PMC6497003_01
Diagram showing some of the possible clinical evolution that can be interpreted as natural history of TS or outcome from non-surgical therapeutic interventions based on YGTSS as a severity measure. This diagram intends to illustrate the current indications for DBS according to earlier and latest criteria. (A) Clinical resolution of TS symptoms. (B) Presence of tics that do not resolve spontaneously or are kept stable under non-surgical treatments. (C) Classical indication for DBS based on the severity of disease and age (18 years). (D) Latest proposed indication for DBS based on severity as a determinant factor even before 18 years of age.. Abbreviations: DBS, deep brain stimulation; TS, Tourette's syndrome; YGTSS, Yale Global Tic Severity Scale.
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Although some recommendations use age as an exclusion criterion (impeding DBS to subjects below 18 or 25), this should not be an absolutely strict criterion (Table 1 and Figure 1).
Targets proposed for DBS treatment in Tourette's syndrome: (A) anterior limb of internal capsule/accumbens; (B) bilateral centromedian-parafascicular complex targeted in an anterolateral thalamic view (basal, anterior, and lateral thalamic views of the right thalamus are displayed for localization within the thalamus); and (C) different parts of GPi. Electrode 1 is located in the posteroventrolateral GPi and electrode 2 is located in the anteromedial GPi. The 3D representations are histological postmortem reconstructions of the nuclei from the University of Sao Paulo - Wurzburg Atlas of the Human Brain (Alho et al, 2018).. Abbreviations: ACC, accumbens; Cau, caudate nucleus; GPi, globus pallidus internus; GPe, globus pallidus externus; Put, putamen; ALIC, anterior limb of internal capsule; CM-Pf, centromedian-parafascicular-thalamic complex; LG, lateral thalamic group; STN, subthalamic group.
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In recent years, the centers of DBS worldwide explored at least nine brain targets for the treatment of TS: centromedian-parafascicular-thalamic complex (CM-Pf), the intersection point between centromedian nucleus, periventricular substance, and inferior ventro-oral nucleus in the thalamus (CM-Spv-Voi), the posterior ventro-oral nucleus, the anterior ventro-oral, and Voi, the GPi anteromedial or posteroventral, the nucleus accumbens (NA), the anterior internal capsule (ALIC), subthalamic nucleus (STN), and globus pallidus externus (GPe) (Figure 2 and Tables 2 and 3).
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