurosurgery, Children’s Hospital of Orange County, Orange, CA, United States
- Department of Neurological Surgery, School of Medicine, University of California Irvine, Irvine, CA, United States
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Liker MA, Sanger TD, MacLean JA, Nataraj J, Arguelles E, Krieger M, Robison A, Olaya J. Stereotactic Awake Basal Ganglia Electrophysiological Recording and Stimulation (SABERS): A Novel Staged Procedure for Personalized Targeting of Deep Brain Stimulation in Pediatric Movement and Neuropsychiatric Disorders. J Child Neurol 2024; 39:33-44. [PMID: 38409793 DOI: 10.1177/08830738231224057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Selection of targets for deep brain stimulation (DBS) has been based on clinical experience, but inconsistent and unpredictable outcomes have limited its use in patients with heterogeneous or rare disorders. In this large case series, a novel staged procedure for neurophysiological assessment from 8 to 12 temporary depth electrodes is used to select targets for neuromodulation that are tailored to each patient's functional needs. Thirty children and young adults underwent deep brain stimulation target evaluation with the new procedure: Stereotactic Awake Basal ganglia Electrophysiological Recording and Stimulation (SABERS). Testing is performed in an inpatient neuromodulation monitoring unit over 5-7 days, and results guide the decision to proceed and the choice of targets for permanent deep brain stimulation implantation. Results were evaluated 3-6 months postoperatively with the Burke-Fahn-Marsden Dystonia Rating Scale and the Barry-Albright Dystonia Scale. Stereotactic Awake Basal ganglia Electrophysiological Recording and Stimulation testing allowed modulation to be tailored to specific neurologic deficits in a heterogeneous population, including subjects with primary dystonia, secondary dystonia, and Tourette syndrome. All but one subject were implanted with 4 permanent deep brain stimulation leads. Results showed significant improvement on both scales at postoperative follow-up. No significant adverse events occurred. Use of the Stereotactic Awake Basal ganglia Electrophysiological Recording and Stimulation protocol with evaluation in the neuromodulation monitoring unit is feasible and results in significant patient benefit compared with previously published results in these populations. This new technique supports a significant expansion of functional neurosurgery to predict effective stimulation targets in a wide range of disorders of brain function, including those for which the optimal target is not yet known.
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Affiliation(s)
- Mark A Liker
- Divison of Neurosurgery, Children's Hospital of Orange County, Orange, CA, USA
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Terence D Sanger
- Samueli School of Engineering, University of California Irvine, Irvine, CA, USA
- Research Institute, Children's Hospital of Orange County, Orange, CA, USA
- Department of Pediatrics, School of Medicine, University of California Irvine, Irvine, CA, USA
- Department of Neurology, Children's Hospital of Orange County, Orange, CA, USA
| | - Jennifer A MacLean
- Research Institute, Children's Hospital of Orange County, Orange, CA, USA
- Department of Neurology, Children's Hospital of Orange County, Orange, CA, USA
| | - Jaya Nataraj
- Samueli School of Engineering, University of California Irvine, Irvine, CA, USA
| | - Enrique Arguelles
- Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, USA
| | - Mark Krieger
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Aaron Robison
- Department of Neurosurgery, School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Joffre Olaya
- Divison of Neurosurgery, Children's Hospital of Orange County, Orange, CA, USA
- Department of Neurological Surgery, School of Medicine, University of California Irvine, Irvine, CA, USA
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MacLean JA, Nataraj J, Davies J, Zakharova A, Kurtz J, Liker MA, Olaya J, Sanger TD. Novel utilization of deep brain stimulation in the pedunculopontine nucleus with globus pallidus internus for treatment of childhood-onset dystonia. Front Hum Neurosci 2023; 17:1270430. [PMID: 37929227 PMCID: PMC10625402 DOI: 10.3389/fnhum.2023.1270430] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/28/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction Deep brain stimulation (DBS) is a well-documented therapy for dystonia utilized in many adult and pediatric movement disorders. Pedunculopontine nucleus (PPN) has been investigated as a DBS target primarily in adult patients with dystonia or dyskinesias from Parkinson's disease, showing improvement in postural instability and gait dysfunction. Due to the difficulty in targeting PPN using standard techniques, it is not commonly chosen as a target for adult or pediatric pathology. There is no current literature describing the targeting of PPN in DBS for childhood-onset dystonia. Methods Two pediatric and one young adult patient with childhood-onset dystonia who underwent DBS implantation at our institution were identified. Patient 1 has Mitochondrial Enoyl CoA Reductase Protein-Associated Neurodegeneration (MEPAN) syndrome. Patient 2 has Glutaric Aciduria Type 1 (GA1). Patient 3 has atypical pantothenate kinase-associated neurodegeneration (PKAN). PPN was identified as a potential target for these patients due to axial or orofacial dystonia. Pre- and post-operative videos taken as part of routine clinical assessments were evaluated and scored on the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) and Barry-Albright Dystonia Scale (BADS). All patients had permanent electrodes placed bilaterally in PPN and globus pallidus internus (GPi). A Likert scale on quality of life was also obtained from the patient/parents as applicable. Results Significant programming was necessary over the first 3-12 months to optimize patients' response to stimulation. All patients experienced at least a 34% improvement in the BFMDRS score. Patients 2 and 3 also experienced an over 30% improvement in BADS score. All patients/parents appreciated improvement in quality of life postoperatively. Discussion Deep brain stimulation in PPN was safely and successfully used in two pediatric patients and one young adult patient with childhood-onset dystonia. These patients showed clinically significant improvements in BFMDRS scoring post operatively. This represents the first reported DBS targeting of PPN in pediatric patients, and suggests that PPN is a possible target for pediatric-onset dystonia with axial and orofacial symptoms that may be refractory to traditional pallidal stimulation alone.
