1
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Hamani C, Davidson B, Rabin JS, Goubran M, Boone L, Hynynen K, De Schlichting E, Meng Y, Huang Y, Jones RM, Baskaran A, Marawi T, Richter MA, Levitt A, Nestor SM, Giacobbe P, Lipsman N. Long-term safety and efficacy of focused ultrasound capsulotomy for obsessive-compulsive disorder and major depressive disorder. Biol Psychiatry 2024:S0006-3223(24)01548-8. [PMID: 39187171 DOI: 10.1016/j.biopsych.2024.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 07/29/2024] [Accepted: 08/18/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND Magnetic resonance-guided focused ultrasound (MRgFUS) trials targeting the anterior limb of the internal capsule have shown promising results. We evaluate the long-term safety and efficacy of MRgFUS capsulotomy in patients with obsessive-compulsive disorder (OCD) and major depressive disorder (MDD). METHODS This phase I single center open label study recruited treatment-resistant OCD and MDD. Outcomes were measured 6mo, 12mo, and 18-24months (long-term) after MRgFUS capsulotomy. Neuropsychological testing and neuroimaging were conducted at baseline and 12mo postoperatively. The primary outcome was safety. The secondary outcome was clinical response, defined for OCD as ≥35% improvement in Yale-Brown obsessive-compulsive scale (YBOCS) scores, and for MDD as a ≥50% reduction in the Hamilton Depression Rating Scale (HAMD-17) scores, compared to baseline. RESULTS No serious adverse effects were registered. In patients with OCD (n=15), baseline YBOCS scores (31.9±1.2) were significantly reduced by 23% (p=0.01) at 6mo and 35% (p<0.0001) at 12mo. In patients with MDD (n=12), a 26% and 25% non-significant reduction in HAMD-17 scores (baseline 24.3±1.2) was observed at 6mo and 12mo, respectively. Neuropsychological testing revealed no negative effects of capsulotomy. In the OCD and MDD cohorts we found a correlation between clinical outcome and lesion laterality, with more medial left (OCD, p=0.08) and more lateral right (MDD, p<0.05) placed lesions being respectively associated with a stronger response. In the MDD cohort, more ventral tracts appeared to be associated with a poorer response. CONCLUSIONS MRgFUS capsulotomy is safe in patients with OCD and MDD and particularly effective in the former population.
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Affiliation(s)
- Clement Hamani
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada.
| | - Benjamin Davidson
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada
| | - Jennifer S Rabin
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada; Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Maged Goubran
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada; Physical Sciences, Sunnybrook Research Institute, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Lyndon Boone
- Physical Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Kullervo Hynynen
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada; Physical Sciences, Sunnybrook Research Institute, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Emmanuel De Schlichting
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Ying Meng
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada
| | - Yuexi Huang
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Ryan M Jones
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Anusha Baskaran
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada
| | - Tulip Marawi
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Margaret Anne Richter
- Sunnybrook Research Institute, Toronto, ON, Canada; Frederick W. Thompson Anxiety Disorders Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Anthony Levitt
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada; Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Sean M Nestor
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada; Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Peter Giacobbe
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada; Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada.
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2
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Hurwitz T, Ching G, Bogod NM, Honey CR. Bilateral Anterior Capsulotomy for Treatment-Resistant Obsessive-Compulsive Disorder. Stereotact Funct Neurosurg 2024:1-15. [PMID: 39182480 DOI: 10.1159/000540503] [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: 03/15/2024] [Accepted: 07/18/2024] [Indexed: 08/27/2024]
Abstract
INTRODUCTION Ablative surgery is an intervention of last resort for treatment-resistant obsessive-compulsive disorder (TROCD). Our center has been using bilateral anterior capsulotomy (BAC) for the past 20 years for patients eligible for limbic surgery. This report details our experience with BAC for TROCD. METHOD Five patients with OCD met eligibility criteria for BAC. Entry protocols were complex and took around 6 months to complete. Stereotactic radiofrequency was used to produce the capsulotomies. Lesion length varied between 5.7 and 16.9 mm in the coronal plane. Patients were followed between 4 and 20 years. RESULTS All 5 patients (100%) were responders as defined by the widely accepted criteria of a reduction of ≥35% in Yale-Brown Obsessive Compulsive Scale (YBOCS) score at 18-month follow-up. Four patients remained responders at the 48 months. One patient was lost to follow-up. Responder status when viewed from the perspective of the YBOCS was sustained over the 4- to 20-year follow-up with one relapse 19 years postsurgery when medications were discontinued. Real-world psychiatric outcomes were different as other vulnerabilities surfaced illustrating the multifactorial determinants of mental health. No patient had any significant long-term neurocognitive or physical side effects. CONCLUSION BAC should remain an option of last resort for patients with severe OCD who remain unresponsive to all other interventions.
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Affiliation(s)
- Trevor Hurwitz
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Geoffrey Ching
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicholas Mark Bogod
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher R Honey
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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3
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Pellow C, Pichardo S, Pike GB. A systematic review of preclinical and clinical transcranial ultrasound neuromodulation and opportunities for functional connectomics. Brain Stimul 2024; 17:734-751. [PMID: 38880207 DOI: 10.1016/j.brs.2024.06.005] [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: 03/01/2024] [Revised: 05/21/2024] [Accepted: 06/05/2024] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND Low-intensity transcranial ultrasound has surged forward as a non-invasive and disruptive tool for neuromodulation with applications in basic neuroscience research and the treatment of neurological and psychiatric conditions. OBJECTIVE To provide a comprehensive overview and update of preclinical and clinical transcranial low intensity ultrasound for neuromodulation and emphasize the emerging role of functional brain mapping to guide, better understand, and predict responses. METHODS A systematic review was conducted by searching the Web of Science and Scopus databases for studies on transcranial ultrasound neuromodulation, both in humans and animals. RESULTS 187 relevant studies were identified and reviewed, including 116 preclinical and 71 clinical reports with subjects belonging to diverse cohorts. Milestones of ultrasound neuromodulation are described within an overview of the broader landscape. General neural readouts and outcome measures are discussed, potential confounds are noted, and the emerging use of functional magnetic resonance imaging is highlighted. CONCLUSION Ultrasound neuromodulation has emerged as a powerful tool to study and treat a range of conditions and its combination with various neural readouts has significantly advanced this platform. In particular, the use of functional magnetic resonance imaging has yielded exciting inferences into ultrasound neuromodulation and has the potential to advance our understanding of brain function, neuromodulatory mechanisms, and ultimately clinical outcomes. It is anticipated that these preclinical and clinical trials are the first of many; that transcranial low intensity focused ultrasound, particularly in combination with functional magnetic resonance imaging, has the potential to enhance treatment for a spectrum of neurological conditions.
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Affiliation(s)
- Carly Pellow
- Department of Radiology, Cumming School of Medicine, University of Calgary, Alberta, T2N 1N4, Canada; Hotchkiss Brain Institute, University of Calgary, Alberta, T2N 4N1, Canada.
| | - Samuel Pichardo
- Department of Radiology, Cumming School of Medicine, University of Calgary, Alberta, T2N 1N4, Canada; Hotchkiss Brain Institute, University of Calgary, Alberta, T2N 4N1, Canada; Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, T2N 1N4, Canada
| | - G Bruce Pike
- Department of Radiology, Cumming School of Medicine, University of Calgary, Alberta, T2N 1N4, Canada; Hotchkiss Brain Institute, University of Calgary, Alberta, T2N 4N1, Canada; Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, T2N 1N4, Canada
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4
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Pineda-Pardo JA, Martínez-Fernández R, Natera-Villalba E, Ruiz-Yanzi A, Rodríguez-Rojas R, Del Alamo M, Jiménez-Castellanos T, Matarazzo M, Gasca-Salas C, Rascol O, Obeso JA. Skull Density Ratio as Arm-Allocation Parameter for a Controlled Focused Ultrasound Trial in Parkinson's Disease. Mov Disord Clin Pract 2024; 11:825-829. [PMID: 38741245 PMCID: PMC11233930 DOI: 10.1002/mdc3.14040] [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: 09/13/2023] [Accepted: 03/17/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND MR-guided focused ultrasound (FUS) thermoablation is an established therapy for movement disorders. FUS candidates must meet a predefined threshold of skull density ratio (SDR), a parameter that accounts for the efficiency in reaching ablative temperatures. Randomized sham-controlled trials to provide definitive therapeutic evidence employ pure randomization of subjects into active treatment or control arms. The latter design has several general limitations. OBJECTIVE To demonstrate that SDR values are not associated with clinically and demographically relevant variables in patients with Parkinson's disease (PD). This in turn would allow using SDR as an arm-allocation parameter, separating patients who will receive active FUS treatment and best medical management treatment (BMT). METHODS We studied a cohort of 215 PD patients who were candidates for FUS subthalamotomy to determine if the SDR was correlated with demographic or clinical variables that could introduce bias for group allocation in a controlled trial. RESULTS SDR was unassociated with age, gender, and clinical motor features nor with levodopa daily dose in our cohort of PD patients. A negative association with age was found for the female subgroup. CONCLUSIONS Our results show that in a PD population considered for FUS subthalamotomy treatment, the SDR may be a valid group-allocation parameter. This could be considered as the basis for a controlled study comparing FUS subthalamotomy vs BMT.
