Three cases of symptom change in Tourette's syndrome and obsessive-compulsive disorder associated with paediatric cerebral malignancies

Psychiatric symptoms in children with low-grade glioma and craniopharyngioma: A systematic review

The presentation of psychiatric symptoms in pediatric low-grade brain tumors is challenging because this can delay proper diagnosis and treatment. We performed a systematic review of psychiatric presenting symptoms of low-grade brain tumors in pediatric patients. We searched the PubMed and Web of Science databases of studies published in English from 1977 until 2019 reporting patients aged ≤21 years at the time of tumor diagnosis who exhibited psychiatric/behavioral symptoms before diagnosis of low-grade glioma (LGG), pilocytic astrocytoma (PA), or craniopharyngioma (CP). Our systematic search strategy coupled each tumor type with patient age and presenting symptoms by using different variations of the search terms "childhood" and "psychiatric symptoms" or "behavioral symptoms." We identified six unique articles that met our inclusion criteria in the LGG search, 27 in the PA search, and 32 in the CP search. Six patients were included in the LGG articles (age range, 3-16 years), 75 in the PA articles (age range, 0.5-21 years), and 87 in the CP articles (age range, 0.67-21 years). The most common presenting symptoms included eating disorders (n = 64) and behavioral changes (n = 49). Our findings demonstrate the need to establish clear criteria for neuroimaging indications for pediatric patients exhibiting eating disorders.

Animal models of tic disorders: a translational perspective

Tics are repetitive, sudden movements and/or vocalizations, typically enacted as maladaptive responses to intrusive premonitory urges. The most severe tic disorder, Tourette syndrome (TS), is a childhood-onset condition featuring multiple motor and at least one phonic tic for a duration longer than 1 year. The pharmacological treatment of TS is mainly based on antipsychotic agents; while these drugs are often effective in reducing tic severity and frequency, their therapeutic compliance is limited by serious motor and cognitive side effects. The identification of novel therapeutic targets and development of better treatments for tic disorders is conditional on the development of animal models with high translational validity. In addition, these experimental tools can prove extremely useful to test hypotheses on the etiology and neurobiological bases of TS and related conditions. In recent years, the translational value of these animal models has been enhanced, thanks to a significant re-organization of our conceptual framework of neuropsychiatric disorders, with a greater focus on endophenotypes and quantitative indices, rather than qualitative descriptors. Given the complex and multifactorial nature of TS and other tic disorders, the selection of animal models that can appropriately capture specific symptomatic aspects of these conditions can pose significant theoretical and methodological challenges. In this article, we will review the state of the art on the available animal models of tic disorders, based on genetic mutations, environmental interventions as well as pharmacological manipulations. Furthermore, we will outline emerging lines of translational research showing how some of these experimental preparations have led to significant progress in the identification of novel therapeutic targets for tic disorders.

Neurosurgical targets for compulsivity: what can we learn from acquired brain lesions?

Treatment efficacy of deep brain stimulation (DBS) and other neurosurgical techniques in refractory obsessive-compulsive disorder (OCD) is greatly dependent on the targeting of relevant brain regions. Over the years, several case reports have been published on either the emergence or resolution of obsessive-compulsive symptoms due to neurological lesions. These reports can potentially serve as an important source of insight into the neuroanatomy of compulsivity and have implications for targets of DBS. For this purpose, we have reviewed all published case reports of patients with acquired or resolved obsessive-compulsive symptoms after brain lesions. We found a total of 37 case reports describing 71 patients with acquired and 6 with resolved obsessive-compulsive symptoms as a result of hemorrhaging, infarctions or removal of tumors. Behavioral symptoms following brain lesions consisted of typical obsessive-compulsive symptoms, but also symptoms within the compulsivity spectrum. These data suggests that lesions in the cortico-striato-thalamic circuit, parietal and temporal cortex, cerebellum and brainstem may induce compulsivity. Moreover, the resolution of obsessive-compulsive symptoms has been reported following lesions in the putamen, internal capsule and fronto-parietal lobe. These case reports provide strong evidence supporting the rationale for DBS in the ventral striatum and internal capsule for treatment of compulsivity and reveal the putamen and fronto-parietal cortex as promising new targets.

