Case Presentation: DBS for Depression

Robert McGovern, MS-IVNeurosurgery Grand Rounds,

Massachusetts General HospitalJuly 16th, 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– 4th 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. VS is a central node in the limbic-cortical-subcortical network thought to be involved in emotional processing

2. VS is central in processing reward and pleasure information

3. VS is ideally suited to modulate reward-motivated behavior

4. VC contains white matter tracts connecting VS to areas mentioned above

Targeting the VC/VS

IC IC

CaudateCaudate

Putamen

Putamen

GP

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 treatment-resistant depression

• Continued research into the structural and functional basis of depression will enable us to further refine our treatment methods

Acknowledgments

• Dr. Emad Eskandar