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Ashkan K, Mirza AB, Tambirajoo K, Furlanetti L. Deep brain stimulation in the management of paediatric neuropsychiatric conditions: Current evidence and future directions. Eur J Paediatr Neurol 2021; 33:146-158. [PMID: 33092983 DOI: 10.1016/j.ejpn.2020.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/21/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Neurosurgery has provided an alternative option for patients with refractory psychiatric indications. Lesion procedures were the initial techniques used, but deep brain stimulation (DBS) has the advantage of relative reversibility and adjustability. This review sets out to delineate the current evidence for DBS use in psychiatric conditions, with an emphasis on the paediatric population, highlighting pitfalls and opportunities. METHODS A systematic review of the literature was conducted on studies reporting the use of DBS in the management of psychiatric disorders. The PRISMA guidelines were employed to structure the review of the literature. Data was discussed focusing on the indications for DBS management of psychiatric conditions in the paediatric age group. RESULTS A total of seventy-three full-text papers reported the use of DBS surgery for the management of psychiatric conditions matching the inclusion criteria. The main indications were Tourette Syndrome (GTS) (15 studies), Obsessive Compulsive Disorder (OCD) (20), Treatment Resistant Depression (TRD) (27), Eating Disorders (ED) (7) and Aggressive Behaviour and self-harm (AB) (4). Out of these, only 11 studies included patients in the paediatric age group (≤18 years-old). Among the paediatric patients, the indications for surgery included GTS, AB and ED. CONCLUSIONS The application of deep brain stimulation for psychiatric indications has progressed at a steady pace in the adult population and at a much slower pace in the paediatric population. Future studies in children should be done in a trial setting with strict and robust criteria. A move towards personalising DBS therapy with new stimulation paradigms will provide new frontiers and possibilities in this growing field.
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Affiliation(s)
- Keyoumars Ashkan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK; King's Health Partners Academic Health Sciences Centre, London, UK
| | - Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK; King's Health Partners Academic Health Sciences Centre, London, UK
| | - Kantharuby Tambirajoo
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK; King's Health Partners Academic Health Sciences Centre, London, UK
| | - Luciano Furlanetti
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK; King's Health Partners Academic Health Sciences Centre, London, UK.
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Johnson KA, Duffley G, Foltynie T, Hariz M, Zrinzo L, Joyce EM, Akram H, Servello D, Galbiati TF, Bona A, Porta M, Meng FG, Leentjens AFG, Gunduz A, Hu W, Foote KD, Okun MS, Butson CR. Basal Ganglia Pathways Associated With Therapeutic Pallidal Deep Brain Stimulation for Tourette Syndrome. BIOLOGICAL PSYCHIATRY: COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2020; 6:961-972. [PMID: 33536144 DOI: 10.1016/j.bpsc.2020.11.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/28/2020] [Accepted: 11/14/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) targeting the globus pallidus internus (GPi) can improve tics and comorbid obsessive-compulsive behavior (OCB) in patients with treatment-refractory Tourette syndrome (TS). However, some patients' symptoms remain unresponsive, the stimulation applied across patients is variable, and the mechanisms underlying improvement are unclear. Identifying the fiber pathways surrounding the GPi that are associated with improvement could provide mechanistic insight and refine targeting strategies to improve outcomes. METHODS Retrospective data were collected for 35 patients who underwent bilateral GPi DBS for TS. Computational models of fiber tract activation were constructed using patient-specific lead locations and stimulation settings to evaluate the effects of DBS on basal ganglia pathways and the internal capsule. We first evaluated the relationship between activation of individual pathways and symptom improvement. Next, linear mixed-effects models with combinations of pathways and clinical variables were compared in order to identify the best-fit predictive models of tic and OCB improvement. RESULTS The best-fit model of tic improvement included baseline severity and the associative pallido-subthalamic pathway. The best-fit model of OCB improvement included baseline severity and the sensorimotor pallido-subthalamic pathway, with substantial evidence also supporting the involvement of the prefrontal, motor, and premotor internal capsule pathways. The best-fit models of tic and OCB improvement predicted outcomes across the cohort and in cross-validation. CONCLUSIONS Differences in fiber pathway activation likely contribute to variable outcomes of DBS for TS. Computational models of pathway activation could be used to develop novel approaches for preoperative targeting and selecting stimulation parameters to improve patient outcomes.
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Affiliation(s)
- Kara A Johnson
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, Utah; Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah
| | - Gordon Duffley
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, Utah; Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah
| | - Thomas Foltynie
- Functional Neurosurgery Unit, Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Marwan Hariz
- Functional Neurosurgery Unit, Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, United Kingdom; Department of Clinical Neuroscience, Umea University, Umea, Sweden
| | - Ludvic Zrinzo
- Functional Neurosurgery Unit, Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Eileen M Joyce
- Functional Neurosurgery Unit, Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Harith Akram
- Functional Neurosurgery Unit, Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Domenico Servello
- Neurosurgical Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Tommaso F Galbiati
- Neurosurgical Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Alberto Bona
- Neurosurgical Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Mauro Porta
- Tourette's Syndrome and Movement Disorders Center, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Fan-Gang Meng
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Albert F G Leentjens
- Department of Psychiatry and Neuropsychology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Aysegul Gunduz
- Norman Fixel Institute for Neurological Diseases, Program for Movement Disorders and Neurorestoration, Departments of Neurology and Neurosurgery, University of Florida, Gainesville, Florida; J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, Florida
| | - Wei Hu
- Norman Fixel Institute for Neurological Diseases, Program for Movement Disorders and Neurorestoration, Departments of Neurology and Neurosurgery, University of Florida, Gainesville, Florida
| | - Kelly D Foote
- Norman Fixel Institute for Neurological Diseases, Program for Movement Disorders and Neurorestoration, Departments of Neurology and Neurosurgery, University of Florida, Gainesville, Florida
| | - Michael S Okun
- Norman Fixel Institute for Neurological Diseases, Program for Movement Disorders and Neurorestoration, Departments of Neurology and Neurosurgery, University of Florida, Gainesville, Florida
| | - Christopher R Butson
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, Utah; Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah; Department of Neurology, University of Utah, Salt Lake City, Utah; Department of Neurosurgery, University of Utah, Salt Lake City, Utah; Department of Psychiatry, University of Utah, Salt Lake City, Utah.
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Mahajan UV, Purger DA, Mantovani A, Williams NR, Espil FM, Han SS, Stein SC, Halpern CH. Deep Brain Stimulation Results in Greater Symptomatic Improvement in Tourette Syndrome than Conservative Measures: A Meta-Analysis. Stereotact Funct Neurosurg 2020; 98:270-277. [PMID: 32434201 DOI: 10.1159/000507059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 03/06/2020] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Deep brain stimulation (DBS) has emerged as a safe and effective therapy for refractory Tourette syndrome (TS). Recent studies have identified several neural targets as effective in reducing TS symptoms with DBS, but, to our knowledge, none has compared the effectiveness of DBS with conservative therapy. METHODS A literature review was performed to identify studies investigating adult patient outcomes reported as Yale Global Tic Severity Scale (YGTSS) scores after DBS surgery, pharmacotherapy, and psychotherapy. Data were pooled using a random-effects model of inverse variance-weighted meta-analysis (n = 168 for DBS, n = 131 for medications, and n = 154 for behavioral therapy). RESULTS DBS resulted in a significantly greater reduction in YGTSS total score (49.9 ± 17.5%) than pharmacotherapy (22.5 ± 15.2%, p = 0.001) or psychotherapy (20.0 ± 11.3%, p < 0.001), with a complication (adverse effect) rate of 0.15/case, 1.13/case, and 0.60/case, respectively. CONCLUSION Our data suggest that adult patients with refractory TS undergoing DBS experience greater symptomatic improvement with surprisingly low morbidity than can be obtained with pharmacotherapy or psychotherapy.