Deep brain stimulation for Tourette syndrome: a prospective pilot study in Japan

OBJECTIVE

Refractory Tourette syndrome (TS) disturbs the social life of patients. Deep brain stimulation (DBS) has recently been applied to relieve severe tics. We report a prospective open-labeled case series of DBS for TS as a pilot study.

CASES AND METHODS

Three patients (19-21 years old, one male) with refractory TS were treated with DBS. They were targeted at the centromedian-parafascicular complex-ventral oral thalamic nuclei of the bilateral thalami.

RESULTS

The scores for the Yale Global Tic Severity Scale decreased from 42.7 ± 2.7 (before DBS) to 26.0 ± 1.7 (one year after DBS) (means ± standard error of means). Intelligence levels of the patients showed no change after surgery. There was no morbidity or mortality. All patients presented an increase in satisfaction with activities of daily living.

CONCLUSIONS

These results support the safety and efficacy of thalamic DBS for TS.

Enlargement of thalamic nuclei in Tourette syndrome

CONTEXT

The basal ganglia and thalamus together connect in parallel closed-loop circuits with the cortex. Previous imaging studies have shown modifications of the basal ganglia and cortical targets in individuals with Tourette syndrome (TS), but less is known regarding the role of the thalamus in TS pathogenesis.

OBJECTIVE

To study the morphological features of the thalamus in children and adults with TS.

DESIGN

A cross-sectional, case-control study using anatomical magnetic resonance imaging.

SETTING

University research center.

PARTICIPANTS

The 283 participants included 149 with TS and 134 normal control individuals aged 6 to 63 years.

MAIN OUTCOME MEASURES

Conventional volumes and measures of surface morphology of the thalamus.

RESULTS

Analyses of conventional volumes and surface morphology were consistent in demonstrating an enlargement in TS-affected thalami. Overall volumes were 5% larger in the group composed of children and adults with TS. Statistical maps of surface contour demonstrated enlargement over the lateral thalamus. Post hoc testing indicated that differences in IQ, comorbid illnesses, and medication use did not account for these findings.

CONCLUSIONS

Morphological abnormalities in the thalamus, together with the disturbances reported in the sensorimotor cortex, striatum, and globus pallidus, support the hypothesis of a circuitwide disorder within motor pathways in TS. The connectivity and function of the numerous and diverse thalamic nuclei within cortical-subcortical circuits constitute an anatomical crossroad wherein enlargement of motor nuclei may represent activity-dependent hypertrophy within this component of cortical-subcortical motor circuits, or an adaptive response within a larger putative compensatory system that could thereby directly modulate activity in motor circuits to attenuate the severity of tics.

Identification and treatment of a pineal region tumor in an adolescent with prodromal psychotic symptoms

An adolescent male patient originally presented to a prodromal clinical research program with severe obsessive-compulsive behaviors and subthreshold symptoms of psychosis, which eventually developed into first-rank psychotic symptoms. The patient was followed over a 2-year period. His symptoms did not respond to psychotherapy or pharmacotherapy. However, when a pineal region tumor was discovered and treated with chemotherapy and autologous stem cell rescue, both psychotic symptoms and psychosocial functioning reverted toward baseline. Although subcortical brain structures have been implicated in the pathophysiology of idiopathic psychosis, reports of psychiatric sequelae of treatment of subcortical tumors are rare. Etiological pathways that may have played a role in symptom development are of particular interest, as understanding these mechanisms may shed light on the pathophysiology of psychotic disorders more generally.

