Deep brain stimulation for dystonia
© Hu and Stead; licensee BioMed Central Ltd. 2014
Received: 6 December 2013
Accepted: 19 January 2014
Published: 21 January 2014
Deep brain stimulation (DBS) is an effective surgical treatment for medication-refractory movement disorders, and has been approved by the United States Food and Drug Administration for treatment of dystonia. The success of DBS in the treatment of dystonia depends on our understanding of the anatomy and physiology of this disorder and close collaboration between neurosurgeons, neurologists, clinical neurophysiologists, neuroradiologists and neuropsychologists. Currently, pallidal DBS is an established treatment option for medically refractive dystonia. This review is intended to provide a comprehensive review of the use of DBS for dystonia, focusing mainly on the surgical aspects, clinical outcome, MRI findings and side effects of DBS.
KeywordsDystonia Deep brain stimulation Surgical outcomes Neuromodulation Globus pallidus
Dystonia is a movement disorder characterized by patterned directional and often sustained muscle contractions and causing twisting and repetitive movements or abnormal postures [1, 2]. Dystonia is also commonly classified by three criteria: anatomical distribution (focal, segmental, or generalized); age of symptom onset (juvenile or adult onset) and etiology, primary, secondary, or symptomatic. Primary dystonias (especially generalized) are often hereditary and may be subdivided by genotype. Although the exact mechanism of dystonia is not well understood, several lines of evidence suggest that the basal ganglia play an important role in dystonia. Usually, medical treatments are unsatisfactory and limited by side effects. Although many focal cases and segmental dystonia may benefit from the treatment of botulinum toxin, some patients do not respond or become resistant to medical treatment later [1–4]. Moreover, botulinum toxin had no effect on the treatment of generalized dystonia . DBS was first applied in cervical dystonia by Mundiner  in 1977. After that, two multicenter studies on bilateral Globus Pallidus pars Interna (GPi) DBS have demonstrated convincing clinical benefit on a large number of patients with primary generalized/segmental dystonia [7–9]. Accordingly, GPi DBS was approved by FDA in 2003 (as a humanitarian device exemption) for patients with chronic, medically intractable dystonia [10–13].
Current application and outcome
All DBS candidates need to be evaluated by DBS neurologist for assessment of the severity of dystonia & disability level by appropriate rating scales, screening for genetic causes (particularly DYT-1 mutation) [14, 15] , or secondary causes of dystonia. Moreover, cognitive and psychiatric assessments are also required as baseline measures. In our institute, the weekly Neuromodulation Committee meeting emphasizes multidisciplinary participation from Neurology, Neurosurgery, Neuropsychology, Psychiatry, Neuroradiology, Neurophysiology and other specialties. Potential dystonia patient candidates for DBS are discussed, and treatment options are considered. Didactic presentations covering current publications in neuromodulation is a regular component.
In order to be considered a DBS candidate, dystonic patients should be fairly disabled and have failed medical management. DYT-1 gene mutation test can also help us to predict the DBS outcome as it has been reported that DYT-1 positive patients had a better outcome [15, 16]. However, the application of DBS in children with secondary dystonia is more controversial [17–19]. It has also been reported that duration of dystonia is negatively correlated with surgery prognosis; patients with shorter disease duration have more favorable postoperative outcomes. Thus, in order to prevent secondary orthopedic complications, DBS surgery needs to be considered earlier [15, 20].
Recently, Moro E. et al.  nicely summarized several key points for DBS patients selection: briefly, young patients with primary dystonia and/or tardive dystonia are likely to have the good outcome from DBS surgery, however, regarding the patients with secondary dystonia, DBS should be carefully considered, due to lack of clinical effectiveness. Additionally, in patients with severe cervical dystonia, a cervical spine MRI is required to quantify the role of spinal degeneration in cervical pain , and to make sure whether or not if the spinal surgery is necessary before or after DBS . Last but not the least the authors also recommend a detail psychiatric evaluation in patients with psychiatric history pre- and post-operatively.
