Complications of deep brain stimulation in Parkinson's disease: a single-center experience of 517 consecutive cases.

BACKGROUND: The number of deep brain stimulation (DBS) procedures is rapidly rising as well as the novel indications. Reporting adverse events related to surgery and to the hardware used is essential to define the risk-to-benefit ratio and develop novel strategies to improve it. OBJECTIVE: To analyze DBS complications (both procedure-related and hardware-related) and further assess potential predictive factors. METHODS: Five hundred seventeen cases of DBS for Parkinson's disease were performed between 2006 and 2021 in a single center (mean follow-up: 4.68 ± 2.86 years). Spearman's Rho coefficient was calculated to search for a correlation between the occurrence of intracerebral hemorrhage (ICH) and the number of recording tracks. Multiple logistic regression analyzed the probability of developing seizures and ICH given potential risk factors. Kaplan-Meier curves were performed to analyze the cumulative proportions of hardware-related complications. RESULTS: Mortality rate was 0.2%, while permanent morbidity 0.6%. 2.5% of cases suffered from ICH which were not influenced by the number of tracks used for recordings. 3.3% reported seizures that were significantly affected by perielectrode brain edema and age. The rate of perielectrode brain edema was significantly higher for Medtronic's leads compared to Boston Scientific's (Χ2(1)= 5.927, P= 0.015). 12.2% of implants reported Hardware-related complications, the most common of which were wound revisions (7.2%). Internal pulse generator models with smaller profiles displayed more favorable hardware-related complication survival curves compared to larger designs (X2(1)= 8.139, P= 0.004). CONCLUSION: Overall DBS has to be considered a safe procedure, but future research is needed to decrease the rate of hardware-related complications which may be related to both the surgical technique and to the specific hardware's design. The increased incidence of perielectrode brain edema associated with certain lead models may likewise deserve future investigation.

Fluorescein sodium-guided resection of a cerebellar lymphoma: case report and literature review.

We report on a patient, who underwent the resection of a cerebellar primary central nervous system lymphoma and was administered intraoperative fluorescein sodium to improve the visualization of the tumor and guide surgery. Low-dosage fluorescein was administered prior to opening the dura so to distinguish contrast-enhanced lymphomatous tissue from the surrounding unenhanced brain cerebellar parenchyma. Intraoperatively, the tumor was indistinguishable from cerebellar parenchyma under the white light, however, after the administration of low-dose intravenous fluorescein, it appeared brightly fluorescent under yellow light, and was safely resected. Our protocol of administration allowed for the sampling of the pathological tissue while at the same time avoiding neurological damage. The fluorescein-guided technique for the resection of primary central nervous system lymphomas has only been rarely described, as surgical excision of such tumors is rarely indicated. Starting from our case, we review and discuss the pertinent literature. Furthermore, an intraoperative video detail is provided.

Early patello-femoral condropathy assessment through quantitative analyses via T2 mapping magnetic resonance after anterior cruciate ligament reconstruction.

BACKGROUND: Patellar femoral chondropathy (FPC) is a common problem in patients undergoing anterior cruciate ligament reconstruction (ACL-R) surgery, which, if left untreated, predisposes to arthrosis. Magnetic resonance imaging (MRI) is the non-invasive gold standard for morphological evaluation of cartilage, while in recent years advanced MRI techniques (such as T2 mapping) have been developed to detect early cartilage biochemical changes. This study evaluates the different onset of early PFC between B-TP-B and HT through T2 mapping. Secondly, it aims to assess the presence of any concordance between self-reported questionnaires and qualitative MRI. MATERIALS AND METHODS: 19 patients enrolled were divided into two groups based on the type of intervention: B-PT-B and HT. After a median time of 54 months from surgery, patients were subjected to conventional MRI, T2 mapping, and clinical-functional evaluation through three self-reported questionnaires: Knee Injury and Osteoarthritis index (KOOS); Tegner Lysholm Knee Scoring Scale; International Knee Documentation Committee (IKDC). RESULTS: There is not statistically significant difference in the comparison between the two MRI techniques and the two reconstructive techniques. KOOS and Tegner Lysholm scales showed significant agreement with MRI results on the grading of chondropathy. CONCLUSIONS: There are no differences between B-TP-B and HT techniques in the early development of PFC detectable through non-invasive methods. Due to the large reduction in the frequency of physical activity following ACL-R and the finding of mild PFC (grade I and II) in a substantial proportion of patients, after a relatively short period from ACL-R, all patients should undergo conservative treatment.

