Case Presentation: DBS for Depression Robert Mc. Govern, MS-IV Neurosurgery Grand Rounds, Massachusetts General Hospital July 16 th, 2009
Patient H&P • 43 y/o M with hx of severe, medically intractable depression – On multiple medications – 15 ECT trials – Placement of VNS without success – Placement of epidural prefrontal cortical stimulator without success • Presents for placement of deep brain stimulating (DBS) electrodes in Ventral Capsule/Ventral Striatum (VC/VS)
Depression • WHO estimates 121 million people worldwide – Leading cause of disability worldwide – 4 th leading contributor to global burden of disease • Affects almost 1 in 5 persons in US • ~ 20% of patients are treatment-resistant • Alternative therapies are needed – Electroconvulsive therapy (ECT) – Vagal Nerve Stimulation (VNS) – Transcranial Magnetic Stimulation (TMS) – Deep Brain Stimulation (DBS)
Neuroanatomy of Depression
Rationale for Targeting the Ventral Capsule/Ventral Striatum 1. 2. 3. 4. VS is a central node in the limbic-cortical-subcortical network thought to be involved in emotional processing VS is central in processing reward and pleasure information VS is ideally suited to modulate reward-motivated behavior VC contains white matter tracts connecting VS to areas mentioned above
Targeting the VC/VS Caudate IC IC Putamen GP Putamen
Operative Procedure • Stereotactic frame placed • Electrodes inserted under local anesthesia • Intra-operative testing – Subjective mood, anxiety, energy level ratings • Placement of batteries under clavicle
Electrode Placement
Operative Results and Post-op Management • Immediate feeling of a “smile” or “giggle” when stimulator turned on • Increase in subjective mood immediately, decrease in anxiety – Described pattern of both short term and long tern changes leading to improvement • Continued on home medications, recovery period, discharged on POD 3
Long Term Follow-Up • Depression rating scales • Hamilton depression and anxiety scores (HAM) • Montgomery Asberg Depression Rating scale (MADRS) • Global Assessment of functioning (GAF) • Detailed neuropsych batter • Complications
Conclusions • DBS offers a safe and effective method of modulating specific brain regions • DBS may become a therapeutic alternative for treatmentresistant depression • Continued research into the structural and functional basis of depression will enable us to further refine our treatment methods
Acknowledgments • Dr. Emad Eskandar
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