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DBS management of Tourette's

DBS management of Tourette's. Matthew Spreadbury. What is it really?. “ A neurological disorder characterized by involuntary tics and vocalizations and often the compulsive utterance of obscenities .” https://www.youtube.com/watch?v=KtCG0wG-5E0

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DBS management of Tourette's

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  1. DBS management of Tourette's Matthew Spreadbury

  2. What is it really? • “Aneurological disorder characterized by involuntary tics and vocalizations and often the compulsive utterance of obscenities.” • https://www.youtube.com/watch?v=KtCG0wG-5E0 • A debilitating disease which often leads to self harm, reduced social interaction, reduced opportunities to work and the ability to receive a full education.

  3. Pathophysiology? • The pathophysiology of TS is still unclear. • Thalamocortical drive? • CM/Pf loops to the motor striatum and the substantia- periventricularis

  4. Routine medication • Clonidine, guanfacine, clonazepam, haloperidol, pimozide, quetiapine, and olanzapine. • High refractory rates to original symptoms. • Psychiatric and behavioral therapy can be useful.

  5. Measurement of severity and suitability for surgery. • Yale Global Tic Severity Scale 1-100 • Psychiatric assessment • Subjective patient assessment • Patient age??

  6. Surgical procedures? • Ablation therapy. • Target areas: Centromedian thalamus, the internal globus pallidus, the external globus pallidus, and the anterior limb of the internal capsule • Thalamic CM/Pf, 5 mm lateral and 8 mm posterior to the mid-commissural point (MCP) along the superior-inferior plane of the anterior commissure-posterior commissure line.

  7. Anatomical location • Bilateral thalamic centromedian/parafascicular complex (CM/Pf)

  8. Case studies • 1.A 17-year-old boy with a 12-year history of TS • Jaw-clenching/teeth-grinding tics forceful enough to have caused dental fractures on several occasions. • On psychiatric evaluation, his comorbid depression and obsessive-compulsive disorder (OCD) were judged to be stable, and he was approved for bilateral CM/Pf stimulation. • The patient had modest early improvement in tics, and it took 6 months before optimal stimulating parameters were found. • YGTSS score 6 months post operation was reduced by 60%

  9. Case studies • 2.A 35 year old woman with a 9-year history of TS and comorbid OCD and ADHD symptoms presented to our center for evaluation. • Simple motor tics involving the face and arms. • The tic repertoire later expanded to include complex vocalizations and patterned movements throughout all body segments. • By 3 years before presentation, the patient developed forceful head tics resulting in the need for narcotic analgesia. • Post op she self-rated at 99% improvement. With YGTSS score of 10!

  10. Benefits and risks? • https://www.youtube.com/watch?v=nDkrD1uCGsM • Infection, haemorrhage, death. • Surgical accuracy is everything! 0.4% Morbidity • Paranoia, anxiety, cranial nerve palsy, elation, sadness, depression, suicidal thoughts (screening is essential). • Mechanical failure, 2000 settings on the transducer (voltage, frequency etc..)

  11. References: • Leckman JF, Bloch MH, Scahill L, King RA. Tourette syndrome: the self under siege. J Child Neurol. 2006;21(8):642-649. • 2. Mink JW. Basal ganglia dysfunction in Tourette’s syndrome: a new hypothesis. Pediatr Neurol. 2001;25(3):190-198. • 3. Leckman JF. Tourette’s syndrome. Lancet. 2002;360(9345): 577-1586. • 4. Temel Y, Visser-Vandewalle V. Surgery in Tourette syndrome. MovDisord. 2004;19(1):3-14. • 5. Visser-Vandewalle V, Temel Y, Boon P, et al. Chronic bilateral thalamic stimulation: a new therapeutic approach in intractable Tourette syndrome: report of three cases. J Neurosurg. 2003; 99(6):1094-1100. • 6. Lyons MK. Deep brain stimulation: current and future clinical applications. Mayo Clin Proc. 2011;86(7):662-672. • 7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association; 1994:xxvii, 886.

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