Deep Brain Stimulation of the Anterior Internal Capsule for the Treatment of Tourette Syndrome: Technical Case Report

Flaherty, Alice W.; Williams, Ziv; Amirnovin, Ramin; Kasper, Ekkehard M.; Rauch, Scott L.; Cosgrove, G. Rees; Eskandar, Emad N.

doi:10.1227/01.neu.0000176854.24694.95

Cited by 164 publications

(155 citation statements)

References 10 publications

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“…61,138 At least three regions have been targeted for Tourette syndrome, including the centromedian-parafascicular nucleus, 113,139,140 anterior GPi, 113,141,142 and anterior limb of the internal capsule. 143 Given the multiplicity of effective stimulation targets, the question naturally arises whether the therapeutic mechanisms are the same. Or, to put it another way, are the compensatory network processes enabled by DBS identical for each target?…”

Section: Why So Many Targets?mentioning

confidence: 99%

Mechanisms and Targets of Deep Brain Stimulation in Movement Disorders

et al. 2008

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Summary:Chronic electrical stimulation of the brain, known as deep brain stimulation (DBS), has become a preferred surgical treatment for medication-refractory movement disorders. Despite its remarkable clinical success, the therapeutic mechanisms of DBS are still not completely understood, limiting opportunities to improve treatment efficacy and simplify selection of stimulation parameters. This review addresses three questions essential to understanding the mechanisms of DBS. 1) How does DBS affect neuronal tissue in the vicinity of the active electrode or electrodes? 2) How do these changes translate into therapeutic benefit on motor symptoms? 3) How do these effects depend on the particular site of stimulation? Early hypotheses proposed that stimulation inhibited neuronal activity at the site of stimulation, mimicking the outcome of ablative surgeries. Recent studies have challenged that view, suggesting that although somatic activity near the DBS electrode may exhibit substantial inhibition or complex modulation patterns, the output from the stimulated nucleus follows the DBS pulse train by direct axonal excitation. The intrinsic activity is thus replaced by high-frequency activity that is time-locked to the stimulus and more regular in pattern. These changes in firing pattern are thought to prevent transmission of pathologic bursting and oscillatory activity, resulting in the reduction of disease symptoms through compensatory processing of sensorimotor information. Although promising, this theory does not entirely explain why DBS improves motor symptoms at different latencies. Understanding these processes on a physiological level will be critically important if we are to reach the full potential of this powerful tool.

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Section: Why So Many Targets?mentioning

confidence: 99%

Mechanisms and Targets of Deep Brain Stimulation in Movement Disorders

et al. 2008

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“…In these patients, electrodes are placed in the subthalamic nucleus or the globus pallidus internus, and provide immediate recovery to otherwise debilitating motor symptoms. In psychiatric disorders, DBS is used in patients with refractory obsessive-compulsive and Tourette's disorders, and preliminary results suggest that DBS is an effective treatment (Abelson et al, 2005;Flaherty et al, 2005;Gross, 2004;Houeto et al, 2005) and stimulation of the nucleus accumbens for this indication has been proposed by one of the authors (Sturm et al, 2003). One group has recently reported the use of DBS in patients with major depression .…”

Section: Introductionmentioning

confidence: 99%

Deep Brain Stimulation to Reward Circuitry Alleviates Anhedonia in Refractory Major Depression