Optimal target selection
Once a patient is identified to be a suitable candidate for DBS, a target for the procedure has to be selected. Numerous studies have demonstrated that the GPi target can improve motor function and disability in primary dystonia [24–27]. The effects of GPi DBS on the cardinal symptoms of dystonia have been established in three randomized controlled clinical trials. Vidailhet, et al. reported a prospective, controlled, multicenter study in 2005  and more recently in 2007 providing updated results . Specifically, 22 severely impaired French patients with primary generalized dystonia were enrolled in the study and the efficacy and safety of pallidal DBS were evaluated with Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) via a blinded review of videotaped sessions. The dystonia movement scores were significantly improved at the three-month evaluation. The overall quality of life was found to be improved at 1 year and maintained at 3 years. The adverse effects of lead fractures, infection and stimulated-related side-effects were reported in 5 patients and were resolved without permanent consequence. In 2006, Kupsch, et al. provided further evidence of benefit in a multicenter, randomized, sham-controlled, double-blind study . Clinical results from 40 patients indicated substantial improvement in almost all movement symptoms (except speech and swallowing), disability level, and quality of life at 6 months post neurostimulation compared with baseline scores. Also, at 3 months, pallidal DBS neurostimulation was more effective than sham stimulation in patients with either primary generalized or segmental dystonia. Furthermore, GPi DBS has been demonstrated to provide long term motor and functional improvement in dystonia patients [7, 27, 28]. As reported in a 2 year follow-up retrospective study of 30 patients with primary dystonia, DBS patients were found to have excellent outcomes in motor and disability scores [29, 30]. Importantly, for DTY-1 positive patients, GPi DBS demonstrated clinical benefit as long as ten years, however, 8 out of 26 patients had an additional GPi DBS because of the worsening dystonic symptoms . In addition, according to a recent literature based series of 44 patients, children and adolescents responded well to GPi-DBS with good tolerance .
A few anecdotal reports suggested that the symptom of dysphonia can also be improved in selected DBS cases . However, problems of speech and swallowing may be more difficult to manage with DBS as assessed by BFMDRS [7, 8, 34]. Worsening of handwriting and stimulation induced parkinsonism have also been reported in DBS patients with cervical dystonia [23, 35–37].
On the other hand, patients’ perceptions of life shift after DBS should also be considered. Undoubtedly, most DBS dystonia patients had an easier, more satisfying life with greater confidence. However, some patients reported that the “new life” after DBS was challenging and stressful, because of concerning about being dependent on the stimulator and dealing with interfering side effects from stimulation. Those patients would need better professional support .
Dystonia-choreoathetosis Cerebral palsy is a common cause of disability in both children and adults, and refractory to pharmaceutical treatment. A recent multicentre prospective pilot study of bilateral GPi-DBS in 13 patients identified that clinical movement score, functional disability, pain, and mental health-related quality of life were significantly improved one year after DBS. The optimum therapeutic target was thought be the posterolateroventral region of the GPi [36, 39–41].
Clinically, the use of DBS is controversial in children with secondary dystonia [19, 42, 43]. However, several case reports indicated that GPi DBS was effective in focal segmental dystonia involved in neck, facial, trunk, upper and lower limbs [44–50]. Interestingly, the combined targets of ventral intermediate nucleus (Vim) plus GPi DBS significantly improved Myoclonus Dystonia, a rare form of movement disorder with epsilon-sarcoglycan gene mutations and prominent action myoclonus plus dystonia . Recently, the subthalamic nucleus (STN) has also been reported to be useful target in dystonia patients [10, 52, 53], Sun et al. proposed that STN DBS could potentially have following advantages over GPi DBS: immediately symptomatic improvement after programming, the lower stimulation parameters with longer battery life; and finally, STN DBS results in better symptomatic control . However, currently, the data is limited and there is a lack of head to head comparisons between STN and GPi stimulation for dystonia. In contrast, secondary dystonia had a less robust response to DBS intervention . The presumed reasons are that secondary dystonia is a complex movement disorders with a combination of hyperkinetic and akinetic-rigid dystonia, the DBS targeted structure often has lesions, and the dystonia is a progressively pathological process [32, 50]. Taken together, although GPi stimulation is currently being regarded as the main DBS target for primary dystonias, focal, and segmental dystonias with substantial clinical benefit, we should continue studying the potential benefit of other targets, particularly for secondary dystonia patients .
Overall, DBS patients tolerated the procedure fairly well , however, clinically, asymptomatic hemorrhage due to the DBS procedure may be difficult to be identified. Recently, our group found that intraoperative MRI is helpful in identifying acute changes involving intracranial hemorrhage and air during DBS surgery, given the fact that these findings are usually clinically silent and often resolve prior to follow-up imaging. We identified that selective use of T2 FLAIR and T2 fast spin echo (FSE) imaging can confirm the presence of air or hemorrhage and preclude the need for CT examinations . On the other hand, hardware related complications including infection and electrode lead displacement, lead or extension fractures, may occur more frequently in dystonia as prominent axial movements cause more mechanical stress. These patients are more likely to complain of stimulation related adverse effects of speech problems, such as dysarthria and dysphonia It should be noted that, despite the fact that most studies indicate that bilateral GPi stimulation does not have significant adverse effect on mood or cognition in dystonia patients, several suicides cases have been reported in GPi DBS dystonia patients. All of them had depression at baseline and it is still unknown whether the suicide was related to the DBS stimulation . As such, close monitoring should be warranted in these patients, given reports of postoperative suicide .
