The neurosurgical treatment of Tourette's syndrome

The treatment of Gilles de la Tourette's syndrome (TS) needs different approaches. In the first place, it is important to give detailed information to the patient, parents, school, or workplace. Generally, this information is sufficient for TS patients to cope withmotor and vocal tics. Second, if tics interfere with social, school, and professional activities, pharmacological treatment may be necessary. Several classes of anti-tic medication are available, in particular the alpha-adrenergic drugs clonidine and guanfacine, neuroleptics such as haloperidol and pimozide, and more recently atypical antipsychotics such as risperidone (1). Third, recent studies have shown that behavioral therapymay, at least in part, control tics (2).Most patients with TS will have a significant reduction of tics by the time they reach adulthood (3). However, a small portion of TS patients continues to have bothersome tics with interfer- MD: KURLAN, JOB: 03329, PAGE: ence of both social and professional life despite adequate pharmacological treatment. In those patients, brain surgery has been employed since the early 1960s. Detailed data on the short-and long-term results are lacking and serious side effects have limited their general use. In fact, in the first edition of this Handbook, surgical treatment for tics is not mentioned, demonstrating the critical view of this form of treatment by TS specialists. Initially, neurosurgical procedures consisted of the destruction of various parts of the brain on the basis of empirical data.Most of the reported patients were operated on because of associated psychiatric disturbances, in particular obsessive-compulsive disorder (OCD) (4). Frequently, the tics were not responsive to the surgical procedure. If tics were reduced by the surgery, it was unclear which target was responsible for the reduction of tics because of the lack of selective lesions (4). In addition, the lesions were very large. Regions in the vicinity of the presumed target could have contributed to the reduction of tics. Table 1 shows an overview of the various presumed targets in recent publications. All authors report serious adverse events in several of the operated patients (5-13). Because of the serious morbidity, neurosurgery as a treatment option in TS was generally abandoned by most specialized TS centers. However, due to the refinement of the stereotactic technique and the safe procedure of deep brain stimulation (DBS) in other movement disorders, such as Parkinson's disease (PD), tremors and dystonia (14-16), neurosurgical treatment has received renewed attention