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Abstract
Tourette syndrome (TS) is a childhood onset neurologic disorder with manifestations including multiple motor and phonic tics, and in most cases a variety of behavioral comorbidities such as attention deficit hyperactivity disorder, obsessive compulsive disorder, and other impulse control disorders. Although it is considered a hereditary disorder, likely modified by environmental factors, genetic studies have yet to uncover relevant causative genes and there is no animal model that mimics the broad clinical phenomenology of TS. There has been a marked increase in the number of neurophysiological, neuroimaging, and other studies on TS. The findings from these studies, however, have been difficult to interpret because of small sample sizes, variability of symptoms across patients, and comorbidities. Although anti-dopaminergic drugs are the most widely used medications in the treatment of TS, there has been increasing interest in other drugs, behavioral therapies, and surgical approaches including deep brain stimulation. Herein, we review the current literature and discuss the complexities of TS and the challenges in understanding its pathophysiology and in selecting the most appropriate treatment. We also offer an expert's view of where the field of TS may be headed.
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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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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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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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Pansaon Piedad JC, Rickards HE, Cavanna AE. What Patients With Gilles de la Tourette Syndrome Should Be Treated With Deep Brain Stimulation and What Is the Best Target? Neurosurgery 2012; 71:173-92. [DOI: 10.1227/neu.0b013e3182535a00] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
AbstractBACKGROUND:Gilles de la Tourette syndrome (GTS) is a chronic neurodevelopmental disorder characterized by tics and associated behavioral symptoms. Over the past decade, deep brain stimulation (DBS) has been increasingly advocated as a reversible and controllable procedure for selected cases of GTS.OBJECTIVE:We set out to answer 2 clinically relevant questions: what patients with GTS should be treated with DBS and what is the best target?METHODS:We conducted a systematic literature review of the published studies of DBS in GTS and critically evaluated the current evidence for both patient and target selection.RESULTS:Since 1999, up to 99 cases of DBS in GTS have been reported in the scientific literature, with varying selection criteria, stimulation targets, and assessment protocols. The vast majority of studies published to date are case reports or case series reporting successful outcomes in terms of both tic severity improvement and tolerability. The reviewed studies suggest that the best candidates are patients with significant functional impairment related to the tic symptoms, who did not respond to conventional pharmacological and behavioral interventions. The globus pallidus internus and thalamus appear to be the safest and most effective targets, especially for patients with “pure” GTS and patients with comorbid obsessive-compulsive symptoms, anxiety, and depression.CONCLUSION:DBS is a promising treatment option for severe cases of GTS. There is a need to reach consensus on the definition of “treatment-refractoriness” and to conduct larger double-blind randomized controlled studies on the most promising targets.
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Affiliation(s)
- John Carlo Pansaon Piedad
- Michael Trimble Neuropsychiatry Research Group, Department of Neuropsychiatry, University of Birmingham and BSMHFT, Birmingham, United Kingdom
| | - Hugh Edward Rickards
- Michael Trimble Neuropsychiatry Research Group, Department of Neuropsychiatry, University of Birmingham and BSMHFT, Birmingham, United Kingdom
| | - Andrea Eugenio Cavanna
- Michael Trimble Neuropsychiatry Research Group, Department of Neuropsychiatry, University of Birmingham and BSMHFT, Birmingham, United Kingdom
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology and UCL, London, United Kingdom
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Bell E, Maxwell B, McAndrews MP, Sadikot A, Racine E. Deep brain stimulation and ethics: perspectives from a multisite qualitative study of Canadian neurosurgical centers. World Neurosurg 2012; 76:537-47. [PMID: 22251502 DOI: 10.1016/j.wneu.2011.05.033] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Revised: 03/18/2011] [Accepted: 05/13/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) is an approved neurosurgical intervention for motor disorders such as Parkinson disease. The emergence of psychiatric uses for DBS combined with the fact that it is an invasive and expensive procedure creates important ethical and social challenges in the delivery of care that need further examination. We endeavored to examine health care provider perspectives on ethical and social challenges encountered in DBS. METHODS Health care providers working in Canadian DBS surgery programs participated in a semistructured interview to identify and characterize ethical and social challenges of DBS. A content analysis of the interviews was conducted. RESULTS Several key ethical issues, such as patient screening and resource allocation, were identified by members of neurosurgical teams. Providers described challenges in selecting patients for DBS on the basis of unclear evidence-based guidance regarding behavioral issues or cognitive criteria. Varied contexts of resource allocation, including some very challenging schemas, were also reported. In addition, the management of patients in the community was highlighted as a source of ethical and clinical complexity, given the need for coordinated long-term care. CONCLUSIONS This study provides insights into the complexity of ethical challenges that providers face in the use of DBS across different neurosurgical centers. We propose actions for health care providers for the long-term care and postoperative monitoring of patients with DBS. More data on patient perspectives in DBS would complement the understanding of key challenges, as well as contribute to best practices, for patient selection, management, and resource allocation.
