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Published on: August 12, 2018
The 5 Pillars in Tourette Syndrome Deep Brain Stimulation Patient Selection: Present and Future
Davide Martino1, Wissam Deeb2, Joohi Jimenez-Shahed2
1From the Department of Clinical Neurosciences (D.M., T.M.P.), Cumming School of Medicine, University of Calgary, Calgary AB, Canada; Hotchkiss Brain Institute (D.M., T.M.P.), University of Calgary, Calgary AB, Canada; Alberta Children's Hospital Research Institute (D.M.), University of Calgary, Calgary AB, Canada; Mathison Centre for Mental Health Research and Education (D.M., T.M.P.), Calgary, AB, Canada; UMass Memorial Medical Center and UMass Medical School (W.D.), Worcester, MA, United States; Department of Neurology (J.J.-S.), Icahn School of Medicine at Mount Sinai, New York, NY, United States; Department of Neurology (I.M., M.S.O.), Norman Fixel Institute for Neurological Diseases, University of Florida Health, Gainesville, FL, United States; Department of Psychiatry (T.M.P.), Pediatrics and Community Health Sciences, University of Calgary, AB, Canada; Edmond J. Safra Program in Parkinson's Disease (A.F.), Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, Ontario, Canada; Division of Neurology, University of Toronto, Toronto, Ontario, Canada; Krembil Brain Institute (A.F.), Toronto, Ontario, Canada; CenteR for Advancing Neurotechnological Innovation to Application (CRANIA) (A.F.), Toronto, ON, Canada; Movement Disorders and Neuromodulation Unit (C.G.), Charité, University Medicine Berlin, Department of Neurology, Berlin, Germany; and Strategic Regulatory Partners (W.W.), LLC. davide.martino@ucalgary.ca.
Abstract:
The selection of patients with Tourette syndrome (TS) for deep brain stimulation (DBS) surgery rests on 5 fundamental pillars. However, the operationalization of the multidisciplinary screening process to evaluate these pillars remains highly diverse, especially across sites. High tic severity and tic-related impact on quality of life (first 2 pillars) require confirmation from objective, validated measures, but malignant features of TS should per se suffice to fulfill this pillar. Failure of behavioral and pharmacologic therapies (third pillar) should be assessed taking into account refractoriness through objective and subjective measures supporting lack of efficacy of all interventions of proven efficacy, as well as true lack of tolerability, adherence, or access. Educational interventions and use of remote delivery formats (for behavioral therapies) play a role in preventing misjudgment of treatment failure. Stability of comorbid psychiatric disorders for 6 months (fourth pillar) is needed to confirm the predominant impact of tics on quality of life, to prevent pseudo-refractoriness, and to maximize the future DBS response. The 18-year age limit (fifth pillar) is currently under reappraisal, considering the potential impact of severe tics in adolescence and the predictive effect of tic severity in childhood on tic severity when transitioning into adulthood. Future advances should aim at a consensus-based definition of failure of specific, noninvasive treatment strategies for tics and of the minimum clinical observation period before considering DBS treatment, the stability of behavioral comorbidities, and the use of a prospective international registry data to identify predictors of positive response to DBS, especially in younger patients.
