Adam P. Burdick

Lack of benefit of accumbens/capsular deep brain stimulation in a patient with both tics and obsessive–compulsive disorder

Lay summary: This case report illustrates lack of clinical efficacy of deep brain stimulation (DBS) for control of tics in a case of mild Tourette syndrome (TS) with severe comorbid obsessive–compulsive disorder (OCD). The brain target for stimulation was the anterior limb internal capsule (ALIC). Objective: To investigate the effect of anterior limb of internal capsule/nucleus accumbens (ALIC-NA) DBS on mild motor and vocal tics in a Tourette syndrome (TS) patient with severe OCD. Background: The optimum target to address symptoms of TS with DBS remains unknown. Earlier lesional therapy utilized thalamic targets and also the ALIC for select cases which had been diagnosed with other psychiatric disorders. Evidence regarding the efficacy of DBS for the symptoms of TS may aid in better defining a brain targets suitability for use. We report efficacy data on ALIC-NA DBS in a patient with severe OCD and mild TS. Methods: A 33-year-old man underwent bilateral ALIC-NA DBS. One month following implantation, a post-operative CT scan was obtained to verify lead locations. Yale Global Tic Severity Scales (YGTSS) and modified Rush Videotape Rating scales (MRVRS) were obtained throughout the first 6 months, as well as careful clinical examinations by a specialized neurology and psychiatry team. The patient has been followed for 30 months. Results: YGTSS scores worsened by 17% during the first 6 months. MRVRS scores also worsened over 30 total months of follow-up. There was a lack of clinically significant tic reduction although subjectively the patient felt tics improved mildly. Conclusion: DBS in the ALIC-NA failed to effectively address mild vocal and motor tics in a patient with TS and severe comorbid OCD.

Identification and management of deep brain stimulation intra- and postoperative urgencies and emergencies.

Deep brain stimulation (DBS) has been increasingly utilized for the therapeutic treatment of movement disorders, and with the advent of this therapy more postoperative urgencies and emergencies have emerged. In this paper, we will review, identify, and suggest management strategies for both intra- and postoperative urgencies and emergencies. We have separated the scenarios into 1--surgery/procedure related, 2--hardware related, 3--stimulation-induced difficulties, and 4--others. We have included ten illustrative (and actual) case vignettes to augment the discussion of each issue.

Cerebral Venous Infarction: A Potentially Avoidable Complication of Deep Brain Stimulation Surgery

Despite numerous reports on the morbidity and mortality of deep brain stimulation (DBS), cerebral venous infarction has rarely been reported. We present four cases of venous infarct secondary to DBS surgery.

Prevalence of Twiddler’s Syndrome as a Cause of Deep Brain Stimulation Hardware Failure

We reviewed our deep brain stimulation patient database to describe hardware complications which resulted from implantable pulse generator mobility, a phenomenon referred to as twiddler’s syndrome. A prospectively collected database of adverse events for all patients operated on at the University of Florida was queried searching for hardware malfunctions. Of 362 total leads implanted in 226 patients since 2002, there were 17 hardware malfunctions. Three of them were due to twiddler’s syndrome, representing 1.3% of patients (3 of 226 patients) and 1.4% of leads (5 of 362 leads). The subjects had characteristic presentations including re-emergence of symptoms, pain along the path of the hardware, abnormal impedances/current drain and radiographic signs of twisting/fracture. In all cases securing the implantable pulse generator within the chest pocket resolved the issue. Twiddler’s syndrome in the population of movement disorder patients treated with deep brain stimulation is an uncommon but important adverse event. It possesses a characteristic presentation and with appropriate diagnostic evaluation it is treatable and future occurrences are preventable.

Do patient's get angrier following STN, GPi, and thalamic deep brain stimulation.