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Affiliation(s)
- Uma V Mahajan
- Case Western Reserve University, Cleveland, Ohio, USA
| | - David A Purger
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Alessandra Mantovani
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Nolan R Williams
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Flint M Espil
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Summer S Han
- Neurosurgery and Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California, USA
| | - Sherman C Stein
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA,
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Pandey S, Dash D. Progress in Pharmacological and Surgical Management of Tourette Syndrome and Other Chronic Tic Disorders. Neurologist 2019; 24:93-108. [DOI: 10.1097/nrl.0000000000000218] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Casagrande SCB, Cury RG, Alho EJL, Fonoff ET. Deep brain stimulation in Tourette's syndrome: evidence to date. Neuropsychiatr Dis Treat 2019; 15:1061-1075. [PMID: 31114210 PMCID: PMC6497003 DOI: 10.2147/ndt.s139368] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Tourette's syndrome (TS) is a neurodevelopmental disorder that comprises vocal and motor tics associated with a high frequency of psychiatric comorbidities, which has an important impact on quality of life. The onset is mainly in childhood and the symptoms can either fade away or require pharmacological therapies associated with cognitive-behavior therapies. In rare cases, patients experience severe and disabling symptoms refractory to conventional treatments. In these cases, deep brain stimulation (DBS) can be considered as an interesting and effective option for symptomatic control. DBS has been studied in numerous trials as a therapy for movement disorders, and currently positive data supports that DBS is partially effective in reducing the motor and non-motor symptoms of TS. The average response, mostly from case series and prospective cohorts and only a few controlled studies, is around 40% improvement on tic severity scales. The ventromedial thalamus has been the preferred target, but more recently the globus pallidus internus has also gained some notoriety. The mechanism by which DBS is effective on tics and other symptoms in TS is not yet understood. As refractory TS is not common, even reference centers have difficulties in performing large controlled trials. However, studies that reproduce the current results in larger and multicenter randomized controlled trials to improve our knowledge so as to support the best target and stimulation settings are still lacking. This article will discuss the selection of the candidates, DBS targets and mechanisms on TS, and clinical evidence to date reviewing current literature about the use of DBS in the treatment of TS.
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Affiliation(s)
- Sara C B Casagrande
- Department of Neurology, School of Medicine, Movement Disorders Center, University of São Paulo, São Paulo, Brazil
| | - Rubens G Cury
- Department of Neurology, School of Medicine, Movement Disorders Center, University of São Paulo, São Paulo, Brazil
| | - Eduardo J L Alho
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo, Brazil,
| | - Erich Talamoni Fonoff
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo, Brazil,
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Welter ML, Houeto JL, Thobois S, Bataille B, Guenot M, Worbe Y, Hartmann A, Czernecki V, Bardinet E, Yelnik J, du Montcel ST, Agid Y, Vidailhet M, Cornu P, Tanguy A, Ansquer S, Jaafari N, Poulet E, Serra G, Burbaud P, Cuny E, Aouizerate B, Pollak P, Chabardes S, Polosan M, Borg M, Fontaine D, Giordana B, Raoul S, Rouaud T, Sauvaget A, Jalenques I, Karachi C, Mallet L. Anterior pallidal deep brain stimulation for Tourette's syndrome: a randomised, double-blind, controlled trial. Lancet Neurol 2017. [PMID: 28645853 DOI: 10.1016/s1474-4422(17)30160-6] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) has been proposed to treat patients with severe Tourette's syndrome, and open-label trials and two small double-blind trials have tested DBS of the posterior and the anterior internal globus pallidus (aGPi). We aimed to specifically assess the efficacy of aGPi DBS for severe Tourette's syndrome. METHODS In this randomised, double-blind, controlled trial, we recruited patients aged 18-60 years with severe and medically refractory Tourette's syndrome from eight hospitals specialised in movement disorders in France. Enrolled patients received surgery to implant bilateral electrodes for aGPi DBS; 3 months later they were randomly assigned (1:1 ratio with a block size of eight; computer-generated pairwise randomisation according to order of enrolment) to receive either active or sham stimulation for the subsequent 3 months in a double-blind fashion. All patients then received open-label active stimulation for the subsequent 6 months. Patients and clinicians assessing outcomes were masked to treatment allocation; an unmasked clinician was responsible for stimulation parameter programming, with intensity set below the side-effect threshold. The primary endpoint was difference in Yale Global Tic Severity Scale (YGTSS) score between the beginning and end of the 3 month double-blind period, as assessed with a Mann-Whitney-Wilcoxon test in all randomly allocated patients who received active or sham stimulation during the double-blind period. We assessed safety in all patients who were enrolled and received surgery for aGPi DBS. This trial is registered with ClinicalTrials.gov, number NCT00478842. FINDINGS Between Dec 6, 2007, and Dec 13, 2012, we enrolled 19 patients. We randomly assigned 17 (89%) patients, with 16 completing blinded assessments (seven [44%] in the active stimulation group and nine [56%] in the sham stimulation group). We noted no significant difference in YGTSS score change between the beginning and the end of the 3 month double-blind period between groups (active group median YGTSS score 68·5 [IQR 34·0 to 83·5] at the beginning and 62·5 [51·5 to 72·0] at the end, median change 1·1% [IQR -23·9 to 38·1]; sham group 73·0 [69·0 to 79·0] and 79·0 [59·0 to 81·5], median change 0·0% [-10·6 to 4·8]; p=0·39). 15 serious adverse events (three in patients who withdrew before stimulation and six each in the active and sham stimulation groups) occurred in 13 patients (three who withdrew before randomisation, four in the active group, and six in the sham group), with infections in DBS hardware in four patients (two who withdrew before randomisation, one in the sham stimulation group, and one in the active stimulation group). Other serious adverse events included one electrode misplacement (active stimulation group), one episode of depressive signs (active stimulation group), and three episodes of increased tic severity and anxiety (two in the sham stimulation group and one in the active stimulation group). INTERPRETATION 3 months of aGPi DBS is insufficient to decrease tic severity for patients with Tourette's syndrome. Future research is needed to investigate the efficacy of aGPi DBS for patients over longer periods with optimal stimulation parameters and to identify potential predictors of the therapeutic response. FUNDING French Ministry of Health.