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Affiliation(s)
- Jennifer A. MacLean
- Department of Neurology, Children’s Hospital of Orange County, Orange, CA, United States
- Research Institute, Children’s Hospital of Orange County, Orange, CA, United States
| | - Jaya Nataraj
- Samueli School of Engineering, University of California, Irvine, Irvine, CA, United States
| | - Jordan Davies
- Division of Neurosurgery, Children’s Hospital of Orange County, Orange, CA, United States
- Department of Neurological Surgery, School of Medicine, University of California, Irvine, Irvine, CA, United States
| | - Aleksandra Zakharova
- Department of Neurology, Children’s Hospital of Orange County, Orange, CA, United States
- Unit of Pediatric Neurology, Faculty of Medicine Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile
| | - Joshua Kurtz
- School of Medicine, University of California, Irvine, Irvine, CA, United States
| | - Mark A. Liker
- Division of Neurosurgery, Children’s Hospital of Orange County, Orange, CA, United States
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Joffre Olaya
- Division of Neurosurgery, Children’s Hospital of Orange County, Orange, CA, United States
- Department of Neurological Surgery, School of Medicine, University of California, Irvine, Irvine, CA, United States
| | - Terence D. Sanger
- Department of Neurology, Children’s Hospital of Orange County, Orange, CA, United States
- Research Institute, Children’s Hospital of Orange County, Orange, CA, United States
- Samueli School of Engineering, University of California, Irvine, Irvine, CA, United States
- Department of Pediatrics, School of Medicine, University of California, Irvine, Irvine, CA, United States
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MacLean JA, Nataraj J, Olaya J, Liker MA, Sanger TD. Deep brain stimulation in an adolescent with hypomyelination with atrophy of the basal ganglia and cerebellum due to a TUBB4A mutation: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2023; 6:CASE23158. [PMID: 37458337 PMCID: PMC10555642 DOI: 10.3171/case23158] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 06/12/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Hypomyelination with atrophy of the basal ganglia and cerebellum (H-ABC) is a rare genetic disease due to a TUBB4A mutation, with motor features including dystonia. Deep brain stimulation (DBS) can be used to treat dystonia in pediatric populations, although the response is highly variable and preferential toward specific etiologies. OBSERVATIONS A single pediatric subject with H-ABC received DBS using a staged procedure involving temporary depth electrode placement, identification of optimal stimulation targets, and permanent electrode implantation. After surgery, the patient significantly improved on both the Burke-Fahn-Marsden Dystonia Rating Scale and the Barry-Albright Dystonia Scale. The patient's response suggests that DBS can have potential benefit in H-ABC. LESSONS TUBB4A mutations are associated with a variety of clinical phenotypes, and there is a lack of clearly identified targets for DBS, with this case being the second reported instance of DBS in this condition. The staged procedure with temporary depth electrode testing is recommended to identify optimal stimulation targets. The response seen in this patient implies that such a staged procedure may provide benefit in other conditions where DBS targets are currently unknown, including rare genetic or metabolic conditions associated with movement disorders.
