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Vogt LM, Yang K, Tse G, Quiroz V, Zaman Z, Wang L, Srouji R, Tam A, Estrella E, Manzi S, Fasano A, Northam WT, Stone S, Moharir M, Gonorazky H, McAlvin B, Kleinman M, LaRovere KL, Gorodetsky C, Ebrahimi-Fakhari D. Recommendations for the Management of Initial and Refractory Pediatric Status Dystonicus. Mov Disord 2024. [PMID: 38619077 DOI: 10.1002/mds.29794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 03/07/2024] [Accepted: 03/11/2024] [Indexed: 04/16/2024] Open
Abstract
Status dystonicus is the most severe form of dystonia with life-threatening complications if not treated promptly. We present consensus recommendations for the initial management of acutely worsening dystonia (including pre-status dystonicus and status dystonicus), as well as refractory status dystonicus in children. This guideline provides a stepwise approach to assessment, triage, interdisciplinary treatment, and monitoring of status dystonicus. The clinical pathways aim to: (1) facilitate timely recognition/triage of worsening dystonia, (2) standardize supportive and dystonia-directed therapies, (3) provide structure for interdisciplinary cooperation, (4) integrate advances in genomics and neuromodulation, (5) enable multicenter quality improvement and research, and (6) improve outcomes. © 2024 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Lindsey M Vogt
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kathryn Yang
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Movement Disorders Program, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriel Tse
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Vicente Quiroz
- Movement Disorders Program, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Zainab Zaman
- Movement Disorders Program, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura Wang
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rasha Srouji
- Movement Disorders Program, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Amy Tam
- Movement Disorders Program, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Elicia Estrella
- Movement Disorders Program, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Shannon Manzi
- Department of Pharmacy, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Krembil Brain Institute, University of Toronto, Toronto, Ontario, Canada
| | - Weston T Northam
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Scellig Stone
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mahendranath Moharir
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hernan Gonorazky
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Brian McAlvin
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Monica Kleinman
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kerri L LaRovere
- Neurocritical Care Consult Service, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Carolina Gorodetsky
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Darius Ebrahimi-Fakhari
- Movement Disorders Program, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Neurocritical Care Consult Service, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Baizabal-Carvallo JF, Cavanna AE, Jankovic J. Tics emergencies and malignant tourette syndrome: Assessment and management. Neurosci Biobehav Rev 2024; 159:105609. [PMID: 38447821 DOI: 10.1016/j.neubiorev.2024.105609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/29/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
Tourette syndrome (TS) is a complex neurodevelopmental disorder characterized by the presence of tics, frequently accompanied by a variety of neuropsychiatric comorbidities. A subset of patients with TS present with severe and disabling symptoms, requiring prompt therapeutic intervention. Some of these manifestations may result in medical emergencies when severe motor or phonic tics lead to damage of anatomical structures closely related to the tic. Examples include myelopathy or radiculopathy following severe neck ("whiplash") jerks or a variety of self-inflicted injuries. In addition to self-aggression or, less commonly, allo-aggression, some patients exhibit highly inappropriate behavior, suicidal tendencies, and rage attacks which increase the burden of the disease and are important components of "malignant TS". This subset of TS is frequently associated with comorbid obsessive-compulsive disorder. Therapeutic measures include intensive behavioral therapy, optimization of oral pharmacotherapy, botulinum toxin injections, and deep brain stimulation.
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Affiliation(s)
- José Fidel Baizabal-Carvallo
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA; Department of Sciences and Engineering, University of Guanajuato, León, Mexico.
| | - Andrea E Cavanna
- Department of Neuropsychiatry, BSMHFT and University of Birmingham, Birmingham, United Kingdom; Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology and University College London, London, United Kingdom; School of Health and Life Sciences, Aston Institute of Health and Neurodevelopment, Aston University, Birmingham, United Kingdom; School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
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Vogt LM, Yan H, Santyr B, Breitbart S, Anderson M, Germann J, Lizarraga KJ, Hewitt AL, Fasano A, Ibrahim GM, Gorodetsky C. Deep Brain Stimulation for Refractory Status Dystonicus in Children: Multicenter Case Series and Systematic Review. Ann Neurol 2023. [PMID: 37714824 DOI: 10.1002/ana.26799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/14/2023] [Accepted: 09/14/2023] [Indexed: 09/17/2023]
Abstract
OBJECTIVE We sought to better understand the workflow, outcomes, and complications of deep brain stimulation (DBS) for pediatric status dystonicus (SD). We present a systematic review, alongside a multicenter case series of pediatric patients with SD treated with DBS. METHODS We collected individual data regarding treatment, stimulation parameters, and dystonia severity for a multicenter case series (n = 8) and all previously published cases (n = 77). Data for case series were used to create probabilistic voxelwise maps of stimulated tissue associated with dystonia improvement. RESULTS In our institutional series, DBS was implanted a mean of 25 days after SD onset. Programming began a mean of 1.6 days after surgery. All 8 patients in our case series and 73 of 74 reported patients in the systematic review had resolution of their SD with DBS, most within 2 to 4 weeks of surgery. Mean follow-up for patients in the case series was 16 months. DBS target for all patients in the case series and 68 of 77 in our systematic review was the globus pallidus pars interna (GPi). In our case series, stimulation of the posterior-ventrolateral GPi was associated with improved dystonia. Mean dystonia improvement was 32% and 51% in our institutional series and systematic review, respectively. Mortality was 4% in the review, which is lower than reported for treatment with pharmacotherapy alone (10-12.5%). INTERPRETATION DBS is a feasible intervention with potential to reverse refractory pediatric SD and improve survival. More work is needed to increase awareness of DBS in this setting, so that it can be implemented in a timely manner. ANN NEUROL 2023.
