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Lapa JDS, Duarte JFS, Campos ACP, Davidson B, Nestor SM, Rabin JS, Giacobbe P, Lipsman N, Hamani C. Adverse Effects of Deep Brain Stimulation for Treatment-Resistant Depression: A Scoping Review. Neurosurgery 2024; 95:509-516. [PMID: 38511957 DOI: 10.1227/neu.0000000000002910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 01/24/2024] [Indexed: 03/22/2024] Open
Abstract
Deep brain stimulation (DBS) is an emerging therapy for treatment-resistant depression (TRD). Although adverse effects have been reported in early-phase and a few randomized clinical trials, little is known about its overall safety profile, which has been assumed to be similar to that of DBS for movement disorders. The objective of this study was to pool existing safety data on DBS for TRD. Following PRISMA guidelines, PubMed was searched for English articles describing adverse outcomes after DBS for TRD. Studies were included if they reported at least 5 patients with a minimal follow-up of 6 months. After abstract (n = 607) and full-article review (n = 127), 28 articles reporting on 353 patients met criteria for final inclusion. Follow-up of the studies retrieved ranged from 12 to 96 months. Hemorrhages occurred in 0.8% of patients and infections in 10.2%. The rate of completed suicide was 2.5%. Development or worsening of depressive symptoms, anxiety, and mania occurred in 18.4%, 9.1%, and 5.1%, respectively. There were some differences between targets, but between-study heterogeneity precluded statistical comparisons. In conclusion, DBS for TRD is associated with surgical and psychiatric adverse events. Hemorrhage and infection occur at rates within an accepted range for other DBS applications. The risk of suicide after DBS for TRD is 2.5% but may not represent a significant deviation from the natural history of TRD. Finally, risks of worsening depression, anxiety, and the incidence of mania should be acknowledged when considering DBS for TRD.
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Affiliation(s)
- Jorge D S Lapa
- Department of Medicine, Federal University of Sergipe, Aracaju , Sergipe , Brazil
- Department Neurosurgery, Hospital de Cirurgia, Aracaju , Sergipe , Brazil
| | - Joel F S Duarte
- Department Neurosurgery, Neurological Institute of Curitiba, Curitiba , Brazil
| | | | - Benjamin Davidson
- Sunnybrook Research Institute, Toronto , Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto , Canada
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Canada
| | - Sean M Nestor
- Sunnybrook Research Institute, Toronto , Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto , Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Canada
| | - Jennifer S Rabin
- Sunnybrook Research Institute, Toronto , Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto , Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto , Canada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Canada
| | - Peter Giacobbe
- Sunnybrook Research Institute, Toronto , Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto , Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Canada
| | - Nir Lipsman
- Sunnybrook Research Institute, Toronto , Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto , Canada
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Canada
| | - Clement Hamani
- Sunnybrook Research Institute, Toronto , Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto , Canada
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Canada
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2
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Allawala AB, Bijanki KR, Adkinson J, Oswalt D, Tsolaki E, Mathew S, Mathura RK, Bartoli E, Provenza N, Watrous AJ, Xiao J, Pirtle V, Mocchi MM, Rajesh S, Diab N, Cohn JF, Borton DA, Goodman WK, Pouratian N, Sheth SA. Stereo-Electroencephalography-Guided Network Neuromodulation for Psychiatric Disorders: The Neurophysiology Monitoring Unit. Oper Neurosurg (Hagerstown) 2024; 27:329-336. [PMID: 39145663 DOI: 10.1227/ons.0000000000001122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 01/19/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Recent advances in stereotactic and functional neurosurgery have brought forth the stereo-electroencephalography approach which allows deeper interrogation and characterization of the contributions of deep structures to neural and affective functioning. We argue that this approach can and should be brought to bear on the notoriously intractable issue of defining the pathophysiology of refractory psychiatric disorders and developing patient-specific optimized stimulation therapies. METHODS We have developed a suite of methods for maximally leveraging the stereo-electroencephalography approach for an innovative application to understand affective disorders, with high translatability across the broader range of refractory neuropsychiatric conditions. RESULTS This article provides a roadmap for determining desired electrode coverage, tracking high-resolution research recordings across a large number of electrodes, synchronizing intracranial signals with ongoing research tasks and other data streams, applying intracranial stimulation during recording, and design choices for patient comfort and safety. CONCLUSION These methods can be implemented across other neuropsychiatric conditions needing intensive electrophysiological characterization to define biomarkers and more effectively guide therapeutic decision-making in cases of severe and treatment-refractory disease.
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Affiliation(s)
- Anusha B Allawala
- School of Engineering, Brown University, Providence, Rhode Island, USA
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Kelly R Bijanki
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Joshua Adkinson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Denise Oswalt
- Department of Neurosurgery, University of Pennsylvania Philadelphia, Pennsylvania, USA
| | - Evangelia Tsolaki
- Department of Neurosurgery, University of California, Los Angeles, California, USA
| | - Sanjay Mathew
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
| | - Raissa K Mathura
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Eleonora Bartoli
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Nicole Provenza
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Andrew J Watrous
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jiayang Xiao
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Victoria Pirtle
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Madaline M Mocchi
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Sameer Rajesh
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Nabeel Diab
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jeffrey F Cohn
- Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David A Borton
- School of Engineering, Brown University, Providence, Rhode Island, USA
| | - Wayne K Goodman
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
| | - Nader Pouratian
- Department of Neurosurgery, University of Texas Southwestern, Dallas, Texas, USA
| | - Sameer A Sheth
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
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3
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Myers J, Xiao J, Mathura R, Shofty B, Pirtle V, Adkinson J, Allawala AB, Anand A, Gadot R, Najera R, Rey HG, Mathew SJ, Bijanki K, Banks G, Watrous A, Bartoli E, Heilbronner SR, Provenza N, Goodman WK, Pouratian N, Hayden BY, Sheth SA. Intracranial Directed Connectivity Links Subregions of the Prefrontal Cortex to Major Depression. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.08.07.24311546. [PMID: 39148826 PMCID: PMC11326344 DOI: 10.1101/2024.08.07.24311546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
Understanding the neural basis of major depressive disorder (MDD) is vital to guiding neuromodulatory treatments. The available evidence supports the hypothesis that MDD is fundamentally a disease of cortical disinhibition, where breakdowns of inhibitory neural systems lead to diminished emotion regulation and intrusive ruminations. Recent research also points towards network changes in the brain, especially within the prefrontal cortex (PFC), as primary sources of MDD etiology. However, due to limitations in spatiotemporal resolution and clinical opportunities for intracranial recordings, this hypothesis has not been directly tested. We recorded intracranial EEG from the dorsolateral (dlPFC), orbitofrontal (OFC), and anterior cingulate cortices (ACC) in neurosurgical patients with MDD. We measured daily fluctuations in self-reported depression severity alongside directed connectivity between these PFC subregions. We focused primarily on delta oscillations (1-3 Hz), which have been linked to GABAergic inhibitory control and intracortical communication. Depression symptoms worsened when connectivity within the left vs. right PFC became imbalanced. In the left hemisphere, all directed connectivity towards the ACC, from the dlPFC and OFC, was positively correlated with depression severity. In the right hemisphere, directed connectivity between the OFC and dlPFC increased with depression severity as well. This is the first evidence that delta oscillations flowing between prefrontal subregions transiently increase intensity when people are experiencing more negative mood. These findings support the overarching hypothesis that MDD worsens with prefrontal disinhibition.
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Campos ACP, Hamani C. Insertional effect following deep brain stimulation electrode implants. Expert Rev Med Devices 2024:1-3. [PMID: 39101794 DOI: 10.1080/17434440.2024.2388135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 07/31/2024] [Indexed: 08/06/2024]
Affiliation(s)
| | - Clement Hamani
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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5
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Brown R, Cherian K, Jones K, Wickham R, Gomez R, Sahlem G. Repetitive transcranial magnetic stimulation for post-traumatic stress disorder in adults. Cochrane Database Syst Rev 2024; 8:CD015040. [PMID: 39092744 PMCID: PMC11295260 DOI: 10.1002/14651858.cd015040.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
BACKGROUND The estimated lifetime prevalence of post-traumatic stress disorder (PTSD) in adults worldwide has been estimated at 3.9%. PTSD appears to contribute to alterations in neuronal network connectivity patterns. Current pharmacological and psychotherapeutic treatments for PTSD are associated with inadequate symptom improvement and high dropout rates. Repetitive transcranial magnetic stimulation (rTMS), a non-invasive therapy involving induction of electrical currents in cortical brain tissue, may be an important treatment option for PTSD to improve remission rates and for people who cannot tolerate existing treatments. OBJECTIVES To assess the effects of repetitive transcranial magnetic stimulation (rTMS) on post-traumatic stress disorder (PTSD) in adults. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trials Register, CENTRAL, MEDLINE, Embase, three other databases, and two clinical trials registers. We checked reference lists of relevant articles. The most recent search was January 2023. SELECTION CRITERIA We included randomized controlled trials (RCTs) assessing the efficacy and safety of rTMS versus sham rTMS for PTSD in adults from any treatment setting, including veterans. Eligible trials employed at least five rTMS treatment sessions with both active and sham conditions. We included trials with combination interventions, where a pharmacological agent or psychotherapy was combined with rTMS for both intervention and control groups. We included studies meeting the above criteria regardless of whether they reported any of our outcomes of interest. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias in accordance with Cochrane standards. Primary outcomes were PTSD severity immediately after treatment and serious adverse events during active treatment. Secondary outcomes were PTSD remission, PTSD response, PTSD severity at two follow-up time points after treatment, dropouts, and depression and anxiety severity immediately after treatment. MAIN RESULTS We included 13 RCTs in the review (12 published; 1 unpublished dissertation), with 577 participants. Eight studies included stand-alone rTMS treatment, four combined rTMS with an evidence-based psychotherapeutic treatment, and one investigated rTMS as an adjunctive to treatment-as-usual. Five studies were conducted in the USA, and some predominantly included white, male veterans. Active rTMS probably makes little to no difference to PTSD severity immediately following treatment (standardized mean difference (SMD) -0.14, 95% confidence interval (CI) -0.54 to 0.27; 3 studies, 99 participants; moderate-certainty evidence). We downgraded the certainty of evidence by one level for imprecision (sample size insufficient to detect a difference of medium effect size). We deemed one study as having a low risk of bias and the remaining two as having 'some concerns' for risk of bias. A sensitivity analysis of change-from-baseline scores enabled inclusion of a greater number of studies (6 studies, 252 participants). This analysis yielded a similar outcome to our main analysis but also indicated significant heterogeneity in efficacy across studies, including two studies with a high risk of bias. Reported rates of serious adverse events were low, with seven reported (active rTMS: 6; sham rTMS: 1). The evidence is very uncertain about the effect of active rTMS on serious adverse events (odds ratio (OR) 5.26, 95% CI 0.26 to 107.81; 5 studies, 251 participants; very low-certainty evidence [Active rTMS: 23/1000, sham rTMS: 4/1000]). We downgraded the evidence by one level for risk of bias and two levels for imprecision. We rated four of five studies as having a high risk of bias, and the fifth as 'some concerns' for bias. We were unable to assess PTSD remission immediately after treatment as none of the included studies reported this outcome. AUTHORS' CONCLUSIONS Based on moderate-certainty evidence, our review suggests that active rTMS probably makes little to no difference to PTSD severity immediately following treatment compared to sham stimulation. However, significant heterogeneity in efficacy was detected when we included a larger number of studies in sensitivity analysis. We observed considerable variety in participant and protocol characteristics across studies included in this review. For example, studies tended to be weighted towards inclusion of either male veterans or female civilians. Studies varied greatly in terms of the proportion of the sample with comorbid depression. Study protocols differed in treatment design and stimulation parameters (e.g. session number/duration, treatment course length, stimulation intensity/frequency, location of stimulation). These differences may affect efficacy, particularly when considering interactions with participant factors. Reported rates of serious adverse events were very low (< 1%) across active and sham conditions. It is uncertain whether rTMS increases the risk of serious adverse event occurrence, as our certainty of evidence was very low. Studies frequently lacked clear definitions for serious adverse events, as well as detail on tracking/assessment of data and information on the safety population. Increased reporting on these elements would likely aid the advancement of both research and clinical recommendations of rTMS for PTSD. Currently, there is insufficient evidence to meta-analyze PTSD remission, PTSD treatment response, and PTSD severity at different periods post-treatment. Further research into these outcomes could inform the clinical use of rTMS. Additionally, the relatively large contribution of data from trials that focused on white male veterans may limit the generalizability of our conclusions. This could be addressed by prioritizing recruitment of more diverse participant samples.
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Affiliation(s)
- Randi Brown
- Clinical Psychology, Palo Alto University, Palo Alto, CA, USA
| | - Kirsten Cherian
- Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Katherine Jones
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Robert Wickham
- Department of Psychological Sciences, Northern Arizona University, Flagstaff, AZ, USA
| | - Rowena Gomez
- Clinical Psychology, Palo Alto University, Palo Alto, CA, USA
- Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Gregory Sahlem
- Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
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Sadeghzadeh S, Swaminathan A, Bhanot P, Steeman S, Xu A, Shah V, Purger DA, Buch VP. Emerging Outlook on Personalized Neuromodulation for Depression: Insights From Tractography-Based Targeting. BIOLOGICAL PSYCHIATRY. COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2024; 9:754-764. [PMID: 38679323 DOI: 10.1016/j.bpsc.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/07/2024] [Accepted: 04/11/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Deep brain stimulation has shown promise in treating individual patients with treatment-resistant depression, but larger-scale trials have been less successful. Here, we created what is, to our knowledge, the largest meta-analysis with individual patient data to date to explore whether the use of tractography enhances the efficacy of deep brain stimulation for treatment-resistant depression. METHODS We systematically reviewed 1823 articles, selecting 32 that contributed data from 366 patients. We stratified the individual patient data based on stimulation target and use of tractography. Using 2-way type III analysis of variance, Welch's 2-sample t tests, and mixed-effects linear regression models, we evaluated changes in depression severity 1 year (9-15 months) postoperatively and at last follow-up (4 weeks to 8 years) as assessed by depression scales. RESULTS Tractography was used for medial forebrain bundle (MFB) (n = 17 tractography/32 total), subcallosal cingulate (SCC) (n = 39 tractography/241 total), and ventral capsule/ventral striatum (n = 3 tractography/41 total) targets; it was not used for bed nucleus of stria terminalis (n = 11), lateral habenula (n = 10), and inferior thalamic peduncle (n = 1). Across all patients, tractography significantly improved mean depression scores at 1 year (p < .001) and last follow-up (p = .009). Within the target cohorts, tractography improved depression scores at 1 year for both MFB and SCC, though significance was met only at the α = 0.1 level (SCC: β = 15.8%, p = .09; MFB: β = 52.4%, p = .10). Within the tractography cohort, patients with MFB tractography showed greater improvement than patients with SCC tractography (72.42 ± 7.17% vs. 54.78 ± 4.08%) at 1 year (p = .044). CONCLUSIONS Our findings underscore the promise of tractography in deep brain stimulation for treatment-resistant depression as a method for personalization of therapy, supporting its inclusion in future trials.
