Julie Bowen

 (AAN) on the management of Tourette syndrome and other chronic tic disorders reflect a growing interest in behavioral treatments and neuromodulation. The guidelines were published in the May 7, 2019, issue of 

 and presented at the 2019 American Academy of Neurology 

“Tourette syndrome and other chronic tic disorders can be of great concern to the person diagnosed and their family, so it is important that doctors let those affected know that tics may improve with time,” said guideline lead author Tamara Pringsheim, MD, MSc, of the 

 in Alberta, Canada. “Treatments can help decrease tic frequency and severity, but they rarely eliminate all tics.”

An acceptable management approach consists of watchful waiting and patient education for those with tics that do not cause physical impairment, pain, emotional distress, or social embarrassment, according to the authors of the guidelines. Most children with tics experience an improvement in symptoms in late adolescence.

For patients with symptoms that interfere with daily activities, the guidelines recommend Comprehensive Behavioral Intervention for Tics (CBIT) as first-line therapy. CBIT, which includes relaxation training, habit-reversal training, and behavioral therapy, has been shown to be effective in both children and adults and has no significant adverse effects.

Because comorbid neurodevelopmental and psychiatric conditions-particularly obsessive-compulsive disorder and attention-deficit/hyperactivity disorder (ADHD)-are common in patients with tics, the guidelines recommend evaluation for these disorders. For some patients, alpha-2 adrenergic agonists (clonidine and guanfacine) can reduce symptoms of both tic disorders and ADHD.

Antipsychotics can reduce tic severity but are associated with extrapyramidal, hormonal, and metabolic adverse effects. If the benefits of antipsychotic therapy outweigh the risks, physicians should start with the lowest effective dose and monitor patients for adverse effects. When therapy needs to be discontinued, gradual tapering of the dosage is recommended.

Botulinum toxin injections can also reduce tic severity in adolescents and adults. The most common adverse effects are weakness and hypophonia, and treatment needs to be repeated after approximately 12 to 16 weeks. Topiramate may be an option for patients with mild tics who have not have good results from or who have not tolerated other treatments; however, it is associated with adverse effects, such as cognitive and language problems, somnolence, and weight loss.

Adults with severe Tourette syndrome that is resistant to medical and behavioral therapy may benefit from deep brain stimulation (DBS). The guidelines caution that there is limited evidence from randomized clinical trials to support DBS, and few operations are performed each year.

Some adults with Tourette syndrome self-medicate with cannabis products. Limited data suggest that delta-9-tetrahydrocannabinol (dronabinol) may reduce the severity of tics in adults. Because cannabis use is illegal or restricted in many states, the guidelines advise that physicians follow local laws on medical marijuana. Cannabis-based medications should be avoided in children, adolescents, women who are pregnant or breastfeeding, and persons with psychosis.

1. Pringsheim T, Okun MS, Holler-Managan Y, et al. 

Practice guideline: the treatment of tics in people with Tourette syndrome and chronic tic disorders. Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology

. Published online May 6, 2019. Doi: 10.1212/WNL.0000000000007466

New AAN guideline for treating Tourette syndrome and other chronic tic disorders

 [press release]. Minneapolis, MN: American Academy of Neurology. May 6, 2019. Accessed May 7, 2019.

Articles

New guidelines reflect a growing interest in behavioral treatments and neuromodulation.

AAN Releases Guidelines for Tourette Syndrome and Other Chronic Tic Disorders

American Academy of Neurology Annual Meeting

 in Philadelphia next week. She will be at the 

 booth (number 2151) on Monday, May 6, from noon to 1:00 PM.

If you miss seeing Dr Moawad in person, a video of her interview, “Emerging Topics in Neurology,” will be playing on a monitor at the booth.

Solving Six: Thinking Through Case Study Clues

, a collection of case reports to challenge your diagnostic acumen. The collection will be available on a free jump drive at the 

 booth. Quantities are limited, so be sure to stop by early to pick up yours.

. He will be at the CompHealth Locum Tenens booth from 11:30 AM to 4 PM on Tuesday, May 7, and Wednesday, May 8, to speak about his new book 

The Locum Life: A Physician’s Guide to Locum Tenens

 and has contributed numerous Challenging Cases: most recently, "

Traumatic Brain Injury With a Normal CT Scan

Severe Headache, Photophobia, and Neck Pain in a Young Woman

 Board Members and authors will be appearing at the 2019 AAN Annual Meeting. Here is a rundown on where you can find them and the programs they will be participating in. Don’t miss this opportunity to hear their presentations.