Possible mechanism of action of DBS
Due to the unknown pathophysiology of dystonia , the knowledge about the mechanism about GPi DBS in dystonia is very limited. It appears that the time between the stimulation beginning and onset of symptom relief is longer (days to weeks) as compared to PD (minutes) . It is plausible that GPi DBS increases output from the stimulated nucleus and activates surrounding fiber pathways, subsequently resulting in a complex pattern of excitatory and inhibitory effects that modulate the entire basal ganglia thalamocortical network. The stimulation-induced regularization of neuronal patterns prevents transmission of pathologic bursting and oscillatory activity within the network, resulting in improved processing of sensorimotor information and reduction of disease symptoms .
DBS provides relief of the main symptoms of dystonia. It is plausible that the clinical benefits of DBS are due to the disruption of the pathological activity in the cotical-basal-gangalia-thalamic-cortical motor loop. Better understanding the mechanism of DBS will undoubtedly help more dystonia patients for long term benefit. With the advent of advanced neuroimaging, like SISCOM, STATISCOM, and 7-Tesla MRI, experienced DBS doctors will be able to optimal DBS target selection and identify the most suitable candidates for it . In addition, new exciting developments of DBS technology is quickly evolving, currently, it is plausible for DBS programmer to have more flexibility in stimulation programming and increased battery duration. Increasing evidence will also help us to apply DBS in secondary dystonia patients and explore potential new optimal target for DBS . Finally, the success of DBS treatment in the dystonia depends on our understanding of the anatomy and physiology of this disorder from basic scientists, and involvement of neurologists, neurosurgeons, neuroradiologists and neuropsychiatrists in outcome studies of DBS surgery.
- Fahn S (Ed): Movement disorders 2. London: Buttersworth; 1987.
- Tarsy D, Simon DK: Dystonia. N Engl J Med 2006, 355: 818-829. 10.1056/NEJMra055549View ArticlePubMed
- Taira T, Hori T: Stereotactic ventrooralis thalamotomy for task-specific focal hand dystonia (writer’s cramp). Stereotact Funct Neurosurg 2003, 80: 88-91. 10.1159/000075165View ArticlePubMed
- Thenganatt MA, Jankovic J: Treatment of dystonia. Neurotherapeutics 2014. in press
- Hamani C, Moro E: Surgery for other movement disorders: dystonia, tics. Curr Opin Neurol 2007, 20: 470-476. 10.1097/WCO.0b013e32825ea69dView ArticlePubMed
- Lang AE: Surgical treatment of dystonia. Adv Neurol 1998, 78: 185-198.PubMed
- Kupsch A, Benecke R, Muller J, et al.: Pallidal deep-brain stimulation in primary generalized or segmental dystonia. N Engl J Med 2006, 355: 1978-1990. 10.1056/NEJMoa063618View ArticlePubMed
- Vidailhet M, Vercueil L, Houeto JL, et al.: Bilateral deep-brain stimulation of the globus pallidus in primary generalized dystonia. N Engl J Med 2005, 352: 459-467. 10.1056/NEJMoa042187View ArticlePubMed
- Vidailhet M, Vercueil L, Houeto JL, et al.: Bilateral, pallidal, deep-brain stimulation in primary generalised dystonia: a prospective 3 year follow-up study. Lancet Neurol 2007, 6: 223-229. 10.1016/S1474-4422(07)70035-2View ArticlePubMed
- Bour LJ, Contarino MF, Foncke EM, et al.: Long-term experience with intraoperative microrecording during DBS neurosurgery in STN and GPi. Acta Neurochir 2010, 152: 2069-2077. 10.1007/s00701-010-0835-yPubMed CentralView ArticlePubMed
- Diamond A, Shahed J, Azher S, Dat-Vuong K, Jankovic J: Globus pallidus deep brain stimulation in dystonia. Mov Disord 2006, 21: 692-695. 10.1002/mds.20767View ArticlePubMed
