Deep brain stimulation in multiple sclerosis-associated tremor. A large, retrospective, longitudinal open label study, with long-term follow-up.

BACKGROUND: Tremor affects up to 25%-58% in multiple sclerosis (MS) population. Deep-brain stimulation (DBS) of the ventral-intermediate nucleus (VIM) of the thalamus is considered as a potential option following medical treatments. Long term DBS efficacy is not well known in these patients with a poor outcome mostly related to disease progression. OBJECTIVE: To report a large and retrospective study of thalamic DBS in MS tremor. METHODS: We conducted a large and retrospective study of patients with MS disabling and pharmacologically resistant upper limb tremor, who underwent thalamic DBS procedure from January 1992 to January 2015 in University Hospital of Henri Mondor, France. Demographic data, clinical assessment and activity daily living were collected. A three-month and twelve-month post-operative assessment with clinical and functional rating scales have been achieved, as well as long term follow-up for most patients. RESULTS: One hundred and four patients underwent DBS procedure. There were 71 female (68%) and 33 male (32%). At three-month post-operative assessment, 64% patients were improved clinically and functionally. Among these, 93% of patients kept a good efficacy at one-year post-operative assessment. Mean duration of follow-up for these patients was 6 years. CONCLUSION: We described a long-term sustained clinical and functional improvement in this large and retrospective report of thalamic DBS. This neuromodulation approach could be a therapeutic option for all severe upper extremity refractory tremor in MS patients.

Vagus nerve stimulation for treatment-resistant depression: is this therapy distinct from other antidepressant treatments?

BACKGROUND: The treatment-resistant depression (TRD) is a very disabling disease. OBJECTIVE: The aim of this article is to provide an overview of the therapeutic activity of vagus nerve stimulation (VNS) therapy system in TRD. We summarised the progress made during the last decade in this area. METHODS: We conducted a non-systematic review on the efficacy and safety of the VNS therapy for this disease. We analysed the results from acute and long-term studies that utilised this technique. Major electronic databases were searched. RESULTS: The patients with TRD may show acute and long-term benefit when treated with this technique. There are promising results for VNS therapy for these patients. The level of evidence as an acute treatment option is only 3, but as chronic treatment is 2. This therapy should be offered as an added long-term treatment option for patients with chronic and recurrent difficult to treat depression. CONCLUSIONS: The antidepressant effects of this procedure remain controversial. The clinical trials have produced mixed results, but VNS therapy for TRD has two distinct features that differentiate it from other antidepressant treatments: a sustained therapeutic response obtained in highly resistant depressive disorders, a favourable safety profile and guaranteed compliance.

New neuromodulation techniques for treatment resistant depression.

In the treatment of depression, when pharmacotherapy, psychotherapy and the oldest brain stimulation techniques are deadlocked, the emergence of new therapies is a necessary development. The field of neuromodulation is very broad and controversial. This article provides an overview of current progress in the technological advances in neuromodulation and neurostimulation treatments for treatment-resistant depression: magnetic seizure therapy; focal electrically administered seizure therapy; low field magnetic stimulation; transcranial pulsed electromagnetic fields; transcranial direct current stimulation; epidural cortical stimulation; trigeminal nerve stimulation; transcutaneous vagus nerve stimulation; transcranial focussed ultrasound; near infra-red transcranial radiation; closed loop stimulation. The role of new interventions is expanding, probably with more efficacy. Nowadays, still under experimentation, neuromodulation will probably revolutionise the field of neuroscience. At present, major efforts are still necessary before that these therapies are likely to become widespread.Key pointsThere is a critical need for new therapies for treatment resistant depression.Newer therapies are expanding. In the future, these therapies, as an evidence-based adjunctive treatments, could offer a good therapeutic choice for the patients with a TRD.The current trend in the new neuromodulation therapies is to apply a personalised treatment.These news therapies can be complementary.That treatment approaches can provide clinically significant benefits.

Epilepsy in multiple sclerosis as a network disease.

This is a review paper, essentially a commentary with summary of literature that actualizes the problem of epilepsy in patients with multiple sclerosis. There is a bidirectional relation between multiple sclerosis and epilepsy. A possible associate pathophysiological pathway is considered. In multiple sclerosis, a combination of gray matter involvement and inflammation could influence epileptogenesis. Patients with multiple sclerosis have individual profiles and an inter-individual variability of epileptogenicity. No treatment guidelines have been specified for these patients. We postulate that an epileptic manifestation means a relapse or an aggravation of the inflammatory process. In this condition, over time, this symptom could integrate into the Expanded Disability Status Scale. Epileptogenesis is an active process and an interesting question is if disease-modifying therapy in multiple sclerosis can prevent, or mitigate, epilepsy. In light of the latest knowledge of the inflammatory process in epilepsy, the possibility of preventing epileptogenesis with actual treatment of MS is emphasized. We would argue that it is a strong argument for starting treatment quicker for both diseases. Over the last few years, the concepts of epilepsy have completely changed. The model of epilepsy in multiple sclerosis can currently be regarded as a network disease and this new concept can have a highly significant clinical impact.