Structural abnormalities in the substantia nigra and neighbouring nuclei in Tourette's syndrome

Although midbrain nuclei (substantia nigra, ventral tegmental area, and periaqueductal grey) are considered candidate loci of pathology in Tourette's syndrome (TS), few imaging studies have examined midbrain structure. The objective of this study was to evaluate the presence of subtle structural abnormalities in the midbrain of patients with TS. High-field magnetic resonance imaging (MRI) (1.5- and 3-T) was used in 23 patients with TS and in 20 age- and sex-matched normal control subjects. Tics symptoms were rated using the Yale Global Tic Severity Scale and comorbid neuropsychiatric disorders were evaluated with standardised psychiatric rating scales. MRI scans revealed subtle structural abnormalities consistent with expanded perivascular spaces (EPVS) in the substantia nigra (compacta and reticulata) and neighbouring nuclei in 6 (26%) patients with TS, but in none of the normal control subjects (P = 0.045). Stereotyped movements were more frequent (P = 0.017) amongst TS patients with midbrain EPVS than in TS patients with normal MRI. Parkinsonism, posttraumatic stress disorder and autistic spectrum disorders exclusively occurred in TS patients with midbrain EPVS. There were no significant between-group differences in other comorbid neuropsychiatric disorders and in tics. Although EPVS are generally viewed as incidental findings, our results suggest that when EPVS are located in the midbrain they may be symptomatic. These abnormalities would reduce the actual number of neurons in specific midbrain nuclei (e.g., substantia nigra) and disrupt their connectivity with limbic, associative, and motor circuits.

Imaging evidence for anatomical disturbances and neuroplastic compensation in persons with Tourette syndrome

BACKGROUND

Tourette syndrome (TS) is a disorder of chronic motor and vocal tics that begins in childhood.

METHODS

A systematic Medline search was conducted to identify existing anatomical imaging studies in persons with TS.

RESULTS

Thirty studies were identified, and their methods and findings were reviewed. Findings of reduced caudate volumes across the life span and thinning of sensorimotor cortices that is proportional with tic severity in children with TS implicate these regions in the genesis of tics. Hypertrophy of limbic and prefrontal cortices and a smaller corpus callosum accompany fewer symptoms in children with TS, likely representing an activity-dependent plasticity within these regions that help to modulate tic severity.

CONCLUSION

Although existing studies differ with respect to sample size, gender composition, quality of clinical characterization, pulse sequences, and methods of image analysis, the preponderance of evidence suggests that disturbances in the development of the motor portions of cortical-subcortical circuits likely predispose to the development TS and that neuroplastic changes in control systems of the brain help to modulate the severity of symptom expression. These findings from cross-sectional studies require confirmation in more representative populations within longitudinal studies.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition symptoms of mania: which one(s) result(s) more often from right than left hemisphere lesions?

Previously published single case reports of patients with a unilateral lesion were assembled. After the lesion, each of the 244 cases presented at least one of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) symptoms of a manic episode, namely, elated or irritable mood, grandiosity, talkativeness, flight of ideas, hyperhedonism, reduced need for sleep, agitation, or distractibility (all optional in DSM-IV). As expected, the subgroup of 59 manic patients had a right hemisphere lesion far more often than a left one. However, this was also true of various sets of the nonmanic cases. Furthermore, elation was not the symptom most strongly associated with lesion side. Elation without mania was not significantly predicted by lesion side. However, talkativeness was strongly predicted by right lesion side whether in manic or nonmanic patients or even when the symptom was the only symptom observed. Agitation was consistently and robustly associated with right lesion side, but not completely distinctly so (it fell short of significance when not accompanied by elation or other symptoms). It is proposed that prevalence of right hemisphere lesions causing mania is primarily related to mental and behavioral disinhibition rather than a shift of mood and that it consists of release of left hemisphere influence.

Increased midbrain gray matter in Tourette's syndrome

OBJECTIVE

To investigate cerebral structure in Tourette's syndrome (TS).

METHODS

Voxel-based morphometry study of high-resolution MRIs in 31 TS patients compared with 31 controls.

RESULTS

Increased gray matter mainly in the left mesencephalon in 31 TS patients.