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Affiliation(s)
- Marie-Laure Welter
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière Hospital, Neurology Department, Paris, France; Clinical Investigation Centre, INSERM 1127, Sorbonne Universités, Université Pierre et Marie Curie Université Paris 06, Paris, France; Unité Mixte de Recherche (UMR) S1127, Centre National de la Recherche Scientifique (CNRS), UMR 7225, Institut du Cerveau et de la Moelle Epinière, Paris, France.
| | - Jean-Luc Houeto
- Department of Neurology, INSERM-Centre d'Investigation Clinique 1402, University of Poitiers, Centre Hospitalier Universitaire (CHU) de Poitiers, Poitiers, France
| | - Stéphane Thobois
- Department of Neurology C, Hôpital Neurologique, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France; CNRS, Lyon Centre for Neuroscience Research, University Lyon 1, Bron, France
| | - Benoit Bataille
- Department of Neurosurgery, INSERM-Centre d'Investigation Clinique 1402, University of Poitiers, Centre Hospitalier Universitaire (CHU) de Poitiers, Poitiers, France
| | - Marc Guenot
- Department of Neurosurgery A, Hôpital Neurologique, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Yulia Worbe
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière Hospital, Neurology Department, Paris, France
| | - Andreas Hartmann
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière Hospital, Neurology Department, Paris, France
| | - Virginie Czernecki
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière Hospital, Neurology Department, Paris, France
| | - Eric Bardinet
- Unité Mixte de Recherche (UMR) S1127, Centre National de la Recherche Scientifique (CNRS), UMR 7225, Institut du Cerveau et de la Moelle Epinière, Paris, France
| | - Jerome Yelnik
- Unité Mixte de Recherche (UMR) S1127, Centre National de la Recherche Scientifique (CNRS), UMR 7225, Institut du Cerveau et de la Moelle Epinière, Paris, France
| | - Sophie Tezenas du Montcel
- AP-HP, Pitié-Salpêtrière Hospital, Biostatistics and Medical Informatics Unit and Clinical Research Unit, Paris, France; Sorbonne Universités, Université Pierre et Marie Curie Université Paris 06, UMR S1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
| | - Yves Agid
- Unité Mixte de Recherche (UMR) S1127, Centre National de la Recherche Scientifique (CNRS), UMR 7225, Institut du Cerveau et de la Moelle Epinière, Paris, France
| | - Marie Vidailhet
- Unité Mixte de Recherche (UMR) S1127, Centre National de la Recherche Scientifique (CNRS), UMR 7225, Institut du Cerveau et de la Moelle Epinière, Paris, France
| | - Philippe Cornu
- Neurosurgery, INSERM 1127, Sorbonne Universités, Université Pierre et Marie Curie Université Paris 06, Paris, France
| | - Audrey Tanguy
- AP-HP, Pitié-Salpêtrière Hospital, Biostatistics and Medical Informatics Unit and Clinical Research Unit, Paris, France
| | - Solène Ansquer
- Department of Neurology, INSERM-Centre d'Investigation Clinique 1402, University of Poitiers, Centre Hospitalier Universitaire (CHU) de Poitiers, Poitiers, France
| | - Nematollah Jaafari
- Department of Psychiatry, INSERM-Centre d'Investigation Clinique 1402, University of Poitiers, Centre Hospitalier Universitaire (CHU) de Poitiers, Poitiers, France
| | - Emmanuel Poulet
- PsyR2 Team, U 1028, INSERM and UMR 5292, Centre Hospitalier Le Vinatier, Bron, France
| | - Giulia Serra
- Department of Neurology C, Hôpital Neurologique, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Pierre Burbaud
- Department of Neurophysiology, Charles Perrens Hospital, University Bordeaux 2, CNRS UMR 5543, Bordeaux, France
| | - Emmanuel Cuny
- Department of Neurosurgery, Charles Perrens Hospital, University Bordeaux 2, CNRS UMR 5543, Bordeaux, France
| | - Bruno Aouizerate
- Department of Psychiatry, Charles Perrens Hospital, University Bordeaux 2, CNRS UMR 5543, Bordeaux, France
| | - Pierre Pollak
- Department of Neurology, Grenoble Alpes University, CHU Grenoble, Grenoble, France
| | - Stephan Chabardes
- Department of Neurosurgery, Grenoble Alpes University, CHU Grenoble, Grenoble, France
| | - Mircea Polosan
- Department of Psychiatry, Grenoble Alpes University, CHU Grenoble, Grenoble, France
| | - Michel Borg
- Department of Neurology, University Hospital, Nice, France
| | - Denys Fontaine
- Department of Neurosurgery, University Hospital, Nice, France
| | - Bruno Giordana
- Department of Psychiatry, University Hospital, Nice, France
| | - Sylvie Raoul
- Department of Neurosurgery, Nantes University Hospital, Nantes, France
| | - Tiphaine Rouaud
- Department of Neurology, Nantes University Hospital, Nantes, France
| | - Anne Sauvaget
- Department of Psychiatry, Nantes University Hospital, Nantes, France
| | - Isabelle Jalenques
- Department of Psychiatry, CHU Clermont-Ferrand and Clermont Auvergne University, Equipe d'Accueil 7280, Clermont-Ferrand, France
| | - Carine Karachi
- Neurosurgery, INSERM 1127, Sorbonne Universités, Université Pierre et Marie Curie Université Paris 06, Paris, France; Unité Mixte de Recherche (UMR) S1127, Centre National de la Recherche Scientifique (CNRS), UMR 7225, Institut du Cerveau et de la Moelle Epinière, Paris, France
| | - Luc Mallet
- Unité Mixte de Recherche (UMR) S1127, Centre National de la Recherche Scientifique (CNRS), UMR 7225, Institut du Cerveau et de la Moelle Epinière, Paris, France; AP-HP, Personalised Neurology and Psychiatry University Department, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Université Paris Est Créteil, Créteil, France; Department of Mental Health and Psychiatry, Geneva University Hospital, University of Geneva, Geneva, Switzerland
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Zhang XH, Li JY, Zhang YQ, Li YJ. Deep Brain Stimulation of the Globus Pallidus Internus in Patients with Intractable Tourette Syndrome: A 1-year Follow-up Study. Chin Med J (Engl) 2017; 129:1022-7. [PMID: 27098785 PMCID: PMC4852667 DOI: 10.4103/0366-6999.180512] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Deep brain stimulation (DBS) has been a promising treatment for patients with refractory Tourette syndrome (TS) for more than a decade. Despite successful DBS treatment of TS in more than 100 patients worldwide, studies with a large patient sample and long-term follow-up assessments are still scarce. Accordingly, we investigated the clinical efficacy and safety of globus pallidus internus (GPi) DBS in the treatment of intractable TS in 24 patients with a 1-year follow-up assessment. Methods: Bilateral/unilateral GPi-DBS was performed in 24 patients with TS. We evaluated symptoms of tics and obsessive-compulsive disorder (OCD) through the Yale Global Tic Severity Scale (YGTSS) and Yale-Brown Obsessive-compulsive Scale (Y-BOCS). We used the Wechsler Adult Intelligence Scale-Revised in China (WAIS-RC) to evaluate the safety of the treatment. We conducted follow-up assessments of all patients for at least 12 months (12–99 months). Results: Symptoms of tics and OCD were significantly relieved at a 12-month follow-up assessment. The mean YGTSS score was 74.04 ± 11.52, 49.83 ± 10.91, 32.58 ± 7.97, and 31.21 ± 8.87 at baseline, 3, 6, and 12 months, respectively. The mean YGTSS scores obtained at the follow-up assessments were significantly different from the baseline (P < 0.05). The improvement in motor tics was superior to that in phonic tics. The mean Y-BOCS scores were 21.61 ± 4.97, 18 ± 4.58, 14.39 ± 3.99, and 13.78 ± 4.56 at baseline, 3, 6, and 12 months, respectively (P < 0.05). We observed a remarkable improvement in psychiatric comorbidities, such as OCD and attention-deficit hyperactivity disorder, after the procedure. WAIS-RC scores were comparable before and after the operation. There were no severe postoperative complications. Conclusion: GPi-DBS appears to comprehensively alleviate tic symptoms and psychiatric comorbidities in patients with TS, thus significantly improving patients’ quality of life.