Assessing response, remission, and treatment resistance in patients with obsessive-compulsive disorder with and without tic disorders: results from a multicenter study.

BACKGROUND: Highlighting the relationship between obsessive-compulsive disorder (OCD) and tic disorder (TD), two highly disabling, comorbid, and difficult-to-treat conditions, Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) acknowledged a new "tic-related" specifier for OCD, ie, obsessive-compulsive tic-related disorder (OCTD). As patients with OCTD may frequently show poor treatment response, the aim of this multicenter study was to investigate rates and clinical correlates of response, remission, and treatment resistance in a large multicenter sample of OCD patients with versus without tics. METHODS: A sample of 398 patients with a DSM-5 diagnosis of OCD with and without comorbid TD was assessed from 10 different psychiatric departments across Italy. For the purpose of the study, treatment response profiles in the whole sample were analyzed comparing the rates of response, remission, and treatment-resistance as well as related clinical features. Multivariate logistic regressions were performed to identify possible factors associated with treatment response. RESULTS: The remission group was associated with later ages of onset of TD and OCD. Moreover, significantly higher rates of psychiatric comorbidities, TD, and lifetime suicidal ideation and attempts emerged in the treatment-resistant group, with larger degrees of perceived worsened quality of life and family involvement. CONCLUSIONS: Although remission was associated with later ages of OCD and TD onset, specific clinical factors, such as early onset and presence of psychiatric comorbidities and concomitant TD, predicted a worse treatment response with a significant impairment in quality of life for both patients and their caregivers, suggesting a worse profile of treatment response for patients with OCTD.

European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part IV: deep brain stimulation.

In 2011 the European Society for the Study of Tourette Syndrome (ESSTS) published its first European clinical guidelines for the treatment of Tourette Syndrome (TS) with part IV on deep brain stimulation (DBS). Here, we present a revised version of these guidelines with updated recommendations based on the current literature covering the last decade as well as a survey among ESSTS experts. Currently, data from the International Tourette DBS Registry and Database, two meta-analyses, and eight randomized controlled trials (RCTs) are available. Interpretation of outcomes is limited by small sample sizes and short follow-up periods. Compared to open uncontrolled case studies, RCTs report less favorable outcomes with conflicting results. This could be related to several different aspects including methodological issues, but also substantial placebo effects. These guidelines, therefore, not only present currently available data from open and controlled studies, but also include expert knowledge. Although the overall database has increased in size since 2011, definite conclusions regarding the efficacy and tolerability of DBS in TS are still open to debate. Therefore, we continue to consider DBS for TS as an experimental treatment that should be used only in carefully selected, severely affected and otherwise treatment-resistant patients.

Suicidal ideation and suicidal attempts in patients with obsessive-compulsive tic-related disorder vs obsessive-compulsive disorder: results of a multicenter Italian study.

