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Deep Brain Stimulation in Refractory Tourette Syndrome

BRUSSELS, BELGIUM -- August 27, 2007 -- Deep brain stimulation (DBS) is a promising, minimally invasive therapy for patients with severe [DEF]refractory[/DEF] Tourette syndrome (TS), according to study findings.

The results of a long-term follow-up, phase 2, observational study were presented here on August 26th at the 11th Congress of the European Federation of Neurological Societies (EFNS) by Mauro Porta, MD, Principal Investigator, Professor and Head, Clinic of Movement Disorder, IRCCS Galeazzi, Milan, Italy.

"A lot of attention has been paid to [TS] recently because many more of its aspects are understood better now than in past times," said Dr. Porta. However, the actual definition of TS remains difficult to pinpoint. What is known about it is that TS has an average onset before 18 to 21 years of age and patients display a combination of multiple motor and vocal tics. These can occur many times a day nearly every day or intermittently over a period of more than a year. TS can also include or be accompanied by a number of associated/related symptoms, such as nonobscene socially inappropriate behaviour, self-injury behaviour, obsessive compulsive behaviour/disorder (OCB/OCD), and attention deficit hyperactivity disorder (ADHD).

The clinical classification of TS now includes the range of manifestations as simple, full-blown, and "plus," with its conservative treatments using a wide range of specifically tic-, ADHD-, and/or OCB-directed agents, combined with educational and supportive intervention.

However, many patients with TS are refractory to such treatments, due to failure of traditional and new antipsychotic drugs and catecholamine inhibitors, intolerable side effects of treatment, and/or lack of significant benefits from more than 2 years of psychobehavioural therapy. These patients thus become candidates for more invasive treatments like DBS, particularly if they show important social impairment, or self-inflicted or TS-linked lesions.

Of the over 650 patients routinely followed through the Italian Tourette Syndrome Association to date, 30 have satisfied the criteria for treatment with DBS, with 3 refusing treatment and caregivers of 3 others not supporting its use; the 22 patients who have undergone DBS and have more than 6 months of follow-up were included in the present analysis.

The main exclusion criteria were for history or presence of severe head trauma, structural brain lesions, or use of dopamine receptor blockers before recognition of tic condition. Other exclusion criteria were comorbid medical conditions precluding surgical procedures or a preexisting implanted electrical device and further preventive psychosocial conditions (eg, poor comprehension of DBS treatment, sociopathic personality, active suicidal ideation, or poor compliance for follow-up).

Primary endpoints included efficacy of DBS on tics and TS "plus" symptoms, timing and regulation of treatment needed, concomitant drug use, and safety. Three targets were chosen for the treatment: the centromedianus (CM)/parafascicularis (PF)/ventralis oralis (VO) nuclei of the thalamus; the globus pallidus internus (GPI); and the nucleus accumbens (NA). Stimulation parameters were for an amplitude of 2 to 5 V, a pulse width of 90 to 180 microseconds, and a frequency of 130 to 180 Hz.

The researchers noted large improvements for the Yale Global Tic Severity Scale scores after the DBS, with gradual improvements with time seen for the Yale-Brown Obsessive-Compulsive Scale for OCB and the State-Trait Anxiety Inventory scores. Furthermore, there was continuing improvement in the patient quality of life over the full 2 years of follow-up, according to a visual analogue scale.

The use of DBS also resulted in reductions in comedication: 23% of patients became drug free and 73% showed a 50% to 75% reduction in drug use; only 1 patient showed no changes in drug use.

Dr. Porta concluded, "We observed only minor side effects, showing that the procedure is good, is safe, and for us we can consider it as a promising, minimally invasive therapy for severe refractory Tourette 'plus' patients."

[Presentation title: Deep Brain Stimulation for Tourette Syndrome Refractory to Conservative Treatment: Long-Term Follow-Up Results. Abstract SC110]
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David Baxter

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They seem to be exploring the use of this treatment technique in a variety of symptom or problem areas in recent months, from depression to OCD to schizophrenia.

It is interesting to follow the research. I'm not sure yet where it will lead, if anywhere, but it's always good to see new options being explored.

See this earlier post with a case study: Deep Brain Stimulation For Tourette
 

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According to the reports and occasional documentary program (Discovery Health) DBS is only considered an option in cases where all other treatment options have failed and the significant risk of this procedure justifies the potential benefit.

There are a limited number of centers performing the procedure and results, particularly in the Tourette cases have been mixed.

One man, as I recall, gained some reduction in tic activity, but was experiencing seizures from the procedure.

It would appear the procedure in its early stages of development, and will be several years before there is conclusive evidence as to its effectiveness.
 

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