Deep Brain Stimulation in Tourette’s Syndrome

Abstract

ObjectiveTourette’s syndrome (TS) is defined by 1 year of persistent motor and vocal tics. Often, the tics are refractory to conventional pharmacologic and psychobehavioral interventions. In these patients, deep brain stimulation (DBS) may be an appropriate intervention. This paper reviews different DBS targets in TS, discusses existing evidence on the efficacy of DBS in TS, highlights adverse effects of the procedure, discusses indications and patient selection as well as future directions for DBS in TS.MethodsA literature review searching PubMed database entries between 2000 and 2015. Search terms included “DBS in Tourette Syndrome”, “Deep brain stimulation in Tourette syndrome,” and “Surgical management of Tourette Syndrome.”ResultsThough there are no universally accepted guidelines defining ideal DBS candidates for TS, age, tic severity, and treatment refractoriness are important factors to consider in patient selection. A variety of targets exist for DBS in TS, but thalamic targets and GPi are the most widely studied. Psychiatric side effects that are target specific should be monitored closely and it is possible that these adverse effects may be resolved with programing. Small randomized controlled trials support the efficacy of DBS in TS.ConclusionDBS for TS is safe and feasible, but large multi-center clinical trials are needed to determine the ideal target and optimal location within a particular target.

Single-unit activity of the anterior Globus pallidus internus in Tourette patients and posterior Globus pallidus internus in dystonic patients

“…Excess muscular contractions have been associated with decreased activity of the main basal ganglia output (SNr/GPi), resulting in an abnormal activation of cortico-basal-ganglia loops, and selection of unwanted motor programs (Albin et al 1989). As a result, the posterior, motor part of GPi has been the target for ablation or deep brain stimulation for both Dystonia (Krauss et al 2004;Hu and Stead 2014) and Tourette's (Fraint and Pal 2015). More recently, the anterior, limbic part of GPi (GPia) has been proposed as a better target for TS (Sachdev et al 2014) (but see also (Fraint and Pal 2015)), and here we have examined single unit activity of neurons in GPia and compared them to that in GPip.…”

“…Deep Brain Stimulation (DBS) of the GPi has been successfully employed to treat Dystonia, with the motor territory of the Internal Pallidum (lateral-posterior, GPip) the most widely used therapeutic target (Krauss et al 2004;Hu and Stead 2014). Medically intractable, severe cases of TS have also been treated with DBS (Fraint and Pal 2015). While the optimal target for Tourette's is still under debate, the medial-anterior part of the Internal Pallidum (limbic part, GPia) has recently been suggested as a DBS target, and good therapeutical outcomes have been reported (Nair et al 2014;Sachdev et al 2014;Zauber et al 2014;Dwarakanath et al 2017).…”

Tiefe Hirnstimulation als Therapieoption für das Tourette-Syndrom

“…ventrooralis internus (Cm-Spv-Voi) im Thalamus [33,43,49], anteromedialer [50] und posterolateraler Globus pallidus internus [51][52][53], Globus pallidus externus [54], anteriorer Schenkel der inneren Kapsel/Ncl. accumbens [55][56][57] [59]. Die anatomischen Zielgebiete unterscheiden sich zusätzlich hinsichtlich der Nebenwirkungen: Zum Beispiel wurden Seh-und Potenzstörungen sowie Fatigue mit thalamischer Stimulation assoziiert [33,[60][61][62].…”

Deep Brain Stimulation- A Novel Approach For Relieving Neurological Disorders: A Review

“…17,18,19,20,21 Tourette syndrome Tourette syndrome is defined by the presence of motor and vocal tics-rapid, repetitive, stereotyped movements or vocalizations-that manifest before the age of 18 years and last for more than 12 months in the absence of secondary causes. 22 Recently, nine targets are followed in DBS for TS, including the thalamic centromedian parafascicular complex (CMPf ), the cross point of the centromedian nucleus-substantia periventricularis-nucleus ventro-oralis nucleus (CM-Spv-Voi), the target of the nucleus ventro-oralis posterior-ventro oralis anterior-Voi complex (Vop-Voa-Voi), the globus pallidus internus (GPi) (anteromedial and posteroventral regions), the nucleus accumbens (NA), the anterior limb of the internal capsule (ALIC), the subthalamic nucleus (STN) and the globus pallidus externus (GPe) 23 In a recent study, three patients had electrodes placed in both the thalamus and the anteromedial GPi, stimulation resulting in a YGTSS improvement of 65%-96% for amGPi, 30%-64% for CMPf and 43%-76% in combination stimulation. Follow up for as long as 60 months in 1 patient demonstrated maintenance of tic improvement.…”