INTERPRETATION

This result constitutes strong and direct evidence supporting Devinsky's hypothesis (Devinsky O. Neuroanatomy of Gilles de la Tourette's syndrome. Possible midbrain involvement. Arch Neurol 1983;40:508-514) according to which midbrain disturbances play an important pathogenic role in TS.

PANDAS: current status and directions for research

The recognition of the five criteria for PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) by Swedo et al established a homogenous subgroup of children with childhood onset obsessive-compulsive disorder (OCD) and/or tic disorders. The five clinical characteristics that define the PANDAS subgroup are the presence of OCD and/or tic disorder, prepubertal age of onset, abrupt onset and relapsing-remitting symptom course, association with neurological abnormalities during exacerbations (adventitious movements or motoric hyperactivity), and a temporal association between symptom exacerbations and a Group-A beta-hemolytic streptococcal (GAS) infection. These five criteria have been used for the purpose of systematic research on the phenomenology and unique therapies for the PANDAS subgroup as well as studies of the pathophysiology of post-streptococcal OCD and tic disorders. The etiology of OCD and tics in the PANDAS subgroup is unknown, but is theorized to occur as a result of post-streptococcal autoimmunity in a manner similar to that of Sydenham's chorea. The working hypothesis for the pathophysiology begins with a GAS infection in a susceptible host that incites the production of antibodies to GAS that crossreact with the cellular components of the basal ganglia, particularly in the caudate nucleus and putamen. The obsessions, compulsions, tics, and other neuropsychiatric symptoms seen in these children are postulated to arise from an interaction of these antibodies with neurons of the basal ganglia.

Childhood-onset obsessive-compulsive disorder and tic disorders: case report and literature review

A subgroup of childhood-onset obsessive-compulsive disorder (OCD) and tic disorders has been found to have a postinfectious autoimmune-mediated etiology. Clinical observations and systematic investigations have shown that a subgroup of children with OCD and/or tic disorders have the onset and subsequent exacerbations of their symptoms following infections with group A beta-hemolytic streptococci (GABHS). This subgroup has been designated by the acronym PANDAS: pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. Five clinical characteristics define the PANDAS subgroup: presence of OCD and/or tic disorder, prepubertal symptom onset, sudden onset or abrupt exacerbations, association with neurological abnormalities during exacerbations (adventitious movements or motoric hyperactivity), and the temporal association between symptom exacerbations and GABHS infections. The proposed poststreptococcal inflammatory etiology provides a unique opportunity for treatment and prevention, including immunomodulatory therapies such as plasma exchange and intravenous immunoglobulin. A placebo-controlled trial revealed that both intravenous immunoglobulin and plasma exchange were effective in reducing neuropsychiatric symptom severity (40 and 55% reductions, respectively) for a group of severely ill children in the PANDAS subgroup. Further research is required to determine why the treatments are helpful and to ascertain whether or not antibiotic prophylaxis can help prevent poststreptococcal symptom exacerbations.

Delayed and severe but transient Tourette syndrome after head injury

A previously well and intellectually normal 7(1/2)-year-old girl developed an acute and severe Tourette syndrome 15 months after sustaining a severe head injury. The patient displayed a dramatic response to haloperidol. Twelve months after the onset of Tourette syndrome the haloperidol was withdrawn, and there was no relapse of either her motor or phonic tics. Seven years after the head injury the patient remains tic free but demonstrates significant emotional and behavioral sequelae. The patient's brain magnetic resonance imaging findings were consistent with those reported previously in adults with Tourette syndrome.

Tourettism and dystonia after subcortical stroke

The term "tourettism" has been used to describe Tourette syndrome (TS)-like symptoms secondary to some specific cause. Tics associated with attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), or both, are commonly present in TS, but this constellation of symptoms has been rarely attributed to stroke. We describe two boys who suffered a subcortical stroke and subsequently developed hemidystonia, tics, and behavioral comorbidities. Both had right hemispheric stroke involving the basal ganglia at 8 years of age, and in both the latency from the stroke to the onset of left hemidystonia was 2 weeks. In addition to ADHD and OCD, both exhibited cranial-cervical motor tics but no phonic tics. The temporal relationship between the stroke and subsequent TS-like symptoms, as well as the absence of phonic tics and family history of TS symptoms in our patients, argues in favor of a cause and effect relationship, and the observed association provides evidence for an anatomic substrate for TS and related symptoms.