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Affiliation(s)
- José Angel Pineda-Pardo
- HM CINAC MADRID (Centro Integral de Neurociencias Abarca Campal). Hospital Universitario HM Puerta del Sur, HM Hospitales, Madrid, Spain
- CIBERNED, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación Sanitaria HM Hospitales, Spain
| | - Raul Martínez-Fernández
- HM CINAC MADRID (Centro Integral de Neurociencias Abarca Campal). Hospital Universitario HM Puerta del Sur, HM Hospitales, Madrid, Spain
- CIBERNED, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación Sanitaria HM Hospitales, Spain
| | - Elena Natera-Villalba
- HM CINAC MADRID (Centro Integral de Neurociencias Abarca Campal). Hospital Universitario HM Puerta del Sur, HM Hospitales, Madrid, Spain
- Instituto de Investigación Sanitaria HM Hospitales, Spain
- PhD Medicine Program, Universidad Autonoma de Madrid, Madrid, Spain
| | - Agustina Ruiz-Yanzi
- HM CINAC MADRID (Centro Integral de Neurociencias Abarca Campal). Hospital Universitario HM Puerta del Sur, HM Hospitales, Madrid, Spain
- Instituto de Investigación Sanitaria HM Hospitales, Spain
| | - Rafael Rodríguez-Rojas
- HM CINAC MADRID (Centro Integral de Neurociencias Abarca Campal). Hospital Universitario HM Puerta del Sur, HM Hospitales, Madrid, Spain
- CIBERNED, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación Sanitaria HM Hospitales, Spain
- Facultad HM de Ciencias de la Salud de la Universidad Camilo José Cela, Madrid, Spain
| | - Marta Del Alamo
- HM CINAC MADRID (Centro Integral de Neurociencias Abarca Campal). Hospital Universitario HM Puerta del Sur, HM Hospitales, Madrid, Spain
- Instituto de Investigación Sanitaria HM Hospitales, Spain
| | - Tamara Jiménez-Castellanos
- HM CINAC MADRID (Centro Integral de Neurociencias Abarca Campal). Hospital Universitario HM Puerta del Sur, HM Hospitales, Madrid, Spain
- Instituto de Investigación Sanitaria HM Hospitales, Spain
- Department of Preventive Medicine, Public Health and Microbiology, Universidad Autónoma de Madrid, Madrid, Spain
| | - Michele Matarazzo
- HM CINAC MADRID (Centro Integral de Neurociencias Abarca Campal). Hospital Universitario HM Puerta del Sur, HM Hospitales, Madrid, Spain
- CIBERNED, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación Sanitaria HM Hospitales, Spain
| | - Carmen Gasca-Salas
- HM CINAC MADRID (Centro Integral de Neurociencias Abarca Campal). Hospital Universitario HM Puerta del Sur, HM Hospitales, Madrid, Spain
- CIBERNED, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación Sanitaria HM Hospitales, Spain
- Universidad San Pablo-CEU, Madrid, Spain
| | - Olivier Rascol
- Clinical Investigation Center CIC 1436, NS-Park/F-CRIN Network and NeuroToul COEN Center; Inserm, University of Toulouse 3 and CHU of Toulouse, F-31000, Toulouse, France
| | - José A Obeso
- HM CINAC MADRID (Centro Integral de Neurociencias Abarca Campal). Hospital Universitario HM Puerta del Sur, HM Hospitales, Madrid, Spain
- CIBERNED, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación Sanitaria HM Hospitales, Spain
- Universidad San Pablo-CEU, Madrid, Spain
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5
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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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6
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Meng Y, Kalia LV, Kalia SK, Hamani C, Huang Y, Hynynen K, Lipsman N, Davidson B. Current Progress in Magnetic Resonance-Guided Focused Ultrasound to Facilitate Drug Delivery across the Blood-Brain Barrier. Pharmaceutics 2024; 16:719. [PMID: 38931843 PMCID: PMC11206305 DOI: 10.3390/pharmaceutics16060719] [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: 03/19/2024] [Revised: 05/12/2024] [Accepted: 05/17/2024] [Indexed: 06/28/2024] Open
Abstract
This review discusses the current progress in the clinical use of magnetic resonance-guided focused ultrasound (MRgFUS) and other ultrasound platforms to transiently permeabilize the blood-brain barrier (BBB) for drug delivery in neurological disorders and neuro-oncology. Safety trials in humans have followed on from extensive pre-clinical studies, demonstrating a reassuring safety profile and paving the way for numerous translational clinical trials in Alzheimer's disease, Parkinson's disease, and primary and metastatic brain tumors. Future directions include improving ultrasound delivery devices, exploring alternative delivery approaches such as nanodroplets, and expanding the application to other neurological conditions.
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Affiliation(s)
- Ying Meng
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Lorraine V. Kalia
- Krembil Research Institute, University Health Network, Toronto, ON M5T 0S8, Canada
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Suneil K. Kalia
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M4N 3M5, Canada
- Krembil Research Institute, University Health Network, Toronto, ON M5T 0S8, Canada
- Center for Advancing Neurotechnological Innovation to Application (CRANIA), University Health Network, Toronto, ON M5T 1M8, Canada
- KITE Research Institute, University Health Network, Toronto, ON M5G 2A2, Canada
| | - Clement Hamani
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Yuexi Huang
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | | | - Nir Lipsman
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Benjamin Davidson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
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Natera-Villalba E, Ruiz-Yanzi MA, Gasca-Salas C, Matarazzo M, Martínez-Fernández R. MR-guided focused ultrasound in movement disorders and beyond: Lessons learned and new frontiers. Parkinsonism Relat Disord 2024; 122:106040. [PMID: 38378311 DOI: 10.1016/j.parkreldis.2024.106040] [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: 02/01/2024] [Accepted: 02/09/2024] [Indexed: 02/22/2024]
Abstract
The development of MR-guided focused ultrasound (MRgFUS) has provided a new therapeutic tool for neuropsychiatric disorders. In contrast to previously available neurosurgical techniques, MRgFUS allows precise impact on deep brain structures without the need for incision and yields an immediate effect. In its high-intensity modality (MRgHIFU), it produces accurate therapeutic thermoablation in previously selected brain targets. Importantly, the production of the lesion is progressive and highly controlled in real-time by both neuroimaging and clinical means. MRgHIFU ablation is already an accepted and widely used treatment for medically-refractory Parkinson's disease and essential tremor. Notably, other neurological disorders and diverse brain targets, including bilateral treatments, are currently under examination. Conversely, the low-intensity modality (MRgLIFU) shows promising prospects in neuromodulation and transient blood-brain barrier opening (BBBO). In the former circumstance, MRgLIFU could serve as a powerful clinical and research tool for non-invasively modulating brain activity and function. BBBO, on the other hand, emerges as a potentially impactful method to influence disease pathogenesis and progression by increasing brain target engagement of putative therapeutic agents. While promising, these applications remain experimental. As a recently developed technology, MRgFUS is not without challenges and questions to be addressed. Further developments and broader experience are necessary to enhance MRgFUS capabilities in both research and clinical practice, as well as to define device constraints. This clinical mini-review aims to provide an overview of the main evidence of MRgFUS application and to highlight unmet needs and future potentialities of the technique.