- Hu W, Klassen BT, Stead M: Surgery for movement disorders. J Neurosurg Sci 2011, 55: 305-317.PubMed
- Lang AE, Houeto JL, Krack P, et al.: Deep brain stimulation: preoperative issues. Mov Disord 2006, 21(Suppl 14):S171-S196.View ArticlePubMed
- Borggraefe I, Mehrkens JH, Telegravciska M, Berweck S, Botzel K, Heinen F: Bilateral pallidal stimulation in children and adolescents with primary generalized dystonia–report of six patients and literature-based analysis of predictive outcomes variables. Brain Dev 2010, 32: 223-228. 10.1016/j.braindev.2009.03.010View ArticlePubMed
- Bronte-Stewart H, Taira T, Valldeoriola F, et al.: Inclusion and exclusion criteria for DBS in dystonia. Mov Disord 2011, 26(Suppl 1):S5-S16.View ArticlePubMed
- Tisch S, Zrinzo L, Limousin P, et al.: Effect of electrode contact location on clinical efficacy of pallidal deep brain stimulation in primary generalised dystonia. J Neurol Neurosurg Psychiatry 2007, 78: 1314-1319. 10.1136/jnnp.2006.109694PubMed CentralView ArticlePubMed
- Alterman RL, Tagliati M: Deep brain stimulation for torsion dystonia in children. Childs Nerv Syst 2007, 23: 1033-1040. 10.1007/s00381-007-0382-xView ArticlePubMed
- Loher TJ, Krauss JK, Burgunder JM, Taub E, Siegfried J: Chronic thalamic stimulation for treatment of dystonic paroxysmal nonkinesigenic dyskinesia. Neurology 2001, 56: 268-270. 10.1212/WNL.56.2.268View ArticlePubMed
- Roubertie A, Mariani LL, Fernandez-Alvarez E, Doummar D, Roze E: Treatment for dystonia in childhood. Eur J Neurol 2012, 19: 1292-1299. 10.1111/j.1468-1331.2011.03649.xView ArticlePubMed
- Starr PA, Bejjani P, Lozano AM, Metman LV, Hariz AM: Stereotactic techniques and perioperative management of DBS in dystonia. Mov Disord 2011, 26(Suppl 1):S23-S30.View ArticlePubMed
- Moro E, Gross RE, Krauss JK: What’s new in surgical treatment for dystonia? Mov Disord 2013, 28: 1013-1020. 10.1002/mds.25550View ArticlePubMed
- Guettard E, Ricard D, Roze E, et al.: Risk factors for spinal cord lesions in dystonic cerebral palsy and generalised dystonia. J Neurol Neurosurg Psychiatry 2012, 83: 159-163. 10.1136/jnnp-2011-300668View ArticlePubMed
- Krauss JK, Loher TJ, Pohle T, et al.: Pallidal deep brain stimulation in patients with cervical dystonia and severe cervical dyskinesias with cervical myelopathy. J Neurol Neurosurg Psychiatry 2002, 72: 249-256. 10.1136/jnnp.72.2.249PubMed CentralView ArticlePubMed
- Anderson WS, Lenz FA: Surgery insight: deep brain stimulation for movement disorders. Nat Clin Pract Neurol 2006, 2: 310-320.View ArticlePubMed
- Pinsker MO, Volkmann J, Falk D, et al.: Deep brain stimulation of the internal globus pallidus in dystonia: target localisation under general anaesthesia. Acta Neurochir 2009, 151: 751-758. 10.1007/s00701-009-0375-5View ArticlePubMed
- Vayssiere N, van der Gaag N, Cif L, et al.: Deep brain stimulation for dystonia confirming a somatotopic organization in the globus pallidus internus. J Neurosurg 2004, 101: 181-188. 10.3171/jns.2004.101.2.0181View ArticlePubMed
- Vitek JL, Delong MR, Starr PA, Hariz MI, Metman LV: Intraoperative neurophysiology in DBS for dystonia. Mov Disord 2011, 26(Suppl 1):S31-S36.View ArticlePubMed
- Starr PA, Turner RS, Rau G, et al.: Microelectrode-guided implantation of deep brain stimulators into the globus pallidus internus for dystonia: techniques, electrode locations, and outcomes. J Neurosurg 2006, 104: 488-501. 10.3171/jns.2006.104.4.488View ArticlePubMed
- Isaias IU, Alterman RL, Tagliati M: Outcome predictors of pallidal stimulation in patients with primary dystonia: the role of disease duration. Brain 2008, 131: 1895-1902. 10.1093/brain/awn120View ArticlePubMed