BACKGROUND: Obsessive-compulsive disorder (OCD) and tic disorder (TD) represent highly disabling, chronic and often comorbid psychiatric conditions. While recent studies showed a high risk of suicide for patients with OCD, little is known about those patients with comorbid TD (OCTD). Aim of this study was to characterize suicidal behaviors among patients with OCD and OCTD. METHODS: Three hundred and thirteen outpatients with OCD (n = 157) and OCTD (n = 156) were recruited from nine different psychiatric Italian departments and assessed using an ad-hoc developed questionnaire investigating, among other domains, suicide attempt (SA) and ideation (SI). The sample was divided into four subgroups: OCD with SA (OCD-SA), OCD without SA (OCD-noSA), OCTD with SA (OCTD-SA), and OCTD without SA (OCTD-noSA). RESULTS: No differences between groups were found in terms of SI, while SA rates were significantly higher in patients with OCTD compared to patients with OCD. OCTD-SA group showed a significant male prevalence and higher unemployment rates compared to OCD-SA and OCD-noSA sample. Both OCTD-groups showed an earlier age of psychiatric comorbidity onset (other than TD) compared to the OCD-SA sample. Moreover, patients with OCTD-SA showed higher rates of other psychiatric comorbidities and positive psychiatric family history compared to the OCD-SA group and to the OCD-noSA groups. OCTD-SA and OCD-SA samples showed higher rates of antipsychotics therapies and treatment resistance compared to OCD-noSA groups. CONCLUSIONS: Patients with OCTD vs with OCD showed a significantly higher rate of SA with no differences in SI. In particular, OCTD-SA group showed different unfavorable epidemiological and clinical features which need to be confirmed in future prospective studies.

Changes in eating behavior after deep brain stimulation for anorexia nervosa. A case study.

PURPOSE: The purpose of this study was to evaluate changes in the nutritional status, body image concerns, and eating behaviors occurring in a patient who underwent deep brain stimulation (DBS) of the bed nucleus of the stria terminalis for treatment-refractory anorexia nervosa (AN). METHODS: Bilateral DBS of the bed nucleus of the stria terminalis was performed in a 37-year-old woman affected by refractory AN. Pre- and post-surgical evaluations were conducted via an array of validated testing instruments, which took into account the weight variations, body image concerns, eating behavior, quality of life, and nutritional status. RESULTS: Overall, eating behavior-, body image concern-, and nutritional status-related testing instruments demonstrated improvements starting from the first post-operative month. Normal body weight was restored after 4 months of stimulation. DISCUSSION: Only a few cases of DBS for AN have been conducted to determine the efficacy of surgery based upon weight variation and psychometric scales for anxiety and affective disorders. In contrast, we have designed a comprehensive approach taking into account the most important aspects of this disease. This approach should be considered in future studies dealing with the neurosurgical treatment of AN.

Image-based analysis and long-term clinical outcomes of deep brain stimulation for Tourette syndrome: a multisite study.

BACKGROUND: Deep brain stimulation (DBS) can be an effective therapy for tics and comorbidities in select cases of severe, treatment-refractory Tourette syndrome (TS). Clinical responses remain variable across patients, which may be attributed to differences in the location of the neuroanatomical regions being stimulated. We evaluated active contact locations and regions of stimulation across a large cohort of patients with TS in an effort to guide future targeting. METHODS: We collected retrospective clinical data and imaging from 13 international sites on 123 patients. We assessed the effects of DBS over time in 110 patients who were implanted in the centromedial (CM) thalamus (n=51), globus pallidus internus (GPi) (n=47), nucleus accumbens/anterior limb of the internal capsule (n=4) or a combination of targets (n=8). Contact locations (n=70 patients) and volumes of tissue activated (n=63 patients) were coregistered to create probabilistic stimulation atlases. RESULTS: Tics and obsessive-compulsive behaviour (OCB) significantly improved over time (p<0.01), and there were no significant differences across brain targets (p>0.05). The median time was 13 months to reach a 40% improvement in tics, and there were no significant differences across targets (p=0.84), presence of OCB (p=0.09) or age at implantation (p=0.08). Active contacts were generally clustered near the target nuclei, with some variability that may reflect differences in targeting protocols, lead models and contact configurations. There were regions within and surrounding GPi and CM thalamus that improved tics for some patients but were ineffective for others. Regions within, superior or medial to GPi were associated with a greater improvement in OCB than regions inferior to GPi. CONCLUSION: The results collectively indicate that DBS may improve tics and OCB, the effects may develop over several months, and stimulation locations relative to structural anatomy alone may not predict response. This study was the first to visualise and evaluate the regions of stimulation across a large cohort of patients with TS to generate new hypotheses about potential targets for improving tics and comorbidities.

A tug of war: antagonistic effective connectivity patterns over the motor cortex and the severity of motor symptoms in Gilles de la Tourette syndrome.