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Affiliation(s)
- Elena Natera-Villalba
- HM CINAC (Centro Integral de Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, HM Hospitales, Madrid, Spain; PhD Medicine Program, Universidad Autónoma de Madrid, Madrid, Spain
| | - María-Agustina Ruiz-Yanzi
- HM CINAC (Centro Integral de Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, HM Hospitales, Madrid, Spain
| | - Carmen Gasca-Salas
- HM CINAC (Centro Integral de Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, HM Hospitales, Madrid, Spain; CIBERNED, Instituto Carlos III, Madrid, Spain; University CEU-San Pablo, Madrid, Spain
| | - Michele Matarazzo
- HM CINAC (Centro Integral de Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, HM Hospitales, Madrid, Spain; CIBERNED, Instituto Carlos III, Madrid, Spain
| | - Raúl Martínez-Fernández
- HM CINAC (Centro Integral de Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, HM Hospitales, Madrid, Spain; CIBERNED, Instituto Carlos III, Madrid, Spain; University CEU-San Pablo, Madrid, Spain.
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8
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Hurwitz TA, Avecillas-Chasin JM, Bogod NM, Honey CR. Ventral targeted anterior capsulotomy for treatment-resistant depression and obsessive-compulsive disorder: A treatment method with cases. J Affect Disord 2024; 350:887-894. [PMID: 38272366 DOI: 10.1016/j.jad.2024.01.176] [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: 06/26/2023] [Revised: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Ablative surgery using bilateral anterior capsulotomy (BAC) is an option for treatment resistant depression (TRD) and obsessive-compulsive disorder (TROCD). The location and extent of the lesion within anterior limb of the internal capsule (ALIC) remains uncertain. Accumulating evidence has suggested that the lesion should be located ventrally while limiting the dorsal extent. Our center is now targeting specific fiber tracts within the lower half of the ALIC. METHOD Presurgical diffusion tensor Magnetic Resonance Imaging (MRI) was used to identify individual fibre tracts within the ventral aspect of the ALIC in the last two patients who underwent BAC at our center. One patient had TRD and the other had both TROCD and TRD. Radiofrequency-induced thermal lesions were created in the identified targets with lesion volumes between 20 and 229 mm3 (average 95 mm3). FINDINGS Both patients were responders with neither experiencing significant side effects including compromised executive functions. LIMITATIONS The generalizability of our findings is limited because the outcome is based on two subjects. CONCLUSION This work suggests that BAC can be individually tailored and more limited to the ventral aspect of the ALIC and is effective and safe for TRD and TROCD. Accumulating data also suggests that to be clinically effective the length of the capsulotomy should be about 10mm. BAC's use may increase with the growing utilization and mastery of magnetic resonance guided focused ultrasound.
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Affiliation(s)
- Trevor A Hurwitz
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.
| | | | - Nicholas M Bogod
- Department of Medicine, Division of Neurology, University of British Columbia, Vancouver, BC, Canada.
| | - Christopher R Honey
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada.
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9
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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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10
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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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11
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Memari E, Khan D, Alkins R, Helfield B. Focused ultrasound-assisted delivery of immunomodulating agents in brain cancer. J Control Release 2024; 367:283-299. [PMID: 38266715 DOI: 10.1016/j.jconrel.2024.01.034] [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: 10/03/2023] [Revised: 01/12/2024] [Accepted: 01/17/2024] [Indexed: 01/26/2024]
Abstract
Focused ultrasound (FUS) combined with intravascularly circulating microbubbles can transiently increase the permeability of the blood-brain barrier (BBB) to enable targeted therapeutic delivery to the brain, the clinical testing of which is currently underway in both adult and pediatric patients. Aside from traditional cancer drugs, this technique is being extended to promote the delivery of immunomodulating therapeutics to the brain, including antibodies, immune cells, and cytokines. In this manner, FUS approaches are being explored as a tool to improve and amplify the effectiveness of immunotherapy for both primary and metastatic brain cancer, a particularly challenging solid tumor to treat. Here, we present an overview of the latest groundbreaking research in FUS-assisted delivery of immunomodulating agents to the brain in pre-clinical models of brain cancer, and place it within the context of the current immunotherapy approaches. We follow this up with a discussion on new developments and emerging strategies for this rapidly evolving approach.
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Affiliation(s)
- Elahe Memari
- Department of Physics, Concordia University, Montreal H4B 1R6, Canada
| | - Dure Khan
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | - Ryan Alkins
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada; Division of Neurosurgery, Department of Surgery, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Brandon Helfield
- Department of Physics, Concordia University, Montreal H4B 1R6, Canada; Department of Biology, Concordia University, Montreal H4B 1R6, Canada.
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12
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Chang JG, Kim SJ, Kim CH. Neuroablative Intervention for Refractory Obsessive-Compulsive Disorder. Psychiatry Investig 2023; 20:997-1006. [PMID: 37997327 PMCID: PMC10678146 DOI: 10.30773/pi.2023.0214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/19/2023] [Accepted: 08/29/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVE This review aims to investigate the progression of neuroablation, along with documented clinical efficacy and safety, in the management of treatment-resistant obsessive-compulsive disorder (OCD). METHODS We searched and compiled clinical research results of neuroablation therapy reported to date. We extracted outcomes related to clinical efficacy, side effects, and surgical complications. Additionally, we summarized key claims and findings. RESULTS Neuroablative intervention is a potential treatment approach for refractory OCD. Recent advancements, such as real-time magnetic resonance monitoring and minimally invasive techniques employing ultrasound and laser, offer distinct advantages in terms of safety and comparative efficacy when compared to conventional methods. However, the absence of randomized controlled trials and long-term outcome data underscores the need for cautious consideration when selecting neuroablation. CONCLUSION Neuroablative intervention shows promise for refractory OCD, but vigilant consideration is essential in both patient selection and surgical method choices due to the potential for rare yet serious complications.
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Affiliation(s)
- Jhin Goo Chang
- Department of Psychiatry, Myongji Hospital, Hanyang University College of Medicine, Goyang, Republic of Korea
| | - Se Joo Kim
- Department of Psychiatry, Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chan-Hyung Kim
- Department of Psychiatry, Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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13
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Asher R, Hyun I, Head M, Cosgrove GR, Silbersweig D. Neuroethical implications of focused ultrasound for neuropsychiatric illness. Brain Stimul 2023; 16:806-814. [PMID: 37150289 DOI: 10.1016/j.brs.2023.04.020] [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: 12/16/2022] [Revised: 04/17/2023] [Accepted: 04/23/2023] [Indexed: 05/09/2023] Open
Abstract
BACKGROUND MR-guided focused ultrasound is a promising intervention for treatment-resistant mental illness, and merits contextualized ethical exploration in relation to more extensive ethical literature regarding other psychosurgical and neuromodulation treatment options for this patient population. To our knowledge, this topic has not yet been explored in the published literature. OBJECTIVE The purpose of this paper is to review and discuss in detail the neuroethical implications of MR-guided focused ultrasound for neuropsychiatric illness as an emerging treatment modality. METHODS Due to the lack of published literature on the topic, the approach involved a detailed survey and review of technical and medical literature relevant to focused ultrasound and established ethical issues related to alternative treatment options for patients with treatment-resistant, severe and persistent mental illness. The manuscript is structured according to thematic and topical findings. RESULTS This technology has potential benefits for patients suffering with severe mental illness, compared with established alternatives. The balance of technical, neuroscientific and clinical considerations should inform ethical deliberations. The nascent literature base, nuances in legal classification and permissibility depending upon jurisdiction, influences of past ethical issues associated with alternative treatments, tone and framing in media articles, and complexity of clinical trials all influence ethical assessment and evaluations of multiple stakeholders. Recommendations for future research are provided based on these factors. CONCLUSION Salient ethical inquiry should be further explored by researchers, clinicians, and ethicists in a nuanced manner methodologically, one which is informed by past and present ethical issues related to alternative treatment options, broader psychiatric treatment frameworks, pragmatic implementation challenges, intercultural considerations, and patients' ethical concerns.
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Affiliation(s)
- Rachel Asher
- Brigham and Women's Hospital/Harvard Medical School, 60 Fenwood Rd, Boston, MA, 02115, USA.
| | - Insoo Hyun
- Center for Bioethics at Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA.
| | - Mitchell Head
- Te Kotahi Research Institute/University of Waikato, Gate 4C, 194H Hillcrest Rd, Hillcrest, Hamilton, 3216, Aotearoa, New Zealand.
| | - G Rees Cosgrove
- Brigham and Women's Hospital/Harvard Medical School, 60 Fenwood Rd, Boston, MA, 02115, USA.
| | - David Silbersweig
- Brigham and Women's Hospital/Harvard Medical School, 60 Fenwood Rd, Boston, MA, 02115, USA.