Oculomotor abnormalities in boys with tourette syndrome with and without ADHD

OBJECTIVE

To assess saccadic eye movements in boys with Tourette syndrome (TS) with and without attention-deficit hyperactivity disorder (ADHD), comparing performance with that of an age-matched group of male controls.

METHOD

Three different saccade tasks (prosaccades, antisaccades, and memory-guided saccades) were used to examine functions necessary for the planning and execution of eye movements, including motor response preparation, response inhibition, and working memory. The study included 14 boys with TS without ADHD (TS-only), 11 boys with TS and ADHD (TS+ADHD), and 10 male controls.

RESULTS

Latency of prosaccades was prolonged in boys with TS (both with and without ADHD) compared with controls. Variability in prosaccade latency was greater in the groups of boys with TS+ADHD compared with both the TS-only and control groups. Response inhibition errors on both the antisaccade task (directional errors) and memory-guided saccade task (anticipatory errors) were increased in boys with TS+ADHD compared with those with TS-only. There were no significant differences among the three groups in accuracy of memory-guided saccades.

CONCLUSIONS

Oculomotor findings suggest that TS is associated with delay in initiation of motor response as evidenced by excessive latency on prosaccades. Signs of impaired response inhibition and variability in motor response appear to be associated with the presence of ADHD.

Muscarinic m1 and m2 receptor proteins in local circuit and projection neurons of the primate striatum: anatomical evidence for cholinergic modulation of glutamatergic prefronto-striatal pathways

The cellular and subcellular localization of muscarinic receptor proteins m1 and m2 was examined in the neostriatum of macaque monkeys by using light and electron microscopic immunocytochemical techniques. Double-labeling immunocytochemistry revealed m1 receptors in calbindin-D28k--positive medium spiny projection neurons. Muscarinic m1 labeling was dramatically more intense in the striatal matrix compartment in juvenile monkeys but more intense in striosomes in the adult caudate, suggesting that m1 expression undergoes a developmental age-dependent change. Ultrastructurally, m1 receptors were predominantly localized in asymmetric synapse-forming spines, indicating that these spines receive extrastriatal excitatory afferents. The association of m1-positive spines with lesion-induced degenerating prefronto-striatal axon terminals demonstrated that these afferents originate in part from the prefrontal cortex. The synaptic localization of m1 in these spines indicates a role of m1 in the modulation of excitatory neurotransmission. To a lesser extent, m1 was present in symmetric synapses, where it may also modulate inhibitory neurotransmission originating from local striatal neurons or the substantia nigra. Conversely, m2/choline acetyltransferase (ChAT) double labeling revealed that m2-positive neurons corresponded to large aspiny cholinergic interneurons and ultrastructurally, that the majority of m2 labeled axons formed symmetric synapses. The remarkable segregation of the m1 and m2 receptor proteins to projection and local circuit neurons suggests a functional segregation of m1 and m2 mediated cholinergic actions in the striatum: m1 receptors modulate extrinsic glutamatergic and monoaminergic afferents and intrinsic GABAergic afferents onto projection neurons, whereas m2 receptors regulate acetylcholine release from axons of cholinergic interneurons.

Immediate and long term outcome after infrathalamic and thalamic lesioning for intractable Tourette's syndrome

OBJECTIVE

The surgical treatment of intractable Tourette's syndrome is controversial. Experience with 17 consecutive patients treated between 1970 and 1998 is reviewed and the efficacy and safety of surgical treatment is assessed.