We tested the hypothesis that Gilles de la Tourette syndrome (GTS) is characterized by perturbed connectivity within cortico-subcortical motor networks. To this end, we performed a dynamic causal modelling (DCM) analysis of fMRI data collected during a finger opposition task in 24 normal controls and 24 GTS patients. The DCM analysis allowed us to assess whether any GTS-specific patterns of brain activity were related to intrinsic and/or to task-dependent connectivity. While no abnormalities were found for task-dependent connectivity, intrinsic connectivity was abnormally increased in the premotor network, with stronger connections from the supplementary motor area (SMA), from the dorsolateral premotor cortex and from the putamen to the right superior frontal gyrus, an area where GTS showed over-activation in a previous univariate analysis. We also found a positive correlation between the connectivity strength from the right basal ganglia to the right primary motor cortex (M1) and disease severity measured by the Yale Global Tic Severity Scale (YGTSS). This pattern was mirrored by a negative correlation between the connection strength from the right SMA to the right area M1 and the YGTSS score. These two reverse correlation effects showed a specific relationship with individual disease severity: the greater the imbalance between subcortical and premotor connectivity towards area M1, the higher the YGTSS score. These results reveal the existence of perturbed intrinsic connectivity patterns in the motor networks of GTS patients with two competing forces operating in a tug of war-like mechanism: aberrant subcortical afferents to M1, compensated for by inputs from the premotor cortex.

Parsing the phenotype of obsessive-compulsive tic disorder (OCTD): a multidisciplinary consensus.

Obsessive-Compulsive Disorder (OCD) and Tic Disorder (TD) are highly disabling and often comorbid conditions. Of note, the DSM-5 acknowledged a new 'tic-related' specifier for OCD, which might be referred to as Obsessive-Compulsive Tic Disorder (OCTD), raising new interest toward a better clinical characterisation of affected patients. Available literature indicates that early onset, male gender, sensory phenomena and obsessions of symmetry, aggressiveness, hoarding, exactness and sounds as well as comorbidity with Attention Deficit Hyperactivity Disorder (ADHD) may be of more frequent observation in patients with OCTD. In order to share expertise in the field from different perspectives, a multidisciplinary panel of Italian clinicians, specifically involved in the clinical care of OCD and TD patients, participated into a consensus initiative, aimed to produce a shared document. As a result, after having examined the most relevant literature, authors sought to critically identify and discuss main epidemiologic, socio-demographic and clinical features characterising OCTD patients, along with other specific aspects including Health-Related Quality-of-Life (HRQoL), economic consequences related with the condition and its management, as well as treatment-related issues, that need to be further investigated.

A functional magnetic resonance imaging investigation of motor control in Gilles de la Tourette syndrome during imagined and executed movements.

The current study investigated the neural correlates of voluntary motor control in 24 adult Gilles de la Tourette (GTS) patients. We examined whether imagination and the execution of the same voluntary movement - finger oppositions with either hand - were associated with specific patterns of activation. We also explored whether these patterns correlated with the severity of the syndrome, as measured by the Yale Global Tic Severity Scale (YGTSS) for motor tics. The presence of brain morphometric abnormalities was also assessed using voxel-based morphometry. Crucial to our experiment was the manipulation of the presence of an explicit motor outflow in the tasks. We anticipated a reduction in the ticking manifestation during the explicit motor task and brain activation differences between GTS patients and 24 age/gender-matched normal controls. The anticipated differences were all evident in the form of hyperactivations in the GTS patients in the premotor and prefrontal areas for both motor tasks for both hands; however, the motor imagery hyperactivations also involved rostral pre-frontal and temporo-parietal regions of the right hemisphere. The blood oxygen level-dependent responses of the premotor cortices during the motor imagery task were significantly correlated with the YGTSS scores. In contrast, no significant brain morphometric differences were found. This study provides evidence of a different neurofunctional organisation of motor control between adult patients with GTS and healthy controls that is independent from the actual execution of motor acts. The presence of an explicit motor outflow in GTS mitigates the manifestation of tics and the need for compensatory brain activity in the brain regions showing task-dependent hyperactivations.

