Case presentation:
A 32-year-old right handed gentleman was diagnosed with TS at the age of 5 with a progression through adolescence, presented by fluctuating complex motor tics including shoulder elevation, repetitive movement in the thumbs and eye blinking, which was accompanied by severe disabling OCD, beginning at the age of 8, sleep disorder for 15 years, adult onset ADHD, and anxiety disorder during the course of illness. He reported social impairment during school and at work. He had several unsuccessful behavioral- and pharmaco- therapies (table 1) since he was diagnosed. He had positive family history of TS in his father accompanied by OCD and simple motor tic in his sister. Due to severe symptoms, lack of response to multiple drugs unsuccessful psycho-behavioral therapy and patient’s functional impairment, he was known as refractory case of TS and became a candidate for DBS surgery.
A consent was obtained from the patient and DBS surgery carried out under local anesthesia. Targets were determined and calculated via Medtronic S8 planning station software and approved via an MRI and microelectrode recording. Electrodes (3389/ Medtronic) were administered thourgh the coronal suture site, parallel to the midline and implanted symmetrically on the anteromedial globus pallidus interna (GPi) (Right: x=15.22, y=6.40, z=-7.74 and Left: x=-14.32, y=7.29, z=-9.37). Stimulation test results during surgery demonstrated proper response with no immediate side effects. Post-operative Computed tomography scan demonstrated the appropriate position of electrodes. No complications were observed after the surgery. An IPG (Active PC/Medtronic) become connected to the leads and implanted subcutaneously in right chest wall.
One month after surgery the IPG was turned on, during assessment, right side stimulation showed no side effects while at the left side dyspnea related to ventral electrodes and paresthesia and vertigo related to dorsal electrodes were detected. The parameters were set on, Amplitude: 1, Pulse width: 80, frequency: 85, Bipolar on the left (3+, 0-) and unipolar on the right (Case+, 8-).
During follow up sessions, patient’s condition was fluctuating in response to alterations in stimulation parameters as it is shown in table 1. At the optimum parameters which was obtained after 8 months, OCD decreased dramatically; on the other hand, however, tics frequency and intensity did not change significantly and ultimately worsen during time. Patient’s improvement in OCD also caused his medications to be reduced (table 1).