Selection of patients with Tourette syndrome for deep brain stimulation surgery

Deep brain stimulation (DBS) is an emerging therapeutic option for severe resistant Tourette syndrome (TS). To date, about 100 cases have been reported in the scientific literature. Different clinical guidelines have been proposed for this procedure from both USA and European centres. A number of issues remain unresolved, mainly in relation to eligibility criteria of patients with TS. We highlight the need for a comprehensive assessment of associated co-morbidities, which are not considered integral part of the syndrome and are not sufficiently evaluated in relation to DBS. The concept of refractoriness, the minimum age of candidates, and the optimal targets for DBS are also controversial

Handwriting Tics in Tourette’s Syndrome: A Single Center Study

Tourette’s syndrome (TS) is a neurodevelopmental disorder typically defined by multiple motor tics and at least one sound tic (1), beginning in childhood or in adolescence. More recently, Tourette’s syndrome has been acknowledged as a broad spectrum syndrome (2), including different comorbidities and coexisting symptoms. When beginning in early childhood TS mainly presents with attention deficit and hyperactivity disorder (ADHD) and tics, when beginning in adolescence instead tics and obsessive-compulsive behavior or disorder (OCB/OCD) are predominant. OCB/OCD trait is present in 60-80% of patients (3), and they are considered as thought tics (4). In many cases motor and sound tics resolve spontaneously in adulthood, though OCB/OCD generally remain. Tics often interfere with subject’s daily activities (5) affecting Quality of Life and causing Social Impairment, particularly in schooling and working. Handwriting is one of the most impaired school activity for TS patients because of the tics presence that hamper learning processes.In our clinical experience handwriting tics (HT) could severely affect and condition TS subjects, but they are not often pointed out in the Literature. For this reason there are not precise data regarding the incidence of HT neither in Tourette’s syndrome patients nor in healthy population

MER and increased operative time are not risk factors for the formation of pneumocephalus during DBS

Abstract Although only recently directional leads have proven their potential to compensate for sub-optimally placed electrodes, optimal lead positioning remains the most critical factor in determining Deep Brain Stimulation (DBS) outcome. Pneumocephalus is a recognized source of error, but the factors that contribute to its formation are still a matter of debate. Among these, operative time is one of the most controversial. Because cases of DBS performed with Microelectrode Recordings (MER) are affected by an increase in surgical length, it is useful to analyze whether MER places patients at risk for increased intracranial air entry. Data of 94 patients from two different institutes who underwent DBS for different neurologic and psychiatric conditions were analyzed for the presence of postoperative pneumocephalus. Operative time and use of MER, as well as other potential risk factors for pneumocephalus (age, awake vs. asleep surgery, number of MER passages, burr hole size, target and unilateral vs. bilateral implants) were examined. Mann-Whitney U and Kruskal-Wallis tests were utilized to compare intracranial air distributions across groups of categorical variables. Partial correlations were used to assess the association between time and volume. A generalized linear model was created to predict the effects of time and MER on the volume of intracranial air, controlling for other potential risk factors identified: age, number of MER passages, awake vs. asleep surgery, burr hole size, target, unilateral vs. bilateral surgery. Significantly different distributions of air volume were noted between different targets, unilateral vs. bilateral implants, and number of MER trajectories. Patients undergoing DBS with MER did not present a significant increase in pneumocephalus compared to patients operated without (p = 0.067). No significant correlation was found between pneumocephalus and time. Using multivariate analysis, unilateral implants exhibited lower volumes of pneumocephalus (p = 0.002). Two specific targets exhibited significantly different volumes of pneumocephalus: the bed nucleus of the stria terminalis with lower volumes (p < 0.001) and the posterior hypothalamus with higher volumes (p = 0.011). MER, time, and other parameters analyzed failed to reach statistical significance. Operative time and use of intraoperative MER are not significant predictors of pneumocephalus during DBS. Air entry is greater for bilateral surgeries and may be also influenced by the specific stimulated target