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Affiliation(s)
- Lindsey M Vogt
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Han Yan
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Brendan Santyr
- Krembil Brain Institute, Toronto, Ontario, Canada
- Center for Advancing Neurotechnological Innovation to Application, Toronto, Ontario, Canada
| | - Sara Breitbart
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Melanie Anderson
- Library Services, University Health Network, Toronto, Ontario, Canada
| | - Jürgen Germann
- Krembil Brain Institute, Toronto, Ontario, Canada
- Center for Advancing Neurotechnological Innovation to Application, Toronto, Ontario, Canada
| | - Karlo J Lizarraga
- Motor Physiology and Neuromodulation Program, Division of Movement Disorders, Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Angela L Hewitt
- Motor Physiology and Neuromodulation Program, Division of Movement Disorders, Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
- Division of Child Neurology, Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Alfonso Fasano
- Krembil Brain Institute, Toronto, Ontario, Canada
- Center for Advancing Neurotechnological Innovation to Application, Toronto, Ontario, Canada
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - George M Ibrahim
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Carolina Gorodetsky
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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Lumsden DE, Cif L, Capuano A, Allen NM. The changing face of reported status dystonicus - A systematic review. Parkinsonism Relat Disord 2023:105438. [PMID: 37268557 DOI: 10.1016/j.parkreldis.2023.105438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/03/2023] [Accepted: 05/07/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Status Dystonicus (SD) represents the most severe end of the spectrum of dystonia. We aimed to explore whether reported features of cases of SD have changed over time. METHODS A systematic review of cases of SD reported from 2017 to 2023 and comparison of features to data extracted from 2 previous literature reviews (epochs 2012-2017 and pre-2012). RESULTS From 53 papers, a total 206 SD episodes in 168 patients were identified from 2017 to 2023. Combining data from all 3 epochs, a total of 339 SD episodes were reported from 277 patients. SD episodes occurred mostly in children, with a trigger identified in 63.4% of episodes, most commonly infection/inflammation. Most reported underlying aetiologies were genetic (e.g. 49.5% between 2017 and 2023), including new associated aetiologies in each epoch. Deep Brain Stimulation (DBS)-related SD increased over time. Neurosurgical interventions were more frequently reported in later epochs. Across the epochs, return to or improvement post SD episode, compared to baseline was reported above 70%. Reported mortality was 4.9% most recently, compared to 11.4% and 7.9%, previously. CONCLUSIONS SD episodes reported have more than doubled in the last 5 years. Reports of medication change-induced SD have become less frequent, whilst episodes of DBS-related SD have become more frequent. More dystonia aetiologies, including novel aetiologies have been reported in recent cohorts, reflecting advances in genetic diagnosis. Neurosurgical interventions are increasingly reported in the management of SD episodes, including novel use of intraventricular baclofen. Overall outcomes from SD remain largely unchanged over time. No prospective epidemiological studies of SD were identified.
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Affiliation(s)
- Daniel E Lumsden
- Complex Motor Disorder Service, Children's Neurosciences, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK; Perinatal Imaging, Imaging Sciences and Biomedical Engineering, King's College London, UK.