Dr Mulukutla talks about complementary and alternative medicine options you can discuss with your patients.

Contemporary Clinical Issues Plenary Session

Advances in the Acute Treatment of Migraine

Mind Over Matter: Meditation for the Practicing Neurologist


	Continuum® Test Your Knowledge: A Multiple-Choice Question Review

Skills Workshop: Practical Training in Injection Techniques in the Treatment of Headache Disorders

Botulinum Toxin #1 and Injection Workshop

What Do I Do Now?: Emergency and Inpatient Management of Migraine and Other Headache Disorders

Our Editor in Chief, Heidi Moawad, MD, will be at the Neurology Times booth (No. 2151) on Monday, May 6, from noon to 1:00 PM.

Meet Our Editor in Chief at the 2019 AAN Annual Meeting

A possible stem cell treatment for patients with traumatic brain injury (TBI) demonstrated positive results in a recent phase 2 trial. The results were announced by the manufacturer of the investigational treatment, the SanBio Group, in a 

American Association of Neurological Surgeons Annual Scientific Meeting

 in San Diego, California, April 13 to 17, 2019.

The trial included 61 patients with stable chronic motor deficits caused by TBI: 46 were treated with the investigational stem cell product, SB623, and 15 underwent sham surgery as a control group. The SB623 cells were implanted directly around the site of brain injury.

Improvement was measured by the change from baseline in the Fugl-Meyer Motor Scale (FMMS) score. The scale measures changes in motor impairment, and a 10 or higher point improvement is considered a clinically meaningful threshold in acquired brain injury. Eighteen patients treated with SB623 (39.1%) reached this threshold compared with one control patient (6.7%). This difference was statistically significant (

No new safety signals were identified. Post-operative headaches were the most common adverse events (42.6%). No significant differences were found in the rate of adverse events between patients treated with SB623 and those who received the placebo treatment (

“The results of this study are truly groundbreaking, demonstrating the possibility of regenerating the brain following injury-a finding that could have significant implications for research in traumatic brain injury and other brain diseases,” said David O. Okonkwo, MD, PhD, Professor of Neurological Surgery and Director of the 

 at the University of Pittsburgh, in a press statement.

For more information on stem cell therapy for other neurological disorders:

Stem Cell Transplantation for Parkinson Disease

AANS 2019: SB623 demonstrated statistically significant improvement in motor function among patients with chronic motor deficit from traumatic brain injury (TBI)

 [press release]. Mountain View, CA: The SanBio Group; April 16, 2019.

Phase 2 trial results suggest the possibility of a treatment that may regenerate brain cells following TBI.

Stem Cell Therapy for Traumatic Brain Injury?

Positron emission tomography (PET) scans have revealed elevated levels of tau in the brains of older adults with obstructive sleep apnea, say researchers who will present 

American Academy of Neurology (AAN) Annual Meeting

Diego Z. Carvalho, MD, and colleagues at the 

 looked at 288 persons aged 65 years and older who did not have cognitive impairment. Bed partners were asked whether they had observed episodes of apnea during sleep. Forty-three participants (15% of the study group) had witnessed apneas while they were sleeping.

The participants underwent both tau-PET and amyloid-PET scans. The entorhinal cortex was selected as the region of interest because it is highly susceptible to tau accumulation, and the cerebellum crus was used as a reference region.

Those with witnessed apneas had on average 4.5% higher levels of tau in the entorhinal cortex than those who did not have apneas (95% CI, 0.011 to 0.087; 

 = .012), after controlling for other factors that could affect tau levels, such as age, sex, education, cardiovascular risk factors, and other sleep disorders.

“Our research results raise the possibility that sleep apnea affects tau accumulation,” said Dr Carvalho in a press statement. “But it’s also possible that higher levels of tau in other regions may predispose a person to sleep apnea, so longer studies are now needed to solve this chicken and egg problem.”

Limitations of the study include its relatively small sample size and preliminary nature, as well as the absence of sleep studies and a lack of information about whether participants were being treated for sleep apnea.

The study was supported by the National Institutes of Health.

1. Carvalho D, St. Louis E, Boeve B, et al. 

Witnessed apneas during sleep are associated with elevated tau-PET signal in the entorhinal cortex in cognitively unimpaired elderly

. Presented at: American Academy of Neurology (AAN) Annual Meeting; May 4-10, 2019; Philadelphia, PA.

Obstructive sleep apnea may affect the accumulation of tau in the brain.

Author | Julie Bowen

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