From 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.
Neurology. 2021 Apr 6;96(14):664-676. doi: 10.1212/WNL.0000000000011704. Epub 2021 Feb 16.
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.
抽动秽语综合征（TS）患者行脑深部电刺激（DBS）手术的选择基于 5 个基本支柱。然而，评估这些支柱的多学科筛查过程的操作仍然高度多样化，尤其是在不同的站点之间。高 tic 严重程度和 tic 对生活质量的影响（前两个支柱）需要通过客观、经过验证的措施来确认，但 TS 的恶性特征本身就足以满足这一要求。行为和药物治疗失败（第三个支柱）应通过客观和主观措施进行评估，这些措施支持所有已证实有效的干预措施缺乏疗效，以及真正缺乏耐受性、依从性或可及性。教育干预措施和远程提供格式的使用（用于行为疗法）在防止对治疗失败的错误判断方面发挥作用。需要稳定的共患精神障碍 6 个月（第四个支柱），以确认 tic 对生活质量的主要影响，防止假性耐药性，并最大限度地提高未来 DBS 反应。18 岁年龄限制（第五个支柱）目前正在重新评估，考虑到青春期严重 tic 的潜在影响以及儿童期 tic 严重程度对成年期 tic 严重程度的预测作用。未来的进展应旨在基于共识的定义，确定 tic 的特定、非侵入性治疗策略的失败，以及在考虑 DBS 治疗之前的最小临床观察期，行为共病的稳定性，以及使用前瞻性国际登记数据来确定对 DBS 治疗的积极反应的预测因素，尤其是在年轻患者中。
