Case Presentation: DBS for Depression Robert McGovern, MS-IV Neurosurgery Grand Rounds,...
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Transcript of Case Presentation: DBS for Depression Robert McGovern, MS-IV Neurosurgery Grand Rounds,...
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