The anarchic brain in action: the contribution of task-based fMRI studies to the understanding of Gilles de la Tourette syndrome.

PURPOSE OF REVIEW: Gilles de la Tourette syndrome (GTS) is a frequent neurological disorder characterized by the production of tics, and frequently associated with obsessive-compulsive disorder or attention-deficit hyperactivity disorder. The aim of this article is to summarize the contribution of imaging activation techniques to the study of the syndrome. RECENT FINDINGS: GTS has been studied with a variety of functional MRI (fMRI)/PET activation paradigms to characterize the origin of tics or their suppression, and how they compare physiologically with voluntary actions or response inhibitions. Current studies indicate overactivations of prefrontal and premotor cortices, including the supplementary motor area, and subcortical structures. Resting state functional connectivity studies complement activation studies in showing perturbed connectivity of cortico-subcortical networks. Several such findings correlate with the severity of the disease. SUMMARY: fMRI activation techniques are contributing a system-level neurophysiological description of GTS and bridge the gap between animal models and clinical observations. fMRI clarifies brain networks involved in different aspects of GTS phenomenology with some good clinical face validity. A future generation of fMRI studies should have higher ambitions and contribute, for example, to treatment optimization including the identification of ideal targets for deep brain stimulation in drug-resistant cases; however, such goals will be achieved only through controlled large-scale cooperative studies.

Tourette syndrome deep brain stimulation: a review and updated recommendations.

Deep brain stimulation (DBS) may improve disabling tics in severely affected medication and behaviorally resistant Tourette syndrome (TS). Here we review all reported cases of TS DBS and provide updated recommendations for selection, assessment, and management of potential TS DBS cases based on the literature and implantation experience. Candidates should have a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V) diagnosis of TS with severe motor and vocal tics, which despite exhaustive medical and behavioral treatment trials result in significant impairment. Deep brain stimulation should be offered to patients only by experienced DBS centers after evaluation by a multidisciplinary team. Rigorous preoperative and postoperative outcome measures of tics and associated comorbidities should be used. Tics and comorbid neuropsychiatric conditions should be optimally treated per current expert standards, and tics should be the major cause of disability. Psychogenic tics, embellishment, and malingering should be recognized and addressed. We have removed the previously suggested 25-year-old age limit, with the specification that a multidisciplinary team approach for screening is employed. A local ethics committee or institutional review board should be consulted for consideration of cases involving persons younger than 18 years of age, as well as in cases with urgent indications. Tourette syndrome patients represent a unique and complex population, and studies reveal a higher risk for post-DBS complications. Successes and failures have been reported for multiple brain targets; however, the optimal surgical approach remains unknown. Tourette syndrome DBS, though still evolving, is a promising approach for a subset of medication refractory and severely affected patients.

Deep brain stimulation for Tourette syndrome: modulation of the limbic-motor interface network.

OBJECTIVE: Deep brain stimulation (DBS) is an effective treatment for medically refractory Tourette syndrome (TS). Several effective targets have been reported, but there is still controversy about the networks involved in the efficacy of DBS for TS. Here, the authors aimed to identify the basal ganglia-thalamo-cortical networks associated with tic and obsessive-compulsive behavior (OCB) improvement and the network link between the two main targets for TS. METHODS: A retrospective analysis of 21 patients treated with pallidal and thalamic DBS was performed. Tics and OCB scores were recorded before and after DBS. The authors localized the electrodes in standard MNI (Montreal Neurological Institute) space and calculated the volume of tissue activated with the settings at the last follow-up to obtain areas of maximal improvement ("sweet spots") among all patients for the pallidal and thalamic targets. Tractography was used to show the white matter pathways associated with maximal tic and OCB improvement. RESULTS: Ten patients treated with pallidal DBS and 11 patients treated with thalamic DBS were included. Responder rates were 80% in the pallidal and 64% in the thalamic target groups. Sweet spots for tics and OCB clustered in several areas across the basal ganglia and thalamus delineated two main networks. Tic reduction in the pallidal target mapped to a limbic pallidothalamic network and in the thalamic target to the premotor thalamocortical network. Putting these two networks together will form the main output of the so-called limbic-motor interface network. However, OCB reduction mapped a dorsomedial prefrontal cortex/dorsal anterior cingulate (dmPFC/dACC) network. CONCLUSIONS: The authors demonstrated the involvement of the limbic-motor interface network during effective DBS for tics in patients with TS. OCB redution was associated with the additional involvement of dmPFC/dACC connections passing dorsal to the head of the globus pallidus pars externa on its way to the thalamus and midbrain.