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Affiliation(s)
- Sina Sadeghzadeh
- Department of Neurosurgery, Stanford University, Stanford, California.
| | | | - Priya Bhanot
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samantha Steeman
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Audrey Xu
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Vaibhavi Shah
- Department of Neurosurgery, Stanford University, Stanford, California
| | - David A Purger
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Vivek P Buch
- Department of Neurosurgery, Stanford University, Stanford, California.
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7
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Wang C, Sun Y, Xing Y, Liu K, Xu K. Role of electrophysiological activity and interactions of lateral habenula in the development of depression-like behavior in a chronic restraint stress model. Brain Res 2024; 1835:148914. [PMID: 38580047 DOI: 10.1016/j.brainres.2024.148914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/20/2024] [Accepted: 04/02/2024] [Indexed: 04/07/2024]
Abstract
Closed-loop deep brain stimulation (DBS) system offers a promising approach for treatment-resistant depression, but identifying universally accepted electrophysiological biomarkers for closed-loop DBS systems targeting depression is challenging. There is growing evidence suggesting a strong association between the lateral habenula (LHb) and depression. Here, we took LHb as a key target, utilizing multi-site local field potentials (LFPs) to study the acute and chronic changes in electrophysiology, functional connectivity, and brain network characteristics during the formation of a chronic restraint stress (CRS) model. Furthermore, our model combining the electrophysiological changes of LHb and interactions between LHb and other potential targets of depression can effectively distinguish depressive states, offering a new way for developing effective closed-loop DBS strategies.
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Affiliation(s)
- Chang Wang
- Qiushi Academy for Advanced Studies (QAAS), Zhejiang University, Hangzhou, China; Nanhu Brain-computer Interface Institute, Hangzhou 311100,China; Zhejiang Provincial Key Laboratory of Cardio-Cerebral Vascular Detection Technology and Medicinal Effectiveness Appraisal, Key Laboratory of Biomedical Engineering of Education Ministry, Department of Biomedical Engineering, Zhejiang University, Hangzhou, China; State Key Lab of Brain-Machine Intelligence, Zhejiang University, Hangzhou, China.
| | - Yuting Sun
- Qiushi Academy for Advanced Studies (QAAS), Zhejiang University, Hangzhou, China; Nanhu Brain-computer Interface Institute, Hangzhou 311100,China; Zhejiang Provincial Key Laboratory of Cardio-Cerebral Vascular Detection Technology and Medicinal Effectiveness Appraisal, Key Laboratory of Biomedical Engineering of Education Ministry, Department of Biomedical Engineering, Zhejiang University, Hangzhou, China; State Key Lab of Brain-Machine Intelligence, Zhejiang University, Hangzhou, China.
| | - Yanjie Xing
- Qiushi Academy for Advanced Studies (QAAS), Zhejiang University, Hangzhou, China; Nanhu Brain-computer Interface Institute, Hangzhou 311100,China; Zhejiang Provincial Key Laboratory of Cardio-Cerebral Vascular Detection Technology and Medicinal Effectiveness Appraisal, Key Laboratory of Biomedical Engineering of Education Ministry, Department of Biomedical Engineering, Zhejiang University, Hangzhou, China; State Key Lab of Brain-Machine Intelligence, Zhejiang University, Hangzhou, China.
| | - Kezhou Liu
- School of Automation (Artificial Intelligence), Hangzhou Dianzi University, Hangzhou 310018, China.
| | - Kedi Xu
- Qiushi Academy for Advanced Studies (QAAS), Zhejiang University, Hangzhou, China; Nanhu Brain-computer Interface Institute, Hangzhou 311100,China; Zhejiang Provincial Key Laboratory of Cardio-Cerebral Vascular Detection Technology and Medicinal Effectiveness Appraisal, Key Laboratory of Biomedical Engineering of Education Ministry, Department of Biomedical Engineering, Zhejiang University, Hangzhou, China; State Key Lab of Brain-Machine Intelligence, Zhejiang University, Hangzhou, China.
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8
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Scangos KW, Sugrue LP. From Sweet Spots to Causal Circuits: Navigating Deep Brain Stimulation Targeting Through Anatomic, Connectomic, and Personalized Approaches. Biol Psychiatry 2024; 96:82-84. [PMID: 38925717 DOI: 10.1016/j.biopsych.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/13/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Katherine W Scangos
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California; Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Leo P Sugrue
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California; Division of Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
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9
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White AJ, Kelly-Hedrick M, Miranda SP, Abdelbarr MM, Lázaro-Muñoz G, Pouratian N, Shen F, Nahed BV, Williamson T. Bioethics and Neurosurgery: An Overview of Existing and Emerging Topics for the Practicing Neurosurgeon. World Neurosurg 2024; 190:181-186. [PMID: 39004179 DOI: 10.1016/j.wneu.2024.07.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 07/05/2024] [Indexed: 07/16/2024]
Abstract
Neurosurgery is a field with complex ethical issues. In this article, we aim to provide an overview of key and emerging ethical issues in neurosurgery with a focus on issues relevant to practicing neurosurgeons. These issues include those of informed consent, capacity, clinical trials, emerging neurotechnology, innovation, equity and justice, and emerging bioethics areas including community engagement and organizational ethics. We argue that bioethics can help neurosurgeons think about and address these issues, and, in turn, the field of bioethics can benefit from engagement by neurosurgeons. Several ideas for increasing engagement in bioethics are proposed.
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Affiliation(s)
- Alexandra J White
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Margot Kelly-Hedrick
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.
| | - Stephen P Miranda
- Department of Neurosurgery, University of Pennsylvania, Pennsylvania, Pennsylvania, USA
| | | | | | - Nader Pouratian
- Department of Neurological Surgery, University of Texas Southwestern, Dallas, Texas, USA
| | - Francis Shen
- Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA; Harvard Law School, Cambridge, Massachusetts, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Theresa Williamson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
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10
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Sakai JT, Tanabe J, Battula S, Zipperly M, Mikulich-Gilbertson SK, Kern DS, Thompson JA, Raymond K, Gerecht PD, Foster K, Abosch A. Deep brain stimulation for the treatment of substance use disorders: a promising approach requiring caution. Front Psychiatry 2024; 15:1435109. [PMID: 39071229 PMCID: PMC11272460 DOI: 10.3389/fpsyt.2024.1435109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Accepted: 06/25/2024] [Indexed: 07/30/2024] Open
Abstract
Substance use disorders are prevalent, causing extensive morbidity and mortality worldwide. Evidence-based treatments are of low to moderate effect size. Growth in the neurobiological understanding of addiction (e.g., craving) along with technological advancements in neuromodulation have enabled an evaluation of neurosurgical treatments for substance use disorders. Deep brain stimulation (DBS) involves surgical implantation of leads into brain targets and subcutaneous tunneling to connect the leads to a programmable implanted pulse generator (IPG) under the skin of the chest. DBS allows direct testing of neurobiologically-guided hypotheses regarding the etiology of substance use disorders in service of developing more effective treatments. Early studies, although with multiple limitations, have been promising. Still the authors express caution regarding implementation of DBS studies in this population and emphasize the importance of safeguards to ensure patient safety and meaningful study results. In this perspectives article, we review lessons learned through the years of planning an ongoing trial of DBS for methamphetamine use disorder.
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Affiliation(s)
- Joseph T. Sakai
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, United States
| | - Jody Tanabe
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Sharonya Battula
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, United States
| | - Morgan Zipperly
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, United States
| | | | - Drew S. Kern
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - John A. Thompson
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, United States
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, United States
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Kristen Raymond
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, United States
| | - Pamela David Gerecht
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Katrina Foster
- National Institute on Drug Abuse, Bethesda, MD, United States
| | - Aviva Abosch
- Department of Neurosurgery, University of Nebraska Medical Center, Omaha, NE, United States
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Mishra A, Begley SL, Shah HA, Santhumayor BA, Ramdhani RA, Fenoy AJ, Schulder M. Why are clinical trials of deep brain stimulation terminated? An analysis of clinicaltrials.gov. World Neurosurg X 2024; 23:100378. [PMID: 38595675 PMCID: PMC11002890 DOI: 10.1016/j.wnsx.2024.100378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 03/30/2024] [Accepted: 04/02/2024] [Indexed: 04/11/2024] Open
Abstract
Background Although deep brain stimulation (DBS) has established uses for patients with movement disorders and epilepsy, it is under consideration for a wide range of neurologic and neuropsychiatric conditions. Objective To review successful and unsuccessful DBS clinical trials and identify factors associated with early trial termination. Methods The ClinicalTrials.gov database was screened for all studies related to DBS. Information regarding condition of interest, study aim, trial design, trial success, and, if applicable, reason for failure was collected. Trials were compared and logistic regression was utilized to identify independent factors associated with trial termination. Results Of 325 identified trials, 79.7% were successful and 20.3% unsuccessful. Patient recruitment, sponsor decision, and device issues were the most cited reasons for termination. 242 trials (74.5%) were interventional with 78.1% successful. There was a statistically significant difference between successful and unsuccessful trials in number of funding sources (p = 0.0375). NIH funding was associated with successful trials while utilization of other funding sources (academic institutions and community organizations) was associated with unsuccessful trials. 83 trials (25.5%) were observational with 84.0% successful; there were no statistically significant differences between successful and unsuccessful observational trials. Conclusion One in five clinical trials for DBS were found to be unsuccessful, most commonly due to patient recruitment difficulties. The source of funding was the only factor associated with trial success. As DBS research continues to grow, understanding the current state of clinical trials will help design successful future studies, thereby minimizing futile expenditures of time, cost, and patient engagement.
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Affiliation(s)
- Akash Mishra
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, USA
| | - Sabrina L. Begley
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, USA
| | - Harshal A. Shah
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, USA
| | - Brandon A. Santhumayor
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, USA
| | - Ritesh A. Ramdhani
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, USA
| | - Albert J. Fenoy
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, USA
| | - Michael Schulder
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, USA
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12
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Abdulrazeq H, Philips AP, Sastry R, Lauro PM, McLaughlin NCR, Asaad WF. The persistent value of lesions in psychiatric neurosurgery. Lancet Psychiatry 2024:S2215-0366(24)00115-9. [PMID: 38906167 DOI: 10.1016/s2215-0366(24)00115-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/23/2024] [Accepted: 04/03/2024] [Indexed: 06/23/2024]
Abstract
Neurosurgery for intractable psychiatric conditions has seen a resurgence with the increasing use of deep brain stimulation (DBS). Although DBS promises reversible neuromodulation and has become more popular than older lesioning methods, lesioning might still be preferred in specific cases. Here, we review the evidence for DBS and lesions in the treatment of intractable neuropsychiatric conditions and consider the factors that favour the continued use of lesioning procedures in appropriately selected cases. Broadly, systemic factors including comparative effectiveness, cost, and ethical arguments support an ongoing role for lesioning. Such a role is also supported by practical considerations including patient experiences of this type of therapy, the relative intensity of follow-up care, access to sparse or specialised follow-up care, and relative infection risk. Overall, we argue that neurosurgical lesion procedures remain an important alternative to DBS and their continued availability is necessary to fulfil the imperatives of mental health parity and enhance access to effective mental health treatments. Nonetheless, the efficacy of DBS and recent advances in closed-loop stimulation and remote programming might provide solutions to some of the challenges associated with wider use of electrical neuromodulation. Concerns about the scarcity of high-level evidence for the efficacy of lesioning procedures as well as the potential irreversible adverse effects of lesioning remain to be addressed.
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Affiliation(s)
- Hael Abdulrazeq
- Department of Neurosurgery, The Warren Alpert Medical School, Brown University, Providence, RI, USA.
| | - Alexander P Philips
- Department of Neurosurgery, The Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Rahul Sastry
- Department of Neurosurgery, The Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Peter M Lauro
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nicole C R McLaughlin
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School, Brown University, Providence, RI, USA; Carney Institute for Brain Science, Brown University, Providence, RI, USA
| | - Wael F Asaad
- Department of Neurosurgery, The Warren Alpert Medical School, Brown University, Providence, RI, USA; Department of Neuroscience, Brown University, Providence, RI, USA; Carney Institute for Brain Science, Brown University, Providence, RI, USA
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13
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Kabotyanski KE, Najera RA, Banks GP, Sharma H, Provenza NR, Hayden BY, Mathew SJ, Sheth SA. Cost-effectiveness and threshold analysis of deep brain stimulation vs. treatment-as-usual for treatment-resistant depression. Transl Psychiatry 2024; 14:243. [PMID: 38849334 PMCID: PMC11161481 DOI: 10.1038/s41398-024-02951-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 05/14/2024] [Accepted: 05/20/2024] [Indexed: 06/09/2024] Open
Abstract
Treatment-resistant depression (TRD) affects approximately 2.8 million people in the U.S. with estimated annual healthcare costs of $43.8 billion. Deep brain stimulation (DBS) is currently an investigational intervention for TRD. We used a decision-analytic model to compare cost-effectiveness of DBS to treatment-as-usual (TAU) for TRD. Because this therapy is not FDA approved or in common use, our goal was to establish an effectiveness threshold that trials would need to demonstrate for this therapy to be cost-effective. Remission and complication rates were determined from review of relevant studies. We used published utility scores to reflect quality of life after treatment. Medicare reimbursement rates and health economics data were used to approximate costs. We performed Monte Carlo (MC) simulations and probabilistic sensitivity analyses to estimate incremental cost-effectiveness ratios (ICER; USD/quality-adjusted life year [QALY]) at a 5-year time horizon. Cost-effectiveness was defined using willingness-to-pay (WTP) thresholds of $100,000/QALY and $50,000/QALY for moderate and definitive cost-effectiveness, respectively. We included 274 patients across 16 studies from 2009-2021 who underwent DBS for TRD and had ≥12 months follow-up in our model inputs. From a healthcare sector perspective, DBS using non-rechargeable devices (DBS-pc) would require 55% and 85% remission, while DBS using rechargeable devices (DBS-rc) would require 11% and 19% remission for moderate and definitive cost-effectiveness, respectively. From a societal perspective, DBS-pc would require 35% and 46% remission, while DBS-rc would require 8% and 10% remission for moderate and definitive cost-effectiveness, respectively. DBS-pc will unlikely be cost-effective at any time horizon without transformative improvements in battery longevity. If remission rates ≥8-19% are achieved, DBS-rc will likely be more cost-effective than TAU for TRD, with further increasing cost-effectiveness beyond 5 years.
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Affiliation(s)
| | - Ricardo A Najera
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Garrett P Banks
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Himanshu Sharma
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Nicole R Provenza
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Benjamin Y Hayden
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Sanjay J Mathew
- Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Sameer A Sheth
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA.