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Affiliation(s)
| | | | | | - Yong-Jie Li
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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Guridi J, Alegre M. Oscillatory activity in the basal ganglia and deep brain stimulation. Mov Disord 2016; 32:64-69. [PMID: 27548437 DOI: 10.1002/mds.26714] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 05/20/2016] [Accepted: 05/22/2016] [Indexed: 11/11/2022] Open
Abstract
Over the past 10 years, research into the neurophysiology of the basal ganglia has provided new insights into the pathophysiology of movement disorders. The presence of pathological oscillations at specific frequencies has been linked to different signs and symptoms in PD and dystonia, suggesting a new model to explain basal ganglia dysfunction. These advances occurred in parallel with improvements in imaging and neurosurgical techniques, both of which having facilitated the more widespread use of DBS to modulate dysfunctional circuits. High-frequency stimulation is thought to disrupt pathological activity in the motor cortex/basal ganglia network; however, it is not easy to explain all of its effects based only on changes in network oscillations. In this viewpoint, we suggest that a return to classic anatomical concepts might help to understand some apparently paradoxical findings. © 2016 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Jorge Guridi
- Neurosurgery and Clinical Neurophysiology Sections, Clinica Universidad de Navarra, Pamplona, Spain
| | - Manuel Alegre
- Neurosurgery and Clinical Neurophysiology Sections, Clinica Universidad de Navarra, Pamplona, Spain
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Akbarian-Tefaghi L, Zrinzo L, Foltynie T. The Use of Deep Brain Stimulation in Tourette Syndrome. Brain Sci 2016; 6:brainsci6030035. [PMID: 27548235 PMCID: PMC5039464 DOI: 10.3390/brainsci6030035] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/13/2016] [Accepted: 08/15/2016] [Indexed: 12/16/2022] Open
Abstract
Tourette syndrome (TS) is a childhood neurobehavioural disorder, characterised by the presence of motor and vocal tics, typically starting in childhood but persisting in around 20% of patients into adulthood. In those patients who do not respond to pharmacological or behavioural therapy, deep brain stimulation (DBS) may be a suitable option for potential symptom improvement. This manuscript attempts to summarise the outcomes of DBS at different targets, explore the possible mechanisms of action of DBS in TS, as well as the potential of adaptive DBS. There will also be a focus on the future challenges faced in designing optimized trials.
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Affiliation(s)
- Ladan Akbarian-Tefaghi
- Institute of Neurology, University College London (UCL), Queen Square, London WC1N 3BG, UK.
| | - Ludvic Zrinzo
- Sobell Department of Motor Neuroscience, University College London (UCL) Institute of Neurology, London WC1N 3BG, UK.
| | - Thomas Foltynie
- Sobell Department of Motor Neuroscience, University College London (UCL) Institute of Neurology, London WC1N 3BG, UK.
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10
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Deeb W, Rossi PJ, Porta M, Visser-Vandewalle V, Servello D, Silburn P, Coyne T, Leckman JF, Foltynie T, Hariz M, Joyce EM, Zrinzo L, Kefalopoulou Z, Welter ML, Karachi C, Mallet L, Houeto JL, Shahed-Jimenez J, Meng FG, Klassen BT, Mogilner AY, Pourfar MH, Kuhn J, Ackermans L, Kaido T, Temel Y, Gross RE, Walker HC, Lozano AM, Khandhar SM, Walter BL, Walter E, Mari Z, Changizi BK, Moro E, Baldermann JC, Huys D, Zauber SE, Schrock LE, Zhang JG, Hu W, Foote KD, Rizer K, Mink JW, Woods DW, Gunduz A, Okun MS. The International Deep Brain Stimulation Registry and Database for Gilles de la Tourette Syndrome: How Does It Work? Front Neurosci 2016; 10:170. [PMID: 27199634 PMCID: PMC4842757 DOI: 10.3389/fnins.2016.00170] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 04/04/2016] [Indexed: 12/24/2022] Open
Abstract
Tourette Syndrome (TS) is a neuropsychiatric disease characterized by a combination of motor and vocal tics. Deep brain stimulation (DBS), already widely utilized for Parkinson's disease and other movement disorders, is an emerging therapy for select and severe cases of TS that are resistant to medication and behavioral therapy. Over the last two decades, DBS has been used experimentally to manage severe TS cases. The results of case reports and small case series have been variable but in general positive. The reported interventions have, however, been variable, and there remain non-standardized selection criteria, various brain targets, differences in hardware, as well as variability in the programming parameters utilized. DBS centers perform only a handful of TS DBS cases each year, making large-scale outcomes difficult to study and to interpret. These limitations, coupled with the variable effect of surgery, and the overall small numbers of TS patients with DBS worldwide, have delayed regulatory agency approval (e.g., FDA and equivalent agencies around the world). The Tourette Association of America, in response to the worldwide need for a more organized and collaborative effort, launched an international TS DBS registry and database. The main goal of the project has been to share data, uncover best practices, improve outcomes, and to provide critical information to regulatory agencies. The international registry and database has improved the communication and collaboration among TS DBS centers worldwide. In this paper we will review some of the key operation details for the international TS DBS database and registry.