- Isaias IU, Alterman RL, Tagliati M: Deep brain stimulation for primary generalized dystonia: long-term outcomes. Arch Neurol 2009, 66: 465-470.View ArticlePubMed
- Cif L, Vasques X, Gonzalez V, et al.: Long-term follow-up of DYT1 dystonia patients treated by deep brain stimulation: an open-label study. Mov Disord 2010, 25: 289-299. 10.1002/mds.22802View ArticlePubMed
- Welter ML, Grabli D, Vidailhet M: Deep brain stimulation for hyperkinetics disorders: dystonia, tardive dyskinesia, and tics. Curr Opin Neurol 2010, 23: 420-425.PubMed
- Muta D, Goto S, Nishikawa S, et al.: Bilateral pallidal stimulation for idiopathic segmental axial dystonia advanced from Meige syndrome refractory to bilateral thalamotomy. Mov Disord 2001, 16: 774-777. 10.1002/mds.1122View ArticlePubMed
- Nebel A, Reese R, Deuschl G, Mehdorn HM, Volkmann J: Acquired stuttering after pallidal deep brain stimulation for dystonia. J Neural Transm 2009, 116: 167-169. 10.1007/s00702-008-0173-xView ArticlePubMed
- Berman BD, Starr PA, Marks WJ Jr, Ostrem JL: Induction of bradykinesia with pallidal deep brain stimulation in patients with cranial-cervical dystonia. Stereotact Funct Neurosurg 2009, 87: 37-44. 10.1159/000195718PubMed CentralView ArticlePubMed
- Tagliati M, Krack P, Volkmann J, et al.: Long-term management of DBS in dystonia: response to stimulation, adverse events, battery changes, and special considerations. Mov Disord 2011, 26(Suppl 1):S54-62.View ArticlePubMed
- Zauber SE, Watson N, Comella CL, Bakay RA, Metman LV: Stimulation-induced parkinsonism after posteroventral deep brain stimulation of the globus pallidus internus for craniocervical dystonia. J Neurosurg 2009, 110: 229-233. 10.3171/2008.6.17621View ArticlePubMed
- Hariz GM, Limousin P, Tisch S, Jahanshahi M, Fjellman-Wiklund A: Patients’ perceptions of life shift after deep brain stimulation for primary dystonia-a qualitative study. Mov Disord 2011, 26: 2101-2106. 10.1002/mds.23796View ArticlePubMed
- Berweck S: BP-DBS for dystonia-choreoathetosis cerebral palsy. Lancet Neurol 2009, 8: 692-693. 10.1016/S1474-4422(09)70172-3View ArticlePubMed
- Ruge D, Tisch S, Hariz MI, et al.: Deep brain stimulation effects in dystonia: time course of electrophysiological changes in early treatment. Mov Disord 2011, 26: 1913-1921. 10.1002/mds.23731PubMed CentralView ArticlePubMed
- Vidailhet M, Yelnik J, Lagrange C, et al.: Bilateral pallidal deep brain stimulation for the treatment of patients with dystonia-choreoathetosis cerebral palsy: a prospective pilot study. Lancet Neurol 2009, 8: 709-717. 10.1016/S1474-4422(09)70151-6View ArticlePubMed
- Eltahawy HA, Feinstein A, Khan F, Saint-Cyr J, Lang AE, Lozano AM: Bilateral globus pallidus internus deep brain stimulation in tardive dyskinesia: a case report. Mov Disord 2004, 19: 969-972. 10.1002/mds.20092View ArticlePubMed
- Krause M, Fogel W, Tronnier V, et al.: Long-term benefit to pallidal deep brain stimulation in a case of dystonia secondary to pantothenate kinase-associated neurodegeneration. Mov Disord 2006, 21: 2255-2257. 10.1002/mds.21166View ArticlePubMed
- Castelnau P, Cif L, Valente EM, et al.: Pallidal stimulation improves pantothenate kinase-associated neurodegeneration. Ann Neurol 2005, 57: 738-741. 10.1002/ana.20457View ArticlePubMed
- Evidente VG, Lyons MK, Wheeler M, et al.: First case of X-linked dystonia-parkinsonism (“Lubag”) to demonstrate a response to bilateral pallidal stimulation. Mov Disord 2007, 22: 1790-1793. 10.1002/mds.21420View ArticlePubMed