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Affiliation(s)
- Emily Bell
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
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Müller-Vahl KR, Cath DC, Cavanna AE, Dehning S, Porta M, Robertson MM, Visser-Vandewalle V. European clinical guidelines for Tourette syndrome and other tic disorders. Part IV: deep brain stimulation. Eur Child Adolesc Psychiatry 2011; 20:209-17. [PMID: 21445726 DOI: 10.1007/s00787-011-0166-4] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Ten years ago deep brain stimulation (DBS) has been introduced as an alternative and promising treatment option for patients suffering from severe Tourette syndrome (TS). It seemed timely to develop a European guideline on DBS by a working group of the European Society for the Study of Tourette Syndrome (ESSTS). For a narrative review a systematic literature search was conducted and expert opinions of the guidelines group contributed also to the suggestions. Of 63 patients reported so far in the literature 59 had a beneficial outcome following DBS with moderate to marked tic improvement. However, randomized controlled studies including a larger number of patients are still lacking. Although persistent serious adverse effects (AEs) have hardly been reported, surgery-related (e.g., bleeding, infection) as well as stimulation-related AEs (e.g., sedation, anxiety, altered mood, changes in sexual function) may occur. At present time, DBS in TS is still in its infancy. Due to both different legality and practical facilities in different European countries these guidelines, therefore, have to be understood as recommendations of experts. However, among the ESSTS working group on DBS in TS there is general agreement that, at present time, DBS should only be used in adult, treatment resistant, and severely affected patients. It is highly recommended to perform DBS in the context of controlled trials.
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Affiliation(s)
- Kirsten R Müller-Vahl
- Clinic of Psychiatry, Socialpsychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.
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Okun MS, Foote KD. Parkinson’s disease DBS: what, when, who and why? The time has come to tailor DBS targets. Expert Rev Neurother 2011; 10:1847-57. [PMID: 21384698 DOI: 10.1586/ern.10.156] [Citation(s) in RCA: 108] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Deep brain stimulation (DBS) has recently been proven to be an effective therapy for medication refractory symptoms of Parkinson's disease. As the evidence base continues to evolve, many important issues have surfaced, including: what operation should be performed (brain target[s],unilateral vs bilateral, simultaneous vs staged); when to operate (how early is too early to intervene?), who should be operated on (disease duration, age, symptom profiles and the use of the interdisciplinary screening team); and finally, why to operate (the rationale of surgery vs medication/apomorphine pumps/duodopa pumps/stem cell trials/gene therapy trials). We will address each of these critical issues, as well make the argument that a tailored approach to DBS and DBS targeting will best serve each potential candidate. We will review the multiple peer reviewed studies and we will emphasize the recently available data from randomized DBS studies.We will argue that moving away from a single DBS target (e.g., subthalamic nucleus DBS) and a single approach to DBS methodology (e.g., bilateral simultaneous operations) is a reasonable next step for the Parkinson's disease community. Following careful interdisciplinary DBS screening, a physician-patient discussion has the potential to establish a patient-centered and symptom-specific outcome for each potential DBS candidate. The interdisciplinary DBS team can function together to formulate and to consider an optimal and tailored approach. A tailored approach will allow for the consideration of the complex and numerous variables that may contribute to a positive or negative overall DBS outcome. We will review and provide expert commentary on a potential interdisciplinary approach to selecting unilateral or alternatively bilateral subthalamic nucleus or globus pallidus internus DBS. Our approach is aimed to maximize benefit(s) and minimize risk(s) in order to best tailor therapy for an individual patient.
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Affiliation(s)
- Michael S Okun
- University of Florida Movement Disorders Center, McKnight Brain Institute, Gainesville, FL USA.
