Electrode displacement after intracerebral hematoma as a complication of a deep brain stimulation procedure

Domenico Servello1, Marco Sassi1, Stefano Bastianello2, Guy Umberto Poloni2, Francesca Mancini3, Claudio Pacchetti31Functional Neurosurgery Unit, Istituto di Ricovero e Cura a Carattere Scientifico Galeazzi, Milan, Italy; 2Neuroradiology Unit; 3Parkinson Disease and Movement Disorder Unit, Istituto di Ricovero e Cura a Carattere Scientifico Mondino, Institute of Neurology, Pavia, Italy Objectives: Deep brain stimulation (DBS) is nowadays considered a safe and effective procedure for various movement disorders in which conservative treatments have failed to show significant therapeutic results. One of the most common complications of definitive electrode positioning is intraparenchymal hemorrhage.Materials and methods: Authors report the case of a 55-year-old female patient treated for Parkinson’s disease in which intraparenchymal hemorrhage developed after DBS procedure, leading to significant (about 8 mm at the neuroradiological controls) displacement of an otherwise correctly positioned DBS electrode.Results: After conservative management, the hematoma spontaneously resolved. Late neuroradiological controls documented correct, symmetrically positioned electrodes, comparable to the immediate postoperative controls.Conclusions: Six months follow-up endpoint results of the DBS treatment were considered satisfying by an independent neurologist, with modest residual neurological deficits, demonstrating that re-positioning of the electrode was unnecessary in this rare complication.Keywords: deep brain stimulation, electrodes, outcomes, implant, case repor

Erratum to: Why so many deep brain stimulation targets in Tourette's syndrome? Toward a broadening of the definition of the syndrome

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Obsessive Compulsive Tic Disorder: appropriate diagnosis and treatment as key elements to improve health and rationalize use of resources

Background: Obsessive Compulsive Tic Disorder (OCTD) has been described recently as an early onset and highly disabling endophenotype of Tic Disorder and Obsessive Compulsive Disorder. OCTD has a relevant but largely unknown clinical, social and economic burden for patients and their families. Our paper aimed to explore relevant aspects of the burden of OCTD. Methods: we conducted a literature review and a pilot study using retrospective demographic, clinical and economic data of patients with OCTD accessing the Galeazzi Hospital in Milan. Results: the literature review shows the absence of information on OCTD. From the pilot study we analysed data of 30 patients (80.0% male, 36.7% aged from 7 to 13 years, 63.3% aged from 15 to 48 years), 83.0% declared that obsessions and/or compulsions were the most important factors determining their social impairment. Adult patients refractory to drug treatment underwent Deep Brain Stimulation plus drugs. The mean clinical scores at the time of diagnosis indicated a severe condition for both tics and obsessive compulsive components. The mean time elapsed from symptoms onset to diagnosis of OCTD was 5.6 years, reaching up to 11 years in one case. Before reaching the correct diagnosis, different specialists visited the patients several times, 93.3% underwent diagnostic examinations and 86.7% took 2 or 3 different drugs. Ten patients were hospitalised and 8 had received psychotherapy. Discussion: Albeit preliminary, these results show that attention is mandatory for establishing correct diagnosis and treatment guidelines to improve health and rationally spend resources for OCTD

Pisa syndrome in Idiopathic Normal Pressure Hydrocephalus.

Abstract Introduction Idiopathic Normal Pressure Hydrocephalus (iNPH) is a complex syndrome of ventriculomegaly that can include parkinsonian-like features besides the classical triad of cognitive decline, urinary incontinence, and gait/balance disturbances. Pisa syndrome (PS) is a postural abnormality often associated with parkinsonism and defined as lateral trunk flexion greater than 10° while standing that resolves in the supine position. We reported a case series of classical "fixed" PS and one case of "Metronome" recurrent side-alternating PS in iNPH, displaying opposite electromyographic patterns of paraspinal muscles. Methods Eighty-five iNPH patients were followed longitudinally for at least one year through scheduled clinical and neuropsychological visits. Results Five (5.9%) subjects revealed PS. None of them had nigrostriatal dopaminergic involvement detected by [123I]FP-CIT SPECT. Among these patients, four had "fixed" PS, whereas one showed a recurrent side-alternating PS which repeatedly improved after ventriculo-peritoneal shunt and following adjustments of the valve-opening pressure of the shunt system. Discussion This is the first case series of PS in iNPH and the first report of "Metronome" PS in iNPH. The prompt response of the abnormal trunk postures through cerebrospinal fluid (CSF) shunt surgery suggests a causative role of an altered CSF dynamics. PS and gait disorders in iNPH could be explained by a direct involvement of cortico-subcortical pathways and subsequent secondary brainstem involvement, with also a possible direct functional damage of the basal ganglia at the postsynaptic level, due to enlargement of the ventricular system and impaired CSF dynamics. The early detection of these cases supports a proper surgical management