- Foote KD, Sanchez JC, Okun MS: Staged deep brain stimulation for refractory craniofacial dystonia with blepharospasm: case report and physiology. Neurosurgery 2005, 56: E415. discussion E415 10.1227/01.NEU.0000147978.67424.42View ArticlePubMed
- Franzini A, Marras C, Ferroli P, et al.: Long-term high-frequency bilateral pallidal stimulation for neuroleptic-induced tardive dystonia. Report of two cases. J Neurosurg 2005, 102: 721-725. 10.3171/jns.2005.102.4.0721View ArticlePubMed
- Novak KE, Nenonene EK, Bernstein LP, Vergenz S, Cozzens JW, Rezak M: Successful bilateral subthalamic nucleus stimulation for segmental dystonia after unilateral pallidotomy. Stereotact Funct Neurosurg 2008, 86: 80-86. 10.1159/000112428View ArticlePubMed
- Trottenberg T, Paul G, Meissner W, Maier-Hauff K, Taschner C, Kupsch A: Pallidal and thalamic neurostimulation in severe tardive dystonia. J Neurol Neurosurg Psychiatry 2001, 70: 557-559. 10.1136/jnnp.70.4.557PubMed CentralView ArticlePubMed
- Vidailhet M, Jutras MF, Grabli D, Roze E: Deep brain stimulation for dystonia. J Neurol Neurosurg Psychiatry 2013, 84: 1029-1042. 10.1136/jnnp-2011-301714View ArticlePubMed
- Oropilla JQ, Diesta CC, Itthimathin P, Suchowersky O, Kiss ZH: Both thalamic and pallidal deep brain stimulation for myoclonic dystonia. J Neurosurg 2010, 112: 1267-1270. 10.3171/2009.10.JNS091062View ArticlePubMed
- Chou KL, Hurtig HI, Jaggi JL, Baltuch GH: Bilateral subthalamic nucleus deep brain stimulation in a patient with cervical dystonia and essential tremor. Mov Disord 2005, 20: 377-380. 10.1002/mds.20341View ArticlePubMed
- Sun B, Chen S, Zhan S, Le W, Krahl SE: Subthalamic nucleus stimulation for primary dystonia and tardive dystonia. Acta Neurochir Suppl 2007, 97: 207-214.View ArticlePubMed
- Ghika J, Villemure JG, Miklossy J, et al.: Postanoxic generalized dystonia improved by bilateral Voa thalamic deep brain stimulation. Neurology 2002, 58: 311-313. 10.1212/WNL.58.2.311View ArticlePubMed
- Huston OO, Watson RE, Bernstein MA, et al.: Intraoperative magnetic resonance imaging findings during deep brain stimulation surgery. J Neurosurg 2011, 115: 852-857. 10.3171/2011.5.JNS101457PubMed CentralView ArticlePubMed
- Kazemi NJ, Worrell GA, Stead SM, et al.: Ictal SPECT statistical parametric mapping in temporal lobe epilepsy surgery. Neurology 2010, 74: 70-76. 10.1212/WNL.0b013e3181c7da20PubMed CentralView ArticlePubMed
- Mullin JP, van Gompel JJ, Lee KH, Meyer FB, Stead M: Surgically treated movement disorders associated with heterotopia: report of 2 cases. J Neurosurg Pediatr 2010, 6: 267-272. 10.3171/2010.5.PEDS10220View ArticlePubMed
- Kleiner-Fisman G, Liang GS, Moberg PJ, et al.: Subthalamic nucleus deep brain stimulation for severe idiopathic dystonia: impact on severity, neuropsychological status, and quality of life. J Neurosurg 2007, 107: 29-36. 10.3171/JNS-07/07/0029View ArticlePubMed
- Jahanshahi M, Czernecki V, Zurowski AM: Neuropsychological, neuropsychiatric, and quality of life issues in DBS for dystonia. Mov Disord 2011, 26(Suppl 1):S63-78.View ArticlePubMed
- Kupsch A, Tagliati M, Vidailhet M, et al.: Early postoperative management of DBS in dystonia: programming, response to stimulation, adverse events, medication changes, evaluations, and troubleshooting. Mov Disord 2011, 26(Suppl 1):S37-53.View ArticlePubMed
- Vitek JL: Pathophysiology of dystonia: a neuronal model. Mov Disord 2002, 17(Suppl 3):S49-S62.View ArticlePubMed
- Miocinovic S, Somayajula S, Chitnis S, Vitek JL: History, applications, and mechanisms of deep brain stimulation. JAMA Neurol 2013, 70: 163-171. 10.1001/2013.jamaneurol.45View ArticlePubMed
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.