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Dianas quirúrgicas en el tratamiento de enfermedades psiquiátricas. Desde el movimiento a las emociones. Neurocirugia (Astur) 2011. [DOI: 10.1016/s1130-1473(11)70001-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Neuner I, Podoll K, Janouschek H, Michel TM, Sheldrick AJ, Schneider F. From psychosurgery to neuromodulation: deep brain stimulation for intractable Tourette syndrome. World J Biol Psychiatry 2010; 10:366-76. [PMID: 19005877 DOI: 10.1080/15622970802513317] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Tourette syndrome is a neuropsychiatric disorder characterized by motor and vocal tics. It is often associated with depression, obsessive-compulsive symptoms, self-injurious behaviour and attention deficit-hyperactivity disorder (ADHD). In intractable patients, neuromodulation using deep brain stimulation (DBS) has widely replaced psychosurgery. Three different key structures are defined for DBS, the medial portion of the thalamus, the globus pallidus internus and the anterior limb of the internal capsule/nucleus accumbens. This is a comprehensive overview on the effect of DBS on motor and non-motor symptoms using different case series and two larger studies.
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Affiliation(s)
- Irene Neuner
- Department of Psychiatry and Psychotherapy, RWTH Aachen University, Aachen, Germany.
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Marks WA, Honeycutt J, Acosta F, Reed M. Deep brain stimulation for pediatric movement disorders. Semin Pediatr Neurol 2009; 16:90-8. [PMID: 19501337 DOI: 10.1016/j.spen.2009.04.001] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Deep brain stimulation (DBS) has been used for the treatment of tremor and dystonia in adults since 1997. With more than 50,000 treated adults, it has become part of the standard care for pharmacoresistant tremor, Parkinson disease, and dystonias. Dystonias are a heterogeneous group of disorders with intrinsic (genetic) and extrinsic etiologic factors. In children and adults, DBS has been used for the treatment of both primary and secondary dystonias. Pediatric use has been more limited, with only a few experienced centers worldwide. Awake surgery can be safely performed with a dedicated multidisciplinary team approach to help ensure appropriate lead placement. It is incumbent upon us, as physicians, to advise patients and payers on the appropriate use of this technology. Neuromodulation of other disorders, including epilepsy, Tourette syndrome, obsessive-compulsive disorder, and depression, by DBS is under active investigation. Pediatric DBS is still in its early stages; experience will help us refine the indications and techniques for applying this complex technology to our most vulnerable patients, which should lead to our common goal of improving quality of life for our patients and their families. We review the role of DBS and our experience with establishing a dedicated pediatric DBS program.
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Affiliation(s)
- Warren A Marks
- Department of Neurology, Cook Children's Medical Center, Fort Worth, TX, USA.
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Goodman WK, Insel TR. Deep brain stimulation in psychiatry: concentrating on the road ahead. Biol Psychiatry 2009; 65:263-6. [PMID: 19167964 DOI: 10.1016/j.biopsych.2008.12.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Accepted: 12/06/2008] [Indexed: 11/19/2022]
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Mukhida K, Bishop M, Hong M, Mendez I. Neurosurgical strategies for Gilles de la Tourette's syndrome. Neuropsychiatr Dis Treat 2008; 4:1111-28. [PMID: 19337454 PMCID: PMC2646643 DOI: 10.2147/ndt.s4160] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Tourette's syndrome (TS) is a neurological disorder characterized by motor and vocal tics that typically begin in childhood and often are accompanied by psychiatric comorbidities. Symptoms of TS may be socially disabling and cause secondary medical complications. Pharmacological therapies remain the mainstay of symptom management. For the subset of patients in whom TS symptoms are medically recalcitrant and do not dissipate by adulthood, neurosurgery may offer an alternative treatment strategy. Greater understanding of the neuroanatomic and pathophysiologic basis of TS has facilitated the development of surgical procedures that aim to ameliorate TS symptoms by lesions or deep brain stimulation of cerebral structures. Herein, the rationale for the surgical management of TS is discussed and neurosurgical experiences since the 1960s are reviewed. The necessity for neurosurgical strategies to be performed with appropriate ethical considerations is highlighted.
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Affiliation(s)
- Karim Mukhida
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
- Departments of Anatomy and Neurobiology and Surgery (Neurosurgery), Dalhousie University, Halifax, Nova Scotia, Canada
| | - Matthew Bishop
- Departments of Anatomy and Neurobiology and Surgery (Neurosurgery), Dalhousie University, Halifax, Nova Scotia, Canada
| | - Murray Hong
- Departments of Anatomy and Neurobiology and Surgery (Neurosurgery), Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ivar Mendez
- Departments of Anatomy and Neurobiology and Surgery (Neurosurgery), Dalhousie University, Halifax, Nova Scotia, Canada
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