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McLaughlin NCR, Magnotti JF, Banks GP, Nanda P, Hoexter MQ, Lopes AC, Batistuzzo MC, Asaad WF, Stewart C, Paulo D, Noren G, Greenberg BD, Malloy P, Salloway S, Correia S, Pathak Y, Sheehan J, Marsland R, Gorgulho A, De Salles A, Miguel EC, Rasmussen SA, Sheth SA. Gamma knife capsulotomy for intractable OCD: Neuroimage analysis of lesion size, location, and clinical response. Transl Psychiatry 2023; 13:134. [PMID: 37185805 PMCID: PMC10130137 DOI: 10.1038/s41398-023-02425-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 02/27/2023] [Accepted: 03/31/2023] [Indexed: 05/17/2023] Open
Abstract
Obsessive-compulsive disorder (OCD) affects 2-3% of the population. One-third of patients are poorly responsive to conventional therapies, and for a subgroup, gamma knife capsulotomy (GKC) is an option. We examined lesion characteristics in patients previously treated with GKC through well-established programs in Providence, RI (Butler Hospital/Rhode Island Hospital/Alpert Medical School of Brown University) and São Paulo, Brazil (University of São Paolo). Lesions were traced on T1 images from 26 patients who had received GKC targeting the ventral half of the anterior limb of the internal capsule (ALIC), and the masks were transformed into MNI space. Voxel-wise lesion-symptom mapping was performed to assess the influence of lesion location on Y-BOCS ratings. General linear models were built to compare the relationship between lesion size/location along different axes of the ALIC and above or below-average change in Y-BOCS ratings. Sixty-nine percent of this sample were full responders (≥35% improvement in OCD). Lesion occurrence anywhere within the targeted region was associated with clinical improvement, but modeling results demonstrated that lesions occurring posteriorly (closer to the anterior commissure) and dorsally (closer to the mid-ALIC) were associated with the greatest Y-BOCS reduction. No association was found between Y-BOCS reduction and overall lesion volume. GKC remains an effective treatment for refractory OCD. Our data suggest that continuing to target the bottom half of the ALIC in the coronal plane is likely to provide the dorsal-ventral height required to achieve optimal outcomes, as it will cover the white matter pathways relevant to change. Further analysis of individual variability will be essential for improving targeting and clinical outcomes, and potentially further reducing the lesion size necessary for beneficial outcomes.
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Affiliation(s)
- N C R McLaughlin
- Butler Hospital, Providence, RI, USA.
- Alpert Medical School of Brown University, Providence, RI, USA.
| | - J F Magnotti
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - G P Banks
- Columbia University Medical Center, New York, NY, USA
| | - P Nanda
- Columbia University Medical Center, New York, NY, USA
| | - M Q Hoexter
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - A C Lopes
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - M C Batistuzzo
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
- Department of Methods and Techniques in Psychology, Pontifical Catholic University, São Paulo, SP, Brazil
| | - W F Asaad
- Alpert Medical School of Brown University, Providence, RI, USA
- Rhode Island Hospital, Providence, RI, USA
| | - C Stewart
- Boston University School of Public Health, Boston, MA, USA
| | - D Paulo
- Columbia University Medical Center, New York, NY, USA
| | - G Noren
- Alpert Medical School of Brown University, Providence, RI, USA
- Rhode Island Hospital, Providence, RI, USA
| | - B D Greenberg
- Butler Hospital, Providence, RI, USA
- Alpert Medical School of Brown University, Providence, RI, USA
- Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - P Malloy
- Butler Hospital, Providence, RI, USA
- Alpert Medical School of Brown University, Providence, RI, USA
| | - S Salloway
- Butler Hospital, Providence, RI, USA
- Alpert Medical School of Brown University, Providence, RI, USA
| | - S Correia
- Alpert Medical School of Brown University, Providence, RI, USA
| | - Y Pathak
- Columbia University Medical Center, New York, NY, USA
| | - J Sheehan
- University of Virginia, Charlottesville, VA, USA
| | | | - A Gorgulho
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - A De Salles
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - E C Miguel
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - S A Rasmussen
- Butler Hospital, Providence, RI, USA
- Alpert Medical School of Brown University, Providence, RI, USA
- Rhode Island Hospital, Providence, RI, USA
| | - S A Sheth
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
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15
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Hariz M. Pros and Cons of Ablation for Functional Neurosurgery in the Neurostimulation Age. Neurosurg Clin N Am 2023; 34:291-299. [PMID: 36906335 DOI: 10.1016/j.nec.2022.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Should one recommend stereotactic ablation for Parkinson disease, tremor, dystonia, and obsessive compulsive disorder, in this era of DBS? The answer depends on several variables such as the symptoms to treat, the patient's preferences and expectations, the surgeons' competence and preference, the availability of financial means (by government health care, by private insurance), the geographical issues, and not least the current and dominating fashion at that particular time. Both ablation and stimulation can be either used alone or even combined (provided expertise in both of them) to treat various symptoms of movement and mind disorders.
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Affiliation(s)
- Marwan Hariz
- Department of Clinical Neuroscience, University Hospital, Umeå 90185, Sweden.
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16
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Abstract
Modern transcranial magnetic resonance-guided focused ultrasound is an incisionless, ablative treatment modality for a growing number of neurologic disorders. This procedure selectively destroys a targeted volume of cerebral tissue and relies on real-time MR thermography to monitor tissue temperatures. By focusing on a submillimeter target through a hemispheric phased array of transducers, ultrasound waves pass through the skull and avoid overheating and brain damage. High-intensity focused ultrasound techniques are increasingly used to create safe and effective stereotactic ablations for medication-refractory movement and other neurologic and psychiatric disorders.
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Affiliation(s)
- Jonathan Pomeraniec
- Department of Neurosurgery, University of Virginia, School of Medicine, PO Box 800212, Charlottesville, VA 22908, USA
| | - W Jeffrey Elias
- Department of Neurosurgery, University of Virginia, School of Medicine, PO Box 800212, Charlottesville, VA 22908, USA.
| | - Shayan Moosa
- Department of Neurosurgery, University of Virginia, School of Medicine, PO Box 800212, Charlottesville, VA 22908, USA
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17
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Chang JG, Kim DW, Jung HH, Chang WS, Kim CH, Kim SJ, Chang JW. Evaluation of changes in neural oscillation after bilateral capsulotomy in treatment refractory obsessive-compulsive disorder using magnetoencephalogram. Asian J Psychiatr 2023; 82:103473. [PMID: 36706511 DOI: 10.1016/j.ajp.2023.103473] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
Bilateral thermal capsulotomy with magnetic resonance-guided focused ultrasound (MRgFUS-capsulotomy) is a promising treatment option for treatment-refractory obsessive-compulsive disorder (OCD). Herein, we investigated the effects of bilateral thermal capsulotomy with MRgFUS on neural oscillations in treatment-refractory OCD patients. Eight patients underwent resting-state MEG with repeated recordings before and 1 and 6 months after MRgFUS-capsulotomy, and the oscillatory power and phase coherence over the entire cortical sensor area were measured. After MRgFUS-capsulotomy, the high beta band power in the fronto-central and temporal areas decreased at 1 month and remained stable for 6 months. Cortical connectivity of the high beta band gradually decreased over the entire cortical area during the following 6 months. At 1 month, improvement in anxiety and depression symptoms was significantly correlated with changes in high beta band power in both the frontotemporal and temporal areas. The treatment effect of MRgFUS-capsulotomy may be attributed to the cortical high beta band. Our results provide an advanced understanding of the neural mechanisms underlying MRgFUS-capsulotomy and other neuromodulatory interventions for treatment-refractory OCD.
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Affiliation(s)
- Jhin Goo Chang
- Department of Psychiatry, Myongji Hospital, Hanyang University College of Medicine, Goyang, the Republic of Korea.
| | - Do-Won Kim
- School of Healthcare and Biomedical Engineering, Chonnam National University, Yeosu, the Republic of Korea
| | - Hyun Ho Jung
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, the Republic of Korea
| | - Won Seok Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, the Republic of Korea
| | - Chan-Hyung Kim
- Department of Psychiatry, Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, the Republic of Korea
| | - Se Joo Kim
- Department of Psychiatry, Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, the Republic of Korea.
| | - Jin Woo Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, the Republic of Korea.