| | - Laura Cif
- Department of Neurosurgery, University Hospital Montpellier, France
| | - Alessandro Capuano
- Department of Neuroscience, Bambino Gesù Children' Hospital, Rome, Italy; Cerebral Palsy Center -NeuropsychiatricUnit - ASL Viterbo, Viterbo, Italy
| | - Nicholas M Allen
- Department of Paediatrics (Neurology), University of Galway, Ireland
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Joshi SP, Thomas M, Yoganathan S, Danda S, Chandran M, Jasper A. Clinico-Etiological Spectrum and Functional Outcomes of Children with Pre-Status Dystonicus and Status Dystonicus (SD): A Descriptive Study. Ann Indian Acad Neurol 2023; 26:268-274. [PMID: 37538432 PMCID: PMC10394458 DOI: 10.4103/aian.aian_660_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 03/05/2023] [Accepted: 03/09/2023] [Indexed: 08/05/2023] Open
Abstract
Background Status dystonicus (SD) is a life-threatening movement disorder emergency characterized by increasingly frequent and severe episodes of generalized dystonia, requiring urgent hospital admission. The diverse clinico-etiological spectrum, high risk of recurrence, and residual disabilities complicate functional outcomes. Aim We aim to describe the clinico-etiological spectrum, radiology, therapeutic options, and follow-up of patients with pre-status dystonicus (pre-SD) and SD. Methodology A cross-sectional retrospective study was carried out in a tertiary care referral center. The clinical, laboratory, and radiology data of all patients aged less than 18 years with pre-SD and SD from January 2010 to December 2020 were collected. The Dystonia Severity Assessment Plan (DSAP) scale for grading severity and the modified Rankin Scale (mRS) for assessing outcome were used at the last follow-up visit. Results Twenty-eight patients (male:female: 2.1:1) experiencing 33 episodes of acute dystonia exacerbation were identified. The median age at the onset of dystonia and SD presentation was 8.71 (range: 0.25-15.75) and 9.12 (range: 1-16.75) years, respectively. Four patients experienced more than one episode of SD. The etiological spectrum of SD includes metabolic (Wilson's disease-13, L-aromatic amino acid decarboxylase deficiency-one, and Gaucher's disease-one), genetic (neurodegeneration with brain iron accumulation-three and KMT2B and THAP 1 gene-related-one each), structural-three, post-encephalitic sequelae (PES)-four, and immune-mediated (anti-NMDA receptor encephalitis-one). Five patients had pre-SD (DSAP grade 3), and 23 patients had established SD (DSAP grade 4-17 and DSAP grade 5-six). The Rapid escalation of chelation therapy precipitated SD in 11 patients with Wilson's disease. Febrile illness or pneumonia precipitated SD in nine patients. Twenty-three episodes of SD required midazolam infusion in addition to anti-dystonic medications. The median duration of hospital stay was 10 days (range: 3-29). Twenty-three patients had resolution of SD but residual dystonia persisted, while two patients had no residual dystonia at follow-up. Three patients succumbed owing to refractory SD and its complications. Conclusion Early identification of triggers, etiology, and appropriate management are essential to calm the dystonic storm.
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Affiliation(s)
- Shridhar P. Joshi
- Paediatric Neurology Unit, Departments of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Maya Thomas
- Paediatric Neurology Unit, Departments of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sangeetha Yoganathan
- Paediatric Neurology Unit, Departments of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sumita Danda
- Medical Genetics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Mahalakshmi Chandran
- Neurochemistry Laboratory, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anitha Jasper
- Radiodiagnosis, Christian Medical College, Vellore, Tamil Nadu, India
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Ghosh R, Dubey S, Das S, Benito-León J. Case Report: Dystonic Storm Following Japanese Encephalitis Virus Infection. Am J Trop Med Hyg 2022; 107:tpmd220020. [PMID: 35940198 PMCID: PMC9490673 DOI: 10.4269/ajtmh.22-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 04/07/2022] [Indexed: 11/07/2022] Open
Abstract
Dystonic storm (also called status dystonicus) is a neurological emergency characterized by sustained/intermittent involuntary generalized muscle contractions resulting in repetitive painful twisting movements and abnormal postures. It is commonly documented in patients with diagnosed primary dystonic syndromes or secondary dystonic states (i.e., patients with inborn errors of metabolism, dystonic cerebral palsy, Wilson's disease, pantothenate kinase-associated neurodegeneration, and exposure to drugs). However, viral-induced dystonic storm cases have rarely been reported. We describe the case of an 11-year-old girl from rural West Bengal (India) with a dystonic storm after Japanese encephalitis. Generalized dystonic spasms lasted for about 10-20 minutes and occurred 20-30 times/day. They were associated with extreme pain, fever, exhaustion, sweating, tachycardia, tachypnea, pupillary dilatation, arterial hypertension, and mutism and were precipitated by a full bladder and relieved somewhat during sleep. When dystonic spasms abated, she had high-grade generalized rigidity of all four limbs and fixed cervical and truncal dystonia. She was put on invasive ventilation and deep intravenous sedation with continuous midazolam infusion and other supportive measures and had a good clinical recovery. During the 12 months of follow-up, she did not have any other episode of a dystonic storm. However, axial rigidity and intermittent appendicular (upper limb) dystonic posturing were observed. The authors also have briefly discussed the differential diagnoses and treatment plans for such a neurological emergency.
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Affiliation(s)
- Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College, Burdwan, West Bengal, India
| | - Souvik Dubey
- Department of Neuromedicine, Bangur Institute of Neurosciences (BIN), Kolkata, West Bengal, India
| | - Shambaditya Das
- Department of Neuromedicine, Bangur Institute of Neurosciences (BIN), Kolkata, West Bengal, India
| | - Julián Benito-León
- Department of Neurology, University Hospital “12 de Octubre”, Madrid, Spain
- Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain
- Department of Medicine, Universidad Complutense, Madrid, Spain
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