Dual-Target Deep Brain Stimulation for Obsessive-Compulsive Disorder and Tourette Syndrome

Deep brain stimulation (DBS) has been used effectively for both treatment-resistant obsessive-compulsive disorder (OCD) and Tourette syndrome (TS) ( 1 Gadot R. Najera R. Hirani S. Anand A. Storch E. Goodman W.K. et al. Efficacy of deep brain stimulation for treatment-resistant obsessive-compulsive disorder: Systematic review and meta-analysis [published online Sep 20].. J Neurol Neurosurg Psychiatry. 2022; (2022 Sep 20;jnnp-2021-328738) Crossref Scopus (7) Google Scholar , 2 Martinez-Ramirez D. Jimenez-Shahed J. Leckman J.F. Porta M. Servello D. Meng F.G. et al. Efficacy and safety of deep brain stimulation in Tourette syndrome: The International Tourette Syndrome Deep Brain Stimulation Public Database and Registry. JAMA Neurol. 2018; 75: 353-359 Crossref PubMed Scopus (133) Google Scholar ). While DBS of the anterior limb of the internal capsule is Food and Drug Administration approved for use in OCD under a Humanitarian Device Exemption, DBS for TS is still considered investigational ( 3 Billnitzer A. Jankovic J. Current management of tics and Tourette syndrome: Behavioral, pharmacologic, and surgical treatments. Neurotherapeutics. 2020; 17: 1681-1693 Crossref PubMed Scopus (38) Google Scholar , 4 Arya S. Filkowski M.M. Nanda P. Sheth S.A. Deep brain stimulation for obsessive-compulsive disorder. Bull Menninger Clin. 2019; 83: 84-96 Crossref PubMed Scopus (15) Google Scholar ). Several DBS targets for TS have been studied, most prominently the globus pallidus internus (GPi) and centromedian/parafascicular thalamus, though no single best target has emerged ( 2 Martinez-Ramirez D. Jimenez-Shahed J. Leckman J.F. Porta M. Servello D. Meng F.G. et al. Efficacy and safety of deep brain stimulation in Tourette syndrome: The International Tourette Syndrome Deep Brain Stimulation Public Database and Registry. JAMA Neurol. 2018; 75: 353-359 Crossref PubMed Scopus (133) Google Scholar , 5 Baldermann J.C. Hennen C. Schüller T. Andrade P. Visser-Vandewalle V. Horn A. et al. Normative functional connectivity of thalamic stimulation for reducing tic severity in Tourette syndrome. Biol Psychiatry Cogn Neurosci Neuroimaging. 2022; 7: 841-844 Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar ). Up to two-thirds of patients with TS present with comorbid OCD ( 6 Hirschtritt M.E. Lee P.C. Pauls D.L. Dion Y. Grados M.A. Illmann C. et al. Lifetime prevalence, age of risk, and genetic relationships of comorbid psychiatric disorders in Tourette syndrome. JAMA Psychiatry. 2015; 72: 325-333 Crossref PubMed Scopus (377) Google Scholar ). In many cases, treatment-resistant dual-diagnosis patients have been treated with one pair of leads in the hope of improving both. In an attempt to optimize outcomes for both disorders, and given the increasing utilization of multilead implantation strategies ( 7 Oliveria S.F. Rodriguez R.L. Bowers D. Kantor D. Hilliard J.D. Monari E.H. et al. Safety and efficacy of dual-lead thalamic deep brain stimulation for patients with treatment-refractory multiple sclerosis tremor: A single-centre, randomised, single-blind, pilot trial. Lancet Neurol. 2017; 16: 691-700 Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar , 8 Mitchell K.T. Schmidt S.L. Cooney J.W. Grill W.M. Peters J. Rahimpour S. et al. Initial clinical outcome with bilateral, dual-target deep brain stimulation trial in Parkinson disease using Summit RC + S. Neurosurgery. 2022; 91: 132-138 Crossref PubMed Scopus (3) Google Scholar , 9 Gadot R. Shofty B. Najera R.A. Anand A. Banks G. Khan A.B. et al. Case report: Dual target deep brain stimulation with externalized programming for post-traumatic complex movement disorder. Front Neurosci. 2021; 15774073 Crossref PubMed Scopus (2) Google Scholar , 10 Kobayashi K. Katayama Y. Oshima H. Watanabe M. Sumi K. Obuchi T. et al. Multitarget, dual-electrode deep brain stimulation of the thalamus and subthalamic area for treatment of Holmes' tremor. J Neurosurg. 2014; 120: 1025-1032 Crossref PubMed Scopus (39) Google Scholar ), we opted for a dual-target strategy in 2 patients with severe TS and OCD. We also utilized recently available sensing-capable implantable pulse generators (IPGs), which present a unique opportunity to study the disease-modifying effects of DBS on OCD- and TS-associated neurophysiology.