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18
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Chu PC, Huang CS, Ing SZ, Yu HY, Fisher RS, Liu HL. Pulsed Focused Ultrasound Reduces Hippocampal Volume Loss and Improves Behavioral Performance in the Kainic Acid Rat Model of Epilepsy. Neurotherapeutics 2023; 20:502-517. [PMID: 36917440 PMCID: PMC10121983 DOI: 10.1007/s13311-023-01363-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2023] [Indexed: 03/16/2023] Open
Abstract
Focused ultrasound (FUS) has the potential to modulate regional brain excitability and possibly aid seizure control; however, effects on behavior of FUS used as a seizure therapy are unknown. This study explores behavioral effects and hippocampal restoration induced by pulsed FUS in a kainic acid (KA) animal model of temporal lobe epilepsy. Twenty-nine male Sprague-Dawley rats were observed for 20 weeks with anatomical magnetic resonance imaging (MRI) and behavioral performance evaluations, comprising measures of anxiety, limb usage, sociability, and memory. FUS targeted to the right hippocampus was given 9 and 14 weeks after KA was delivered to the right amygdala. Ultrasound pulsations were delivered with the acoustic settings of 0.25 of mechanical index, 0.5 W/cm2 of intensity spatial peak temporal average (ISPTA), 100 Hz of pulse repetition frequency, and 30% of duty cycle, during three consecutive pulse trains of 10 min separated by 5-min rests. Controls included normal animals with sham injections and KA-exposed animals without FUS exposure. Longitudinal MRI observations showed that FUS substantially protected hippocampal and striatal structures from KA-induced atrophy. KA alone increased anxiety, impaired contralateral limb usage, and reduced sociability and learning. Two courses of FUS sonications partially ameliorated these impairments by enhancing exploring and learning, balancing limb usage, and increasing social interaction. The histology results indicated that two sonications enhanced neuroprotection effect and decreased the inflammation markers induced by KA. This study supports existence of both neuroprotective and beneficial behavioral effects from low-intensity pulsed ultrasound in the KA animal model of epilepsy.
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Affiliation(s)
- Po-Chun Chu
- Department of Electrical Engineering, National Taiwan University, Taipei, Taiwan
| | - Chen-Syuan Huang
- Department of Electrical Engineering, National Taiwan University, Taipei, Taiwan
| | - Shan-Zhi Ing
- School of Veterinary Medicine, National Taiwan University, Taipei, Taiwan
| | - Hsiang-Yu Yu
- Department of Neurology, Taipei Veteran General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Robert S Fisher
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Hao-Li Liu
- Department of Electrical Engineering, National Taiwan University, Taipei, Taiwan.
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19
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Shofty B, Gadot R, Provenza N, Storch EA, Goodman WK, Sheth SA. Neurosurgical Approaches for Treatment-Resistant Obsessive-Compulsive Disorder. Psychiatr Clin North Am 2023; 46:121-132. [PMID: 36740348 DOI: 10.1016/j.psc.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Treatment-resistant obsessive-compulsive disorder (trOCD) is a severely disabling, life-threatening psychiatric disorder affecting ∼0.5% of the US population. Following the failure of multiple medical and psychotherapeutic treatment lines, patients with trOCD, like others with functional disorders, may benefit from invasive neuromodulation. Cumulative evidence suggests that disrupting abnormal hyperdirect cortico-striato-thalamo-cortical (CSTC) pathway activity offers sustainable, robust symptomatic relief in most patients. Multiple surgical approaches allow for modulation of the CSTC pathway, including stereotactic lesions and electrical stimulation. This review aims to describe the modern neurosurgical approaches for trOCD, recent advances in our understanding of pathophysiology, and future therapeutic directions.
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Affiliation(s)
- Ben Shofty
- Department of Neurosurgery, University of Utah, 175 North Medical Drive East, 5th Floor, Salt Lake City, UT 84132, USA
| | - Ron Gadot
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge Street Suite 9A, Houston, TX 77030, USA
| | - Nicole Provenza
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge Street Suite 9A, Houston, TX 77030, USA
| | - Eric A Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA
| | - Wayne K Goodman
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA
| | - Sameer A Sheth
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge Street Suite 9A, Houston, TX 77030, USA; Department of Psychiatry, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA.
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20
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Becker CR, Milad MR. Contemporary Approaches Toward Neuromodulation of Fear Extinction and Its Underlying Neural Circuits. Curr Top Behav Neurosci 2023; 64:353-387. [PMID: 37658219 DOI: 10.1007/7854_2023_442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
Neuroscience and neuroimaging research have now identified brain nodes that are involved in the acquisition, storage, and expression of conditioned fear and its extinction. These brain regions include the ventromedial prefrontal cortex (vmPFC), dorsal anterior cingulate cortex (dACC), amygdala, insular cortex, and hippocampus. Psychiatric neuroimaging research shows that functional dysregulation of these brain regions might contribute to the etiology and symptomatology of various psychopathologies, including anxiety disorders and post traumatic stress disorder (PTSD) (Barad et al. Biol Psychiatry 60:322-328, 2006; Greco and Liberzon Neuropsychopharmacology 41:320-334, 2015; Milad et al. Biol Psychiatry 62:1191-1194, 2007a, Biol Psychiatry 62:446-454, b; Maren and Quirk Nat Rev Neurosci 5:844-852, 2004; Milad and Quirk Annu Rev Psychol 63:129, 2012; Phelps et al. Neuron 43:897-905, 2004; Shin and Liberzon Neuropsychopharmacology 35:169-191, 2009). Combined, these findings indicate that targeting the activation of these nodes and modulating their functional interactions might offer an opportunity to further our understanding of how fear and threat responses are formed and regulated in the human brain, which could lead to enhancing the efficacy of current treatments or creating novel treatments for PTSD and other psychiatric disorders (Marin et al. Depress Anxiety 31:269-278, 2014; Milad et al. Behav Res Ther 62:17-23, 2014). Device-based neuromodulation techniques provide a promising means for directly changing or regulating activity in the fear extinction network by targeting functionally connected brain regions via stimulation patterns (Raij et al. Biol Psychiatry 84:129-137, 2018; Marković et al. Front Hum Neurosci 15:138, 2021). In the past ten years, notable advancements in the precision, safety, comfort, accessibility, and control of administration have been made to the established device-based neuromodulation techniques to improve their efficacy. In this chapter we discuss ten years of progress surrounding device-based neuromodulation techniques-Electroconvulsive Therapy (ECT), Transcranial Magnetic Stimulation (TMS), Magnetic Seizure Therapy (MST), Transcranial Focused Ultrasound (TUS), Deep Brain Stimulation (DBS), Vagus Nerve Stimulation (VNS), and Transcranial Electrical Stimulation (tES)-as research and clinical tools for enhancing fear extinction and treating PTSD symptoms. Additionally, we consider the emerging research, current limitations, and possible future directions for these techniques.
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Affiliation(s)
- Claudia R Becker
- Department of Psychiatry, NYU Grossman School of Medicine, New York, NY, USA
| | - Mohammed R Milad
- Department of Psychiatry, NYU Grossman School of Medicine, New York, NY, USA.
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21
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Deep brain stimulation of the nucleus accumbens in the treatment of severe alcohol use disorder: a phase I pilot trial. Mol Psychiatry 2022; 27:3992-4000. [PMID: 35858989 DOI: 10.1038/s41380-022-01677-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 06/15/2022] [Accepted: 06/17/2022] [Indexed: 02/07/2023]
Abstract
Alcohol use disorder (AUD) is a highly prevalent, often refractory, medical illness. The symptoms of AUD are driven by dysfunction in several neurocircuits centered on the nucleus accumbens (NAc). Case reports and animal studies suggest NAc-DBS may be an effective harm-reduction treatment in severe AUD. Six patients with severe, refractory AUD underwent NAc-DBS. Safety metrics and clinical outcomes were recorded. Positron emission tomography (FDG-PET) was used to measure glucose metabolism in the NAc at baseline and 6 months. Functional magnetic resonance imaging (fMRI) was used to characterize postoperative changes in NAc functional connectivity to the rest of the brain, as well as NAc and dorsal striatal reactivity to alcoholic visual cues. This study was registered with ClinicalTrials.gov, NCT03660124. All patients experienced a reduction in craving. There was a significant reduction in alcohol consumption, alcohol-related compulsivity, and anxiety at 12 months. There was no significant change in depression. FDG-PET analysis demonstrated reduced NAc metabolism by 6 months, which correlated with improvements in compulsive drinking behaviors. Clinical improvement correlated with reduced functional connectivity between the NAc and the visual association cortex. Active DBS was associated with reduced activation of the dorsal striatum during passive viewing of alcohol-containing pictures. NAc-DBS is feasible and safe in patients with severe, otherwise refractory AUD. It is associated with a reduction in cravings and addictive behavior. A potential mechanism underlying this process is a down-regulation of the NAc, a disruption of its functional connectivity to the visual association cortex, and interference of cue-elicited dorsal striatum reactivity. Trial Registration NCT03660124 ( www.clinicaltrials.gov ).