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14
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Remore LG, Tolossa M, Wei W, Karnib M, Tsolaki E, Rifi Z, Bari AA. Deep Brain Stimulation of the Medial Forebrain Bundle for Treatment-Resistant Depression: A Systematic Review Focused on the Long-Term Antidepressive Effect. Neuromodulation 2024; 27:690-700. [PMID: 37115122 DOI: 10.1016/j.neurom.2023.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 03/11/2023] [Accepted: 03/20/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE Major depression affects millions of people worldwide and has important social and economic consequences. Since up to 30% of patients do not respond to several lines of antidepressive drugs, deep brain stimulation (DBS) has been evaluated for the management of treatment-resistant depression (TRD). The superolateral branch of the medial forebrain bundle (slMFB) appears as a "hypothesis-driven target" because of its role in the reward-seeking system, which is dysfunctional in depression. Although initial results of slMFB-DBS from open-label studies were promising and characterized by a rapid clinical response, long-term outcomes of neurostimulation for TRD deserve particular attention. Therefore, we performed a systematic review focused on the long-term outcome of slMFB-DBS. MATERIALS AND METHODS A literature search using Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria was conducted to identify all studies reporting changes in depression scores after one-year follow-up and beyond. Patient, disease, surgical, and outcome data were extracted for statistical analysis. The Montgomery-Åsberg Depression Rating Scale (ΔMADRS) was used as the clinical outcome, defined as percentage reduction from baseline to follow-up evaluation. Responders' and remitters' rates were also calculated. RESULTS From 56 studies screened for review, six studies comprising 34 patients met the inclusion criteria and were analyzed. After one year of active stimulation, ΔMADRS was 60.7% ± 4%; responders' and remitters' rates were 83.8% and 61.5%, respectively. At the last follow-up, four to five years after the implantation, ΔMADRS reached 74.7% ± 4.6%. The most common side effects were stimulation related and reversible with parameter adjustments. CONCLUSIONS slMFB-DBS appears to have a strong antidepressive effect that increases over the years. Nevertheless, to date, the overall number of patients receiving implantations is limited, and the slMFB-DBS surgical technique seems to have an important impact on the clinical outcome. Further multicentric studies in a larger population are needed to confirm slMFB-DBS clinical outcomes.
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Affiliation(s)
- Luigi Gianmaria Remore
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA; University of Milan "La Statale," Milan, Italy.
| | - Meskerem Tolossa
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Wexin Wei
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Evangelia Tsolaki
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Ziad Rifi
- University of California Los Angeles, Los Angeles, CA, USA
| | - Ausaf Ahmad Bari
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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15
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Varela RB, Boschen SL, Yates N, Houghton T, Blaha CD, Lee KH, Bennet KE, Kouzani AZ, Berk M, Quevedo J, Valvassori SS, Tye SJ. Anti-manic effect of deep brain stimulation of the ventral tegmental area in an animal model of mania induced by methamphetamine. Bipolar Disord 2024; 26:376-387. [PMID: 38558302 DOI: 10.1111/bdi.13423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Treatment of refractory bipolar disorder (BD) is extremely challenging. Deep brain stimulation (DBS) holds promise as an effective treatment intervention. However, we still understand very little about the mechanisms of DBS and its application on BD. AIM The present study aimed to investigate the behavioural and neurochemical effects of ventral tegmental area (VTA) DBS in an animal model of mania induced by methamphetamine (m-amph). METHODS Wistar rats were given 14 days of m-amph injections, and on the last day, animals were submitted to 20 min of VTA DBS in two different patterns: intermittent low-frequency stimulation (LFS) or continuous high-frequency stimulation (HFS). Immediately after DBS, manic-like behaviour and nucleus accumbens (NAc) phasic dopamine (DA) release were evaluated in different groups of animals through open-field tests and fast-scan cyclic voltammetry. Levels of NAc dopaminergic markers were evaluated by immunohistochemistry. RESULTS M-amph induced hyperlocomotion in the animals and both DBS parameters reversed this alteration. M-amph increased DA reuptake time post-sham compared to baseline levels, and both LFS and HFS were able to block this alteration. LFS was also able to reduce phasic DA release when compared to baseline. LFS was able to increase dopamine transporter (DAT) expression in the NAc. CONCLUSION These results demonstrate that both VTA LFS and HFS DBS exert anti-manic effects and modulation of DA dynamics in the NAc. More specifically the increase in DA reuptake driven by increased DAT expression may serve as a potential mechanism by which VTA DBS exerts its anti-manic effects.
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Affiliation(s)
- Roger B Varela
- Functional Neuromodulation and Novel Therapeutics Laboratory, Asia Pacific Centre for Neuromodulation, Queensland Brain Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Suelen L Boschen
- Department of Neurologic Surgery, Neural Engineering Laboratories, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Applied Computational Neurophysiology and Neuromodulation Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Nathanael Yates
- Functional Neuromodulation and Novel Therapeutics Laboratory, Asia Pacific Centre for Neuromodulation, Queensland Brain Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Tristan Houghton
- Functional Neuromodulation and Novel Therapeutics Laboratory, Asia Pacific Centre for Neuromodulation, Queensland Brain Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Charles D Blaha
- Department of Neurologic Surgery, Neural Engineering Laboratories, Mayo Clinic, Rochester, Minnesota, USA
| | - Kendall H Lee
- Department of Neurologic Surgery, Neural Engineering Laboratories, Mayo Clinic, Rochester, Minnesota, USA
| | - Kevin E Bennet
- Department of Neurologic Surgery, Neural Engineering Laboratories, Mayo Clinic, Rochester, Minnesota, USA
- Division of Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Abbas Z Kouzani
- School of Engineering, Deakin University, Geelong, Victoria, Australia
| | - Michael Berk
- School of Medicine, IMPACT-The Institute for Mental and Physical Health and Clinical Translation, Barwon Health, Deakin University, Geelong, Victoria, Australia
| | - João Quevedo
- Faillace Department of Psychiatry and Behavioral Sciences, Center for Interventional Psychiatry, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, Texas, USA
- Faillace Department of Psychiatry and Behavioral Sciences, Center of Excellence on Mood Disorders, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas, USA
- Faillace Department of Psychiatry and Behavioral Sciences, Translational Psychiatry Program, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas, USA
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, Santa Catarina, Brazil
| | - Samira S Valvassori
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, Santa Catarina, Brazil
| | - Susannah J Tye
- Functional Neuromodulation and Novel Therapeutics Laboratory, Asia Pacific Centre for Neuromodulation, Queensland Brain Institute, The University of Queensland, Brisbane, Queensland, Australia
- Department of Psychiatry and Psychology, Translational Neuroscience Laboratory, Mayo Clinic, Rochester, Minnesota, USA
- Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia, USA
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16
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Neimat JS, Bina RW, Koenig SC, Demirors E, Guida R, Burke R, Melodia T, Jimenez J. A Novel Closed-Loop Electrical Brain Stimulation Device Featuring Wireless Low-Energy Ultrasound Power and Communication. Neuromodulation 2024:S1094-7159(24)00071-0. [PMID: 38819342 DOI: 10.1016/j.neurom.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 01/27/2024] [Accepted: 02/13/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVES This study aimed to indicate the feasibility of a prototype electrical neuromodulation system using a closed-loop energy-efficient ultrasound-based mechanism for communication, data transmission, and recharging. MATERIALS AND METHODS Closed-loop deep brain stimulation (DBS) prototypes were designed and fabricated with ultrasonic wideband (UsWB) communication technology and miniaturized custom electronics. Two devices were implanted short term in anesthetized Göttingen minipigs (N = 2). Targeting was performed using preoperative magnetic resonance imaging, and locations were confirmed postoperatively by computerized tomography. DBS systems were tested over a wide range of stimulation settings to mimic minimal, typical, and/or aggressive clinical settings, and evaluated for their ability to transmit data through scalp tissue and to recharge the DBS system using UsWB. RESULTS Stimulation, communication, reprogramming, and recharging protocols were successfully achieved in both subjects for amplitude (1V-6V), frequency (50-250 Hz), and pulse width (60-200 μs) settings and maintained for ≥six hours. The precision of pulse settings was verified with <5% error. Communication rates of 64 kbit/s with an error rate of 0.05% were shown, with no meaningful throughput degradation observed. Time to recharge to 80% capacity was <9 minutes. Two DBS systems also were implanted in the second test animal, and independent bilateral stimulation was successfully shown. CONCLUSIONS The system performed at clinically relevant implant depths and settings. Independent bilateral stimulation for the duration of the study with a 4F energy storage and full rapid recharge were achieved. Continuous function extrapolates to six days of continuous stimulation in future design iterations implementing application specific integrated circuit level efficiency and 15F storage capacitance. UsWB increases energy efficiency, reducing storage requirements and thereby enabling device miniaturization. The device can enable intelligent closed-loop stimulation, remote system monitoring, and optimization and can serve as a power/data gateway to interconnect the intrabody network with the Internet of Medical Things.
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Affiliation(s)
- Joseph S Neimat
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA.
| | - Robert W Bina
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA
| | - Steven C Koenig
- Department of Bioengineering, University of Louisville, Louisville, KY, USA; Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY, USA
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17
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Adegoke T, Subramanian S, Daunis D, Bick S, Ward HB. A Case of Treatment-Resistant Depression Complicated by Traumatic Brain Injury and Seizure: Implications for Interventional Treatment and Psychiatric Training. Harv Rev Psychiatry 2024; 32:117-125. [PMID: 38728571 DOI: 10.1097/hrp.0000000000000394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Affiliation(s)
- Timothy Adegoke
- From Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN (Drs. Adegoke, Daunis, and Ward); Harvard Medical School, Departments of Psychiatry and Neurology, Beth Israel Deaconess Medical Center, Boston, MA (Dr. Subramanian); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (Dr. Bick)
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18
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Fennema D, Barker GJ, O’Daly O, Duan S, Carr E, Goldsmith K, Young AH, Moll J, Zahn R. The Role of Subgenual Resting-State Connectivity Networks in Predicting Prognosis in Major Depressive Disorder. BIOLOGICAL PSYCHIATRY GLOBAL OPEN SCIENCE 2024; 4:100308. [PMID: 38645404 PMCID: PMC11033067 DOI: 10.1016/j.bpsgos.2024.100308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/18/2023] [Accepted: 03/05/2024] [Indexed: 04/23/2024] Open
Abstract
Background A seminal study found higher subgenual frontal cortex resting-state connectivity with 2 left ventral frontal regions and the dorsal midbrain to predict better response to psychotherapy versus medication in individuals with treatment-naïve major depressive disorder (MDD). Here, we examined whether these subgenual networks also play a role in the pathophysiology of clinical outcomes in MDD with early treatment resistance in primary care. Methods Forty-five people with current MDD who had not responded to ≥2 serotonergic antidepressants (n = 43, meeting predefined functional magnetic resonance imaging minimum quality thresholds) were enrolled and followed over 4 months of standard care. Functional magnetic resonance imaging resting-state connectivity between the preregistered subgenual frontal cortex seed and 3 previously identified left ventromedial, ventrolateral prefrontal/insula, and dorsal midbrain regions was extracted. The clinical outcome was the percentage change on the self-reported 16-item Quick Inventory of Depressive Symptomatology. Results We observed a reversal of our preregistered hypothesis in that higher resting-state connectivity between the subgenual cortex and the a priori ventrolateral prefrontal/insula region predicted favorable rather than unfavorable clinical outcomes (rs39 = -0.43, p = .006). This generalized to the sample including participants with suboptimal functional magnetic resonance imaging quality (rs43 = -0.35, p = .02). In contrast, no effects (rs39 = 0.12, rs39 = -0.01) were found for connectivity with the other 2 preregistered regions or in a whole-brain analysis (voxel-based familywise error-corrected p < .05). Conclusions Subgenual connectivity with the ventrolateral prefrontal cortex/insula is relevant for subsequent clinical outcomes in current MDD with early treatment resistance. Its positive association with favorable outcomes could be explained primarily by psychosocial rather than the expected pharmacological changes during the follow-up period.
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Affiliation(s)
- Diede Fennema
- Centre of Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, Centre for Affective Disorders, King’s College London, London, United Kingdom
| | - Gareth J. Barker
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Owen O’Daly
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Suqian Duan
- Centre of Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, Centre for Affective Disorders, King’s College London, London, United Kingdom
| | - Ewan Carr
- Department of Biostatics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Kimberley Goldsmith
- Department of Biostatics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Allan H. Young
- Centre of Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, Centre for Affective Disorders, King’s College London, London, United Kingdom
- National Service for Affective Disorders, South London and Maudsley National Health Service Foundation Trust, London, United Kingdom
| | - Jorge Moll
- Cognitive and Behavioural Neuroscience Unit, D’Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Roland Zahn
- Centre of Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, Centre for Affective Disorders, King’s College London, London, United Kingdom
- Cognitive and Behavioural Neuroscience Unit, D’Or Institute for Research and Education, Rio de Janeiro, Brazil
- National Service for Affective Disorders, South London and Maudsley National Health Service Foundation Trust, London, United Kingdom
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19
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Li L, Zhang B, Zhao W, Sheng D, Yin L, Sheng X, Yao D. Multimodal Technologies for Closed-Loop Neural Modulation and Sensing. Adv Healthc Mater 2024:e2303289. [PMID: 38640468 DOI: 10.1002/adhm.202303289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 03/11/2024] [Indexed: 04/21/2024]
Abstract
Existing methods for studying neural circuits and treating neurological disorders are typically based on physical and chemical cues to manipulate and record neural activities. These approaches often involve predefined, rigid, and unchangeable signal patterns, which cannot be adjusted in real time according to the patient's condition or neural activities. With the continuous development of neural interfaces, conducting in vivo research on adaptive and modifiable treatments for neurological diseases and neural circuits is now possible. In this review, current and potential integration of various modalities to achieve precise, closed-loop modulation, and sensing in neural systems are summarized. Advanced materials, devices, or systems that generate or detect electrical, magnetic, optical, acoustic, or chemical signals are highlighted and utilized to interact with neural cells, tissues, and networks for closed-loop interrogation. Further, the significance of developing closed-loop techniques for diagnostics and treatment of neurological disorders such as epilepsy, depression, rehabilitation of spinal cord injury patients, and exploration of brain neural circuit functionality is elaborated.
