We describe a patient with fluspirilene-induced tardive dyskinesia of the choreiform oro-facial-laryngeal type resistant to various conservative approaches for 7 years who underwent deep brain stimulation of the internal pallidal globe. We found immediate and marked suppression of her perioral involuntary movements with unilateral stimulation at 60 Hz.
"Conversely, in 2 cases with follow-up of 5 months and 18 months, the patients appeared to develop a tolerance to treatment, requiring escalation of stimulation  . These same patients also developed rebound dyskinesias when the stimulator was turned off, i.e., their dyskinesias were worse than they had been prior to surgery   "
[Show abstract][Hide abstract] ABSTRACT: Tardive dyskinesia (TD) can be a disabling condition and is frequently refractory to medical therapy. Over the past decade there have been many reports of TD patients experiencing significant benefit with deep brain stimulation (DBS) of the globus pallidus interna (GPi). The growing literature on this treatment option for TD consists predominantly of case reports and series. The reported benefit ranges widely, but the majority of cases experienced at least a 50% improvement in symptoms. The anatomical distribution of dyskinesias has not clearly influenced outcome, though fixed postures appear less likely to improve than phasic movements. Onset of benefit can be immediate or take months, and benefit is sustained in most cases, for at least 6 months and up to several years. A wide variety of voltages, frequencies, and pulse widths have demonstrated efficacy. A small number of reports which examined psychiatric symptoms before and after surgery did not find any decline, and in some cases revealed improvement in mood. However, these overall positive results should be interpreted with caution, as the majority of reports lacked blinded assessments, control groups, or standardized therapy parameters. Finally, we present an illustrative case of refractory tardive dyskinesia treated with GPi-DBS with 5 years of follow-up and 4 accompanying video segments.
"Medical treatments for tardive dyskinesia are usually of weak or shortlasting efficacy (Soares and McGrath, 1999). For these intractable cases, deep brain stimulation (DBS) of the internal globus pallidus (GPi) has been proposed, which leads to a dramatic improvement of the motor symptoms, as recently demonstrated by several case reports and in a controlled study from our group (Schrader et al, 2004; Eltahawy et al, 2004; Trottenberg et al, 2005; Franzini et al, 2005; Damier et al, 2007). The improvement in tardive dyskinesia with DBS of the GPi is comparable to the one observed in primary generalized dystonia (Vidailhet et al, 2005). "
[Show abstract][Hide abstract] ABSTRACT: Tardive dystonia (TD) is a disabling disorder induced by neuroleptics. Internal globus pallidus (GPi) stimulation can dramatically improve TD. The present positron emission tomography and H(2)(15)O study aimed to characterize the abnormalities of brain activation of TD and the impact of GPi stimulation on these abnormalities in five TD patients treated with GPi stimulation and eight controls. Changes of regional cerebral blood flow (rCBF) were determined: (i) at rest; (ii) when moving a joystick with the right hand in three freely chosen directions in on and off bilateral GPi stimulation. A significant increase of rCBF was found in TD patients in off-stimulation condition compared to controls: (1) during motor execution in the prefrontal, premotor lateral, and anterior cingulate cortex; (2) at rest, in the prefrontal and anterior cingulate cortex and the cerebellum. Internal globus pallidus stimulation led to a reduction of rCBF (1) during motor execution, in the primary motor and prefrontal cortex and the cerebellum; (2) at rest, in the primary motor and anterior cingulate cortex and supplementary motor area. The results are as follows: (1) TD is related to an excess of brain activity notably in the prefrontal and premotor areas; (2) GPi stimulation reduces the activation of motor, premotor, and prefrontal cortex as well as cerebellum.
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