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22
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Update in the clinical application of focused ultrasound. Curr Opin Neurol 2022; 35:525-535. [PMID: 35788096 DOI: 10.1097/wco.0000000000001073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To review the most recent evidence about the clinical applicability of transcranial MRI-guided focused ultrasound (MRgFUS), including clinical evidence and indications, recent technical developments for its use and future prospects. RECENT FINDINGS Unilateral MRgFUS thalamotomy for both essential and parkinsonian tremors is an approved and well established therapy. Recent studies have focused on its long-term safety and efficacy as well as technical advances for refining the approach. Moreover, ultrasound has expanded its application in Parkinson's disease, with clinical trials successfully targeting other brain regions like the subthalamic nucleus, the globus pallidus and the pallidothalamic tract, providing benefits for features that thalamotomy neglects. New indications, such as focal dystonia or neuropsychiatric conditions (namely obsessive-compulsive disorder and depression) have also been explored, with encouraging preliminary results. Finally, the application of ultrasound in low-intensity modality allows other approaches like focal blood-brain barrier opening and neuromodulation, which promise to be highly relevant in translational research. SUMMARY MRgFUS is a growing emergent technique. Its application in clinical routine is becoming widely accepted as a therapeutic option. Novel approaches and new potential applications are anticipated.
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Baek H, Lockwood D, Mason EJ, Obusez E, Poturalski M, Rammo R, Nagel SJ, Jones SE. Clinical Intervention Using Focused Ultrasound (FUS) Stimulation of the Brain in Diverse Neurological Disorders. Front Neurol 2022; 13:880814. [PMID: 35614924 PMCID: PMC9124976 DOI: 10.3389/fneur.2022.880814] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/07/2022] [Indexed: 12/02/2022] Open
Abstract
Various surgical techniques and pharmaceutical treatments have been developed to improve the current technologies of treating brain diseases. Focused ultrasound (FUS) is a new brain stimulation modality that can exert a therapeutic effect on diseased brain cells, with this effect ranging from permanent ablation of the pathological neural circuit to transient excitatory/inhibitory modulation of the neural activity depending on the acoustic energy of choice. With the development of intraoperative imaging technology, FUS has become a clinically available noninvasive neurosurgical option with visual feedback. Over the past 10 years, FUS has shown enormous potential. It can deliver acoustic energy through the physical barrier of the brain and eliminate abnormal brain cells to treat patients with Parkinson's disease and essential tremor. In addition, FUS can help introduce potentially beneficial therapeutics at the exact brain region where they need to be, bypassing the brain's function barrier, which can be applied for a wide range of central nervous system disorders. In this review, we introduce the current FDA-approved clinical applications of FUS, ranging from thermal ablation to blood barrier opening, as well as the emerging applications of FUS in the context of pain control, epilepsy, and neuromodulation. We also discuss the expansion of future applications and challenges. Broadening FUS technologies requires a deep understanding of the effect of ultrasound when targeting various brain structures in diverse disease conditions in the context of skull interface, anatomical structure inside the brain, and pathology.
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Affiliation(s)
- Hongchae Baek
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
- Center for Neurological Restoration, Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
| | - Daniel Lockwood
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
| | | | - Emmanuel Obusez
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
| | | | - Richard Rammo
- Center for Neurological Restoration, Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
| | - Sean J. Nagel
- Center for Neurological Restoration, Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
| | - Stephen E. Jones
- Cleveland Clinic, Imaging Institute, Cleveland, OH, United States
- *Correspondence: Stephen E. Jones
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Messina G, Vetrano IG, Bonomo G, Broggi G. Role of deep brain stimulation in management of psychiatric disorders. PROGRESS IN BRAIN RESEARCH 2022; 270:61-96. [PMID: 35396031 DOI: 10.1016/bs.pbr.2022.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Nowadays, most of patients affected by psychiatric disorders are successfully treated with conservative therapies. Still, a variable percentage of them demonstrate resistance to conventional treatments, and alternative methods can then be considered. During the last 20 years, there is a progressive interest in use of deep brain stimulation (DBS) in mental illnesses. It has become clear nowadays, that this modality may be effectively applied under specific indications in some patients with major depressive disorder, obsessive-compulsive disorder, anorexia nervosa and other eating disorders, Tourette syndrome, schizophrenia, substance use disorder, and even pathologically aggressive behavior. Despite the fact that the efficacy of neuromodulation with DBS, as well as of various lesional interventions, in cases of mental illnesses is still not fully established, there are several premises for wider applications of such "unclassical" psychiatric treatments in the future. Novel technologies of DBS, developments in non-invasive lesioning using stereotactic radiosurgery and transcranial magnetic resonance-guided focused ultrasound, and advances of neurophysiological and neuroimaging modalities may bolster further clinical applications of psychiatric neurosurgery, improve its results, and allow for individually selected treatment strategies tailored to specific needs of the patient.
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Affiliation(s)
- Giuseppe Messina
- Functional Neurosurgery Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Ignazio G Vetrano
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giulio Bonomo
- Functional Neurosurgery Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giovanni Broggi
- Functional Neurosurgery Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurosurgery, M Cecilia Hospital-GVM, Ravenna, Italy
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25
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Mustroph ML, Cosgrove GR, Williams ZM. The Evolution of Modern Ablative Surgery for the Treatment of Obsessive-Compulsive and Major Depression Disorders. Front Integr Neurosci 2022; 16:797533. [PMID: 35464603 PMCID: PMC9026193 DOI: 10.3389/fnint.2022.797533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 02/07/2022] [Indexed: 11/30/2022] Open
Abstract
In this review, we describe the evolution of modern ablative surgery for intractable psychiatric disease, from the original image-guided cingulotomy procedure described by Ballantine, to the current bilateral anterior cingulotomy using MRI-guided stereotactic techniques. Extension of the single lesion bilateral cingulotomy to the extended bilateral cingulotomy and subsequent staged limbic leucotomy (LL) is also discussed. Other ablative surgeries for psychiatric disease including subcaudate tractotomy (SCT) and anterior capsulotomy (AC) using modern MRI-guided ablative techniques, as well as radiosurgical capsulotomy, are described. Finally, the potential emerging role of MR-guided focused ultrasound (MRgFUS) for treating conditions such as major depressive disorder (MDD) and obsessive-compulsive disorder (OCD) is discussed.
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Affiliation(s)
- Martina Laetitia Mustroph
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - G. Rees Cosgrove
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Ziv M. Williams
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Harvard-MIT Division of Health Sciences and Technology, Boston, MA, United States
- Program in Neuroscience, Harvard Medical School, Boston, MA, United States
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26
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Rabin JS, Nyman AJ, Davidson B, Zakzanis KK, Giacobbe P, Hamani C, Nestor S, Lipsman N. Commonly used outcome measures in neurosurgical trials for major depressive disorder might not capture clinically meaningful treatment effects. J Neurol Neurosurg Psychiatry 2022; 93:455-456. [PMID: 35078915 PMCID: PMC8921571 DOI: 10.1136/jnnp-2021-327688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 12/16/2021] [Indexed: 11/23/2022]
Affiliation(s)
- Jennifer S Rabin
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, Ontario, Canada .,Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Alexander J Nyman
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Benjamin Davidson
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Konstantine K Zakzanis
- Department of Psychology, University of Toronto Scarborough, Toronto, Ontario, Canada.,Graduate Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto, Ontario, Canada
| | - Peter Giacobbe
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Clement Hamani
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sean Nestor
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nir Lipsman
- Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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27
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Satzer D, Mahavadi A, Lacy M, Grant JE, Warnke P. Interstitial laser anterior capsulotomy for obsessive-compulsive disorder: lesion size and tractography correlate with outcome. J Neurol Neurosurg Psychiatry 2022; 93:317-323. [PMID: 34716192 DOI: 10.1136/jnnp-2021-327730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/27/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Anterior capsulotomy is a well-established treatment for refractory obsessive-compulsive disorder (OCD). MRI-guided laser interstitial thermal therapy (LITT) allows creation of large, sharply demarcated lesions with the safeguard of real-time imaging. OBJECTIVE To characterise the outcomes of laser anterior capsulotomy, including radiographical predictors of improvement. METHODS Patients with severe OCD refractory to pharmacotherapy and cognitive-behavioural therapy underwent bilateral anterior capsulotomy via LITT. The primary outcome was per cent reduction in Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score over time. Lesion size was measured on postablation MRI. Disconnection of the anterior limb of the internal capsule (ALIC) was assessed via individual and normative tractography. RESULTS Eighteen patients underwent laser anterior capsulotomy. Median follow-up was 6 months (range 3-51 months). Time occupied by obsessions improved immediately (median Y-BOCS item 1 score 4-1, p=0.002). Mean (±SD) decrease in Y-BOCS score at last follow-up was 46%±32% (16±11 points, p<0.0001). Sixty-one per cent of patients were responders. Seven patients (39%) exhibited transient postoperative apathy. One patient had an asymptomatic intracerebral haemorrhage. Reduction in Y-BOCS score was positively associated with ablation volume (p=0.006). Individual tractography demonstrated durable ALIC disconnection. Normative tractography revealed a dorsal-ventral gradient, with disconnection of orbitofrontal streamlines most strongly associated with a positive response (p<0.0001). CONCLUSIONS Laser anterior capsulotomy resulted in immediate, marked improvement in OCD symptom severity. Larger lesions permit greater disconnection of prefrontal-subcortical pathways involved in OCD. The importance of greater disconnection is presumably related to variation in ALIC structure and the complex role of the PFC in OCD.
