De novo and rescue DBS leads for refractory Tourette syndrome patients with severe comorbid OCD: a multiple case report

Abstract

Invasive treatment for Gilles de la Tourette syndrome has shown interesting results in a number of published reports; it seems to be evolving into a promising therapeutic procedure for those patients demonstrating disabling clinical pictures who are refractory to conservative treatments. There are important issues concerning the stimulated brain target, with different nuclei currently under investigation. Our group asked in this pilot study whether Tourette syndrome could be treated by tailoring specific brain targets for specific symptoms. Deep brain stimulation for Tourette syndrome may thus in the future be tailored and patient specific, utilizing specific target regions for individual clinical manifestations. In our early experience we did not adequately address non-motor clinical symptoms as we only used a thalamic target. More recently in an obsessive compulsive disease cohort we have had success in using the anterior limb of the internal capsule and nucleus accumbens region as targets for stimulation. We therefore explored the option of a "rescue" procedure for our Tourette patients with persistent obsessive-compulsive disorder following ventralis oralis/centromedianus-parafascicularis (Vo/CM-Pf) deep brain stimulation. Following two cases where rescue anterior limb of internal capsule/nucleus accumbens leads were employed, we performed two additional procedures (anterior limb of the internal capsule plus ventralis oralis/centromedianus-parafascicularis and anterior limb of the internal capsule alone) with some mild improvement of comorbid obsessive-compulsive disorder, although the number of observations in this case series was low. Overall, the effects observed with using the anterior limb of the internal capsule either alone or as a rescue were less than expected. In this report we detail our experience with this approach.

Thalamocingulate Interactions In Performance Monitoring

“…An important aim for future research is to examine the relative contributions of these inputs for performance monitoring and cognitive control. The present findings may also be of potential clinical interest as deep brain stimulation (DBS) in nearby thalamic regions has recently been used for the treatment of Tourette's syndrome (Servello et al, 2008(Servello et al, , 2009). It will be important to see whether and how the impaired performance monitoring in this disorder (Johannes et al, 2002;Müller et al, 2003), reflected in increased ERN amplitudes, is modulated by DBS in the thalamus; moreover, the implantation of depth electrodes may allow direct recording of electrical activity in these regions (Marceglia et al, 2010) and link it to performance monitoring and other cognitive functions.…”

Deep brain stimulation (DBS) at the interface of neurology and psychiatry

“…Future directions will most certainly include the use of closed-loop systems and may utilize a patient-controlled function, since tics are intermittent and the sufferer often has a premonitory urge (80). In the future, a TS patient may utilize multiple leads to treat different symptom clusters (81)(82)(83).…”

Estimulação cerebral profunda na síndrome de Tourette

“…Servello et al 35 38 relataram a evolução de 36 pacientes operados a partir de 2004, submetidos a 79 procedimentos (mais de um procedimento por paciente, dependendo da sintomatologia), dos quais 67 foram realizados na área talâmica intralaminar/ventral oral, dois no globo pálido posterior e 10 no núcleo accumbens. Não está claro, mas deduz-se que esses 36 pacientes incluem os 18 inicialmente operados.…”