Letter to the Editor. Tourette syndrome: tripartite considerations in DBS

Adriana Vázquez-MedinaUniversity of Puerto Rico, Medical Sciences Campus School of Medicine, San Juan, Puerto Rico

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Grazia DianoPlovdiv Medical University, Plovdiv, Bulgaria

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Manthia A. PapageorgakopoulouUniversity of Patras, School of Medicine, Patras, Achaia, Greece

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Andrea Otamendi-LopezMayo Clinic, School of Medicine, Jacksonville, FL

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TO THE EDITOR: We read with great interest the article published by Morishita et al.1 regarding the neuroanatomy involved in deep brain stimulation (DBS) for Tourette syndrome (TS) (Morishita T, Sakai Y, Iida H, et al. Neuroanatomical considerations for optimizing thalamic deep brain stimulation in Tourette syndrome. J Neurosurg. 2022;136[1]:231-241). The authors evaluate the relationship between lead positioning and clinical effects, both therapeutic and adverse, by using neuroimaging techniques and detailed information from the clinical course. The findings identify an ideal trajectory and placement in association with nearby structures in order to avoid side effects related to mood, paresthesia, and dizziness. The study also addresses the importance of considering anatomical variations in trajectory planning and the association between the optimal lead station and microlesion effect as an indicator of a potentially positive outcome. In this letter we address the following: considering different DBS targets and incorporating patient-specific imaging techniques.

When treating TS with DBS, the different outcomes may directly correlate to structural and functional connectomes in the brain. Thus, the selection of target nuclei adapted to a personal phenotype of the disease should be considered. In the introduction to the article, the authors state that stimulation of different DBS targets for TS, including the centromedian (CM) thalamic nucleus and the globus pallidus internus (GPi), has been reported to be equally effective. This is essentially true, but we wish to point out a recent meta-analysis by Wehmeyer et al. that found evidence of preferential targeting.2 For example, stimulation of the GPi led to reduced obsessive-compulsive disorder symptoms, significantly more than thalamic stimulation. We consider this differential outcome to be relevant because approximately 50% of the children with TS have significant obsessive-compulsive symptoms, and 30% meet the diagnostic criteria of obsessive-compulsive disorder.3 This is a study the authors could further investigate.

We would also like to highlight the importance of incorporating imaging techniques in neurosurgery to analyze patient-specific interventions, particularly in therapies like DBS, in which factors like lead misplacement may result in stereotactic targeting error and, consequently, treatment failure. Previous DBS studies for many neurological and psychiatric conditions have reported electrode locations with respect to the anterior and posterior commissures. This method poses the limitation of not significantly correlating outcomes with electrode positioning.4,5 Recognizing this, the authors used the Montreal Neurological Institute space, 3D anatomical atlases, and normative connectomes. Furthermore, elucidating the interplay between clinical response, stimulation parameters, and lead electrode positioning is vital. As do the authors of this article, we recognize that further research is imperative to determine this patient-specific tripartite relationship (clinical response–stimulation parameters–electrode placement).

As aspiring neurosurgeons, we found this article compelling, not only for the relevance of its content, but also for its visuals. The images and video portray wonderfully the written body of the article and greatly enhance our understanding of the topic. As a concluding remark for this short commentary, we want to acknowledge this article as an incredibly well-done “illustrated guide” for future physicians and researchers to use when determining which gray areas and knowledge gaps in the neurosurgical field they seek to address.

Disclosures

The authors report no conflict of interest.

References

  • 1

    Morishita T, Sakai Y, Iida H, et al. Neuroanatomical considerations for optimizing thalamic deep brain stimulation in Tourette syndrome. J Neurosurg. 2022;136(1):231241.

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  • 2

    Wehmeyer L, Schüller T, Kiess J, et al. Target-specific effects of deep brain stimulation for Tourette syndrome: a systematic review and meta-analysis. Front Neurol. 2021;12 769275.

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  • 3

    Lombroso PJ, Scahill L. Tourette syndrome and obsessive–compulsive disorder. Brain Dev. 2008;30(4):231237.

  • 4

    Horn A, Kühn AA, Merkl A, Shih L, Alterman R, Fox M. Probabilistic conversion of neurosurgical DBS electrode coordinates into MNI space. NeuroImage. 2017;150:395404.

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  • 5

    Nestor KA, Jones JD, Butson CR, et al. Coordinate-based lead location does not predict Parkinson’s disease deep brain stimulation outcome. PLoS ONE. 2014;9(4):e93524.