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Affiliation(s)
- David Satzer
- Neurosurgery, University of Chicago Biological Sciences Division, Chicago, Illinois, USA
| | - Anil Mahavadi
- Neurosurgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Maureen Lacy
- Psychaitry and Behavioral Neuroscience, University of Chicago Biological Sciences Division, Chicago, Illinois, USA
| | - Jon E Grant
- Psychiatry, University of Chicago Biological Sciences Division, Chicago, Illinois, USA
| | - Peter Warnke
- Neurosurgery, University of Chicago Biological Sciences Division, Chicago, Illinois, USA
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Müller S, van Oosterhout A, Bervoets C, Christen M, Martínez-Álvarez R, Bittlinger M. Concerns About Psychiatric Neurosurgery and How They Can Be Overcome: Recommendations for Responsible Research. NEUROETHICS-NETH 2022. [DOI: 10.1007/s12152-022-09485-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Background
Psychiatric neurosurgery is experiencing a revival. Beside deep brain stimulation (DBS), several ablative neurosurgical procedures are currently in use. Each approach has a different profile of advantages and disadvantages. However, many psychiatrists, ethicists, and laypeople are sceptical about psychiatric neurosurgery.
Methods
We identify the main concerns against psychiatric neurosurgery, and discuss the extent to which they are justified and how they might be overcome. We review the evidence for the effectiveness, efficacy and safety of each approach, and discuss how this could be improved. We analyse whether and, if so, how randomised controlled trials (RCTs) can be used in the different approaches, and what alternatives are available if conducting RCTs is impossible for practical or ethical reasons. Specifically, we analyse the problem of failed RCTs after promising open-label studies.
Results
The main concerns are: (i) reservations based on historical psychosurgery, (ii) concerns about personality changes, (iii) concerns regarding localised interventions, and (iv) scepticism due to the lack of scientific evidence. Given the need for effective therapies for treatment-refractory psychiatric disorders and preliminary evidence for the effectiveness of psychiatric neurosurgery, further research is warranted and necessary. Since psychiatric neurosurgery has the potential to modify personality traits, it should be held to the highest ethical and scientific standards.
Conclusions
Psychiatric neurosurgery procedures with preliminary evidence for efficacy and an acceptable risk–benefit profile include DBS and micro- or radiosurgical anterior capsulotomy for intractable obsessive–compulsive disorder. These methods may be considered for individual treatment attempts, but multi-centre RCTs are necessary to provide reliable evidence.
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29
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Common and differential connectivity profiles of deep brain stimulation and capsulotomy in refractory obsessive-compulsive disorder. Mol Psychiatry 2022; 27:1020-1030. [PMID: 34703025 DOI: 10.1038/s41380-021-01358-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 10/03/2021] [Accepted: 10/08/2021] [Indexed: 11/08/2022]
Abstract
Neurosurgical interventions including deep brain stimulation (DBS) and capsulotomy have been demonstrated effective for refractory obsessive-compulsive disorder (OCD), although treatment-shared/-specific network mechanisms remain largely unclear. We retrospectively analyzed resting-state fMRI data from three cohorts: a cross-sectional dataset of 186 subjects (104 OCD and 82 healthy controls), and two longitudinal datasets of refractory patients receiving ventral capsule/ventral striatum DBS (14 OCD) and anterior capsulotomy (27 OCD). We developed a machine learning model predictive of OCD symptoms (indexed by the Yale-Brown Obsessive Compulsive Scale, Y-BOCS) based on functional connectivity profiles and used graphic measures of network communication to characterize treatment-induced profile changes. We applied a linear model on 2 levels treatments (DBS or capsulotomy) and outcome to identify whether pre-surgical network communication was associated with differential treatment outcomes. We identified 54 functional connectivities within fronto-subcortical networks significantly predictive of Y-BOCS score in patients across 3 independent cohorts, and observed a coexisting pattern of downregulated cortico-subcortical and upregulated cortico-cortical network communication commonly shared by DBS and capsulotomy. Furthermore, increased cortico-cortical communication at ventrolateral and centrolateral prefrontal cortices induced by DBS and capsulotomy contributed to improvement of mood and anxiety symptoms, respectively (p < 0.05). Importantly, pretreatment communication of ventrolateral and centrolateral prefrontal cortices were differentially predictive of mood and anxiety improvements by DBS and capsulotomy (effect sizes = 0.45 and 0.41, respectively). These findings unravel treatment-shared and treatment-specific network characteristics induced by DBS and capsulotomy, which may facilitate the search of potential evidence-based markers for optimally selecting among treatment options for a patient.
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30
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Ahmed AK, Guo S, Kelm N, Clanton R, Melhem ER, Gullapalli RP, Ksendzovsky A, Eisenberg HM, Miller TR, Gandhi D. Technical Comparison of Treatment Efficiency of Magnetic Resonance-Guided Focused Ultrasound Thalamotomy and Pallidotomy in Skull Density Ratio-Matched Patient Cohorts. Front Neurol 2022; 12:808810. [PMID: 35126300 PMCID: PMC8813961 DOI: 10.3389/fneur.2021.808810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 12/17/2021] [Indexed: 11/24/2022] Open
Abstract
Objective MR-guided focused ultrasound (MRgFUS) is increasingly being used to treat patients with essential tremor (ET) and Parkinson's disease (PD) with thalamotomy and pallidotomy, respectively. Pallidotomy is performed off-center within the cranium compared to thalamotomy and may present challenges to therapeutic lesioning due to this location. However, the impact of target location on treatment efficiency and ability to create therapeutic lesions has not been studied. This study aimed to compare the physical efficiency of MRgFUS thalamotomy and pallidotomy. Methods Treatment characteristics were compared between patients treated with thalamotomy (n = 20) or pallidotomy (n = 20), matched by skull density ratios (SDR). Aspects of treatment efficiency were compared between these groups. Demographic and comparative statistics were conducted to assess these differences. Acoustic field simulations were performed to compare and validate the simulated temperature profile for VIM and GPi ablation. Results Lower SDR values were associated with greater energy requirement for thalamotomy (R2 = 0.197, p = 0.049) and pallidotomy (R2 = 0.342, p = 0.007). The impact of low SDR on efficiency reduction was greater for pallidotomy, approaching significance (p = 0.061). A nearly two-fold increase in energy was needed to reach 50°C in pallidotomy (10.9kJ) than in thalamotomy (5.7kJ), (p = 0.002). Despite lower energy requirement, the maximum average temperature reached was higher in thalamotomy (56.7°C) than in pallidotomy (55.0°C), (p = 0.017). Mean incident angle of acoustic beams was lesser in thalamotomy (12.7°) than in pallidotomy (18.6°), (p < 0.001). For all patients, a lesser mean incident angle correlated with a higher maximum average temperature reached (R2 = 0.124, p = 0.026), and less energy needed to reach 50°C (R2=0.134, p = 0.020). Greater skull thickness was associated with a higher maximum energy for a single sonication for thalamotomy (R2 = 0.206, p = 0.045) and pallidotomy (R2 = 0.403, p = 0.003). An acoustic and temperature field simulation validated similar findings for thalamotomy and pallidotomy in a single patient. Conclusion The centrally located VIM offers a more efficient location for therapeutic lesioning compared to GPi pallidotomy in SDR matched cohort of patients. The impact on therapeutic lesioning with lower SDR may be greater for pallidotomy patients. As newer off-center targets are investigated, these findings can inform patient selection and treatment requirements for lesion production.