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Affiliation(s)
- Wissam Deeb
- Department of Neurology, University of Florida and Center for Movement Disorders and Neurorestoration Gainesville, FL, USA
| | - Peter J Rossi
- Department of Neurology, University of Florida and Center for Movement Disorders and Neurorestoration Gainesville, FL, USA
| | - Mauro Porta
- Tourette's Syndrome and Movement Disorders Center, Galeazzi Hospital Milan, Italy
| | | | | | - Peter Silburn
- Asia-Pacific Centre for Neuromodulation, Queensland Brain InstituteBrisbane, Queensland, Australia; University of Queensland Centre for Clinical Research, The University of QueenslandBrisbane, Queensland, Australia
| | - Terry Coyne
- University of Queensland Centre for Clinical Research, The University of QueenslandBrisbane, Queensland, Australia; BrizBrain&SpineBrisbane, QLD, Australia
| | - James F Leckman
- Departments of Psychiatry, Pediatrics and Psychology, Child Study Center, Yale University New Haven, CT, USA
| | - Thomas Foltynie
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology London, UK
| | - Marwan Hariz
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology London, UK
| | - Eileen M Joyce
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology London, UK
| | - Ludvic Zrinzo
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology London, UK
| | - Zinovia Kefalopoulou
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology London, UK
| | - Marie-Laure Welter
- Assistance publique - Hôpitaux de Paris, Institut du Cerveau et de la Moelle Epiniere, Institut National de la Santé et de la Recherche Médicale 1127, Pitié-Salpêtrière Hospital, Sorbonne Universités, UPMC Univ Paris 06, Unité Mixte de Recherche 1127, Centre National de la Recherche Scientifique, Unité Mixte de Recherche 7225 Paris, France
| | - Carine Karachi
- Institut National de la Santé et de la Recherche Médicale U 1127, Centre National de la Recherche Scientifique UMR 7225, Sorbonne Universités, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinièreParis, France; Department of Neurosurgery, Assistance Publique - Hôpitaux de Paris, Hôpital de la Pitié-SalpêtrièreParis, France
| | - Luc Mallet
- Institut National de la Santé et de la Recherche Médicale U 1127, Centre National de la Recherche Scientifique UMR 7225, Sorbonne Universités, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinièreParis, France; Assistance publique - Hôpitaux de Paris, DHU Pe-PSY, Pôle de Psychiatrie et d'addictologie des Hôpitaux Universitaires H Mondor, Université Paris Est CréteilCréteil, France; Department of Mental Health and Psychiatry, Geneva University HospitalGeneva, Switzerland
| | - Jean-Luc Houeto
- Service de Neurologie, Institut National de la Santé et de la Recherche Médicale-Centres d'Investigation Clinique 1402, Centre Hospitalier Universitaire de Grenoble de Poitiers, Université de Poitiers Poitiers, France
| | - Joohi Shahed-Jimenez
- Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine Houston, TX, USA
| | - Fan-Gang Meng
- Beijing Neurosurgical Institute, Capital Medical University Beijing, China
| | - Bryan T Klassen
- Department of Neurology, Mayo Clinic College of Medicine Rochester, MN, USA
| | - Alon Y Mogilner
- Department of Neurosurgery, Center for Neuromodulation, NYU Langone Medical Center New York, NY, USA
| | - Michael H Pourfar
- Department of Neurosurgery, Center for Neuromodulation, NYU Langone Medical Center New York, NY, USA
| | - Jens Kuhn
- Department of Psychiatry and Psychotherapy, University of Cologne Cologne, Germany
| | - L Ackermans
- Department of Neurosurgery, Maastricht University Medical Centre Maastricht, Netherlands
| | - Takanobu Kaido
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry Kodaira, Japan
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical CenterMaastricht, Netherlands; Faculty of Health, Medicine and Life Sciences, School for Mental Health and Neuroscience, Maastricht UniversityMaastricht, Netherlands
| | - Robert E Gross
- Department of Neurosurgery, Emory University Atlanta, GA, USA
| | - Harrison C Walker
- Department of Neurology, Department of Biomedical Engineering, University of Alabama at Birmingham Birmingham, AL, USA
| | - Andres M Lozano
- Division of Neurosurgery, University of Toronto Toronto, Canada
| | - Suketu M Khandhar
- Department of Neurology, The Permanente Medical Group (Tidewater Physicians Multispecialty Group), Movement Disorders Program Sacramento, CA, USA
| | - Benjamin L Walter
- University Hospitals, Case Western Reserve University School of Medicine Cleveland, OH, USA
| | - Ellen Walter
- Department of Neurology, University Hospitals Case Medical Center, Neurological Institute Cleveland, OH, USA
| | - Zoltan Mari
- Parkinson's & Movement Disorder Center/Division, Johns Hopkins University, School of Medicine Baltimore, MD, USA
| | - Barbara K Changizi
- Department of Neurology, The Ohio State University Wexner Medical Center Columbus, OH, USA
| | - Elena Moro
- Division of Neurology, Centre Hospitalier Universitaire de Grenoble Grenoble, Grenoble Alpes University Grenoble, France
| | - Juan C Baldermann
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Köln Köln, Germany
| | - Daniel Huys
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Köln Köln, Germany
| | - S Elizabeth Zauber
- Department of Neurology, Indiana University School of Medicine Indianapolis, IN, USA
| | - Lauren E Schrock
- Department of Neurology, University of Utah Salt Lake City, UT, USA
| | - Jian-Guo Zhang
- Department of Functional Neurosurgery, Beijing Tiantan Hospital, Capital Medical University Beijing, China
| | - Wei Hu
- Department of Neurology, University of Florida and Center for Movement Disorders and Neurorestoration Gainesville, FL, USA
| | - Kelly D Foote
- Department of Neurology, University of Florida and Center for Movement Disorders and NeurorestorationGainesville, FL, USA; Department of Neurological Surgery, University of FloridaGainesville, FL, USA
| | - Kyle Rizer
- Department of Neurology, University of Florida and Center for Movement Disorders and Neurorestoration Gainesville, FL, USA
| | - Jonathan W Mink
- Department of Neurology, University of Rochester Medical Center Rochester, NY, USA
| | - Douglas W Woods
- Department of Psychology, Marquette University Milwaukee, WI, USA
| | - Aysegul Gunduz
- Department of Neurology, University of Florida and Center for Movement Disorders and NeurorestorationGainesville, FL, USA; J. Crayton Pruitt Family Department of Biomedical Engineering, University of FloridaGainesville, FL, USA
| | - Michael S Okun
- Department of Neurology, University of Florida and Center for Movement Disorders and Neurorestoration Gainesville, FL, USA
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11
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Deeb W, Rossi PJ, Porta M, Visser-Vandewalle V, Servello D, Silburn P, Coyne T, Leckman JF, Foltynie T, Hariz M, Joyce EM, Zrinzo L, Kefalopoulou Z, Welter ML, Karachi C, Mallet L, Houeto JL, Shahed-Jimenez J, Meng FG, Klassen BT, Mogilner AY, Pourfar MH, Kuhn J, Ackermans L, Kaido T, Temel Y, Gross RE, Walker HC, Lozano AM, Khandhar SM, Walter BL, Walter E, Mari Z, Changizi BK, Moro E, Baldermann JC, Huys D, Zauber SE, Schrock LE, Zhang JG, Hu W, Foote KD, Rizer K, Mink JW, Woods DW, Gunduz A, Okun MS. The International Deep Brain Stimulation Registry and Database for Gilles de la Tourette Syndrome: How Does It Work? Front Neurosci 2016. [PMID: 27199634 DOI: 10.3389/fnins.2016.00170/abstract] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
Tourette Syndrome (TS) is a neuropsychiatric disease characterized by a combination of motor and vocal tics. Deep brain stimulation (DBS), already widely utilized for Parkinson's disease and other movement disorders, is an emerging therapy for select and severe cases of TS that are resistant to medication and behavioral therapy. Over the last two decades, DBS has been used experimentally to manage severe TS cases. The results of case reports and small case series have been variable but in general positive. The reported interventions have, however, been variable, and there remain non-standardized selection criteria, various brain targets, differences in hardware, as well as variability in the programming parameters utilized. DBS centers perform only a handful of TS DBS cases each year, making large-scale outcomes difficult to study and to interpret. These limitations, coupled with the variable effect of surgery, and the overall small numbers of TS patients with DBS worldwide, have delayed regulatory agency approval (e.g., FDA and equivalent agencies around the world). The Tourette Association of America, in response to the worldwide need for a more organized and collaborative effort, launched an international TS DBS registry and database. The main goal of the project has been to share data, uncover best practices, improve outcomes, and to provide critical information to regulatory agencies. The international registry and database has improved the communication and collaboration among TS DBS centers worldwide. In this paper we will review some of the key operation details for the international TS DBS database and registry.