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Affiliation(s)
- Lizhu Li
- Sichuan Provincial Key Laboratory for Human Disease Gene Study and the Center for Medical Genetics, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Bozhen Zhang
- School of Materials Science and Engineering, The Key Laboratory of Advanced Materials of Ministry of Education, State Key Laboratory of New Ceramics and Fine Processing, Laboratory of Flexible Electronics Technology, Tsinghua University, Beijing, 100084, China
| | - Wenxin Zhao
- Department of Electronic Engineering, Beijing National Research Center for Information Science and Technology, Institute for Precision Medicine, Laboratory of Flexible Electronics Technology, IDG/McGovern Institute for Brain Research, Tsinghua University, Beijing, 100084, China
| | - David Sheng
- Department of Electronic Engineering, Beijing National Research Center for Information Science and Technology, Institute for Precision Medicine, Laboratory of Flexible Electronics Technology, IDG/McGovern Institute for Brain Research, Tsinghua University, Beijing, 100084, China
| | - Lan Yin
- School of Materials Science and Engineering, The Key Laboratory of Advanced Materials of Ministry of Education, State Key Laboratory of New Ceramics and Fine Processing, Laboratory of Flexible Electronics Technology, Tsinghua University, Beijing, 100084, China
| | - Xing Sheng
- Department of Electronic Engineering, Beijing National Research Center for Information Science and Technology, Institute for Precision Medicine, Laboratory of Flexible Electronics Technology, IDG/McGovern Institute for Brain Research, Tsinghua University, Beijing, 100084, China
| | - Dezhong Yao
- Sichuan Provincial Key Laboratory for Human Disease Gene Study and the Center for Medical Genetics, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, 611731, China
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20
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Yatsuda K, Yu W, Gomez-Tames J. Population-level insights into temporal interference for focused deep brain neuromodulation. Front Hum Neurosci 2024; 18:1308549. [PMID: 38708141 PMCID: PMC11066208 DOI: 10.3389/fnhum.2024.1308549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 04/09/2024] [Indexed: 05/07/2024] Open
Abstract
The ability to stimulate deep brain regions in a focal manner brings new opportunities for treating brain disorders. Temporal interference (TI) stimulation has been suggested as a method to achieve focused stimulation in deep brain targets. Individual-level knowledge of the interferential currents has permitted personalizing TI montage via subject-specific digital human head models, facilitating the estimation of interferential electric currents in the brain. While this individual approach offers a high degree of personalization, the significant intra-and inter-individual variability among specific head models poses challenges when comparing electric-field doses. Furthermore, MRI acquisition to develop a personalized head model, followed by precise methods for placing the optimized electrode positions, is complex and not always available in various clinical settings. Instead, the registration of individual electric fields into brain templates has offered insights into population-level effects and enabled montage optimization using common scalp landmarks. However, population-level knowledge of the interferential currents remains scarce. This work aimed to investigate the effectiveness of targeting deep brain areas using TI in different populations. The results showed a trade-off between deep stimulation and unwanted cortical neuromodulation, which is target-dependent at the group level. A consistent modulated electric field appeared in the deep brain target when the same montage was applied in different populations. However, the performance in terms of focality and variability varied when the same montage was used among populations. Also, group-level TI exhibited greater focality than tACS, reducing unwanted neuromodulation volume in the cortical part by at least 1.5 times, albeit with higher variability. These results provide valuable population-level insights when considering TI montage selection.
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Affiliation(s)
- Kanata Yatsuda
- Department of Medical Engineering, Graduate School of Engineering, Chiba University, Chiba, Japan
| | - Wenwei Yu
- Center for Frontier Medical Engineering, Chiba University, Chiba, Japan
| | - Jose Gomez-Tames
- Center for Frontier Medical Engineering, Chiba University, Chiba, Japan
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21
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Patel E, Ramaiah P, Mamaril-Davis JC, Bauer IL, Koujah D, Seideman T, Kelbert J, Nosova K, Bina RW. Outcome differences between males and females undergoing deep brain stimulation for treatment-resistant depression: systematic review and individual patient data meta-analysis. J Affect Disord 2024; 351:481-488. [PMID: 38296058 DOI: 10.1016/j.jad.2024.01.251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/22/2024] [Accepted: 01/26/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND Treatment-resistant depression (TRD) occurs more commonly in women. Deep brain stimulation (DBS) is an emerging treatment for TRD, and its efficacy continues to be explored. However, differences in treatment outcomes between males and females have yet to be explored in formal analysis. METHODS A PRISMA-compliant systematic review of DBS for TRD studies was conducted. Patient-level data were independently extracted by two authors. Treatment response was defined as a 50 % or greater reduction in depression score. Percent change in depression scores by gender were evaluated using random-effects analyses. RESULTS Of 737 records, 19 studies (129 patients) met inclusion criteria. The mean reduction in depression score for females was 57.7 % (95 % CI, 64.33 %-51.13 %), whereas for males it was 35.2 % (95 % CI, 45.12 %-25.23 %) (p < 0.0001). Females were more likely to respond to DBS for TRD when compared to males (OR = 2.44, 95 % CI 1.06, 1.95). These differences varied in significance when stratified by DBS anatomical target, age, and timeframe for responder classification. LIMITATIONS Studies included were open-label trials with small sample sizes. CONCLUSIONS Our findings suggest that females with TRD respond at higher rates to DBS treatment than males. Further research is needed to elucidate the implications of these results, which may include connectomic sexual dimorphism, depression phenotype variations, or unrecognized symptom reporting differences. Methodological standardization of outcome scales, granular demographic data, and individual subject outcomes would allow for more robust comparisons between trials.
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Affiliation(s)
- Ekta Patel
- University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Priya Ramaiah
- University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | | | - Isabel L Bauer
- University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Dalia Koujah
- University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Travis Seideman
- University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - James Kelbert
- University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Kristin Nosova
- Department of Neurosurgery, Banner University Medical Center/University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Robert W Bina
- Department of Neurosurgery, Banner University Medical Center/University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA.
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22
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Seas A, Noor MS, Choi KS, Veerakumar A, Obatusin M, Dahill-Fuchel J, Tiruvadi V, Xu E, Riva-Posse P, Rozell CJ, Mayberg HS, McIntyre CC, Waters AC, Howell B. Subcallosal cingulate deep brain stimulation evokes two distinct cortical responses via differential white matter activation. Proc Natl Acad Sci U S A 2024; 121:e2314918121. [PMID: 38527192 PMCID: PMC10998591 DOI: 10.1073/pnas.2314918121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 02/20/2024] [Indexed: 03/27/2024] Open
Abstract
Subcallosal cingulate (SCC) deep brain stimulation (DBS) is an emerging therapy for refractory depression. Good clinical outcomes are associated with the activation of white matter adjacent to the SCC. This activation produces a signature cortical evoked potential (EP), but it is unclear which of the many pathways in the vicinity of SCC is responsible for driving this response. Individualized biophysical models were built to achieve selective engagement of two target bundles: either the forceps minor (FM) or cingulum bundle (CB). Unilateral 2 Hz stimulation was performed in seven patients with treatment-resistant depression who responded to SCC DBS, and EPs were recorded using 256-sensor scalp electroencephalography. Two distinct EPs were observed: a 120 ms symmetric response spanning both hemispheres and a 60 ms asymmetrical EP. Activation of FM correlated with the symmetrical EPs, while activation of CB was correlated with the asymmetrical EPs. These results support prior model predictions that these two pathways are predominantly activated by clinical SCC DBS and provide first evidence of a link between cortical EPs and selective fiber bundle activation.
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Affiliation(s)
- Andreas Seas
- Department of Biomedical Engineering, Duke University, Durham, NC27708
- Department of Neurosurgery, Duke University, Durham, NC27708
| | - M. Sohail Noor
- Department of Biomedical Engineering, Duke University, Durham, NC27708
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH10900
| | - Ki Sueng Choi
- Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY10029
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA30329
| | - Ashan Veerakumar
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA30329
| | - Mosadoluwa Obatusin
- Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY10029
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA30329
| | - Jacob Dahill-Fuchel
- Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY10029
| | - Vineet Tiruvadi
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA30329
| | - Elisa Xu
- Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY10029
| | - Patricio Riva-Posse
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA30329
| | - Christopher J. Rozell
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA30332
| | - Helen S. Mayberg
- Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY10029
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA30329
| | - Cameron C. McIntyre
- Department of Biomedical Engineering, Duke University, Durham, NC27708
- Department of Neurosurgery, Duke University, Durham, NC27708
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH10900
| | - Allison C. Waters
- Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY10029
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA30329
| | - Bryan Howell
- Department of Biomedical Engineering, Duke University, Durham, NC27708
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH10900
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23
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Johnson KA, Okun MS, Scangos KW, Mayberg HS, de Hemptinne C. Deep brain stimulation for refractory major depressive disorder: a comprehensive review. Mol Psychiatry 2024; 29:1075-1087. [PMID: 38287101 DOI: 10.1038/s41380-023-02394-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 12/18/2023] [Accepted: 12/21/2023] [Indexed: 01/31/2024]
Abstract
Deep brain stimulation (DBS) has emerged as a promising treatment for select patients with refractory major depressive disorder (MDD). The clinical effectiveness of DBS for MDD has been demonstrated in meta-analyses, open-label studies, and a few controlled studies. However, randomized controlled trials have yielded mixed outcomes, highlighting challenges that must be addressed prior to widespread adoption of DBS for MDD. These challenges include tracking MDD symptoms objectively to evaluate the clinical effectiveness of DBS with sensitivity and specificity, identifying the patient population that is most likely to benefit from DBS, selecting the optimal patient-specific surgical target and stimulation parameters, and understanding the mechanisms underpinning the therapeutic benefits of DBS in the context of MDD pathophysiology. In this review, we provide an overview of the latest clinical evidence of MDD DBS effectiveness and the recent technological advancements that could transform our understanding of MDD pathophysiology, improve the clinical outcomes for MDD DBS, and establish a path forward to develop more effective neuromodulation therapies to alleviate depressive symptoms.
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Affiliation(s)
- Kara A Johnson
- Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Michael S Okun
- Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Katherine W Scangos
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Helen S Mayberg
- Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Coralie de Hemptinne
- Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA.
- Department of Neurology, University of Florida, Gainesville, FL, USA.
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24
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Leserri S, Segura-Amil A, Nowacki A, Debove I, Petermann K, Schäppi L, Preti MG, Van De Ville D, Pollo C, Walther S, Nguyen TAK. Linking connectivity of deep brain stimulation of nucleus accumbens area with clinical depression improvements: a retrospective longitudinal case series. Eur Arch Psychiatry Clin Neurosci 2024; 274:685-696. [PMID: 37668723 PMCID: PMC10994999 DOI: 10.1007/s00406-023-01683-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 08/14/2023] [Indexed: 09/06/2023]
Abstract
Treatment-resistant depression is a severe form of major depressive disorder and deep brain stimulation is currently an investigational treatment. The stimulation's therapeutic effect may be explained through the functional and structural connectivities between the stimulated area and other brain regions, or to depression-associated networks. In this longitudinal, retrospective study, four female patients with treatment-resistant depression were implanted for stimulation in the nucleus accumbens area at our center. We analyzed the structural and functional connectivity of the stimulation area: the structural connectivity was investigated with probabilistic tractography; the functional connectivity was estimated by combining patient-specific stimulation volumes and a normative functional connectome. These structural and functional connectivity profiles were then related to four clinical outcome scores. At 1-year follow-up, the remission rate was 66%. We observed a consistent structural connectivity to Brodmann area 25 in the patient with the longest remission phase. The functional connectivity analysis resulted in patient-specific R-maps describing brain areas significantly correlated with symptom improvement in this patient, notably the prefrontal cortex. But the connectivity analysis was mixed across patients, calling for confirmation in a larger cohort and over longer time periods.
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Affiliation(s)
- Simona Leserri
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- ARTORG Center for Biomedical Engineering Research, University Bern, Bern, Switzerland
- Neuro-X Institute, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Alba Segura-Amil
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- ARTORG Center for Biomedical Engineering Research, University Bern, Bern, Switzerland
| | - Andreas Nowacki
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ines Debove
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Katrin Petermann
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lea Schäppi
- Translational Research Center, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Maria Giulia Preti
- Neuro-X Institute, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
- CIBM Center for Biomedical Imaging, Lausanne, Switzerland
- Department of Radiology and Medical InformaticsFaculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Dimitri Van De Ville
- Neuro-X Institute, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
- CIBM Center for Biomedical Imaging, Lausanne, Switzerland
- Department of Radiology and Medical InformaticsFaculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Claudio Pollo
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sebastian Walther
- Translational Research Center, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - T A Khoa Nguyen
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
- ARTORG Center for Biomedical Engineering Research, University Bern, Bern, Switzerland.
- ARTORG IGT, Murtenstrasse 50, 3008, Bern, Switzerland.
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25
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Ranjan M, Mahoney JJ, Rezai AR. Neurosurgical neuromodulation therapy for psychiatric disorders. Neurotherapeutics 2024; 21:e00366. [PMID: 38688105 PMCID: PMC11070709 DOI: 10.1016/j.neurot.2024.e00366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 04/09/2024] [Accepted: 04/16/2024] [Indexed: 05/02/2024] Open
Abstract
Psychiatric disorders are among the leading contributors to global disease burden and disability. A significant portion of patients with psychiatric disorders remain treatment-refractory to best available therapy. With insights from the neurocircuitry of psychiatric disorders and extensive experience of neuromodulation with deep brain stimulation (DBS) in movement disorders, DBS is increasingly being considered to modulate the neural network in psychiatric disorders. Currently, obsessive-compulsive disorder (OCD) is the only U.S. FDA (United States Food and Drug Administration) approved DBS indication for psychiatric disorders. Medically refractory depression, addiction, and other psychiatric disorders are being explored for DBS neuromodulation. Studies evaluating DBS for psychiatric disorders are promising but lack larger, controlled studies. This paper presents a brief review and the current state of DBS and other neurosurgical neuromodulation therapies for OCD and other psychiatric disorders. We also present a brief review of MR-guided Focused Ultrasound (MRgFUS), a novel form of neurosurgical neuromodulation, which can target deep subcortical structures similar to DBS, but in a noninvasive fashion. Early experiences of neurosurgical neuromodulation therapies, including MRgFUS neuromodulation are encouraging in psychiatric disorders; however, they remain investigational. Currently, DBS and VNS are the only FDA approved neurosurgical neuromodulation options in properly selected cases of OCD and depression, respectively.
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Affiliation(s)
- Manish Ranjan
- Department of Neurosurgery, WVU Rockefeller Neuroscience Institute, Morgantown, WV, USA.
| | - James J Mahoney
- Department of Behavioral Medicine and Psychiatry, WVU Rockefeller Neuroscience Institute, Morgantown, WV, USA; Department of Neuroscience, WVU Rockefeller Neuroscience Institute, Morgantown, WV, USA
| | - Ali R Rezai
- Department of Neurosurgery, WVU Rockefeller Neuroscience Institute, Morgantown, WV, USA; Department of Neuroscience, WVU Rockefeller Neuroscience Institute, Morgantown, WV, USA
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26
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Hamani C, Davidson B, Lipsman N, Abrahao A, Nestor SM, Rabin JS, Giacobbe P, Pagano RL, Campos ACP. Insertional effect following electrode implantation: an underreported but important phenomenon. Brain Commun 2024; 6:fcae093. [PMID: 38707711 PMCID: PMC11069120 DOI: 10.1093/braincomms/fcae093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/08/2023] [Accepted: 03/26/2024] [Indexed: 05/07/2024] Open
Abstract
Deep brain stimulation has revolutionized the treatment of movement disorders and is gaining momentum in the treatment of several other neuropsychiatric disorders. In almost all applications of this therapy, the insertion of electrodes into the target has been shown to induce some degree of clinical improvement prior to stimulation onset. Disregarding this phenomenon, commonly referred to as 'insertional effect', can lead to biased results in clinical trials, as patients receiving sham stimulation may still experience some degree of symptom amelioration. Similar to the clinical scenario, an improvement in behavioural performance following electrode implantation has also been reported in preclinical models. From a neurohistopathologic perspective, the insertion of electrodes into the brain causes an initial trauma and inflammatory response, the activation of astrocytes, a focal release of gliotransmitters, the hyperexcitability of neurons in the vicinity of the implants, as well as neuroplastic and circuitry changes at a distance from the target. Taken together, it would appear that electrode insertion is not an inert process, but rather triggers a cascade of biological processes, and, as such, should be considered alongside the active delivery of stimulation as an active part of the deep brain stimulation therapy.