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Affiliation(s)
- Jennifer A. MacLean
- Department of Neurology, Children’s Hospital of Orange County, Orange, California
- Research Department, Children’s Hospital of Orange County, Orange, California
| | - Jaya Nataraj
- Henry Samueli School of Engineering, University of California Irvine, Irvine, California
| | - Joffre Olaya
- Divison of Neurosurgery, Children’s Hospital of Orange County, Orange, California
- Departments of Neurological Surgery and
| | - Mark A. Liker
- Divison of Neurosurgery, Children’s Hospital of Orange County, Orange, California
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California Los Angeles, Los Angeles, California
| | - Terence D. Sanger
- Department of Neurology, Children’s Hospital of Orange County, Orange, California
- Research Department, Children’s Hospital of Orange County, Orange, California
- Henry Samueli School of Engineering, University of California Irvine, Irvine, California
- Pediatrics, School of Medicine, University of California Irvine, Irvine, California; and
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Hartmann A, Andrén P, Atkinson-Clement C, Czernecki V, Delorme C, Debes NM, Szejko N, Ueda K, Black K. Tourette syndrome research highlights from 2021. F1000Res 2022; 11:716. [PMID: 35923292 PMCID: PMC9315233 DOI: 10.12688/f1000research.122708.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2022] [Indexed: 11/05/2022] Open
Abstract
We summarize selected research reports from 2021 relevant to Tourette syndrome that the authors consider most important or interesting. The authors welcome article suggestions and thoughtful feedback from readers.
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Affiliation(s)
- Andreas Hartmann
- Department of Neurology, APHP, Sorbonne University, Hôpital de la Pitié-Salpêtrière, Paris, 75013, France,
| | - Per Andrén
- Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Stockholm, Sweden
| | - Cyril Atkinson-Clement
- Paris Brain Institute (ICM), Sorbonne Université, Inserm, CNRS, APHP, Paris, 75013, France
| | - Virginie Czernecki
- Department of Neurology, APHP, Sorbonne University, Hôpital de la Pitié-Salpêtrière, Paris, 75013, France
| | - Cécile Delorme
- Department of Neurology, APHP, Sorbonne University, Hôpital de la Pitié-Salpêtrière, Paris, 75013, France
| | | | - Natalia Szejko
- Department of Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Keisuke Ueda
- Department of Psychiatry, Neurology, Radiology and Neuroscience, Washington University in St. Louis, Saint Louis, Missouri, USA
| | - Kevin Black
- Department of Psychiatry, Neurology, Radiology and Neuroscience, Washington University in St. Louis, Saint Louis, Missouri, USA
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Hernandez-Martin E, Arguelles E, Liker M, Robison A, Sanger TD. Increased movement-related signals in both basal ganglia and cerebellar output pathways in two children with dystonia. Front Neurol 2022; 13:989340. [PMID: 36158959 PMCID: PMC9500435 DOI: 10.3389/fneur.2022.989340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/23/2022] [Indexed: 11/25/2022] Open
Abstract
The contribution of different brain regions to movement abnormalities in children with dystonia is unknown. Three awake subjects undergoing depth electrode implantation for assessments of potential deep brain recording targets performed a rhythmic figure-8 drawing task. Two subjects had dystonia, one was undergoing testing for treatment of Tourette Syndrome and had neither dystonia nor abnormal movements during testing. Movement-related signals were evaluated by determining the magnitude of task-related frequency components. Brain signals were recorded in globus pallidus internus (GPi), the ventral oralis anterior/posterior (VoaVop) and the ventral intermediate (Vim) nuclei of the thalamus. In comparison to the subject without dystonia, both children with dystonia showed increased task-related activity in GPi and Vim. This finding is consistent with a role of both basal ganglia and cerebellar outputs in the pathogenesis of dystonia. Our results further suggest that frequency analysis of brain recordings during cyclic movements may be a useful tool for analysis of the presence of movement-related signals in various brain regions.
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Affiliation(s)
- Estefania Hernandez-Martin
- Department of Electrical Engineering and Computer Science, University of California, Irvine, Irvine, CA, United States
- *Correspondence: Estefania Hernandez-Martin
| | - Enrique Arguelles
- Neuroscience Institute, Children's Hospital of Orange County (CHOC), Orange, CA, United States
| | - Mark Liker
- Department of Neurology, Children's Hospital of Los Angeles (CHLA), Los Angeles, CA, United States
| | - Aaron Robison
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, United States
| | - Terence D. Sanger
- Department of Electrical Engineering and Computer Science, University of California, Irvine, Irvine, CA, United States
- Department of Biomedical Engineering, University of Southern California (USC), Los Angeles, CA, United States
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