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We retrospectively evaluated a cohort of three patients with\n                    <jats:italic>GNAL<\/jats:italic>\n                    variants treated with GPi-DBS, documenting individual long-term outcomes spanning up to 25 years. Dystonia severity was assessed using the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) and the Burke\u2009\u2212\u2009Fahn\u2009\u2212\u2009Marsden Dystonia Rating Scale (BFMDRS). We also documented bradykinetic symptoms and levodopa response. A literature review was added focusing on DBS outcomes and the effects of levodopa in DYT-GNAL and 18pdel-associated dystonia. In our patients, TWSTRS severity subscale I was reduced by 63% in early (\u2264\u200912months; 20.7 to 7.7 points) and 81% in late follow-up (&gt;\u200912months; 20.7 to 4 points) after GPi-DBS \u03c7. BFMDRS decreased by 67% and 44%; each with a Kendall\u2019s coefficient of 0.78, indicating a high degree of concordance in improvement trajectories. Two patients exhibited bradykinesia, which was levodopa-responsive in one. GPi-DBS responses have been reported for another ten DYT-GNAL and two 18pdel-patients. Bradykinesia prompted levodopa challenges in 15 patients, resulting in improvement in five. Long-term follow-up data from three DYT-GNAL patients treated with DBS showed sustained improvement in dystonia, particularly in cervical symptoms. Bradykinesia may be an inherent clinical feature of GNAL-related dystonia, warranting further investigation.\n                  <\/jats:p>","DOI":"10.1007\/s00702-026-03109-z","type":"journal-article","created":{"date-parts":[[2026,2,3]],"date-time":"2026-02-03T11:59:52Z","timestamp":1770119992000},"page":"2907-2916","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Long-term efficiency of pallidal DBS and the role of Levodopa treatment in DYT-GNAL and 18p deletion syndrome associated dystonia: an observational study and review of literature"],"prefix":"10.1007","volume":"133","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9524-7836","authenticated-orcid":false,"given":"Johanna","family":"Reimer","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Friederike","family":"Schumann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katja","family":"Lohmann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas G.","family":"Riemer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joachim K.","family":"Krauss","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gerd-Helge","family":"Schneider","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea A.","family":"K\u00fchn","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9063-0556","authenticated-orcid":false,"given":"Patricia","family":"Krause","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,2,3]]},"reference":[{"key":"3109_CR1","doi-asserted-by":"publisher","first-page":"120","DOI":"10.14802\/jmd.19006","volume":"12","author":"JH Ahn","year":"2019","unstructured":"Ahn JH, Kim AR, Kim NKD, Park WY, Kim JS, Kim M, Park J, Lee JI, Cho JW, Cho KR, Youn J (2019) The effect of globus pallidus Interna deep brain stimulation on a dystonia patient with the GNAL mutation compared to patients with DYT1 and DYT6. 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K.L. reports financial support was provided by German Research Foundation. P.K. reports a relationship with Medtronic, AbbVie, and Stadapharm that includes: consulting or advisory. P.K. reports a relationship with Abbott, and Stadapharm that includes: board membership. A.A.K. reports a relationship with Medtronic, Boston Scientific, and Stada Pharm that includes: consulting or advisory. J.K.K. reports a relationship with Boston Scientific, Medtronic, and Inomed that includes: consulting or advisory. P.K. is a participant of the Clinical Fellow Program funded by the Stiftung Charit\u00e9. J.R. is a participant in the BIH-Charit\u00e9 Junior Clinician Scientist Program funded by the Charit\u00e9 \u2013 Universit\u00e4tsmedizin Berlin and Berlin Institute of Health. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.","order":1,"name":"Ethics","label":"Competing Interests","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This study has been approved by the local ethics committee of Charit\u00e9 \u2013 Universit\u00e4tsmedizin Berlin (EA1\/120\/24) and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.","order":2,"name":"Ethics","label":"Ethical statement","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Written informed consent for publication (including print and online) has been obtained from all individuals depicted in the video material. The signed consent forms are available and can be provided to the journal upon request.","order":3,"name":"Ethics","label":"Patient consent forms","group":{"name":"EthicsHeading","label":"Declarations"}}]}}