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Affiliation(s)
- Clement Hamani
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Benjamin Davidson
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Nir Lipsman
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Agessandro Abrahao
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Sean M Nestor
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Jennifer S Rabin
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto M5G 1V7, Canada
| | - Peter Giacobbe
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Rosana L Pagano
- Laboratory of Neuroscience, Hospital Sírio-Libanês, São Paulo, SP CEP 01308-060, Brazil
| | - Ana Carolina P Campos
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Laboratory of Neuroscience, Hospital Sírio-Libanês, São Paulo, SP CEP 01308-060, Brazil
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27
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Unadkat P, Quevedo J, Soares J, Fenoy A. Opportunities and challenges for the use of deep brain stimulation in the treatment of refractory major depression. DISCOVER MENTAL HEALTH 2024; 4:9. [PMID: 38483709 PMCID: PMC10940557 DOI: 10.1007/s44192-024-00062-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 03/08/2024] [Indexed: 03/17/2024]
Abstract
Major Depressive Disorder continues to remain one of the most prevalent psychiatric diseases globally. Despite multiple trials of conventional therapies, a subset of patients fail to have adequate benefit to treatment. Deep brain stimulation (DBS) is a promising treatment in this difficult to treat population and has shown strong antidepressant effects across multiple cohorts. Nearly two decades of work have provided insights into the potential for chronic focal stimulation in precise brain targets to modulate pathological brain circuits that are implicated in the pathogenesis of depression. In this paper we review the rationale that prompted the selection of various brain targets for DBS, their subsequent clinical outcomes and common adverse events reported. We additionally discuss some of the pitfalls and challenges that have prevented more widespread adoption of this technology as well as future directions that have shown promise in improving therapeutic efficacy of DBS in the treatment of depression.
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Affiliation(s)
- Prashin Unadkat
- Elmezzi Graduate School of Molecular Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, USA
| | - Joao Quevedo
- Center of Excellence On Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, (UT Health), Houston, TX, USA
| | - Jair Soares
- Center of Excellence On Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, (UT Health), Houston, TX, USA
| | - Albert Fenoy
- Elmezzi Graduate School of Molecular Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA.
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, USA.
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA.
- Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, USA.
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine, Feinstein Institutes for Medical Research, Northwell Health, 805 Northern Boulevard, Suite 100, Great Neck, NY, 11021, USA.
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28
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Zrinzo L. Severe Refractory Obsessive Compulsive Disorder and Depression: Should We Consider Stereotactic Neurosurgery? Neuropsychiatr Dis Treat 2024; 20:469-478. [PMID: 38463457 PMCID: PMC10921944 DOI: 10.2147/ndt.s407210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 02/22/2024] [Indexed: 03/12/2024] Open
Abstract
Functional neurosurgery involves modulation of activity within neural circuits that drive pathological activity. Neurologists and neurosurgeons have worked closely together, advancing the field for over a century, such that neurosurgical procedures for movement disorders are now accepted as "standard of care", benefiting hundreds of thousands of patients. As with movement disorders, some neuropsychiatric illnesses, including obsessive compulsive disorder and depression, can be framed as disorders of neural networks. Over the past two decades, evidence has accumulated that stereotactic neurosurgery can help some patients with mental disorders. Nevertheless, despite the availability of class I evidence for some interventions, there is a huge mismatch between the prevalence of severe refractory mental disorders and the number of referrals made to specialised functional neurosurgery services. This paper examines the historical trajectory of neurosurgery for movement and mental disorders. A review of neurosurgical techniques, including stereotactic radiofrequency ablation, gamma knife, deep brain stimulation, and magnetic resonance imaging guided focused ultrasound, explains the high degree of safety afforded by technological advances in the field. Evidence from clinical trials supporting functional neurosurgery for mental disorders, including obsessive compulsive disorder and depression, is presented. An improved understanding of modern functional neurosurgery should foster collaboration between psychiatry and neurosurgery, providing hope to patients whose symptoms are refractory to all other treatments.
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Affiliation(s)
- Ludvic Zrinzo
- Unit of Functional Neurosurgery, UCL Queen Square Institute of Neurology, London, UK
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29
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Ramasubbu R, Brown EC, Mouches P, Moore JA, Clark DL, Molnar CP, Kiss ZHT, Forkert ND. Multimodal imaging measures in the prediction of clinical response to deep brain stimulation for refractory depression: A machine learning approach. World J Biol Psychiatry 2024; 25:175-187. [PMID: 38185882 DOI: 10.1080/15622975.2023.2300795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/27/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVES This study compared machine learning models using unimodal imaging measures and combined multi-modal imaging measures for deep brain stimulation (DBS) outcome prediction in treatment resistant depression (TRD). METHODS Regional brain glucose metabolism (CMRGlu), cerebral blood flow (CBF), and grey matter volume (GMV) were measured at baseline using 18F-fluorodeoxy glucose (18F-FDG) positron emission tomography (PET), arterial spin labelling (ASL) magnetic resonance imaging (MRI), and T1-weighted MRI, respectively, in 19 patients with TRD receiving subcallosal cingulate (SCC)-DBS. Responders (n = 9) were defined by a 50% reduction in HAMD-17 at 6 months from the baseline. Using an atlas-based approach, values of each measure were determined for pre-selected brain regions. OneR feature selection algorithm and the naïve Bayes model was used for classification. Leave-out-one cross validation was used for classifier evaluation. RESULTS The performance accuracy of the CMRGlu classification model (84%) was greater than CBF (74%) or GMV (74%) models. The classification model using the three image modalities together led to a similar accuracy (84%0 compared to the CMRGlu classification model. CONCLUSIONS CMRGlu imaging measures may be useful for the development of multivariate prediction models for SCC-DBS studies for TRD. The future of multivariate methods for multimodal imaging may rest on the selection of complementing features and the developing better models.Clinical Trial Registration: ClinicalTrials.gov (#NCT01983904).
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Affiliation(s)
- Rajamannar Ramasubbu
- Department of Psychiatry, Clinical Neurosciences, Mathison Centre for Mental Health Research & Education, Calgary, Alberta, Canada
- Hotchkiss Brain Institute Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Elliot C Brown
- School of Health and Care Management, Arden University, Berlin, Germany
| | - Pauline Mouches
- Department of Radiology, Clinical Neurosciences, Hotchkiss Brain Institute, Cumming school of medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jasmine A Moore
- Department of Radiology, Clinical Neurosciences, Hotchkiss Brain Institute, Cumming school of medicine, University of Calgary, Calgary, Alberta, Canada
| | - Darren L Clark
- Department of Psychiatry, Clinical Neurosciences, Mathison Centre for Mental Health Research & Education, Calgary, Alberta, Canada
- Hotchkiss Brain Institute Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christine P Molnar
- Department of Radiology, Cumming school of medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zelma H T Kiss
- Department of Psychiatry, Clinical Neurosciences, Mathison Centre for Mental Health Research & Education, Calgary, Alberta, Canada
- Hotchkiss Brain Institute Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nils D Forkert
- Department of Radiology, Clinical Neurosciences, Hotchkiss Brain Institute, Cumming school of medicine, University of Calgary, Calgary, Alberta, Canada
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30
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Bader ER, Boro AD, Killian NJ, Eskandar EN. A method for precisely timed, on-demand intracranial stimulation using the RNS device. Brain Stimul 2024; 17:444-447. [PMID: 38554856 DOI: 10.1016/j.brs.2024.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/20/2024] [Accepted: 03/24/2024] [Indexed: 04/02/2024] Open
Affiliation(s)
- Edward R Bader
- Department of Neurological Surgery, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Alexis D Boro
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Nathaniel J Killian
- Department of Neurological Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Emad N Eskandar
- Department of Neurological Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
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Allawala A, Bijanki KR, Oswalt D, Mathura RK, Adkinson J, Pirtle V, Shofty B, Robinson M, Harrison MT, Mathew SJ, Goodman WK, Pouratian N, Sheth SA, Borton DA. Prefrontal network engagement by deep brain stimulation in limbic hubs. Front Hum Neurosci 2024; 17:1291315. [PMID: 38283094 PMCID: PMC10813208 DOI: 10.3389/fnhum.2023.1291315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/26/2023] [Indexed: 01/30/2024] Open
Abstract
Prefrontal circuits in the human brain play an important role in cognitive and affective processing. Neuromodulation therapies delivered to certain key hubs within these circuits are being used with increasing frequency to treat a host of neuropsychiatric disorders. However, the detailed neurophysiological effects of stimulation to these hubs are largely unknown. Here, we performed intracranial recordings across prefrontal networks while delivering electrical stimulation to two well-established white matter hubs involved in cognitive regulation and depression: the subcallosal cingulate (SCC) and ventral capsule/ventral striatum (VC/VS). We demonstrate a shared frontotemporal circuit consisting of the ventromedial prefrontal cortex, amygdala, and lateral orbitofrontal cortex where gamma oscillations are differentially modulated by stimulation target. Additionally, we found participant-specific responses to stimulation in the dorsal anterior cingulate cortex and demonstrate the capacity for further tuning of neural activity using current-steered stimulation. Our findings indicate a potential neurophysiological mechanism for the dissociable therapeutic effects seen across the SCC and VC/VS targets for psychiatric neuromodulation and our results lay the groundwork for personalized, network-guided neurostimulation therapy.
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Affiliation(s)
- Anusha Allawala
- School of Engineering, Brown University, Providence, RI, United States
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Kelly R. Bijanki
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Denise Oswalt
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Raissa K. Mathura
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Joshua Adkinson
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Victoria Pirtle
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Ben Shofty
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, United States
| | - Meghan Robinson
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Matthew T. Harrison
- Division of Applied Mathematics, Brown University, Providence, RI, United States
| | - Sanjay J. Mathew
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Wayne K. Goodman
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Nader Pouratian
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, TX, United States
| | - Sameer A. Sheth
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - David A. Borton
- School of Engineering, Brown University, Providence, RI, United States
- Department of Veterans Affairs, Center for Neurorestoration and Neurotechnology, Providence, RI, United States
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Sellers KK, Cohen JL, Khambhati AN, Fan JM, Lee AM, Chang EF, Krystal AD. Closed-loop neurostimulation for the treatment of psychiatric disorders. Neuropsychopharmacology 2024; 49:163-178. [PMID: 37369777 PMCID: PMC10700557 DOI: 10.1038/s41386-023-01631-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/31/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023]
Abstract
Despite increasing prevalence and huge personal and societal burden, psychiatric diseases still lack treatments which can control symptoms for a large fraction of patients. Increasing insight into the neurobiology underlying these diseases has demonstrated wide-ranging aberrant activity and functioning in multiple brain circuits and networks. Together with varied presentation and symptoms, this makes one-size-fits-all treatment a challenge. There has been a resurgence of interest in the use of neurostimulation as a treatment for psychiatric diseases. Initial studies using continuous open-loop stimulation, in which clinicians adjusted stimulation parameters during patient visits, showed promise but also mixed results. Given the periodic nature and fluctuations of symptoms often observed in psychiatric illnesses, the use of device-driven closed-loop stimulation may provide more effective therapy. The use of a biomarker, which is correlated with specific symptoms, to deliver stimulation only during symptomatic periods allows for the personalized therapy needed for such heterogeneous disorders. Here, we provide the reader with background motivating the use of closed-loop neurostimulation for the treatment of psychiatric disorders. We review foundational studies of open- and closed-loop neurostimulation for neuropsychiatric indications, focusing on deep brain stimulation, and discuss key considerations when designing and implementing closed-loop neurostimulation.
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Affiliation(s)
- Kristin K Sellers
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Joshua L Cohen
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - Ankit N Khambhati
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Joline M Fan
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, CA, USA
| | - A Moses Lee
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - Edward F Chang
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Andrew D Krystal
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA.
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Theiss P, Pucci FG, Slavin KV. Invasive Neuromodulation Techniques for Treatment-Resistant Depression. Curr Top Behav Neurosci 2024; 66:297-311. [PMID: 38082109 DOI: 10.1007/7854_2023_460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2024]
Abstract
Surgically implanted neurostimulation devices for the treatment of depression have been studied for the last three decades. While the surgical risk associated with these treatment approaches clearly limits their use to the most severely impacted depressed patients, they offer a unique opportunity to better understand the impact of relatively localized alteration of neural activity in patient groups. As a result, these approaches provide a strict test of the role of individual neural structures or networks in mechanistic models of depression. In this chapter, we review the proposed mechanisms of action and evidence for clinical efficacy of vagal nerve stimulation, deep brain stimulation, and epidural cortical stimulation in patients with depression. The evidence for efficacy remains limited for all three modalities, but the long-term follow-up studies of treated patients have highlighted the importance of interactions between neural regions in determining therapeutic response, and suggest that personalized approaches to stimulation are likely to be required.
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Affiliation(s)
- Peter Theiss
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Francesco G Pucci
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA.
- Neurology Section, Jesse Brown Veterans Administration Medical Center, Chicago, IL, USA.
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Chan JL, Carpentier AV, Middlebrooks EH, Okun MS, Wong JK. Current perspectives on tractography-guided deep brain stimulation for the treatment of mood disorders. Expert Rev Neurother 2024; 24:11-24. [PMID: 38037329 DOI: 10.1080/14737175.2023.2289573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/27/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION Deep brain stimulation (DBS) is an emerging therapy for mood disorders, particularly treatment-resistant depression (TRD). Different brain areas implicated in depression-related brain networks have been investigated as DBS targets and variable clinical outcomes highlight the importance of target identification. Tractography has provided insight into how DBS modulates disorder-related brain networks and is being increasingly used to guide DBS for psychiatric disorders. AREAS COVERED In this perspective, an overview of the current state of DBS for TRD and the principles of tractography is provided. Next, a comprehensive review of DBS targets is presented with a focus on tractography. Finally, the challenges and future directions of tractography-guided DBS are discussed. EXPERT OPINION Tractography-guided DBS is a promising tool for improving DBS outcomes for mood disorders. Tractography is particularly useful for targeting patient-specific white matter tracts that are not visible using conventional structural MRI. Developments in tractography methods will help refine DBS targeting for TRD and may facilitate symptom-specific precision neuromodulation. Ultimately, the standardization of tractography methods will be essential to transforming DBS into an established therapy for mood disorders.