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Affiliation(s)
- Wissam Deeb
- Department of Neurology, University of Florida and Center for Movement Disorders and Neurorestoration Gainesville, FL, USA
| | - Peter J Rossi
- Department of Neurology, University of Florida and Center for Movement Disorders and Neurorestoration Gainesville, FL, USA
| | - Mauro Porta
- Tourette's Syndrome and Movement Disorders Center, Galeazzi Hospital Milan, Italy
| | | | | | - Peter Silburn
- Asia-Pacific Centre for Neuromodulation, Queensland Brain InstituteBrisbane, Queensland, Australia; University of Queensland Centre for Clinical Research, The University of QueenslandBrisbane, Queensland, Australia
| | - Terry Coyne
- University of Queensland Centre for Clinical Research, The University of QueenslandBrisbane, Queensland, Australia; BrizBrain&SpineBrisbane, QLD, Australia
| | - James F Leckman
- Departments of Psychiatry, Pediatrics and Psychology, Child Study Center, Yale University New Haven, CT, USA
| | - Thomas Foltynie
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology London, UK
| | - Marwan Hariz
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology London, UK
| | - Eileen M Joyce
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology London, UK
| | - Ludvic Zrinzo
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology London, UK
| | - Zinovia Kefalopoulou
- Sobell Department of Motor Neuroscience, University College London Institute of Neurology London, UK
| | - Marie-Laure Welter
- Assistance publique - Hôpitaux de Paris, Institut du Cerveau et de la Moelle Epiniere, Institut National de la Santé et de la Recherche Médicale 1127, Pitié-Salpêtrière Hospital, Sorbonne Universités, UPMC Univ Paris 06, Unité Mixte de Recherche 1127, Centre National de la Recherche Scientifique, Unité Mixte de Recherche 7225 Paris, France
| | - Carine Karachi
- Institut National de la Santé et de la Recherche Médicale U 1127, Centre National de la Recherche Scientifique UMR 7225, Sorbonne Universités, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinièreParis, France; Department of Neurosurgery, Assistance Publique - Hôpitaux de Paris, Hôpital de la Pitié-SalpêtrièreParis, France
| | - Luc Mallet
- Institut National de la Santé et de la Recherche Médicale U 1127, Centre National de la Recherche Scientifique UMR 7225, Sorbonne Universités, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinièreParis, France; Assistance publique - Hôpitaux de Paris, DHU Pe-PSY, Pôle de Psychiatrie et d'addictologie des Hôpitaux Universitaires H Mondor, Université Paris Est CréteilCréteil, France; Department of Mental Health and Psychiatry, Geneva University HospitalGeneva, Switzerland
| | - Jean-Luc Houeto
- Service de Neurologie, Institut National de la Santé et de la Recherche Médicale-Centres d'Investigation Clinique 1402, Centre Hospitalier Universitaire de Grenoble de Poitiers, Université de Poitiers Poitiers, France
| | - Joohi Shahed-Jimenez
- Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine Houston, TX, USA
| | - Fan-Gang Meng
- Beijing Neurosurgical Institute, Capital Medical University Beijing, China
| | - Bryan T Klassen
- Department of Neurology, Mayo Clinic College of Medicine Rochester, MN, USA
| | - Alon Y Mogilner
- Department of Neurosurgery, Center for Neuromodulation, NYU Langone Medical Center New York, NY, USA
| | - Michael H Pourfar
- Department of Neurosurgery, Center for Neuromodulation, NYU Langone Medical Center New York, NY, USA
| | - Jens Kuhn
- Department of Psychiatry and Psychotherapy, University of Cologne Cologne, Germany
| | - L Ackermans
- Department of Neurosurgery, Maastricht University Medical Centre Maastricht, Netherlands
| | - Takanobu Kaido
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry Kodaira, Japan
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical CenterMaastricht, Netherlands; Faculty of Health, Medicine and Life Sciences, School for Mental Health and Neuroscience, Maastricht UniversityMaastricht, Netherlands
| | - Robert E Gross
- Department of Neurosurgery, Emory University Atlanta, GA, USA
| | - Harrison C Walker
- Department of Neurology, Department of Biomedical Engineering, University of Alabama at Birmingham Birmingham, AL, USA
| | - Andres M Lozano
- Division of Neurosurgery, University of Toronto Toronto, Canada
| | - Suketu M Khandhar
- Department of Neurology, The Permanente Medical Group (Tidewater Physicians Multispecialty Group), Movement Disorders Program Sacramento, CA, USA
| | - Benjamin L Walter
- University Hospitals, Case Western Reserve University School of Medicine Cleveland, OH, USA
| | - Ellen Walter
- Department of Neurology, University Hospitals Case Medical Center, Neurological Institute Cleveland, OH, USA
| | - Zoltan Mari
- Parkinson's & Movement Disorder Center/Division, Johns Hopkins University, School of Medicine Baltimore, MD, USA
| | - Barbara K Changizi
- Department of Neurology, The Ohio State University Wexner Medical Center Columbus, OH, USA
| | - Elena Moro
- Division of Neurology, Centre Hospitalier Universitaire de Grenoble Grenoble, Grenoble Alpes University Grenoble, France
| | - Juan C Baldermann
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Köln Köln, Germany
| | - Daniel Huys
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Köln Köln, Germany
| | - S Elizabeth Zauber
- Department of Neurology, Indiana University School of Medicine Indianapolis, IN, USA
| | - Lauren E Schrock
- Department of Neurology, University of Utah Salt Lake City, UT, USA
| | - Jian-Guo Zhang
- Department of Functional Neurosurgery, Beijing Tiantan Hospital, Capital Medical University Beijing, China
| | - Wei Hu
- Department of Neurology, University of Florida and Center for Movement Disorders and Neurorestoration Gainesville, FL, USA
| | - Kelly D Foote
- Department of Neurology, University of Florida and Center for Movement Disorders and NeurorestorationGainesville, FL, USA; Department of Neurological Surgery, University of FloridaGainesville, FL, USA
| | - Kyle Rizer
- Department of Neurology, University of Florida and Center for Movement Disorders and Neurorestoration Gainesville, FL, USA
| | - Jonathan W Mink
- Department of Neurology, University of Rochester Medical Center Rochester, NY, USA
| | - Douglas W Woods
- Department of Psychology, Marquette University Milwaukee, WI, USA
| | - Aysegul Gunduz
- Department of Neurology, University of Florida and Center for Movement Disorders and NeurorestorationGainesville, FL, USA; J. Crayton Pruitt Family Department of Biomedical Engineering, University of FloridaGainesville, FL, USA
| | - Michael S Okun
- Department of Neurology, University of Florida and Center for Movement Disorders and Neurorestoration Gainesville, FL, USA
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Baldermann JC, Schüller T, Huys D, Becker I, Timmermann L, Jessen F, Visser-Vandewalle V, Kuhn J. Deep Brain Stimulation for Tourette-Syndrome: A Systematic Review and Meta-Analysis. Brain Stimul 2015; 9:296-304. [PMID: 26827109 DOI: 10.1016/j.brs.2015.11.005] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 10/15/2015] [Accepted: 11/13/2015] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND A significant proportion of patients with Tourette syndrome (TS) continue to experience symptoms across adulthood that in severe cases fail to respond to standard therapies. For these cases, deep brain stimulation (DBS) is emerging as a promising treatment option. OBJECTIVE We conducted a systematic literature review to evaluate the efficacy of DBS for GTS. METHODS Individual data of case reports and series were pooled; the Yale Global Tic Severity Scale (YGTSS) was chosen as primary outcome parameter. RESULTS In total, 57 studies were eligible, including 156 cases. Overall, DBS resulted in a significant improvement of 52.68% (IQR = 40.74, p < 0.001) in the YGTSS. Analysis of controlled studies significantly favored stimulation versus off stimulation with a standardized mean difference of 0.96 (95% CI: 0.36-1.56). Disentangling different target points revealed significant YGTSS reductions after stimulation of the thalamus, the posteroventrolateral part and the anteromedial part of the globus pallidus internus, the anterior limb of the internal capsule and nucleus accumbens with no significant difference between these targets. A significant negative correlation of preoperative tic scores with the outcome of thalamic stimulation was found. CONCLUSIONS Despite small patient numbers, we conclude that DBS for GTS is a valid option for medically intractable patients. Different brain targets resulted in comparable improvement rates, indicating a modulation of a common network. Future studies might focus on a better characterization of the clinical effects of distinct regions, rather than searching for a unique target.