METHODS

These patients were retrospectively reclassified into subtypes according to the protocol of the Tourette's Syndrome Study Group. One patient was excluded from the study. Ventriculography based stereotactic zona incerta (ZI) and ventrolateral/ lamella medialis thalamotomy (VL/LM) were performed on all patients. The preoperative, postoperative, and late tic severities were assessed by the tic severity rating scale. The median follow up of 11 patients (65%) was 7 years (range 3.5-17 years) and six patients were lost to long term follow up.

RESULTS

Median age was 23 years (range 11-40) at the time of surgery. Median duration of illness was 14 years (range 3-33). The mean preoperative motor and vocal tic severities were estimated to be 4.44 (SD 0.63) and 3.81 (SD 0.66), respectively. Unilateral ZI lesioning and VL/LM lesioning selected by asymmetry of symptoms provide an effective control of tic severity (p motor and vocal<0.001). In attenuation of contralateral symptoms, a second surgical intervention in the relevant side could reduce tic severity sufficiently (p motor<0.01; p vocal<0.005). Transient complications occurred in 68% of patients. Only one permanent complication was registered in six patients followed up after unilateral surgery. Two out of five patients followed up after bilateral surgery had disabling side effects of surgery.

CONCLUSIONS

ZI and VL/LM lesioning provide a significant long term reduction of tic severity in intractable Tourette's syndrome. Adequate selection of the side of first intervention might prevent the patient from increased risk of bilateral surgery.

Case study: suprasellar germinoma presenting with psychotic and obsessive-compulsive symptoms

This case describes a 13-year-old boy who had a suprasellar germinoma involving the bilateral basal ganglia. His presenting symptoms included left-sided weakness, diabetes insipidus, a decline in academic functioning as well as psychotic and obsessive-compulsive symptoms. His neuroradiological findings and clinical symptoms lend support to the potential role of the basal ganglia in psychotic and obsessive-compulsive symptomatology.

Expletives: neurolinguistic and neurobehavioral perspectives on swearing

Severe aphasia, adult left hemispherectomy, Gilles de la Tourette syndrome (GTS), and other neurological disorders have in common an increased use of swearwords. There are shared linguistic features in common across these language behaviors, as well as important differences. We explore the nature of swearing in normal human communication, and then compare the clinical presentations of selectively preserved, impaired and augmented swearing. These neurolinguistic observations, considered along with related neuroanatomical and neurochemical information, provide the basis for considering the neurobiological foundation of various types of swearing behaviors.

The effect of hypothalamic peptide YY on hippocampal acetylcholine release in vivo: implications for limbic function in binge-eating behavior

Central injection of peptide YY (PYY) in sated rats produces the most powerful stimulating effect of food intake known to date. The neural mechanisms by which PYY regulates appetite are not clear but may be important because abnormal levels of PYY have been implicated in the neurobiology of bulimia nervosa. Interactions between brain acetylcholine (ACh) and PYY had not been studied. Therefore, the present experiments were designed to explore the in vivo release of ACh from the hippocampus (HPC) of rats in response to hypothalamic infusion of PYY. Hippocampal ACh release was found to increase 400% in response to 10 microg PYY. In a separate experiment, blockade of the same area of the HPC with bilateral intracerebral injections of 3.5 microg scopolamine did not affect intake stimulated by intrahypothalamic injection of 4 microg PYY. Furthermore, a third experiment showed, for the first time, that PYY (2.5-10.0 microg) can elicit robust feeding when infused directly into the HPC. The significance of these findings to the activation of limbic functions such as memory, reinforcement, and obsessional processes that accompany human binge-eating syndromes is discussed.

Neuropsychiatric disorders

Neuropsychiatric disorders of childhood include autism spectrum disorders, disorders comprising attention deficits (attention-deficit-hyperactivity disorder and deficits in attention, motor control and perception), tics (motor or vocal, or both), and obsessions and compulsions (obsessive-compulsive disorder). They affect a small proportion of the child population. They can now reliably be diagnosed, and are valid and clinically meaningful conditions. Effective interventions are available for most of these disorders.