Vertical gaze palsy after thalamic stimulation for Tourette syndrome: case report.
ABSTRACT We describe a patient who developed a vertical gaze paralysis after deep brain stimulation performed for intractable Tourette syndrome due to a small deep bleeding in the upper mesencephalon.
A 39-year-old man underwent thalamic deep brain stimulation for intractable Tourette syndrome. Immediately postoperatively, he had diplopia and dizziness. The neurological examination revealed vertical gaze palsy with preserved vertical oculocephalic movements. A postoperative computed tomography scan revealed a discrete high-density lesion across the midline at the distal end of the left electrode. This area corresponds with the pretectal area, including the rostral interstitial nucleus of the medial longitudinal fasciculus, with sparing of the oculomotor and rubral nuclei.
Six months postoperatively, maximal upward and downward smooth pursuit eye movements were achieved. Upward saccadic velocities were still reduced by 20 to 25 degrees.
This case report describes a complication that might demand special attention during the planning of thalamic deep brain stimulation for the treatment of Tourette syndrome. Examination of both horizontal and vertical eye movements during deep brain stimulation surgery is recommended.
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ABSTRACT: Deep brain stimulation (DBS) may improve disabling tics in severely affected medication and behaviorally resistant Tourette syndrome (TS). Here we review all reported cases of TS DBS and provide updated recommendations for selection, assessment, and management of potential TS DBS cases based on the literature and implantation experience. Candidates should have a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V) diagnosis of TS with severe motor and vocal tics, which despite exhaustive medical and behavioral treatment trials result in significant impairment. Deep brain stimulation should be offered to patients only by experienced DBS centers after evaluation by a multidisciplinary team. Rigorous preoperative and postoperative outcome measures of tics and associated comorbidities should be used. Tics and comorbid neuropsychiatric conditions should be optimally treated per current expert standards, and tics should be the major cause of disability. Psychogenic tics, embellishment, and malingering should be recognized and addressed. We have removed the previously suggested 25-year-old age limit, with the specification that a multidisciplinary team approach for screening is employed. A local ethics committee or institutional review board should be consulted for consideration of cases involving persons younger than 18 years of age, as well as in cases with urgent indications. Tourette syndrome patients represent a unique and complex population, and studies reveal a higher risk for post-DBS complications. Successes and failures have been reported for multiple brain targets; however, the optimal surgical approach remains unknown. Tourette syndrome DBS, though still evolving, is a promising approach for a subset of medication refractory and severely affected patients. © 2014 International Parkinson and Movement Disorder Society. © 2014 International Parkinson and Movement Disorder Society.Movement disorders : official journal of the Movement Disorder Society. 12/2014;
- Parkinsonism & Related Disorders 11/2014; · 4.13 Impact Factor
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ABSTRACT: In 1999, Deep Brain Stimulation (DBS) was introduced as a new therapeutic approach for patients suffering from refractory Tourette syndrome (TS). This initial target was located in the medial part of the thalamus, based on the good results of thalamotomies described by Hassler in 1970. Up until now, more than 100 cases have been published worldwide of Tourette patients receiving DBS. The targets have been diverse and can be divided in four brain areas: the thalamus (medial parts, and ventral parts), the globus pallidus internus (posteroventrolateral part, and anteromedial part), the globus pallidus externus, and the internal capsule / nucleus accumbens. The subthalamic nucleus has also been suggested as a potential target for DBS in TS, based on the good effect of DBS on tics in a patient suffering from Parkinson's disease and TS. In the majority of cases, there was a clear effect on tics. The effect on associated behavioural disorders is varying. Although stimulation-induced unwanted effects have been described, severe complications are rare and include two small hematomas at the tip of one electrode. Serious and lasting side effects or complications are rare. Although stimulation-induced and mainly transient unwanted effects have been described, the positive effect seems clearly to predominate. The majority of published studies include only a small number of patients. This underlines the importance of all cases being published, and that ideally the same protocol be followed so that results can be compared. A strict selection of patients and a standardized evaluation of the effects on tics, associated behavioural disorders, complications and exact position of the electrodes is therefore of great importance. The actual published reports suggest that the best effects can be obtained with DBS of the thalamus, and the anteromedial part of the globus pallidus internus.Journal of Obsessive-Compulsive and Related Disorders 07/2014; · 0.81 Impact Factor