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Affiliation(s)
- Juan Carlos Baldermann
- Department of Psychiatry and Psychotherapy, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany.
| | - Thomas Schüller
- Department of Psychiatry and Psychotherapy, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany
| | - Daniel Huys
- Department of Psychiatry and Psychotherapy, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany
| | - Ingrid Becker
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany
| | - Lars Timmermann
- Department of Neurology, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany
| | - Frank Jessen
- Department of Psychiatry and Psychotherapy, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany
| | - Veerle Visser-Vandewalle
- Department of Stereotactic and Functional Neurosurgery, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany
| | - Jens Kuhn
- Department of Psychiatry and Psychotherapy, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany
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Cleary DR, Ozpinar A, Raslan AM, Ko AL. Deep brain stimulation for psychiatric disorders: where we are now. Neurosurg Focus 2015; 38:E2. [DOI: 10.3171/2015.3.focus1546] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Fossil records showing trephination in the Stone Age provide evidence that humans have sought to influence the mind through physical means since before the historical record. Attempts to treat psychiatric disease via neurosurgical means in the 20th century provided some intriguing initial results. However, the indiscriminate application of these treatments, lack of rigorous evaluation of the results, and the side effects of ablative, irreversible procedures resulted in a backlash against brain surgery for psychiatric disorders that continues to this day. With the advent of psychotropic medications, interest in invasive procedures for organic brain disease waned.
Diagnosis and classification of psychiatric diseases has improved, due to a better understanding of psychiatric patho-physiology and the development of disease and treatment biomarkers. Meanwhile, a significant percentage of patients remain refractory to multiple modes of treatment, and psychiatric disease remains the number one cause of disability in the world. These data, along with the safe and efficacious application of deep brain stimulation (DBS) for movement disorders, in principle a reversible process, is rekindling interest in the surgical treatment of psychiatric disorders with stimulation of deep brain sites involved in emotional and behavioral circuitry.
This review presents a brief history of psychosurgery and summarizes the development of DBS for psychiatric disease, reviewing the available evidence for the current application of DBS for disorders of the mind.
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Affiliation(s)
- Daniel R. Cleary
- 1Department of Neurology, Yale Medical School, New Haven, Connecticut
| | - Alp Ozpinar
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Ahmed M. Raslan
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Andrew L. Ko
- 3Department of Neurological Surgery, University of Washington, Seattle, Washington
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14
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Smith KM, Spindler MA. Uncommon applications of deep brain stimulation in hyperkinetic movement disorders. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2015; 5:278. [PMID: 25713746 PMCID: PMC4314611 DOI: 10.7916/d84x56hp] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 11/20/2014] [Indexed: 12/12/2022]
Abstract
Background In addition to the established indications of tremor and dystonia, deep brain stimulation (DBS) has been utilized less commonly for several hyperkinetic movement disorders, including medication-refractory myoclonus, ballism, chorea, and Gilles de la Tourette (GTS) and tardive syndromes. Given the lack of adequate controlled trials, it is difficult to translate published reports into clinical use. We summarize the literature, draw conclusions regarding efficacy when possible, and highlight concerns and areas for future study. Methods A Pubmed search was performed for English-language articles between January 1980 and June 2014. Studies were selected if they focused primarily on DBS to treat the conditions of focus. Results We identified 49 cases of DBS for myoclonus-dystonia, 21 for Huntington's disease, 15 for choreacanthocytosis, 129 for GTS, and 73 for tardive syndromes. Bilateral globus pallidus interna (GPi) DBS was the most frequently utilized procedure for all conditions except GTS, in which medial thalamic DBS was more common. While the majority of cases demonstrate some improvement, there are also reports of no improvement or even worsening of symptoms in each condition. The few studies including functional or quality of life outcomes suggest benefit. A limited number of studies included blinded on/off testing. There have been two double-blind controlled trials performed in GTS and a single prospective double-blind, uncontrolled trial in tardive syndromes. Patient characteristics, surgical target, stimulation parameters, and duration of follow-up varied among studies. Discussion Despite these extensive limitations, the literature overall supports the efficacy of DBS in these conditions, in particular GTS and tardive syndromes. For other conditions, the preliminary evidence from small studies is promising and encourages further study.
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Affiliation(s)
- Kara M Smith
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Meredith A Spindler
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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15
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Schrock LE, Mink JW, Woods DW, Porta M, Servello D, Visser-Vandewalle V, Silburn PA, Foltynie T, Walker HC, Shahed-Jimenez J, Savica R, Klassen BT, Machado AG, Foote KD, Zhang JG, Hu W, Ackermans L, Temel Y, Mari Z, Changizi BK, Lozano A, Auyeung M, Kaido T, Agid Y, Welter ML, Khandhar SM, Mogilner AY, Pourfar MH, Walter BL, Juncos JL, Gross RE, Kuhn J, Leckman JF, Neimat JA, Okun MS. Tourette syndrome deep brain stimulation: a review and updated recommendations. Mov Disord 2014; 30:448-71. [PMID: 25476818 DOI: 10.1002/mds.26094] [Citation(s) in RCA: 171] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 10/06/2014] [Accepted: 10/08/2014] [Indexed: 12/16/2022] Open
Abstract
Deep brain stimulation (DBS) may improve disabling tics in severely affected medication and behaviorally resistant Tourette syndrome (TS). Here we review all reported cases of TS DBS and provide updated recommendations for selection, assessment, and management of potential TS DBS cases based on the literature and implantation experience. Candidates should have a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V) diagnosis of TS with severe motor and vocal tics, which despite exhaustive medical and behavioral treatment trials result in significant impairment. Deep brain stimulation should be offered to patients only by experienced DBS centers after evaluation by a multidisciplinary team. Rigorous preoperative and postoperative outcome measures of tics and associated comorbidities should be used. Tics and comorbid neuropsychiatric conditions should be optimally treated per current expert standards, and tics should be the major cause of disability. Psychogenic tics, embellishment, and malingering should be recognized and addressed. We have removed the previously suggested 25-year-old age limit, with the specification that a multidisciplinary team approach for screening is employed. A local ethics committee or institutional review board should be consulted for consideration of cases involving persons younger than 18 years of age, as well as in cases with urgent indications. Tourette syndrome patients represent a unique and complex population, and studies reveal a higher risk for post-DBS complications. Successes and failures have been reported for multiple brain targets; however, the optimal surgical approach remains unknown. Tourette syndrome DBS, though still evolving, is a promising approach for a subset of medication refractory and severely affected patients.