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Affiliation(s)
- Jason L Chan
- Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, Florida, USA
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Ariane V Carpentier
- Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, Florida, USA
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | | | - Michael S Okun
- Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, Florida, USA
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Joshua K Wong
- Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, Florida, USA
- Department of Neurology, University of Florida, Gainesville, Florida, USA
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Widge AS. Closing the loop in psychiatric deep brain stimulation: physiology, psychometrics, and plasticity. Neuropsychopharmacology 2024; 49:138-149. [PMID: 37415081 PMCID: PMC10700701 DOI: 10.1038/s41386-023-01643-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/28/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023]
Abstract
Deep brain stimulation (DBS) is an invasive approach to precise modulation of psychiatrically relevant circuits. Although it has impressive results in open-label psychiatric trials, DBS has also struggled to scale to and pass through multi-center randomized trials. This contrasts with Parkinson disease, where DBS is an established therapy treating thousands of patients annually. The core difference between these clinical applications is the difficulty of proving target engagement, and of leveraging the wide range of possible settings (parameters) that can be programmed in a given patient's DBS. In Parkinson's, patients' symptoms change rapidly and visibly when the stimulator is tuned to the correct parameters. In psychiatry, those same changes take days to weeks, limiting a clinician's ability to explore parameter space and identify patient-specific optimal settings. I review new approaches to psychiatric target engagement, with an emphasis on major depressive disorder (MDD). Specifically, I argue that better engagement may come by focusing on the root causes of psychiatric illness: dysfunction in specific, measurable cognitive functions and in the connectivity and synchrony of distributed brain circuits. I overview recent progress in both those domains, and how it may relate to other technologies discussed in companion articles in this issue.
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Affiliation(s)
- Alik S Widge
- Department of Psychiatry & Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA.
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36
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Downar J, Siddiqi SH, Mitra A, Williams N, Liston C. Mechanisms of Action of TMS in the Treatment of Depression. Curr Top Behav Neurosci 2024; 66:233-277. [PMID: 38844713 DOI: 10.1007/7854_2024_483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2024]
Abstract
Transcranial magnetic stimulation (TMS) is entering increasingly widespread use in treating depression. The most common stimulation target, in the dorsolateral prefrontal cortex (DLPFC), emerged from early neuroimaging studies in depression. Recently, more rigorous casual methods have revealed whole-brain target networks and anti-networks based on the effects of focal brain lesions and focal brain stimulation on depression symptoms. Symptom improvement during therapeutic DLPFC-TMS appears to involve directional changes in signaling between the DLPFC, subgenual and dorsal anterior cingulate cortex, and salience-network regions. However, different networks may be involved in the therapeutic mechanisms for other TMS targets in depression, such as dorsomedial prefrontal cortex or orbitofrontal cortex. The durability of therapeutic effects for TMS involves synaptic neuroplasticity, and specifically may depend upon dopamine acting at the D1 receptor family, as well as NMDA-receptor-dependent synaptic plasticity mechanisms. Although TMS protocols are classically considered 'excitatory' or 'inhibitory', the actual effects in individuals appear quite variable, and might be better understood at the level of populations of synapses rather than individual synapses. Synaptic meta-plasticity may provide a built-in protective mechanism to avoid runaway facilitation or inhibition during treatment, and may account for the relatively small number of patients who worsen rather than improve with TMS. From an ethological perspective, the antidepressant effects of TMS may involve promoting a whole-brain attractor state associated with foraging/hunting behaviors, centered on the rostrolateral periaqueductal gray and salience network, and suppressing an attractor state associated with passive threat defense, centered on the ventrolateral periaqueductal gray and default-mode network.
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Affiliation(s)
- Jonathan Downar
- Department of Psychiatry, Faculty of Medicine, Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada.
| | - Shan H Siddiqi
- Center for Brain Circuit Therapeutics, Brigham & Women's Hospital, Boston, MA, USA
- Department of Psychiatry, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anish Mitra
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Nolan Williams
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Conor Liston
- Department of Psychiatry, Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
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Liu F, Huang S, Guo D, Li X, Han Y. Deep brain stimulation of ventromedial prefrontal cortex reverses depressive-like behaviors via BDNF/TrkB signaling pathway in rats. Life Sci 2023; 334:122222. [PMID: 38084673 DOI: 10.1016/j.lfs.2023.122222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/18/2023] [Accepted: 10/26/2023] [Indexed: 12/18/2023]
Abstract
AIM Deep brain stimulation (DBS) is currently under investigation as a potential therapeutic approach for managing major depressive disorder (MDD) and ventromedial prefrontal cortex (vmPFC) is recognized as a promising target region. Therefore, the present study aimed to investigate a preclinical paradigm of bilateral vmPFC DBS and examine the molecular mechanisms underlying its antidepressant-like effects using chronic unpredictable stress (CUS) model in rats. MAIN METHODS Male rats were subjected to stereotaxic surgery and deep brain stimulation paradigm in non-stressed and CUS rats respectively, and the therapeutic effect of DBS were assessed by a series of behavioral tests including sucrose preference test, open field test, elevated plus maze test, and forced swim test. The potential involvement of the BDNF/TrkB signaling pathway and its downstream effects in this process were also investigated using western blot. KEY FINDINGS We identified that a stimulation protocol consisting of 130 Hz, 200 μA, 90 μs pulses administered for 5 h per day over a period of 7 days effectively mitigated CUS-induced depressive-like and anxiety-like behaviors in rats. These therapeutic effects were associated with the enhancement of the BDNF/TrkB signaling pathway and its downstream ERK1/2 activity. SIGNIFICANCE These findings provide valuable insights into the potential clinical utility of vmPFC DBS as an approach of improving the symptoms experienced by individuals with MDD. This evidence contributes to our understanding of the neurobiological basis of depression and offers promise for the development of more effective treatments.
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Affiliation(s)
- Fanglin Liu
- National Institute on Drug Dependence and Beijing Key Laboratory of Drug Dependence Research, Peking University, Beijing 100191, China; Department of Neurobiology, School of Basic Medical Sciences, Peking University Health Science Center, Beijing 100191, China
| | - Shihao Huang
- National Institute on Drug Dependence and Beijing Key Laboratory of Drug Dependence Research, Peking University, Beijing 100191, China; Department of Neurobiology, School of Basic Medical Sciences, Peking University Health Science Center, Beijing 100191, China
| | - Dan Guo
- National Institute on Drug Dependence and Beijing Key Laboratory of Drug Dependence Research, Peking University, Beijing 100191, China; Department of Neurobiology, School of Basic Medical Sciences, Peking University Health Science Center, Beijing 100191, China
| | - Xin Li
- National Institute on Drug Dependence and Beijing Key Laboratory of Drug Dependence Research, Peking University, Beijing 100191, China
| | - Ying Han
- National Institute on Drug Dependence and Beijing Key Laboratory of Drug Dependence Research, Peking University, Beijing 100191, China.
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Rissardo JP, Vora NM, Tariq I, Mujtaba A, Caprara ALF. Deep Brain Stimulation for the Management of Refractory Neurological Disorders: A Comprehensive Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1991. [PMID: 38004040 PMCID: PMC10673515 DOI: 10.3390/medicina59111991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/04/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023]
Abstract
In recent decades, deep brain stimulation (DBS) has been extensively studied due to its reversibility and significantly fewer side effects. DBS is mainly a symptomatic therapy, but the stimulation of subcortical areas by DBS is believed to affect the cytoarchitecture of the brain, leading to adaptability and neurogenesis. The neurological disorders most commonly studied with DBS were Parkinson's disease, essential tremor, obsessive-compulsive disorder, and major depressive disorder. The most precise approach to evaluating the location of the leads still relies on the stimulus-induced side effects reported by the patients. Moreover, the adequate voltage and DBS current field could correlate with the patient's symptoms. Implantable pulse generators are the main parts of the DBS, and their main characteristics, such as rechargeable capability, magnetic resonance imaging (MRI) safety, and device size, should always be discussed with patients. The safety of MRI will depend on several parameters: the part of the body where the device is implanted, the part of the body scanned, and the MRI-tesla magnetic field. It is worth mentioning that drug-resistant individuals may have different pathophysiological explanations for their resistance to medications, which could affect the efficacy of DBS therapy. Therefore, this could explain the significant difference in the outcomes of studies with DBS in individuals with drug-resistant neurological conditions.
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Affiliation(s)
| | - Nilofar Murtaza Vora
- Medicine Department, Terna Speciality Hospital and Research Centre, Navi Mumbai 400706, India;
| | - Irra Tariq
- Medicine Department, United Medical & Dental College, Karachi 75600, Pakistan;
| | - Amna Mujtaba
- Medicine Department, Karachi Medical & Dental College, Karachi 74700, Pakistan;
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Runia N, Mol GJJ, Hillenius T, Hassanzadeh Z, Denys DAJP, Bergfeld IO. Effects of deep brain stimulation on cognitive functioning in treatment-resistant depression: a systematic review and meta-analysis. Mol Psychiatry 2023; 28:4585-4593. [PMID: 37730844 DOI: 10.1038/s41380-023-02262-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 08/31/2023] [Accepted: 09/08/2023] [Indexed: 09/22/2023]
Abstract
Deep brain stimulation (DBS) is a promising intervention for treatment-resistant depression (TRD). Effects on cognitive functioning are unclear since they have been studied in small samples. We aim to estimate the impact of DBS on cognitive functioning in TRD with a systematic review and meta-analyses. After systematically searching PubMed we included 10 studies which compared standardized neuropsychological tests before and after DBS or between active and sham DBS in TRD. Different random-effects meta-analyses were done for different cognitive (sub-)domains and for different follow-up time windows (<6 months, 6-18 months, and >18 months). We found no significant differences in cognitive functioning up to 6 months of DBS. After 6-18 months of DBS small to moderate improvements were found in verbal memory (Hedge's g = 0.22, 95% CI = [0.01-0.43], p = 0.04), visual memory (Hedge's g = 0.37, 95% CI = [0.03-0.71], p = 0.04), attention/psychomotor speed (Hedge's g = 0.26, 95% CI = [0.02-0.50], p = 0.04) and executive functioning (Hedge's g = 0.37, 95% CI = [0.15-0.59], p = 0.001). Not enough studies could be retrieved for a meta-analysis of effects after >18 months of DBS or for the comparison of active and sham DBS. Qualitatively, generally no differences in cognitive functioning between active and sham DBS were found. No cognitive decline was found in this meta-analysis up to 18 months of DBS in patients with TRD. Results even suggest small positive effects of DBS on cognitive functioning in TRD, although this should be interpreted with caution due to lack of controlled data.
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Affiliation(s)
- N Runia
- Department of Psychiatry, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam Neuroscience, Amsterdam, The Netherlands.
- Amsterdam Brain and Cognition, Amsterdam, The Netherlands.
| | - G J J Mol
- Department of Psychiatry, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - T Hillenius
- Department of Psychiatry, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Z Hassanzadeh
- Department of Psychiatry, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - D A J P Denys
- Department of Psychiatry, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Amsterdam, The Netherlands
- Amsterdam Brain and Cognition, Amsterdam, The Netherlands
| | - I O Bergfeld
- Department of Psychiatry, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Amsterdam, The Netherlands
- Amsterdam Brain and Cognition, Amsterdam, The Netherlands
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George MS, Huffman S, Doose J, Sun X, Dancy M, Faller J, Li X, Yuan H, Goldman RI, Sajda P, Brown TR. EEG synchronized left prefrontal transcranial magnetic stimulation (TMS) for treatment resistant depression is feasible and produces an entrainment dependent clinical response: A randomized controlled double blind clinical trial. Brain Stimul 2023; 16:1753-1763. [PMID: 38043646 PMCID: PMC10872322 DOI: 10.1016/j.brs.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 10/19/2023] [Accepted: 11/19/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND Synchronizing a TMS pulse with a person's underlying EEG rhythm can modify the brain's response. It is unclear if synchronizing rTMS trains might boost the antidepressant effect of TMS. In this first-in-human trial, we demonstrated that a single TMS pulse over the prefrontal cortex produces larger effects in the anterior cingulate depending on when it is fired relative to the individual's EEG alpha phase. OBJECTIVE/HYPOTHESES We had three hypotheses. 1) It is feasible to synchronize repetitive TMS (rTMS) delivery to a person's preferred prefrontal alpha phase in each train of every session during a 30-visit TMS depression treatment course. 2) EEG-synchronized rTMS would produce progressive entrainment greater than unsynchronized (UNSYNC) rTMS. And 3) SYNC TMS would have better antidepressant effects than UNSYNC (remission, final Hamilton Depression Rating <10). METHODS We enrolled (n = 34) and treated (n = 28) adults with treatment resistant depression (TRD) and randomized them to receive six weeks (30 treatments) of left prefrontal rTMS at their individual alpha frequency (IAF) (range 6-13 Hz). Prior to starting the clinical trial, all patients had an interleaved fMRI-EEG-TMS (fET) scan to determine which phase of their alpha rhythm would produce the largest BOLD response in their dorsal anterior cingulate. Our clinical EEG-rTMS system then delivered the first TMS pulse in each train time-locked to this patient-specific 'preferred phase' of each patient's left prefrontal alpha oscillation. We randomized patients (1:1) to SYNC or UNSYNC, and all were treated at their IAF. Only the SYNC patients had the first pulse of each train for all sessions synchronized to their individualized preferred alpha phase (75 trains/session ×30 sessions, 2250 synchronizations per patient over six weeks). The UNSYNC group used a random firing with respect to the alpha wave. All other TMS parameters were balanced between the two groups. The system interfaced with a MagStim Horizon air-cooled Fig. 8 TMS coil. All patients were treated at their IAF, coil in the F3 position, 120 % MT, frequency 6-13 Hz, 40 pulses per train, average 15-s inter-train interval, 3000 pulses per session. All patients, raters, and treaters were blinded. RESULTS In the intent to treat (ITT) sample, both groups had significant clinical improvement from baseline with no significant between-group differences, with the USYNC group having mathematically more remitters but fewer responders. (ITT -15 SYNC; 13 UNSYNC, response 5 (33 %), 1 (7 %), remission 2 (13 %), 6 (46 %). The same was true with the completer sample - 12 SYNC; 12 UNSYNC, response 4, 4 (both 30 %), remission 2 (17 %), 3 (25 %)). The clinical EEG phase synchronization system performed well with no failures. The average treatment session was approximately 90 min, with 30 min for placing the EEG cap and the actual TMS treatment for 45 min (which included gathering 10 min of resting EEG). Four subjects (1 SYNC) withdrew before six weeks of treatment. All 24 completer patients were treated for six weeks despite the trial occurring during the COVID pandemic. SYNC patients exhibited increased post-stimulation EEG entrainment over the six weeks. A detailed secondary analysis of entrainment data in the SYNC group showed that responders and non-responders in this group could be cleanly separated based on the total number of sessions with entrainment and the session-to-session precision of the entrained phase. For the SYNC group only, depression improvement was greater when more sessions were entrained at similar phases. CONCLUSIONS Synchronizing prefrontal TMS with a patient's prefrontal alpha frequency in a blinded clinical trial is possible and produces progressive EEG entrainment in synchronized patients only. There was no difference in overall clinical response in this small clinical trial. A secondary analysis showed that the consistency of the entrained phase across sessions was significantly associated with response outcome only in the SYNC group. These effects may not simply be due to how the stimulation is delivered but also whether the patient's brain can reliably entrain to a precise phase. EEG-synchronized clinical delivery of TMS is feasible and requires further study to determine the best method for determining the phase for synchronization.
