Bilateral Globus Pallidus Externus Deep Brain Stimulation for the Treatment of Refractory Tourette Syndrome: An Open Clinical Trial.

OBJECTIVES: We have previously proposed that Tourette syndrome (TS) is the clinical expression of the hyperactivity of globus pallidus externus (GPe) and various cortical areas. This study was designed to test this hypothesis by verifying the efficacy and safety of bilateral GPe deep brain stimulation (DBS) for treating refractory TS. MATERIALS AND METHODS: In this open clinical trial, 13 patients were operated on. Target coordinates (center of GPe) were obtained by direct visualization. Physiological mapping was performed with macrostimulation and microrecording. Primary and secondary outcome measures were, respectively, responder and improvement rates of TS and comorbidities, according to pre- and postoperative scores on the following assessment instruments: Yale Global Tic Severity Scale, Yale-Brown Obsessive Compulsive Scale, Beck Depression Inventory/Hamilton Depression Rating Scale, Beck Anxiety Inventory/Hamilton Anxiety Rating Scale, and Concentrated Attention test. RESULTS: Intraoperative stimulation (100 Hz/5.0V) did not produce any adverse effects or impact on tics. Microrecording revealed bursting cells discharging synchronously with tics in the central part of the dorsal half of GPe. Patients were followed up for a mean of 61.46±48.50 months. Responder rates were 76.9%, 75%, 71.4%, 71.4%, and 85.7%, respectively, for TS, obsessive-compulsive disorder (OCD), depression, anxiety, and attention deficit hyperactivity disorder. Mean improvements among responders in TS, OCD, depression, and anxiety were 77.4%, 74.7%, 89%, and 84.8%, respectively. After starting stimulation, tic improvement was usually delayed, taking up to ten days to manifest. Afterward, it increased over time, usually reaching its maximum at approximately one year postoperatively. The best stimulation parameters were 2.3V to 3.0V, 90 to 120 µsec, and 100 to 150 Hz, and the most effective contacts were the two dorsal ones. Two complications were registered: reversible impairment of previous depression and transient unilateral bradykinesia. CONCLUSIONS: Bilateral GPe-DBS proved to be low risk and quite effective for treating TS and comorbidities, ratifying the pathophysiological hypothesis that led to this study. Moreover, it compared favorably with DBS of other targets currently in use.

The impact of subcaudate tractotomy on delusions and hallucinations in psychotic patients.

BACKGROUND: Delusions and hallucinations, hallmarks of the psychotic disorders, usually do not respond to surgical intervention. For many years, the surgical technique of choice for the treatment of refractory aggressiveness in psychotic patients in our Service was amygdalotomy in isolation or associated with anterior cingulotomy. No improvement of hallucinations and delusions was noticed in any of these patients. To improve the control of aggression, subcaudate tractotomy was added to the previous surgical protocol. The main goal of the present study was to investigate the impact of this modified surgical approach on delusions and hallucinations. METHODS: Retrospective analysis of the medical records of psychotic patients presenting with treatment-resistant aggressiveness, delusions, and hallucinations submitted to bilateral subcaudate tractotomy + bilateral anterior cingulotomy + bilateral amygdalotomy in our institution. RESULTS: Five patients, all males, with ages ranging from 25 to 65 years, followed up by a mean of 45.6 months (17-72 months), fulfilled the inclusion criteria. Delusions and hallucinations were abolished in four of them. CONCLUSION: These results suggest that the key element for relieving these symptoms was the subcaudate tractotomy and that the orbitofrontal and ventromedial prefrontal cortices play an important role in the genesis of hallucinatory and delusional symptoms of schizophrenia and other psychoses.

Transposiçäo de pênis e escroto: apresentaçäo de 16 casos de uma nova proposiçäo cirúrgica / Penis and scrotum transposition: report of 16 cases and a new surgical proposition

Apresentam-se 16 casos de crianças com transposiçäo de pênis e escroto, com hipospádia e bifidez escrotal, dos quais 14 foram operados pela técnica de Glenn com modificaçöes. Faz-se uma revisäo bibliográfica, compilando 39 casos de crianças operadas por diferentes técnicas cirúrgicas, dentre as quais a descrita por Glenn. No entanto, näo foi encontrada casuística semelhante à do presente trabalho

Transposiçäo de pênis e escroto: apresentaçäo de 18 casos e uma nova proposiçäo de técnica cirúrgica / Penis and scrotum transposition: report of 18 cases and proposal of a new surgical technique

As autores apresentam 18 casos de crianças com transposiçäo de pênis e escroto, associada com hipospadia e escroto bífido, dos quais 15 foram operados pela técnica de Glenn, com modificaçöes. Fazem uma revisäo bibliográfica, compilando 59 casos de crianças operadas por diferentes técnicas cirúrgicas, dentre elas a descrita por Glenn. No entanto, foram encontradas duas casuísticas semelhantes ao presente trabalho