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Affiliation(s)
- Lauren E Schrock
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
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Abstract
Tourette's syndrome (TS) is a childhood neuropsychiatric disorder characterized by multiple involuntary motor and vocal tics. It is commonly associated with other behavioral disorders including attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, anxiety, depression, and self-injurious behaviors. Tourette's syndrome can be effectively managed with psychobehavioral and pharmacological treatments, and many patients experience an improvement in tics in adulthood. However, symptoms may persist and cause severe impairment in a small subset of patients despite available therapies. In recent years, deep brain stimulation (DBS) has been shown to be a promising treatment option for such patients. Since the advent of its use in 1999, multiple targets have been identified in DBS for TS, including the medial thalamus, globus pallidus internus, globus pallidus externus, anterior limb of the internal capsule/nucleus accumbens, and subthalamic nucleus. While the medial thalamus is the most commonly reported trajectory, the optimal surgical target for TS is still a topic of much debate. This paper provides a review of the available literature regarding the use of DBS for TS.
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Affiliation(s)
- Janine Rotsides
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
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Dehning S, Leitner B, Schennach R, Müller N, Bötzel K, Obermeier M, Mehrkens JH. Functional outcome and quality of life in Tourette's syndrome after deep brain stimulation of the posteroventrolateral globus pallidus internus: long-term follow-up. World J Biol Psychiatry 2014; 15:66-75. [PMID: 24304122 DOI: 10.3109/15622975.2013.849004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Deep brain stimulation (DBS) for Tourette's syndrome (TS) in various targets has been in the focus for some years. However, there are hardly any data on "psychosocial" outcome after DBS for TS. The aim of the present study therefore was to focus on the functional outcome and "psychosocial changes" in TS patients after DBS. METHODS Six patients with treatment-refractory TS underwent GPi-DBS. The Yale Global Tic Severity Scale (YGTSS) was used to evaluate symptomatic outcome. Psychosocial changes were assessed applying the Global Assessment of Functioning Scale (GAF) and the Gilles-de-la-Tourette-Syndrome Quality-of-Life scale (GTS-QOL) with additionally documenting psychosocial changes. Follow-up ranged between 12 and 72 months. RESULTS In all symptomatic responders (4 of 6) we found a significant functional improvement (mean GAF increasing from 53.75 (± 7.5) pre-operatively to 83.75 (± 7.5) at last follow-up) along with a positive correlation with the course of GTS-QOL (R(2) = 0.62). CONCLUSIONS Treatment success should not only be assessed with the classic "tic-scales", but also with the GAF and GTS-QOL. Although improvement of tics seems to be positively correlated with improved functional outcome, symptomatic improvement may lead to unexpected major psychosocial changes - which both the patient and the clinicians in charge - should be prepared for.
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Affiliation(s)
- Sandra Dehning
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University , Munich , Germany
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18
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Abstract
Gilles de la Tourette syndrome is a movement disorder characterized by repetitive stereotyped motor and phonic movements with varying degrees of psychiatric comorbidity. Deep brain stimulation (DBS) has emerged as a novel therapeutic intervention for patients with refractory Tourette syndrome. Since 1999, more than 100 patients have undergone DBS at various targets within the corticostriatothalamocortical network thought to be implicated in the underlying pathophysiology of Tourette syndrome. Future multicenter clinical trials and the use of a centralized online database to compare the results are necessary to determine the efficacy of DBS for Tourette syndrome.
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Affiliation(s)
- Won Kim
- Department of Neurosurgery, University of California, Los Angeles 10945, Le Conte Avenue, Suite 2120, Los Angeles, CA 90095, USA.
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Müller-Vahl KR. Surgical treatment of Tourette syndrome. Neurosci Biobehav Rev 2012; 37:1178-85. [PMID: 23041074 DOI: 10.1016/j.neubiorev.2012.09.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 09/19/2012] [Accepted: 09/26/2012] [Indexed: 11/15/2022]
Abstract
In severely affected, treatment resistant patients with Tourette syndrome (TS) new therapeutic strategies are urgently needed. Since 1999, 34 studies including more than 90 patients have been performed to investigate the efficacy and safety of deep brain stimulation (DBS) in the treatment of tics resulting in the vast majority of patients in an improvement of tics and in some patients even of comorbidities. Both surgery-related (e.g., bleeding, infection) and stimulation-related adverse events (e.g., loss of energy, blurred vision) seem to occur only in a minority of patients and not to cause significant impairment, respectively. Since randomized controlled studies including a larger number of patients are still lacking, up to now, no definite conclusion can be drawn. Therefore, at present time DBS is recommended only in adult, treatment resistant, and severely affected patients. However, most experts have no doubt that DBS is indeed effective in the treatment of tics. Future studies should aim to identify which target in which patient is optimal depending on the individual symptomatology.
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Affiliation(s)
- Kirsten R Müller-Vahl
- Clinic of Psychiatry, Socialpsychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany.
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Viswanathan A, Jimenez-Shahed J, Baizabal Carvallo JF, Jankovic J. Deep brain stimulation for Tourette syndrome: target selection. Stereotact Funct Neurosurg 2012; 90:213-24. [PMID: 22699684 DOI: 10.1159/000337776] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Accepted: 03/03/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Tourette syndrome (TS) is a complex neurological disorder manifested chiefly by motor and phonic tics and a variety of behavioral comorbidities, including attention disorder, obsessive-compulsive disorder and impulse control problems. Surgical treatment is increasingly considered when tics become troublesome or even disabling or self-injurious despite optimal medical therapy. In this review, we describe the surgical techniques, stimulation parameters, outcomes of deep brain stimulation (DBS) in TS, and critically review target choices. METHODS A search of the PubMed database was performed to identify all articles discussing DBS and TS. 'Tourette' and 'Stimulation' were used as MeSH headings. RESULTS Since the first report of thalamic DBS for TS in 1999, follow-up on less than 100 patients has been reported in the literature. Reported targets for DBS include the thalamic centromedian nucleus and substantia periventricularis, posteroventral globus pallidus internus, ventromedial globus pallidus internus, globus pallidus externus, anterior limb of the internal capsule and nucleus accumbens. CONCLUSIONS Determination of the optimal surgical target will require a multicenter, randomized trial, and an expanded understanding of the neurobiology of TS.
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Affiliation(s)
- Ashwin Viswanathan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA.
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