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Takashi MorishitaFukuoka University School of Medicine, Fukuoka, Japan

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Yuki SakaiATR Brain Information Communication Research Laboratory Group, Kyoto, Japan

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Response

We thank Vázquez-Medina and colleagues for their insightful comments. As they pointed out, the 3D understanding of neuroanatomical structures is critical in DBS surgery. The stereotactic targeting of the CM thalamic nucleus in TS is different from that in other disorders. The targeting concept of CM DBS was explained in a paper by Visser-Vandewalle et al. as the therapeutic effect could be delivered to the CM as well as the medial (facial) area of the ventralis oralis nucleus.1 On the other hand, the DBS electrodes were aimed at a more posterolateral area of the CM nucleus for the treatment of minimally conscious state2 and refractory epilepsy.3 DBS practitioners should be aware of the subtle differences among these targets, even though the name of the approach is the same.

The learning process of stereotactic techniques has been partially dogmatic; however, 3D presentation of the DBS electrode positions is helpful for readers to understand the surgical concept. Additionally, Vázquez-Medina et al. pointed out the important issue that DBS of other targets such as the GPi and anterior limb of internal capsule were reportedly equally effective in comparison to CM DBS.4,5 The therapeutic mechanisms of action among these targets, however, may be different. We therefore consider that it would be useful to extend the lines of our study to other DBS approaches, and that further neuroimaging studies analyzing the data of international multicenter databases are warranted.

References

  • 1

    Visser-Vandewalle V, Ackermans L, van der Linden C, et al. Deep brain stimulation in Gilles de la Tourette’s syndrome. Neurosurgery. 2006;58(3):E590.

  • 2

    Chudy D, Deletis V, Almahariq F, Marcinkovic P, Skrlin J, Paradzik V. Deep brain stimulation for the early treatment of the minimally conscious state and vegetative state: experience in 14 patients. J Neurosurg. 2018;128(4):11891198.

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  • 3

    Velasco AL, Velasco F, Jimenez F, et al. Neuromodulation of the centromedian thalamic nuclei in the treatment of generalized seizures and the improvement of the quality of life in patients with Lennox-Gastaut syndrome. Epilepsia. 2006;47(7):12031212.

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  • 4

    Baldermann JC, Schuller T, Huys D, et al. Deep brain stimulation for Tourette-syndrome: a systematic review and meta-analysis. Brain Stimul. 2016;9(2):296304.

  • 5

    Martinez-Ramirez D, Jimenez-Shahed J, Leckman JF, et al. Efficacy and safety of deep brain stimulation in Tourette syndrome: the International Tourette Syndrome Deep Brain Stimulation Public Database and Registry. JAMA Neurol. 2018;75(3):353359.

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Illustration from Di Somma et al. (pp 1187–1190). Published with permission from Glia Media | Artist: Martha Headworth, MS.

  • 1

    Morishita T, Sakai Y, Iida H, et al. Neuroanatomical considerations for optimizing thalamic deep brain stimulation in Tourette syndrome. J Neurosurg. 2022;136(1):231241.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Wehmeyer L, Schüller T, Kiess J, et al. Target-specific effects of deep brain stimulation for Tourette syndrome: a systematic review and meta-analysis. Front Neurol. 2021;12 769275.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Lombroso PJ, Scahill L. Tourette syndrome and obsessive–compulsive disorder. Brain Dev. 2008;30(4):231237.

  • 4

    Horn A, Kühn AA, Merkl A, Shih L, Alterman R, Fox M. Probabilistic conversion of neurosurgical DBS electrode coordinates into MNI space. NeuroImage. 2017;150:395404.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Nestor KA, Jones JD, Butson CR, et al. Coordinate-based lead location does not predict Parkinson’s disease deep brain stimulation outcome. PLoS ONE. 2014;9(4):e93524.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 1

    Visser-Vandewalle V, Ackermans L, van der Linden C, et al. Deep brain stimulation in Gilles de la Tourette’s syndrome. Neurosurgery. 2006;58(3):E590.

  • 2

    Chudy D, Deletis V, Almahariq F, Marcinkovic P, Skrlin J, Paradzik V. Deep brain stimulation for the early treatment of the minimally conscious state and vegetative state: experience in 14 patients. J Neurosurg. 2018;128(4):11891198.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Velasco AL, Velasco F, Jimenez F, et al. Neuromodulation of the centromedian thalamic nuclei in the treatment of generalized seizures and the improvement of the quality of life in patients with Lennox-Gastaut syndrome. Epilepsia. 2006;47(7):12031212.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Baldermann JC, Schuller T, Huys D, et al. Deep brain stimulation for Tourette-syndrome: a systematic review and meta-analysis. Brain Stimul. 2016;9(2):296304.

  • 5

    Martinez-Ramirez D, Jimenez-Shahed J, Leckman JF, et al. Efficacy and safety of deep brain stimulation in Tourette syndrome: the International Tourette Syndrome Deep Brain Stimulation Public Database and Registry. JAMA Neurol. 2018;75(3):353359.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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