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Affiliation(s)
- Mark S George
- Brain Stimulation Division, Psychiatry, MUSC, Charleston, SC, USA; Ralph H. Johnson VA Medical Center, Charleston SC, USA.
| | - Sarah Huffman
- Brain Stimulation Division, Psychiatry, MUSC, Charleston, SC, USA
| | - Jayce Doose
- Department of Radiology, MUSC, Charleston, SC, USA
| | - Xiaoxiao Sun
- Department of Biomedical Engineering, Columbia University, New York, NY, USA
| | - Morgan Dancy
- Brain Stimulation Division, Psychiatry, MUSC, Charleston, SC, USA
| | - Josef Faller
- Department of Biomedical Engineering, Columbia University, New York, NY, USA
| | - Xingbao Li
- Brain Stimulation Division, Psychiatry, MUSC, Charleston, SC, USA
| | - Han Yuan
- Bioengineering Dept, University of Oklahoma, Norman, OK, USA
| | | | - Paul Sajda
- Department of Biomedical Engineering, Columbia University, New York, NY, USA; Department of Radiology, Columbia University Irving Medical Center, New York, NY, USA
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Scherer M, Harmsen IE, Samuel N, Elias GJB, Germann J, Boutet A, MacLeod CE, Giacobbe P, Rowland NC, Lozano AM, Milosevic L. Oscillatory network markers of subcallosal cingulate deep brain stimulation for depression. Brain Stimul 2023; 16:1764-1775. [PMID: 38061548 PMCID: PMC10947774 DOI: 10.1016/j.brs.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/12/2023] [Accepted: 11/27/2023] [Indexed: 12/24/2023] Open
Abstract
Identifying functional biomarkers related to treatment success can aid in expediting therapy optimization, as well as contribute to a better understanding of the neural mechanisms of the treatment-resistant depression (TRD) and subcallosal cingulate deep brain stimulation (SCC-DBS). Magnetoencephalography data were obtained from 16 individuals with SCC-DBS for TRD and 25 healthy subjects. The first objective of the study was to identify region-specific oscillatory modulations that both (i) discriminate individuals with TRD (with SCC-DBS OFF) from healthy controls, and (ii) discriminate TRD treatment responders from non-responders (with SCC-DBS ON). The second objective of this work was to further explore the effects of stimulation intensity and frequency on oscillatory activity in the identified brain regions of interest. Oscillatory power analyses led to the identification of brain regions that differentiated responders from non-responders based on modulations of increased alpha (8-12 Hz) and decreased gamma (32-116 Hz) power within nodes of the default mode, central executive, and somatomotor networks, Broca's area, and lingual gyrus. Within these nodes, it was also found that low stimulation frequency had stronger effects on oscillatory modulation than increased stimulation intensity. The identified functional network biomarkers implicate modulation of TRD-related activity in brain regions involved in emotional control/processing, motor control, and the interaction between speech, vision, and memory, which have all been implicated in depression. These electrophysiological biomarkers have the potential to be used as functional proxies for therapy optimization. Additional stimulation parameter analyses revealed that oscillatory modulations can be strengthened by increasing stimulation intensity or reducing frequency, which may represent potential avenues of direction in non-responders.
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Affiliation(s)
- M Scherer
- Krembil Brain Institute, University Health Network, Toronto, Canada; Institute of Biomedical Engineering, University of Toronto, Canada
| | - I E Harmsen
- Krembil Brain Institute, University Health Network, Toronto, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; Mitchell Goldhar MEG Unit, University Health Network, Toronto, Canada
| | - N Samuel
- Krembil Brain Institute, University Health Network, Toronto, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - G J B Elias
- Krembil Brain Institute, University Health Network, Toronto, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - J Germann
- Krembil Brain Institute, University Health Network, Toronto, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - A Boutet
- Krembil Brain Institute, University Health Network, Toronto, Canada; Joint Department of Medical Imaging, University of Toronto, Canada
| | - C E MacLeod
- Department of Psychology, Neuroscience & Behaviour, McMaster University, Hamilton, Ontario, Canada
| | - P Giacobbe
- Department of Psychiatry, Sunnybrook Health Sciences, University of Toronto, Toronto, Ontario, Canada
| | - N C Rowland
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA; Murray Center for Research on Parkinson's Disease and Related Disorders, Medical University of South Carolina, Charleston, SC, USA
| | - A M Lozano
- Krembil Brain Institute, University Health Network, Toronto, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada; Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Canada
| | - L Milosevic
- Krembil Brain Institute, University Health Network, Toronto, Canada; Institute of Biomedical Engineering, University of Toronto, Canada; Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Canada; KITE Research Institute, University Health Network, Toronto, Canada.
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Noecker AM, Mlakar J, Bijanki KR, Griswold MA, Pouratian N, Sheth SA, McIntyre CC. Stereo-EEG-guided network modulation for psychiatric disorders: Interactive holographic planning. Brain Stimul 2023; 16:1799-1805. [PMID: 38135359 PMCID: PMC10784872 DOI: 10.1016/j.brs.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Connectomic modeling studies are expanding understanding of the brain networks that are modulated by deep brain stimulation (DBS) therapies. However, explicit integration of these modeling results into prospective neurosurgical planning is only beginning to evolve. One challenge of employing connectomic models in patient-specific surgical planning is the inherent 3D nature of the results, which can make clinically useful data integration and visualization difficult. METHODS We developed a holographic stereotactic neurosurgery research tool (HoloSNS) that integrates patient-specific brain models into a group-based visualization environment for interactive surgical planning using connectomic hypotheses. HoloSNS currently runs on the HoloLens 2 platform and it enables remote networking between headsets. This allowed us to perform surgical planning group meetings with study co-investigators distributed across the country. RESULTS We used HoloSNS to plan stereo-EEG and DBS electrode placements for each patient participating in a clinical trial (NCT03437928) that is targeting both the subcallosal cingulate and ventral capsule for the treatment of depression. Each patient model consisted of multiple components of scientific data and anatomical reconstructions of the head and brain (both patient-specific and atlas-based), which far exceed the data integration capabilities of traditional neurosurgical planning workstations. This allowed us to prospectively discuss and evaluate the positioning of the electrodes based on novel connectomic hypotheses. CONCLUSIONS The 3D nature of the surgical procedure, brain imaging data, and connectomic modeling results all highlighted the utility of employing holographic visualization to support the design of unique clinical experiments to explore brain network modulation with DBS.
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Affiliation(s)
- Angela M Noecker
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA; Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Jeffrey Mlakar
- Interactive Commons, Case Western Reserve University, Cleveland, OH, USA
| | - Kelly R Bijanki
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Mark A Griswold
- Interactive Commons, Case Western Reserve University, Cleveland, OH, USA; Department of Radiology, Case Western Reserve University, Cleveland, OH, USA
| | - Nader Pouratian
- Department of Neurosurgery, University of Texas Southwestern, Dallas, TX, USA
| | - Sameer A Sheth
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Cameron C McIntyre
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA; Department of Biomedical Engineering, Duke University, Durham, NC, USA; Department of Neurosurgery, Duke University, Durham, NC, USA.
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McIntyre RS, Alsuwaidan M, Baune BT, Berk M, Demyttenaere K, Goldberg JF, Gorwood P, Ho R, Kasper S, Kennedy SH, Ly-Uson J, Mansur RB, McAllister-Williams RH, Murrough JW, Nemeroff CB, Nierenberg AA, Rosenblat JD, Sanacora G, Schatzberg AF, Shelton R, Stahl SM, Trivedi MH, Vieta E, Vinberg M, Williams N, Young AH, Maj M. Treatment-resistant depression: definition, prevalence, detection, management, and investigational interventions. World Psychiatry 2023; 22:394-412. [PMID: 37713549 PMCID: PMC10503923 DOI: 10.1002/wps.21120] [Citation(s) in RCA: 83] [Impact Index Per Article: 83.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/17/2023] Open
Abstract
Treatment-resistant depression (TRD) is common and associated with multiple serious public health implications. A consensus definition of TRD with demonstrated predictive utility in terms of clinical decision-making and health outcomes does not currently exist. Instead, a plethora of definitions have been proposed, which vary significantly in their conceptual framework. The absence of a consensus definition hampers precise estimates of the prevalence of TRD, and also belies efforts to identify risk factors, prevention opportunities, and effective interventions. In addition, it results in heterogeneity in clinical practice decision-making, adversely affecting quality of care. The US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have adopted the most used definition of TRD (i.e., inadequate response to a minimum of two antidepressants despite adequacy of the treatment trial and adherence to treatment). It is currently estimated that at least 30% of persons with depression meet this definition. A significant percentage of persons with TRD are actually pseudo-resistant (e.g., due to inadequacy of treatment trials or non-adherence to treatment). Although multiple sociodemographic, clinical, treatment and contextual factors are known to negatively moderate response in persons with depression, very few factors are regarded as predictive of non-response across multiple modalities of treatment. Intravenous ketamine and intranasal esketamine (co-administered with an antidepressant) are established as efficacious in the management of TRD. Some second-generation antipsychotics (e.g., aripiprazole, brexpiprazole, cariprazine, quetiapine XR) are proven effective as adjunctive treatments to antidepressants in partial responders, but only the olanzapine-fluoxetine combination has been studied in FDA-defined TRD. Repetitive transcranial magnetic stimulation (TMS) is established as effective and FDA-approved for individuals with TRD, with accelerated theta-burst TMS also recently showing efficacy. Electroconvulsive therapy is regarded as an effective acute and maintenance intervention in TRD, with preliminary evidence suggesting non-inferiority to acute intravenous ketamine. Evidence for extending antidepressant trial, medication switching and combining antidepressants is mixed. Manual-based psychotherapies are not established as efficacious on their own in TRD, but offer significant symptomatic relief when added to conventional antidepressants. Digital therapeutics are under study and represent a potential future clinical vista in this population.
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Affiliation(s)
- Roger S McIntyre
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Mohammad Alsuwaidan
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Bernhard T Baune
- Department of Psychiatry, University of Münster, Münster, Germany
- Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia
| | - Michael Berk
- Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia
- Deakin University IMPACT Institute, Geelong, VIC, Australia
| | - Koen Demyttenaere
- Department of Psychiatry, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Joseph F Goldberg
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Philip Gorwood
- Department of Psychiatry, Sainte-Anne Hospital, Paris, France
| | - Roger Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Institute for Health Innovation and Technology, National University of Singapore, Singapore
| | - Siegfried Kasper
- Department of Psychiatry and Psychotherapy and Center of Brain Research, Molecular Neuroscience Branch, Medical University of Vienna, Vienna, Austria
| | - Sidney H Kennedy
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Josefina Ly-Uson
- Department of Psychiatry and Behavioral Medicine, University of The Philippines College of Medicine, Manila, The Philippines
| | - Rodrigo B Mansur
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - R Hamish McAllister-Williams
- Northern Center for Mood Disorders, Translational and Clinical Research Institute, Newcastle University, and Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - James W Murrough
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Andrew A Nierenberg
- Dauten Family Center for Bipolar Treatment Innovation, Massachusetts General Hospital, Boston, MA, USA
| | - Joshua D Rosenblat
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Gerard Sanacora
- Department of Psychiatry, Yale University, New Haven, CT, USA
| | - Alan F Schatzberg
- Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA
| | - Richard Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stephen M Stahl
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Madhukar H Trivedi
- Department of Psychiatry, University of Illinois Chicago, Chicago, IL, USA
| | - Eduard Vieta
- Department of Psychiatry and Psychology, Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
| | - Maj Vinberg
- Mental Health Centre, Northern Zealand, Copenhagen University Hospital - Mental Health Services CPH, Copenhagen, Denmark
| | - Nolan Williams
- Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA
| | - Allan H Young
- Department of Psychological Medicine, King's College London, London, UK
| | - Mario Maj
- Department of Psychiatry, University of Campania "Luigi Vanvitelli", Naples, Italy
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Kozlov M. Is depression lifting? AI that interprets brain waves has answers. Nature 2023; 622:17. [PMID: 37740021 DOI: 10.1038/d41586-023-02979-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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Campos ACP, Pagano RL, Lipsman N, Hamani C. What do we know about astrocytes and the antidepressant effects of DBS? Exp Neurol 2023; 368:114501. [PMID: 37558154 DOI: 10.1016/j.expneurol.2023.114501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/29/2023] [Accepted: 08/05/2023] [Indexed: 08/11/2023]
Abstract
Treatment-resistant depression (TRD) is a debilitating condition that affects millions of individuals worldwide. Deep brain stimulation (DBS) has been widely used with excellent outcomes in neurological disorders such as Parkinson's disease, tremor, and dystonia. More recently, DBS has been proposed as an adjuvant therapy for TRD. To date, the antidepressant efficacy of DBS is still controversial, and its mechanisms of action remain poorly understood. Astrocytes are the most abundant cells in the nervous system. Once believed to be a "supporting" element for neuronal function, astrocytes are now recognized to play a major role in brain homeostasis, neuroinflammation and neuroplasticity. Because of its many roles in complex multi-factorial disorders, including TRD, understanding the effect of DBS on astrocytes is pivotal to improve our knowledge about the antidepressant effects of this therapy. In depression, the number of astrocytes and the expression of astrocytic markers are decreased. One of the potential consequences of this reduced astrocytic function is the development of aberrant glutamatergic neurotransmission, which has been documented in several models of depression-like behavior. Evidence from preclinical work suggests that DBS may directly influence astrocytic activity, modulating the release of gliotransmitters, reducing neuroinflammation, and altering structural tissue organization. Compelling evidence for an involvement of astrocytes in potential mechanisms of DBS derive from studies suggesting that pharmacological lesions or the inhibition of these cells abolishes the antidepressant-like effect of DBS. In this review, we summarize preclinical data suggesting that the modulation of astrocytes may be an important mechanism for the antidepressant-like effects of DBS.
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Affiliation(s)
- Ana Carolina P Campos
- Sunnybrook Research Institute, Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Centre, Toronto, Canada; Laboratory of Neuroscience, Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | - Rosana L Pagano
- Laboratory of Neuroscience, Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | - Nir Lipsman
- Sunnybrook Research Institute, Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Centre, Toronto, Canada; Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Clement Hamani
- Sunnybrook Research Institute, Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Centre, Toronto, Canada; Division of Neurosurgery, University of Toronto, Toronto, Canada.
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Alagapan S, Choi KS, Heisig S, Riva-Posse P, Crowell A, Tiruvadi V, Obatusin M, Veerakumar A, Waters AC, Gross RE, Quinn S, Denison L, O'Shaughnessy M, Connor M, Canal G, Cha J, Hershenberg R, Nauvel T, Isbaine F, Afzal MF, Figee M, Kopell BH, Butera R, Mayberg HS, Rozell CJ. Cingulate dynamics track depression recovery with deep brain stimulation. Nature 2023; 622:130-138. [PMID: 37730990 PMCID: PMC10550829 DOI: 10.1038/s41586-023-06541-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 08/09/2023] [Indexed: 09/22/2023]
Abstract
Deep brain stimulation (DBS) of the subcallosal cingulate (SCC) can provide long-term symptom relief for treatment-resistant depression (TRD)1. However, achieving stable recovery is unpredictable2, typically requiring trial-and-error stimulation adjustments due to individual recovery trajectories and subjective symptom reporting3. We currently lack objective brain-based biomarkers to guide clinical decisions by distinguishing natural transient mood fluctuations from situations requiring intervention. To address this gap, we used a new device enabling electrophysiology recording to deliver SCC DBS to ten TRD participants (ClinicalTrials.gov identifier NCT01984710). At the study endpoint of 24 weeks, 90% of participants demonstrated robust clinical response, and 70% achieved remission. Using SCC local field potentials available from six participants, we deployed an explainable artificial intelligence approach to identify SCC local field potential changes indicating the patient's current clinical state. This biomarker is distinct from transient stimulation effects, sensitive to therapeutic adjustments and accurate at capturing individual recovery states. Variable recovery trajectories are predicted by the degree of preoperative damage to the structural integrity and functional connectivity within the targeted white matter treatment network, and are matched by objective facial expression changes detected using data-driven video analysis. Our results demonstrate the utility of objective biomarkers in the management of personalized SCC DBS and provide new insight into the relationship between multifaceted (functional, anatomical and behavioural) features of TRD pathology, motivating further research into causes of variability in depression treatment.
