Background: There have been several reports of successful deep brain stimulation (DBS) for the treatment of severe Gilles de la Tourette syndrome (GTS). Method: 18 cases of GTS who were resistant to at least 6 months of standard and innovative treatments, as well as to psychobehavioural techniques, underwent DBS. DBS was placed bilaterally in the centromedian–parafascicular (CM–Pfc) and ventralis oralis complex of the thalamus. Patients were evaluated after surgery, with immediate and formal assessments at least every 3 months, including “on–off” and “sham off” in the first nine patients. Results: All patients responded well to DBS, although to differing degrees. The duration of follow-up assessments ranged from 3 to 18 months. The comorbid symptoms of obsessive–compulsive behaviour, obsessive–compulsive disorder, self-injurious behaviours, anxiety and premonitory sensations decreased after treatment with DBS. There were no serious permanent adverse effects. Conclusions: DBS is a useful and safe treatment for severe GTS. The results of ours and previous DBS reports suggest that the CM–Pfc and ventralis oralis complex of the thalamus may be a good DBS target for GTS.

OBJECTIVE To examine surgical findings and results of microvascular decompression (MVD) for trigeminal neuralgia (TN), including patients with multiple sclerosis, to bring new insight about the role of microvascular compression in the pathogenesis of the disorder and the role of MVD in its treatment. METHODS Between 1990 and 1998, 250 patients affected by trigeminal neuralgia underwent MVD in the Department of Neurosurgery of the “Istituto Nazionale Neurologico C Besta” in Milan. Limiting the review to the period 1991–6, to exclude the “learning period” (the first 50 cases) and patients with less than 1 year follow up, surgical findings and results were critically analysed in 148 consecutive cases, including 10 patients with multiple sclerosis. RESULTS Vascular compression of the trigeminal nerve was found in all cases. The recurrence rate was 15.3% (follow up 1–7 years, mean 38 months). In five of 10 patients with multiple sclerosis an excellent result was achieved (follow up 12–39 months, mean 24 months). Patients with TN for more than 84 months did significantly worse than those with a shorter history (p<0.05). There was no mortality and most complications occurred in the learning period. Surgical complications were not related to age of the patients. CONCLUSIONS Aetiopathogenesis of trigeminal neuralgia remains a mystery. These findings suggest a common neuromodulatory role of microvascular compression in both patients with or without multiple sclerosis rather than a direct causal role. MVD was found to be a safe and effective procedure to relieve typical TN in patients of all ages. It should be proposed as first choice surgery to all patients affected by TN, even in selected cases with multiple sclerosis, to give them the opportunity of pain relief without sensory deficits.

Surgical therapies for Tourette syndrome have been used since the early 1960s. Ablative procedures were initially used to target specific areas of the brain; these approaches revealed inconsistent, but in many cases reasonably positive, clinical outcomes, particularly on motor tics. Ablative surgical procedures did not become mainstream and largely disappeared from the treatment arsenal for Tourette syndrome.¹ Deep brain stimulation (DBS) for Tourette syndrome, introduced in 1999,² is a surgical therapy that uses an implantable device to deliver electrical stimulation to specific and carefully targeted brain structures. Deep brain stimulation is approved by the US Food and Drug Administration and Conformité Européene Mark approved in the European Union for the treatment of selected cases of Parkinson disease and essential tremor. Deep brain stimulation has a Conformité Européene Mark for selected cases of primary and secondary dystonia.³ Deep brain stimulation also received approval from the US Food and Drug Administration under a humanitarian device exemption for dystonia and obsessive-compulsive disorder.⁴ Although DBS is not approved for Tourette syndrome in the United States and other countries, multiple single reports and case series have collectively demonstrated that DBS could be a potentially valuable therapy for select cases of severe medication-resistant Tourette syndrome. A recent systematic review and meta-analysis of 57 studies including 156 cases of DBS for Tourette syndrome reported an overall improvement of 53% as measured by the total Yale Global Tic Severity Scale (YGTSS) score.⁵

Background: Eighteen patients with severe and refractory Tourette syndrome (TS) underwent bilateral thalamic deep brain stimulation (DBS). Objective: To assess the long-term outcome on tics, behavioral symptoms, and cognitive functions in the largest case series of thalamic DBS for TS to date. Methods: In this prospective cohort study, 15 of the original 18 patients were evaluated before and after surgery according to a standardized protocol that included both neuropsychiatric and neuropsychological assessments. Results: In addition to marked reduction in tic severity (p = 0.001), 24-month follow-up ratings showed improvement in obsessive-compulsive symptoms (p = 0.009), anxiety symptoms (p = 0.001), depressive symptoms (p = 0.001), and subjective perception of social functioning/quality of life (p = 0.002) in 15 of 18 patients. There were no substantial differences on measures of cognitive functions before and after DBS. Conclusions: At 24-month follow-up, tic severity was improved in patients with intractable Tourette syndrome (TS) who underwent bilateral thalamic deep brain stimulation. Available data from 15 of 18 patients also showed that neuropsychiatric symptoms were improved and cognitive performances were not disadvantaged. Controlled studies on larger cohorts with blinded protocols are needed to verify that this procedure is effective and safe for selected patients with TS. Level of evidence: This study provides class IV evidence that bilateral thalamic deep brain stimulation reduces global tic severity measured 24 months after implantation in patients with severe intractable Tourette syndrome.