VOLKAN TOPÇUOĞLU, Ayşe Rodopman ARMAN, Çağrı YAZGAN, Alper ARMAN, Aylan Gımzal GÜNENTÜR, Duygu Şahin BİÇER

Tourettism in a 73 year-old man after coronary artery by-pass surgery

Koroner arter bypass greft cerrahisinden (KABGC) sekiz ay sonra motor ve vokal tikleri gelişen bir olguyu sunuyoruz. Burnunu karıştırma ve sümkürme gibi birkaç motor tik ve bağırma şeklinde bir vokal tik görülen hasta, öncül duyusal uyaranlar da tanımladı. Bu tiklerin ilk kez KABGC'den sonra ortaya çıkmış olması olgumuzun önemli özelliğidir. Manyetik rezonans görüntüleme bilateral bazal gangliyonlarda iskemik alanlar ve tek foton emisyon bilgisayarlı tomografi incelemesi sağ kaudat nukleusta ve bilateral frontotemporoparietal kortekste hipoperfüzyon göstermiş olup, bu alanlar tik patogenezi ile ilişkili beyin bölgeleridir. KAGBC öncesi kraniyal görüntülemelerin olmaması nedeniyle kesin bir çıkarımda bulunmak güç olmakla birlikte, tiklerin KABGC sırasındaki perfüzyon anomalisinin sonucunda ortaya çıktığı öne sürülebilir.

Koroner arter bypass cerrahisinden sonra 73 yaşındaki bir erkek hastada tourettizm

We present a patient who developed motor and vocal tics eight moths after a coronary artery bypass graft surgery (CABGS). The patient demonstrated a few motor tics like picking, blowing his nose and a vocal tic in the form of shouting. He also described premonitory sensory urges. Appearance of these tics for the first time ever after the CABGS in a 73 year-old male patient is the significance of our case. The patient had ischemic regions in the bilateral basal ganglia in the magnetic resonance imaging (MRI) and his single photon emission tomography (SPECT) examination revealed hypoperfusion in right caudate nucleus and bilateral frontotemporoparietal cortex which are the brain regions associated with tic pathogenesis. Although reaching a definitive conclusion is difficult since we do not have preoperative cranial imaging, we suggest that tics might have appeared as a result of perfusion abnormality he had incurred during the CABGS.

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1) Leckman JF, Bradley SP, Pauls DL, Cohen DJ. Tic disorders. Psychiatr Clin North Am 1997; 20: 839-861.
2) Kumar R, Lang AE. Secondary tic disorders. Neurol Clin 1997; 15: 309-331.
3) Singer HS. Neurobiology of Tourette syndrome. Neurol Clin 1997; 15: 357-379.
4) Scarborough JE, White W, Derilus FE, Mathew JP, Newman MF, Landolfo KP. Neurologic outcomes after coronary artery bypass grafting with and without cardiopulmonary bypass. Semin Thorac Cardiovasc Surg 2003; 15: 52-62.
5) Singer HS, Dela Cruz PS, Abrams MT, Bean SC, Reiss AL. A Tourette-like syndrome following cardiopulmonary bypass and hypothermia: MRI volumetric measurements. Mov Disord 1997; 12: 588-592.
6) Cohen AJ, Leckman JF. Sensory phenomena associated with Gilles de la Tourette's syndrome. J Clin Psychiatry 1992; 53: 319-23.
7) Taylor KM. Brain damage during cardiopulmonary bypass. Ann Thorac Surg 1998; 65: 20-26.
8) Kwak CH, Jankovic J. Tourettism and dystonia after subcortical stroke. Mov Disord 2002; 17: 821-825.
9) Bleeker HE.Gilles de la Tourette's syndrome with direct evidence of organicity. Psychiatr Clin 1978; 11: 147-154.
10) Masso JF, Obeso JA. Coprolalia associated with hemiballismus: response to tetrabenazine. Clin Neuropharmacol 1985; 8: 189-190.
11) Ward CD. Transient feelings of compulsion caused by hemispheric lesions: three cases. J Neurol Neurosurg Psychiatry 1988; 51: 266-268.
12) Sheppard DM, Bradshaw JL, Purcele R, Pantelis C. Tourette's and comorbid syndromes: obsessive compulsive and attention deficit hyperactivity disorder. A common etiology?. Clin Psychol Rev 1999; 19: 531-552.
13) Stoetter B, Blesa R, Chase TN. Regional abnormalities in cerebral glucose metabolism in Tourette's syndrome [Abstract]. Neurology 1992; 42: 396.
14) Winbeck K, Bruckmaier K, Etgen T, von Einsiedel HG, Rottinger M, Sander D. Transient ischemic attack and stroke can be differentiated by analyzing early diffusion-weighted imaging signal intensity changes. Stroke 2004; 35: 1095-1099.
15) Gass A, Ay H, Szabo K, Koroshetz WJ. Diffusion-weighted MRI for the "small stuff": the details of acute cerebral ischaemia. Lancet Neurol 2004; 3: 39-45.