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Affiliation(s)
- Sankaraleengam Alagapan
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Ki Sueng Choi
- Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stephen Heisig
- Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Patricio Riva-Posse
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Andrea Crowell
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Vineet Tiruvadi
- Wallace H. Coulter Department of Biomedical Engineering at Georgia Institute of Technology and Emory University, Atlanta, GA, USA
- Emory University School of Medicine, Atlanta, GA, USA
| | - Mosadoluwa Obatusin
- Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ashan Veerakumar
- Department of Psychiatry, Schulich School of Medicine and Dentistry at Western University, London, Ontario, Canada
| | - Allison C Waters
- Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Robert E Gross
- Wallace H. Coulter Department of Biomedical Engineering at Georgia Institute of Technology and Emory University, Atlanta, GA, USA
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Sinead Quinn
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Lydia Denison
- Emory University School of Medicine, Atlanta, GA, USA
| | - Matthew O'Shaughnessy
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Marissa Connor
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Gregory Canal
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Jungho Cha
- Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rachel Hershenberg
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Tanya Nauvel
- Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Faical Isbaine
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Muhammad Furqan Afzal
- Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Martijn Figee
- Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brian H Kopell
- Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Robert Butera
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, USA
- Wallace H. Coulter Department of Biomedical Engineering at Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Helen S Mayberg
- Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Christopher J Rozell
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, USA.
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Elias GJB, Germann J, Boutet A, Beyn ME, Giacobbe P, Song HN, Choi KS, Mayberg HS, Kennedy SH, Lozano AM. Local neuroanatomical and tract-based proxies of optimal subcallosal cingulate deep brain stimulation. Brain Stimul 2023; 16:1259-1272. [PMID: 37611657 DOI: 10.1016/j.brs.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 08/02/2023] [Accepted: 08/19/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Deep brain stimulation of the subcallosal cingulate area (SCC-DBS) is a promising neuromodulatory therapy for treatment-resistant depression (TRD). Biomarkers of optimal target engagement are needed to guide surgical targeting and stimulation parameter selection and to reduce variance in clinical outcome. OBJECTIVE/HYPOTHESIS We aimed to characterize the relationship between stimulation location, white matter tract engagement, and clinical outcome in a large (n = 60) TRD cohort treated with SCC-DBS. A smaller cohort (n = 22) of SCC-DBS patients with differing primary indications (bipolar disorder/anorexia nervosa) was utilized as an out-of-sample validation cohort. METHODS Volumes of tissue activated (VTAs) were constructed in standard space using high-resolution structural MRI and individual stimulation parameters. VTA-based probabilistic stimulation maps (PSMs) were generated to elucidate voxelwise spatial patterns of efficacious stimulation. A whole-brain tractogram derived from Human Connectome Project diffusion-weighted MRI data was seeded with VTA pairs, and white matter streamlines whose overlap with VTAs related to outcome ('discriminative' streamlines; Puncorrected < 0.05) were identified using t-tests. Linear modelling was used to interrogate the potential clinical relevance of VTA overlap with specific structures. RESULTS PSMs varied by hemisphere: high-value left-sided voxels were located more anterosuperiorly and squarely in the lateral white matter, while the equivalent right-sided voxels fell more posteroinferiorly and involved a greater proportion of grey matter. Positive discriminative streamlines localized to the bilateral (but primarily left) cingulum bundle, forceps minor/rostrum of corpus callosum, and bilateral uncinate fasciculus. Conversely, negative discriminative streamlines mostly belonged to the right cingulum bundle and bilateral uncinate fasciculus. The best performing linear model, which utilized information about VTA volume overlap with each of the positive discriminative streamline bundles as well as the negative discriminative elements of the right cingulum bundle, explained significant variance in clinical improvement in the primary TRD cohort (R = 0.46, P < 0.001) and survived repeated 10-fold cross-validation (R = 0.50, P = 0.040). This model was also able to predict outcome in the out-of-sample validation cohort (R = 0.43, P = 0.047). CONCLUSION(S) These findings reinforce prior indications of the importance of white matter engagement to SCC-DBS treatment success while providing new insights that could inform surgical targeting and stimulation parameter selection decisions.
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Affiliation(s)
- Gavin J B Elias
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, M5T 2S8, Canada; Krembil Research Institute, University of Toronto, Toronto, M5T 0S8, Canada
| | - Jürgen Germann
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, M5T 2S8, Canada; Krembil Research Institute, University of Toronto, Toronto, M5T 0S8, Canada
| | - Alexandre Boutet
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, M5T 2S8, Canada; Krembil Research Institute, University of Toronto, Toronto, M5T 0S8, Canada; Joint Department of Medical Imaging, University of Toronto, Toronto, M5T 1W7, Canada
| | - Michelle E Beyn
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, M5T 2S8, Canada
| | - Peter Giacobbe
- Department of Psychiatry, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, M4N 3M5, Canada
| | - Ha Neul Song
- Nash Family Center for Advanced Circuit Therapeutics, Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, NY, 10019, USA
| | - Ki Sueng Choi
- Nash Family Center for Advanced Circuit Therapeutics, Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, NY, 10019, USA; Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Helen S Mayberg
- Nash Family Center for Advanced Circuit Therapeutics, Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, NY, 10019, USA; Departments of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Sidney H Kennedy
- Krembil Research Institute, University of Toronto, Toronto, M5T 0S8, Canada; ASR Suicide and Depression Studies Unit, St. Michael's Hospital, University of Toronto, M5B 1M8, Canada; Department of Psychiatry, University Health Network and University of Toronto, Toronto, M5T 2S8, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, M5T 2S8, Canada; Krembil Research Institute, University of Toronto, Toronto, M5T 0S8, Canada.
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Ghaderi AH, Brown EC, Clark DL, Ramasubbu R, Kiss ZHT, Protzner AB. Functional brain network features specify DBS outcome for patients with treatment resistant depression. Mol Psychiatry 2023; 28:3888-3899. [PMID: 37474591 DOI: 10.1038/s41380-023-02181-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 06/29/2023] [Accepted: 07/05/2023] [Indexed: 07/22/2023]
Abstract
Deep brain stimulation (DBS) has shown therapeutic benefits for treatment resistant depression (TRD). Stimulation of the subcallosal cingulate gyrus (SCG) aims to alter dysregulation between subcortical and cortex. However, the 50% response rates for SCG-DBS indicates that selection of appropriate patients is challenging. Since stimulation influences large-scale network function, we hypothesized that network features can be used as biomarkers to inform outcome. In this pilot project, we used resting-state EEG recorded longitudinally from 10 TRD patients with SCG-DBS (11 at baseline). EEGs were recorded before DBS-surgery, 1-3 months, and 6 months post surgery. We used graph theoretical analysis to calculate clustering coefficient, global efficiency, eigenvector centrality, energy, and entropy of source-localized EEG networks to determine their topological/dynamical features. Patients were classified as responders based on achieving a 50% or greater reduction in Hamilton Depression (HAM-D) scores from baseline to 12 months post surgery. In the delta band, false discovery rate analysis revealed that global brain network features (segregation, integration, synchronization, and complexity) were significantly lower and centrality of subgenual anterior cingulate cortex (ACC) was higher in responders than in non-responders. Accordingly, longitudinal analysis showed SCG-DBS increased global network features and decreased centrality of subgenual ACC. Similarly, a clustering method separated two groups by network features and significant correlations were identified longitudinally between network changes and depression symptoms. Despite recent speculation that certain subtypes of TRD are more likely to respond to DBS, in the SCG it seems that underlying brain network features are associated with ability to respond to DBS. SCG-DBS increased segregation, integration, and synchronizability of brain networks, suggesting that information processing became faster and more efficient, in those patients in whom it was lower at baseline. Centrality results suggest these changes may occur via altered connectivity in specific brain regions especially ACC. We highlight potential mechanisms of therapeutic effect for SCG-DBS.
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Affiliation(s)
- Amir Hossein Ghaderi
- Department of Psychology, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neuroscience, University of Calgary, Calgary, AB, Canada
| | - Elliot C Brown
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neuroscience, University of Calgary, Calgary, AB, Canada
- Mathison Centre for Mental Health, University of Calgary, Calgary, AB, Canada
- Arden University Berlin, 10963, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Berlin, Germany
- Berlin Institute of Health, 10117, Berlin, Germany
| | - Darren Laree Clark
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neuroscience, University of Calgary, Calgary, AB, Canada
- Mathison Centre for Mental Health, University of Calgary, Calgary, AB, Canada
| | - Rajamannar Ramasubbu
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neuroscience, University of Calgary, Calgary, AB, Canada
- Mathison Centre for Mental Health, University of Calgary, Calgary, AB, Canada
| | - Zelma H T Kiss
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.
- Department of Clinical Neuroscience, University of Calgary, Calgary, AB, Canada.
- Mathison Centre for Mental Health, University of Calgary, Calgary, AB, Canada.
| | - Andrea B Protzner
- Department of Psychology, University of Calgary, Calgary, AB, Canada.
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.
- Mathison Centre for Mental Health, University of Calgary, Calgary, AB, Canada.
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49
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Giordano U, Mizera J, Żak E, Pilch J, Tomecka P, Dudzik T, Palczewski M, Biziorek W, Piotrowski P. Surgical treatment methods in the course of psychiatric disorders: Deep brain stimulation-Novel insights and indications. Indian J Psychiatry 2023; 65:799-807. [PMID: 37736228 PMCID: PMC10510643 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_266_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/06/2023] [Accepted: 07/12/2023] [Indexed: 09/23/2023] Open
Abstract
Deep brain stimulation (DBS) is a relatively dated treatment procedure that emerged in the late 1980s. Nonetheless, numerous studies are being carried out to examine its influence on the human brain and develop new treatment indications. This systematic review aims to summarize the current state of knowledge referring to DBS, investigate novel insights into its indications, and discuss the technical aspects and rationale behind DBS application. In particular, we sought to subject to scrutiny the application of DBS specifically in anorexia nervosa (AN), various addiction types, depression, and obsessive-compulsive disorders (OCDs). The method is supposed to offer promising results, especially in pharmacologically resistant forms of the upper-mentioned psychiatric disorders. Moreover, further insight has been provided into the historical notions of the method and differences in the surgical approach in specific disease entities. Furthermore, we mark the possible influence of comorbidities on treatment results. Our review consists of articles and studies found on PubMed, Google Scholar, Cochrane, and Scopus, which were then analyzed with scrutiny in the identification process, including the most resourceful ones. After methodological quality and risk of bias assessment, a total of 53 studies were included. To this date, DBS's usefulness in the treatment of AN, OCDs, depression, and addictions has been proven, despite an ongoing debate concerning the technical aspects and parameters when applying DBS. To the best of our knowledge, we have not found any paper that would recapitulate the current state of DBS in the context of psychiatric disorders with an addition of technical insights.
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Affiliation(s)
- Ugo Giordano
- Department of Psychiatry, University Clinical Hospital (USK) in Wroclaw, Wroclaw Medical University, Wroclaw, Poland
| | - Jakub Mizera
- Department of Psychiatry, Students Scientific Association at the Clinic of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
| | - Elżbieta Żak
- Department of Psychiatry, Students Scientific Association at the Clinic of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
| | - Justyna Pilch
- Department of Psychiatry, Students Scientific Association at the Clinic of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
| | - Paulina Tomecka
- Department of Psychiatry, Students Scientific Association at the Clinic of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
| | - Tomasz Dudzik
- Department of Psychiatry, Students Scientific Association at the Clinic of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
| | - Mikołaj Palczewski
- Department of Psychiatry, Students Scientific Association at the Clinic of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
| | - Weronika Biziorek
- Department of Psychiatry, Students Scientific Association at the Clinic of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
| | - Patryk Piotrowski
- Department of Psychiatry, University Clinical Hospital (USK) in Wroclaw, Wroclaw Medical University, Wroclaw, Poland
- Department of Psychiatry, Students Scientific Association at the Clinic of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
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50
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Cao D, Liu Q, Zhang J, Li J, Jiang T. State-specific modulation of mood using intracranial electrical stimulation of the orbitofrontal cortex. Brain Stimul 2023; 16:1112-1122. [PMID: 37467951 DOI: 10.1016/j.brs.2023.07.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/09/2023] [Accepted: 07/13/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Orbitofrontal cortex (OFC) is a promising target for intracranial electrical stimulation (iES) aimed at improving mood states. However, knowledge gaps remain regarding the underlying neural mechanisms of iES effects, such as the effect of the OFC target in comparison with other emotional network targets, the impact of brain state at the time of stimulation, and the neural response induced by iES at both local and network scales. OBJECTIVE Our study aims to address the neural mechanisms underlying the effects of iES in improving mood states. METHODS We conducted a study in 24 epilepsy patients who received iES through implanted electrodes in the emotional network and compared the effects of iES on multiple targets in the emotional network. RESULTS We found that only iES applied to the orbitofrontal cortex (OFC) led to mood improvement and changes in neural activity. We also observed that iES to the OFC suppressed the delta-theta power when the brain was in a low mood state. Moreover, the iES to the OFC decreased delta-theta power and increased gamma power at local regions within the emotional network, and enhanced the information flow through the frequency domain among regions within the emotional network. CONCLUSIONS These findings provide insight into the neural correlates of iES-induced mood improvement and support the potential of iES as a therapeutic intervention for mood disorders.
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Affiliation(s)
- Dan Cao
- Brainnetome Center, Institute of Automation, Chinese Academy of Sciences, Beijing, China
| | - Qihong Liu
- Key Laboratory for NeuroInformation of the Ministry of Education, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, China
| | - Jiaqi Zhang
- Brainnetome Center, Institute of Automation, Chinese Academy of Sciences, Beijing, China; School of Artificial Intelligence, University of Chinese Academy of Sciences, Beijing, China
| | - Jin Li
- School of Psychology, Capital Normal University, Beijing, 100048, China.
| | - Tianzi Jiang
- Brainnetome Center, Institute of Automation, Chinese Academy of Sciences, Beijing, China; School of Artificial Intelligence, University of Chinese Academy of Sciences, Beijing, China; Research Center for Augmented Intelligence, Zhejiang Lab, 311100, Hangzhou, China.
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