Schläepfer

Cohen

Frick

et al. 2007

Neuropsychopharmacol

884

561

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Deep brain stimulation (DBS) to different sites allows interfering with dysfunctional network function implicated in major depression.Because a prominent clinical feature of depression is anhedoniaFthe inability to experience pleasure from previously pleasurable activitiesFand because there is clear evidence of dysfunctions of the reward system in depression, DBS to the nucleus accumbens might offer a new possibility to target depressive symptomatology in otherwise treatment-resistant depression. Three patients suffering from extremely resistant forms of depression, who did not respond to pharmacotherapy, psychotherapy, and electroconvulsive therapy, were implanted with bilateral DBS electrodes in the nucleus accumbens. Stimulation parameters were modified in a double-blind manner, and clinical ratings were assessed at each modification. Additionally, brain metabolism was assessed 1 week before and 1 week after stimulation onset. Clinical ratings improved in all three patients when the stimulator was on, and worsened in all three patients when the stimulator was turned off. Effects were observable immediately, and no side effects occurred in any of the patients. Using FDG-PET, significant changes in brain metabolism as a function of the stimulation in fronto-striatal networks were observed. No unwanted effects of DBS other than those directly related to the surgical procedure (eg pain at sites of implantation) were observed. Dysfunctions of the reward systemFin which the nucleus accumbens is a key structureFare implicated in the neurobiology of major depression and might be responsible for impaired reward processing, as evidenced by the symptom of anhedonia. These preliminary findings suggest that DBS to the nucleus accumbens might be a hypothesis-guided approach for refractory major depression. Neuropsychopharmacology (2008) 33, 368-377; doi:10.1038/sj.npp.1301408; published online 11 April 2007 Keywords: deep brain stimulation; major depression; anhedonia; nucleus accumbens; brain stimulation; Cg25 INTRODUCTIONTraditional methods of alleviating depression largely stem from serendipitous observations of antidepressant effects of substances such as iproniazid (originally developed as a treatment for tuberculosis) or imipramine (originally developed as a treatment for schizophrenia). In particular, increasing levels of monoamine neurotransmitters in the synaptic cleft are associated with improvements of depressive symptoms. This insight led to a more targeted drug discovery process, resulting in drugs with fewer side effects, such as SSRIs. These medication treatments, in conjunction with certain methods of psychotherapy and electroconvulsive therapy, are effective at alleviating depressive symptomatology in most patients (Andrews and Nemeroff, 1994;Mann, 2005). However, these treatments do not work for all patients. A sizable minority of patients does not respond. Indeed, twelve percent of patients suffering from major depression have a poor outcome even after 5 years of treatment (Keller et al, 1992). Patien...

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“…This means that at age 18, tics already persist for [10][11][12] years. Since fluctuations of tics are most obvious during the early course of the disease, DBS…”

Section: Rationalementioning

confidence: 99%

European clinical guidelines for Tourette syndrome and other tic disorders. Part IV: deep brain stimulation

Müller‐Vahl

Cath

Cavanna

et al. 2011

Eur Child Adolesc Psychiatry

151

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Objective: Ten years ago deep brain stimulation (DBS) has been introduced as an alternative and promising treatment option for patients suffering from severe Tourette Syndrome (TS). It seemed timely to develop a European guideline on DBS by a working group of the European Society for the Study of Tourette Syndrome (ESSTS).Methods: For a narrative review a systematic literature search was conducted and expert opinions of the guidelines group contributed also to the suggestions.Results: Of 63 patients reported so far in the literature 59 had a beneficial outcome following DBS with moderate to marked tic improvement. However, randomized controlled studies including a larger number of patients are still lacking. Although persistent serious adverse effects (AEs) have hardly been reported, surgery-(e.g., bleeding, infection) as well as stimulation-related AEs (e.g., sedation, anxiety, altered mood, changes in sexual function) may occur. Conclusion:At present time, DBS in TS is still in its infancy. Due to both different legality and practical facilities in different European countries these guidelines, therefore, have to be understood as recommendations of experts. However, among the ESSTS working group on DBS in TS there is general agreement that, at present time, DBS should only be used in adult, treatment resistant, and severely affected patients. It is highly recommended to perform DBS in the context of controlled trials.3

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Deep Brain Stimulation of the Anterior Internal Capsule for the Treatment of Tourette Syndrome: Technical Case Report

Abstract: Our findings suggest that stimulation of the anterior internal capsule may be a safe and effective procedure for the treatment of Tourette syndrome.

Cited by 164 publications

References 10 publications

Mechanisms and Targets of Deep Brain Stimulation in Movement Disorders

Mechanisms and Targets of Deep Brain Stimulation in Movement Disorders

Deep Brain Stimulation to Reward Circuitry Alleviates Anhedonia in Refractory Major Depression

European clinical guidelines for Tourette syndrome and other tic disorders. Part IV: deep brain stimulation

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