Adaptive deep brain stimulation (aDBS) for tourette syndrome

Deep brain stimulation (DBS) has emerged as a novel therapy for the treatment of several movement and neuropsychiatric disorders, and may also be suitable for the treatment of Tourette syndrome (TS). The main DBS targets used to date in patients with TS are located within the basal ganglia-thalamo-cortical circuit involved in the pathophysiology of this syndrome. They include the ventralis oralis/centromedian-parafascicular (Vo/CM-Pf) nucleus of the thalamus and the nucleus accumbens. Current DBS treatments deliver continuous electrical stimulation and are not designed to adapt to the patient\u2019s symptoms, thereby contributing to unwanted side effects. Moreover, continuous DBS can lead to rapid battery depletion, which necessitates frequent battery replacement surgeries. Adaptive deep brain stimulation (aDBS), which is controlled based on neurophysiological biomarkers, is considered one of the most promising approaches to optimize clinical benefits and to limit the side effects of DBS. aDBS consists of a closed-loop system designed to measure and analyse a control variable reflecting the patient\u2019s clinical condition and to modify on-line stimulation settings to improve treatment efficacy. Local field potentials (LFPs), which are sums of pre- and post-synaptic activity arising from large neuronal populations, directly recorded from electrodes implanted for DBS can theoretically represent a reliable correlate of clinical status in patients with TS. The well-established LFP-clinical correlations in patients with Parkinson\u2019s disease reported in the last few years provide the rationale for developing and implementing new aDBS devices whose efficacies are under evaluation in humans. Only a few studies have investigated LFP activity recorded from DBS target structures and the relationship of this activity to clinical symptoms in TS. Here, we review the available literature supporting the feasibility of an LFP-based aDBS approach in patients with TS. In addition, to increase such knowledge, we report explorative findings regarding LFP data recently acquired and analysed in patients with TS after DBS electrode implantation at rest, during voluntary and involuntary movements (tics), and during ongoing DBS. Data available up to now suggest that patients with TS have oscillatory patterns specifically associated with the part of the brain they are recorded from, and thereby with clinical manifestations. The Vo/CM-Pf nucleus of the thalamus is involved in movement execution and the pathophysiology of TS. Moreover, the oscillatory patterns in TS are specifically modulated by DBS treatment, as reflected by improvements in TS symptoms. These findings suggest that LFPs recorded from DBS targets may be used to control new aDBS devices capable of adaptive stimulation responsive to the symptoms of TS

“Manage, Negotiate, and Challenge Identities”: Young Italian-Canadian Identities from the Eyetalian Perspective

This study is an investigation of identity and Italian-Canadian youth in the post-World War Two period. A thorough examination of the limited secondary literature on this topic, as well an analysis of the works of authors, journalists and others published in the Toronto-based magazine Eyetalian, presents the intricacies of hybrid identity for young Italian Canadians. The various essays and other materials published in Eyetalian suggest the complex nature of identity which arises from generational differences, a search for identity (and what it means to be Italian Canadian), and the reproduction of traditional cultural values. The analysis proposes that identity for youth of Italian-Canadian descent is extremely elaborate, heterogeneous and fluid

Deep Brain Stimulation for Gilles de la Tourette Syndrome: Toward Limbic Targets

Gilles de la Tourette syndrome (GTS) is a complex neurodevelopmental disorder characterized by tics and, frequently, psychiatric and behavioral comorbidities. Above all, obsessive compulsive disorder/behavior (OCD/OCB) influences the clinical picture and has a severe impact on quality of life, eventually more than the tics themselves. Deep brain stimulation (DBS) is an effective therapy in selected, refractory cases. Clinical response to DBS may vary according to the clinical picture, comorbidities, and to the anatomical target. This retrospective study compares the results obtained from DBS in the ventralis oralis/centromedian-parascicular nucleus of the thalamus (Voi-Cm/Pf) (41 patients) and antero-medial Globus Pallidus internus (am-GPi) (14 patients), evaluating clinical response over time by means of Yale Global Tic Severity Scale (YGTSS) and Yale–Brown Obsessive-Compulsive Scale (YBOCS) scores over a period of 48 months. A significant and stable improvement in the YGTSS and YBOCS has been obtained in both groups (p < 0.001). There was a significant difference in YBOCS improvement over time between the am-GPi group and the Voi-Cm/Pf group, indicating a better and faster control of OCD/OCB symptoms in the former group. The ratio of hardware removal was 23% and limited to 13 patients in the Voi-Cm/Pf group. These results confirm that DBS is an effective therapy in treating GTS and suggest that the am-GPi might be superior to Voi-Cm/Pf in alleviating comorbid OCD/OCB