Objective: To present a case of severe tardive syndrome (TS) successfully treated with MRI-guided laser interstitial thermal therapy (LITT) unilateral pallidotomy and discuss its implications.

Background: Tardive syndrome manifests as a spectrum of motor and non-motor symptoms caused by chronic treatment with dopamine receptor blocking agents (DRBA). The most common features include orofacial dyskinesia, generalized chorea and dystonia. These symptoms are often disabling and refractory to medical treatment. Surgical approaches most commonly involve DBS with few case reports of pallidotomy. There are concerns with implanting devices in some TS patients because of their underlying behavioral syndrome. We present a case with substantial response to unilateral pallidotomy in the treatment of tardive syndrome. Additionally, this case was performed using a minimally invasive neurosurgical technique, MRI-guided LITT.

Method: Medical record and video review

Results: A 42-year-old man with ADHD, OCD and intellectual disability, treated with DRBA, including haloperidol, risperidone and olanzapine, presented with severe tardive syndrome. He first developed symptoms of orofacial movements in adolescence followed by more severe generalized dystonic and dyskinetic movements in his late 20s. These resulted in significant difficulty with ADLs including feeding, dressing, walking, and sleeping. Treatment with clonazepam and deutetrabenazine was unsuccessful. Due to behavioral issues, we chose to treat him with unilateral pallidotomy. His pre-operative Burke-Fahn-Marsden Dystonia Rating Scale motor score (BFMDRS-MS) was 47 and disability score (BFMDRS-DS) was 10. He underwent a right pallidotomy using with MR guided LITT. No post-operative adverse events occurred. He appreciated maximal and sustained benefit two weeks after the procedure, alongside a tapered dose of deutetrabenazine. His post-operative BFMDRS-MS was 9.5 and BFMDRS-MS DS was 8.

Conclusion: This case provides evidence for the safety and utility of MRI-guided LITT pallidotomy in treatment of refractory tardive syndrome. This procedure should be considered for those patients with a contradiction for implantation of DBS hardware.

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5. Hashimoto, Takao et al. “Pallidotomy for severe tardive jaw-opening dystonia.” Stereotactic and functional neurosurgery vol. 88,2 (2010): 105-8. doi:10.1159/000280822
6. Lenders, M W P M et al. “Long term results of unilateral posteroventral pallidotomy for antipsychotic drug induced tardive dyskinesia.” Journal of neurology, neurosurgery, and psychiatry vol. 76,7 (2005): 1039. doi:10.1136/jnnp.2004.044438
7. Harris, Meghan et al. “MRI-guided laser interstitial thermal thalamotomy for medically intractable tremor disorders.” Movement disorders : official journal of the Movement Disorder Society vol. 34,1 (2019): 124-129. doi:10.1002/mds.27545

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MDS Abstracts - https://www.mdsabstracts.org/abstract/treatment-of-severe-tardive-syndrome-with-pallidotomy-a-case-report/