Lack of benefit of accumbens/capsular deep brain stimulation in a patient with both tics and obsessive–compulsive disorder

Abstract

Lay summary: This case report illustrates lack of clinical efficacy of deep brain stimulation (DBS) for control of tics in a case of mild Tourette syndrome (TS) with severe comorbid obsessive–compulsive disorder (OCD). The brain target for stimulation was the anterior limb internal capsule (ALIC). Objective: To investigate the effect of anterior limb of internal capsule/nucleus accumbens (ALIC-NA) DBS on mild motor and vocal tics in a Tourette syndrome (TS) patient with severe OCD. Background: The optimum target to address symptoms of TS with DBS remains unknown. Earlier lesional therapy utilized thalamic targets and also the ALIC for select cases which had been diagnosed with other psychiatric disorders. Evidence regarding the efficacy of DBS for the symptoms of TS may aid in better defining a brain target's suitability for use. We report efficacy data on ALIC-NA DBS in a patient with severe OCD and mild TS. Methods: A 33-year-old man underwent bilateral ALIC-NA DBS. One month following implantation, a post-operative CT scan was obtained to verify lead locations. Yale Global Tic Severity Scales (YGTSS) and modified Rush Videotape Rating scales (MRVRS) were obtained throughout the first 6 months, as well as careful clinical examinations by a specialized neurology and psychiatry team. The patient has been followed for 30 months. Results: YGTSS scores worsened by 17% during the first 6 months. MRVRS scores also worsened over 30 total months of follow-up. There was a lack of clinically significant tic reduction although subjectively the patient felt tics improved mildly. Conclusion: DBS in the ALIC-NA failed to effectively address mild vocal and motor tics in a patient with TS and severe comorbid OCD.

Keywords:

• Tourette's syndrome
• Deep brain stimulation
• Nucleus accumbens
• Anterior limb of internal capsule

Acknowledgments

Sources of support: NIH/NIMH, Eric and Jennifer Scott Fund. This study was supported partially by a grant from the NIH (R21 MH064161; PI Goodman), and also through the University of Florida Foundation.