Pallidal and thalamic neurostimulation in severe tardive dystonia

Abstract

A 70 year old woman presented with a 6 year history of medically refractory severe tardive dystonia. After informed consent, a bilateral stereotactic electrode placement targeting the ventral intermediate thalamic nucleus (VIM) and the globus pallidus internus (GPi) was performed. After bilateral stimulation of the GPi, the patient showed a clear and stable improvement of the painful dystonic syndrome within hours. Stimulation of the VIM did not improve the hyperkinetic movements and simultaneous stimulation of both the GPi and the VIM did not result in any additional benefit. The possible pathophysiological mechanisms are discussed. (J Neurol Neurosurg Psychiatry 2001;70:557-559)

Unilateral thalamic and pallidal deep brain stimulation for idiopathic hemidystonia: results of individual and combined stimulations. Case report

“…9 The thalamic anatomy has many descriptions that could lead to targeting changes, and the fact that it has unclear and overlapped nuclear borders interferes with the clinical analysis. Even changes inside a thalamic nucleus can have a different effect; for example, the posteromedial part of the Vim can treat tremor and drug-induced dyskinesias, and the anterolateral part can only treat tremor, 22 which can also be explained by stimulation of a nearby nucleus.…”

“…Final programming was in the GPi: 450 μsec, 130 Hz, 1.0 V; and in the ventral oral complex: 60 μsec, 130 Hz, 3.0 V. Other studies did not find benefits with thalamic stimulation. 17,22,24 In a retrospective evaluation of 19 patients, Vercueil et al 24 found that those treated with GPi DBS had a better outcome, and 3 patients in the thalamic group had rescue GPi DBS, with subsequent improvement. One hemidystonic patient lost thalamic stimulation benefits; this individual had a greater response with pallidal stimulation.…”

“…5,6, 8,9,16-19, 21,22,24 Motor improvement with GPi DBS, Vim DBS, or with both simultaneously, might be explained by the different types of dystonia evaluated and by targeting. 22,24 Not all studies were designed initially for combined stimulation; in some studies a secondary surgery was performed to implant electrodes at different targets after failure of the first. 9,17,24 A 2006 meta-analysis 9 showed that the GPi stimulation had significantly better outcomes compared with the posterior portion of the ventrolateral nucleus of the thalamus, which includes Vim and part of the ventral oral (Vo) complex, 9,16 but the majority of the patients reviewed had primary dystonia.…”

“…Stereotactic ablation of the globus pallidus internus (GPi) and thalamus are being massively replaced by deep brain stimulation (DBS). 5,9,10,14,21,22,24 Pallidal stimulation is indicated for several types of dystonia, especially the primary type with hyperkinetic movements. However, other targets such as the thalamus and the subthalamic nucleus (STN) show good results in tremor, myoclonus, and task-specific dystonia, and for rescue therapy.…”

12 Deep Brain Stimulation for Dystonia

“…However, several case reports indicated that GPi DBS was effective in focal segmental dystonia involved in neck, facial, trunk, upper and lower limbs [44][45][46][47][48][49][50]. Interestingly, the combined targets of ventral intermediate nucleus (Vim) plus GPi DBS significantly improved Myoclonus Dystonia, a rare form of movement disorder with epsilon-sarcoglycan gene mutations and prominent action myoclonus plus dystonia [51].…”