Transcript Case Presentation: DBS for Depression

Case Presentation:
DBS for Depression
Robert McGovern, MS-IV
Neurosurgery Grand Rounds,
Massachusetts General Hospital
July 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.
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
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