Objective: We report a case of a young woman with refractory severe TS treated with DBS on anterior globus pallidus internus.

Background: The Tourette Syndrome (TS) is a neurobehavioral disease characterized by multiple motor and at least one phonic tics that usually begins during childhood and associated with behavioral comorbidities. Clinical criteria for the indication of DBS is severe tic disorder with functional impairment and neuropsychiatric comorbidities stable and treated. Many target sites for stimulation have been previously described for TS, most commonly centromedian-parafascicular-thalamic complex, anterior globus pallidus internus and nucleus accumbens.

Method: A 51 year-old woman was diagnosed with Tourette`s Syndrome since 28 years old and severe tic with functional impairment. Her symptoms were vocal and motor tics several times a day with throat clearing, grunting, sniffing, coughing and repeating words or phrases. The patient`s history also includes anxiety, obsessive compulsive disorder and attention deficit. Previous treatment with psychological therapy and medication were refractory.

Results: She was submitted to bilateral DBS implantation at the anterior globus pallidus internus. Programming parameters were Amplitude 3.0 mA (left GPi) and 3.5 mA (right GPi), pulse width 90 μs, frequency 130 Hz, electrode configuration monopolar stimulation vental in both hemispheres 0 – C +. BrainSense Survey Local Field Potential identified peak in low-frequency delta (0-3 Hz) and theta (4–7 Hz), that could be correlated with TS pathophysiology in anterior GPi. After 1 year follow-up the tics improved by 53% in Yale Global Tic Severity Scale (YGTSS). Sum of Motor and Phonic Tic Severity Scales were 47/50 before surgery and 22/50 after DBS implantation.

Conclusion: DBS is a recognized treatment option for refractory Tourette Syndrome patients with acceptable morbidity and good outcomes. LFP recordings helped to clarify the pathophysiology of Tourette syndrome and to define new strategies for DBS treatment, based on the delivery of stimulation in accordance with changes in the electrical activity. Local field potential guided programming can be a readily accessible tool for improving current DBS programming practices compared to clinically based programming. Further research is necessary to establish consensus on target and programming strategies.

References: 1 – Frey J, Malaty IA. Tourette Syndrome Treatment Updates: a Review and Discussion of the Current and Upcoming Literature. Curr Neurol Neurosci Rep. 2022 Feb;22(2):123-142. doi: 10.1007/s11910-022-01177 8. Epub 2022 Feb 2. PMID: 35107785; PMCID: PMC8809236.
2 – Andrade P, Visser-Vandewalle V. DBS in Tourette syndrome: where are we standing now? J Neural Transm (Vienna). 2016 Jul;123(7):791-796. doi: 10.1007/s00702-016-1569-7. Epub 2016 May 21. PMID: 27209036.
3 – Müller-Vahl KR, Szejko N, Verdellen C, Roessner V, Hoekstra PJ, Hartmann A, Cath DC. European clinical guidelines for Tourette syndrome and other tic disorders: summary statement. Eur Child Adolesc Psychiatry. 2022 Mar;31(3):377-382. doi: 10.1007/s00787-021-01832-4. Epub 2021 Jul 10. PMID: 34244849; PMCID: PMC8940881.

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