An Observational Longitudinal Study on Seasonal Variations in Tourette Syndrome: Evidence for a Role of Ambient Temperature in Tic Exacerbation.

Tourette syndrome (TS) is a high-incidence neurobehavioral disorder that generally begins in childhood. Several factors play a role in its etiology, including genetic influence and auto-immune activation by streptococcal infections. In general, symptoms subside after the end of adolescence, but, in a significant number of patients, they remain in adulthood. In this study, we evaluated temporal variations in the two core clinical features of TS including tics and obsessive-compulsive disorder (OCD) symptoms. An observational longitudinal study lasting 15 months (2017-2019) was conducted on a cohort of 24 people recruited in Milan (Italy) who were diagnosed with a subtype of TS known as obsessive-compulsive tic disorder. Inclusion criteria included a global score of the Yale global tic severity scale (Y-GTSS) > 50, a Yale-Brown obsessive-compulsive scale (Y-BOCS) global score > 15, and TS onset at least one year prior. Y-GTSS and Y-BOCS data were acquired at six time points, together with local environmental data. Tics, but not OCD symptoms, were found to be more severe in spring and summer compared with winter and autumn (p < 0.001). Changes in tics displayed an appreciable oscillation pattern in the same subject and also a clear synchrony among different subjects, indicating an external orchestrating factor. Ambient temperature showed a significant correlation with Y-GTSS measurements (p < 0.001). We argue that the increase in tics observed during hot seasons can be related to increasing ambient temperature. We believe that our results can shed light on the seasonal dynamics of TS symptomatology and provide clues for preventing their worsening over the year.

Mapping Gilles de la Tourette syndrome through the distress and relief associated with tic-related behaviors: an fMRI study.

Personal distress associated with tic urges or inhibition and relief associated with tic production are defining features of the personal experience in Gilles de la Tourette syndrome (GTS). These affective phenomena have not been studied using fMRI, hindering our understanding of GTS pathophysiology and possible treatments. Here, we present a novel cross-sectional fMRI study designed to map tic-related phenomenology using distress and relief as predicting variables. We adopted a mental imagery approach and dissected the brain activity associated with different phases of tic behaviors, premonitory urges, and the ensuing tic execution or inhibition: these were compared with the mental simulation of "relaxed situations" and pre-determined stereotyped motor behaviors. We then explored whether the ensuing brain patterns correlated with the distress or relief perceived for the different phases of the tasks. Patients experienced a higher level of distress during the imagery of tic-triggering scenarios and no relief during tic inhibition. On the other hand, patients experienced significant relief during tic imagery. Distress during tic-triggering scenarios and relief during tic imagery were significantly correlated. The distress perceived during urges correlated with increased activation in cortical sensorimotor areas, suggesting a motor alarm. Conversely, relief during tic execution was positively associated with the activity of a subcortical network. The activity of the putamen was associated with both distress during urges and relief during tic execution. These findings highlight the importance of assessing the affective component of tic-related phenomenology. Subcortical structures may be causally involved in the affective component of tic pathophysiology, with the putamen playing a central role in both tic urge and generation. We believe that our results can be readily translated into clinical practice for the development of personalized treatment plans tailored to each patient's unique needs.

Pathological gambling in Parkinson's disease: subthalamic oscillations during economics decisions.