OBJECTIVE The objective of the study was to examine whether deep brain stimulation (DBS) of the subthalamic nucleus (STN), the globus pallidus internus (GPi), and/or the ventralis intermedius thalamic nucleus (Vim) was associated with making patients angrier pre to post-surgical intervention. BACKGROUND Secondary outcome analysis of the NIH COMPARE Parkinsons Disease DBS trial revealed that participants were angrier and had more mood and cognitive side effects following DBS. Additionally blinded on/off analysis did not change anger scores. The sample size was small but suggested that STN DBS may have been worse than GPi in provoking anger. We endeavored to examine this question utilizing a larger dataset (the UF INFORM database), and also we included a third surgical target (Vim), which has been utilized for a different disease, essential tremor. METHODS Consecutive patients from the University of Florida Movement Disorders Center who were implanted with unilateral DBS for Parkinsons disease (STN or GPi) or essential tremor (Vim) were included. Patients originally implanted at outside institutions were excluded. Pre-operative and 4- to 6-month post-operative Visual Analog Mood Scale (VAMS) scores for all three groups were compared; additionally, pre-operative and 1- to 3-month scores were compared for STN and GPi patients. A linear regression model was utilized to analyze the relationship between the VAMS anger score and the independent variables of age, years with symptoms, Mini-Mental Status Examination (MMSE) score, handedness, ethnicity, gender, side of surgery, target of surgery, baseline Dementia Rating Scale (DRS) total score, baseline Beck Depression Index (BDI) score, micro- and macroelectrode passes, and years of education. Levodopa equivalent dosages and dopamine agonist use were analyzed for a potential impact on anger scores. RESULTS A total of 322 unilateral DBS procedures were analyzed, with STN (n=195), Vim (n=71), and GPi (n=56) making up the cohort. An ANOVA was used to detect significant differences among the three targets in the changes pre- to post-operatively. Similar to the COMPARE dataset, at 4 months, the only subscore of VAMS to reveal a significant difference between the three targets was the angry subscore, with GPi revealing a mean (standard) change of 2.38 (9.53); STN, 4.82 (14.52); and Vim, -1.17 (11.51) (p=0.012). At 1-3 months post-operation, both STN and GPi groups were significantly angrier (p=0.004), but there was no significant difference between the two groups. However, GPi patients were significantly more confused as compared to STN patients (p=0.016). The linear regression model which sought independent explanatory variables revealed a relationship between the VAMS anger score and the surgical target and the disease duration. The mean changes for STN and GPi DBS pre- to post-operation were 11.67 (p=0.001) and 8.21 (p=0.022) units more than those with Vim, respectively. For every year added of disease duration, the VAMS anger score increased by 0.24 (p=0.022). For the GPi and STN groups, number of microelectrode passes was significantly associated with angry score changes (p=0.014), with the anger score increasing 2.29 units per microelectrode pass. Independent variables not associated with the VAMS anger score included the surgery side, handedness, gender, ethnicity, education, age at surgery, MMSE, DRS, and BDI scores. Although the STN group significantly decreased in LED when compared to GPi, there was no relationship to anger scores. Similarly, dopamine agonist use was not different between STN and GPi groups and did not correlate with the VAMS anger score changes. CONCLUSIONS STN and GPi DBS for Parkinsons disease were associated with significantly higher anger scores pre- to post-DBS as compared to Vim for essential tremor. Anger score changes in STN and GPi patients seem to be associated with microelectrode passes, suggesting that it may be a lesional effect. PD patients with longer disease duration may be particularly susceptible, and this should be kept in mind when discussing the potential of DBS surgery for an individual patient. Essential tremor patients who on average have much longer disease durations did not get angrier. The changes in anger scores were not related to LED change or dopamine agonist use. Whether the induction of anger is disease-specific or target-specific is not currently known; however, our data would suggest that PD patients implanted in STN or GPi are at a potential risk. Finally, on closer inspection of the COMPARE DBS data, VAMS anger scores did not change on or off DBS, suggesting that anger changes may be more of a lesional effect rather than a stimulation induced one (Okun et al., 2009).

Advancing deep brain stimulation for obsessive-compulsive disorder

Evaluation of: Denys D, Mantione M, Figee M et al. Deep brain stimulation of the nucleus accumbens for treatment-refractory obsessive–compulsive disorder. Arch. Gen. Psychiatry 67(10), 1061–1068 (2010). Herein we review a prospective trial of deep brain stimulation (DBS) for the treatment of severely debilitating, medication-refractory obsessive–compulsive disorder (OCD) recently published in Archives of General Psychiatry by Denys et al. This prospective 16-subject study, while having some technical limitations, is an excellent addition to the existing literature supporting the use of DBS in the region of the nucleus accumbens for severe OCD. It provides further evidence of efficacy and safety, sham versus active stimulation evidence that this efficacy is real, and several key observations on how DBS interacts with the brain that can shed light on the neuropathophysiology of OCD itself.

Perioperative Emergencies Associated with Deep Brain Stimulation

Deep brain stimulation (DBS) has become an established procedure for movement and neuropsychiatric disorders. With the increased use of DBS, DBS-related problems have emerged as more common, and awareness of these issues has become more important for clinicians. Adverse events vary widely depending on the situation. We deal only with emergent situations here and separate the possible scenarios into: (1) perioperative (intra- and early postoperative) and (2) postoperative (following 2–4 weeks) settings. With ten clinical vignettes, we address how clinicians should appropriately detect and manage the emergent/urgent issues in a DBS cohort.

Contents Vol. 88, 2010

A. Abosch, Minneapolis, Minn. M.L.J. Apuzzo, Los Angeles, Calif. T. Aziz, Oxford N.M. Barbaro, San Francisco, Calif. A.L. Benabid, Grenoble G. Broggi, Milan B.P. Brophy, Adelaide K.J. Burchiel, Portland, Oreg. J.W. Chang, Seoul G.R. Cosgrove, Providence, R.I. E.N. Eskandar, Boston, Mass. W.A. Friedman, Gainesville, Fla. R.E. Gross, Atlanta, Ga. T. Hori, Tokyo M.G. Kaplitt, New York, N.Y. Y. Katayama, Tokyo P.J. Kelly, New York, N.Y. D.S. Kondziolka, Pittsburgh, Pa. J.K. Krauss, Hannover A. Lozano, Toronto, Ont. L.D. Lunsford, Pittsburgh, Pa. V. Rajshekhar, Vellore J. Regis, Marseille A.R. Rezai, Columbus, Ohio M. Schulder, Manhassett, N.Y. M.P. Sindou, Lyon K.V. Slavin, Chicago, Ill. Z. Tian, Beijing F. Velasco Campos, Mexico City O. Vilela Filho, Goiânia Offi cial Journal of the World Society for Stereotactic and Functional Neurosurgery

Erratum to: The number and nature of emergency department encounters in patients with deep brain stimulators

) R. L. Rodriguez I. A. Malaty N. E. Krock M. M. Medley I. U. Haq M. S. OkunDepartment of Neurology, University of Florida,Gainesville, USAe-mail: aresnick@ufl.eduK. D. Foote A. BurdickDepartment of Neurosurgery, University of Florida,Gainesville, USAJ. L. Moll D. L. CardenDepartment of Emergency Medicine, University of Florida,Gainesville, USA