Pathological gambling develops in up to 8% of patients with Parkinson's disease. Although the pathophysiology of gambling remains unclear, several findings argue for a dysfunction in the basal ganglia circuits. To clarify the role of the subthalamic nucleus in pathological gambling, we studied its activity during economics decisions. We analyzed local field potentials recorded from deep brain stimulation electrodes in the subthalamic nucleus while parkinsonian patients with (n = 8) and without (n = 9) pathological gambling engaged in an economics decision-making task comprising conflictual trials (involving possible risk-taking) and non conflictual trials. In all parkinsonian patients, subthalamic low frequencies (2-12 Hz) increased during economics decisions. Whereas, in patients without gambling, low-frequency oscillations exhibited a similar pattern during conflictual and non conflictual stimuli, in those with gambling, low-frequency activity increased significantly more during conflictual than during non conflictual stimuli. The specific low-frequency oscillatory pattern recorded in patients with Parkinson's disease who gamble could reflect a subthalamic dysfunction that makes their decisional threshold highly sensitive to risky options. When parkinsonian patients process stimuli related to an economics task, low-frequency subthalamic activity increases. This task-related change suggests that the cognitive-affective system that drives economics decisional processes includes the subthalamic nucleus. The specific subthalamic neuronal activity during conflictual decisions in patients with pathological gambling supports the idea that the subthalamic nucleus is involved in behavioral strategies and in the pathophysiology of gambling.

Safety in the use of dexmedetomidine (precedex) for deep brain stimulation surgery: our experience in 23 randomized patients.

OBJECTIVE: Evaluation of safety and efficacy of dexmedetomidine in deep brain stimulation (DBS) surgery. MATERIALS AND METHODS: A cohort of 23 patients, candidates for DBS for Parkinson's disease, Tourette syndrome, or obsessive-compulsive disorder, was randomized in two groups: dexmedetomidine group and control group. Standard anesthesiologic parameters were recorded and analyzed, together with the need for other medications. A ten-degree scale (visual analog scale) assessing patient discomfort during DBS also was recorded at the end of surgery. RESULTS: The results demonstrated good stability of intraoperative monitoring: no respiratory depression and good overall cooperation with the neurologist, while no side-effects were recorded. CONCLUSIONS: Our conclusion is that dexmedetomidine should be considered as a valuable option for sedation in poorly collaborating patients undergoing DBS surgery.

The Imitation Game in Children With Tourette Syndrome: A Lack of Impulse Control to Mirror Environmental Stimuli.

The learning process in humans requires continuous contacts with environmental stimuli, especially during neurodevelopmental growth. These functions are assisted by the coding potential of mirror neurons to serve social interactions. This ability to learn imitating the observed behavior is no longer necessary during adulthood, and control mechanisms prevent automatic mirroring. However, children with Gilles de la Tourette syndrome could encounter coding errors at the level of the mirror neurons system as these cortical regions are themselves the ones affected in the syndrome. Combined with impulsivity, the resulting sign would be a manifest echopraxia that persists throughout adulthood, averting these individuals from the appraisal of a spot-on motor control.

Subthalamic local field beta oscillations during ongoing deep brain stimulation in Parkinson's disease in hyperacute and chronic phases.

In the past years, local field potential (LFP) signals recorded from the subthalamic nucleus (STN) in patients undergoing deep brain stimulation (DBS) for Parkinson's disease (PD) disclosed that DBS has a controversial effect on STN beta oscillations recorded 2-7 days after surgery for macroelectrode implantation. Nothing is known about these DBS-induced oscillatory changes 30 days after surgery. We recorded STN LFPs during ongoing DBS in 7 patients with PD, immediately (hyperacute phase) and 30 days (chronic phase) after surgery. STN LFP recordings showed stationary intranuclear STN beta LFP activity in hyperacute and chronic phases, confirming that beta peaks were also present in chronic recordings. Power spectra of nuclei with significant beta activity (54% of the sample) showed that it decreased significantly during DBS (p=0.021) under both recording conditions. The time course of beta activity showed more evident DBS-induced changes in the chronic than in the hyperacute phase (p=0.014). DBS-induced changes in STN beta LFPs in patients undergoing DBS in chronic phase provide useful information for developing a new neurosignal-controlled adaptive DBS system.