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Affiliation(s)
- Abdul-Kareem Ahmed
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
- *Correspondence: Abdul-Kareem Ahmed
| | - Sijia Guo
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | | | | | - Elias R. Melhem
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Rao P. Gullapalli
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Alexander Ksendzovsky
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Howard M. Eisenberg
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Timothy R. Miller
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Dheeraj Gandhi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
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Lee YK, Gold MS, Fuehrlein BS. Looking beyond the opioid receptor: A desperate need for new treatments for opioid use disorder. J Neurol Sci 2022; 432:120094. [PMID: 34933249 DOI: 10.1016/j.jns.2021.120094] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 12/10/2021] [Accepted: 12/12/2021] [Indexed: 10/19/2022]
Abstract
The mainstay of treatment for opioid use disorder (OUD) is opioid agonist therapy (OAT), which modulates opioid receptors to reduce substance craving and use. OAT maintains dependence on opioids but helps reduce overdose and negative sequelae of substance abuse. Despite increasing availability of OAT, its effectiveness is limited by difficulty in initiating and maintaining patients on treatment. With the worsening opioid epidemic in the United States and rising overdose deaths, a more durable and effective treatment for OUD is necessary. This paper reviews novel treatments being investigated for OUD, including neuromodulatory interventions, psychedelic drugs, and other novel approaches. Neuromodulatory interventions can stimulate the addiction neural circuitry involving the dorsolateral prefrontal cortex and deeper mesolimbic structures to curb craving and reduce use, and multiple clinical trials for interventional treatment for OUD are currently conducted. Similarly, psychedelic agents are being investigated for efficacy in OUD specifically. There is a resurgence of interest in psychedelic agents' therapeutic potential, with evidence of improving mood symptoms and decreased substance use even after just one dose. Exact mechanism of their anti-addictive effect is not fully elucidated, but psychedelic agents do not maintain opioid dependence and some may even be helpful in abating symptoms of withdrawal. Other potential approaches for OUD include targeting different parts of the dopamine-dependent addiction pathway, identifying susceptible genes and modulating gene products, as well as utilizing vaccines as immunotherapy to blunt the addictive effects of substances. Much more clinical data are needed to support efficacy and safety of these therapies in OUD, but these proposed novel treatments look beyond the opioid receptor to offer hope for a more durably effective OUD treatment.
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Affiliation(s)
- Yu Kyung Lee
- School of Medicine, Yale University, 333 Cedar St, New Haven, CT 06510, USA.
| | - Mark S Gold
- Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO 63110, USA.
| | - Brian S Fuehrlein
- Department of Psychiatry, Yale University, 300 George Street, New Haven, CT 06511, USA.
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Spivak NM, Tyler WJ, Bari AA, Kuhn TP. Ultrasound as a Neurotherapeutic: A Circuit- and System-Based Interrogation. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2022; 20:32-35. [PMID: 35746933 PMCID: PMC9063590 DOI: 10.1176/appi.focus.20210022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Focused ultrasound is a novel brain stimulation modality that combines the noninvasiveness of repetitive transcranial magnetic stimulation and the precision of deep brain stimulation. In this review, the authors examine low-intensity focused ultrasound for brain mapping and neuromodulation. They also discuss high-intensity focused ultrasound, which is used for incisionless surgeries, such as capsulotomies for obsessive-compulsive disorder. Future potential applications of focused ultrasound are also presented.
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33
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Kumar R, Aadil KR, Mondal K, Mishra YK, Oupicky D, Ramakrishna S, Kaushik A. Neurodegenerative disorders management: state-of-art and prospects of nano-biotechnology. Crit Rev Biotechnol 2021; 42:1180-1212. [PMID: 34823433 DOI: 10.1080/07388551.2021.1993126] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Neurodegenerative disorders (NDs) are highly prevalent among the aging population. It affects primarily the central nervous system (CNS) but the effects are also observed in the peripheral nervous system. Neural degeneration is a progressive loss of structure and function of neurons, which may ultimately involve cell death. Such patients suffer from debilitating memory loss and altered motor coordination which bring up non-affordable and unavoidable socio-economic burdens. Due to the unavailability of specific therapeutics and diagnostics, the necessity to control or manage NDs raised the demand to investigate and develop efficient alternative approaches. Keeping trends and advancements in view, this report describes both state-of-the-art and challenges in nano-biotechnology-based approaches to manage NDs, toward personalized healthcare management. Sincere efforts are being made to customize nano-theragnostics to control: therapeutic cargo packaging, delivery to the brain, nanomedicine of higher efficacy, deep brain stimulation, implanted stimulation, and managing brain cell functioning. These advancements are useful to design future therapy based on the severity of the patient's neurodegenerative disease. However, we observe a lack of knowledge shared among scientists of a variety of expertise to explore this multi-disciplinary research field for NDs management. Consequently, this review will provide a guideline platform that will be useful in developing novel smart nano-therapies by considering the aspects and advantages of nano-biotechnology to manage NDs in a personalized manner. Nano-biotechnology-based approaches have been proposed as effective and affordable alternatives at the clinical level due to recent advancements in nanotechnology-assisted theragnostics, targeted delivery, higher efficacy, and minimal side effects.
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Affiliation(s)
- Raj Kumar
- Department of Pharmaceutical Sciences, Center for Drug Delivery and Nanomedicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Keshaw Ram Aadil
- Center for Basic Sciences, Pt. Ravishankar Shukla University, Raipur, India
| | - Kunal Mondal
- Materials Science and Engineering Department, Idaho National Laboratory, Idaho Falls, ID, USA
| | - Yogendra Kumar Mishra
- Mads Clausen Institute, NanoSYD, University of Southern Denmark, Sønderborg, Denmark
| | - David Oupicky
- Department of Pharmaceutical Sciences, Center for Drug Delivery and Nanomedicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Seeram Ramakrishna
- Center for Nanotechnology and Sustainability, National University of Singapore, Singapore, Singapore
| | - Ajeet Kaushik
- NanoBioTech Laboratory, Health Systems Engineering, Department of Environmental Engineering, Florida Polytechnic University, Lakeland, FL, USA
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Davidson B, Hamani C, Rabin JS, Meng Y, Richter MA, Giacobbe P, Lipsman N. Magnetic Resonance-Guided Focused Ultrasound Capsulotomy for Musical Obsessions. Biol Psychiatry 2021; 90:e49-e50. [PMID: 32862969 DOI: 10.1016/j.biopsych.2020.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/02/2020] [Accepted: 07/06/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Benjamin Davidson
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada; Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Clement Hamani
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada; Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer S Rabin
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada; Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada; Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada
| | - Ying Meng
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada; Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Margaret Anne Richter
- Frederick W. Thompson Anxiety Disorders Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada; Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Peter Giacobbe
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada; Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada; Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada.
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Stieglitz LH, Oertel MF, Accolla EA, Bally J, Bauer R, Baumann CR, Benninger D, Bohlhalter S, Büchele F, Hägele-Link S, Kägi G, Krack P, Krüger MT, Mahendran S, Möller JC, Mylius V, Piroth T, Werner B, Kaelin-Lang A. Consensus Statement on High-Intensity Focused Ultrasound for Functional Neurosurgery in Switzerland. Front Neurol 2021; 12:722762. [PMID: 34630296 PMCID: PMC8493868 DOI: 10.3389/fneur.2021.722762] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/18/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Magnetic resonance-guided high-intensity focused ultrasound (MRgHiFUS) has evolved into a viable ablative treatment option for functional neurosurgery. However, it is not clear yet, how this new technology should be integrated into current and established clinical practice and a consensus should be found about recommended indications, stereotactic targets, patient selection, and outcome measurements. Objective: To sum up and unify current knowledge and clinical experience of Swiss neurological and neurosurgical communities regarding MRgHiFUS interventions for brain disorders to be published as a national consensus paper. Methods: Eighteen experienced neurosurgeons and neurologists practicing in Switzerland in the field of movement disorders and one health physicist representing 15 departments of 12 Swiss clinical centers and 5 medical societies participated in the workshop and contributed to the consensus paper. All experts have experience with current treatment modalities or with MRgHiFUS. They were invited to participate in two workshops and consensus meetings and one online meeting. As part of workshop preparations, a thorough literature review was undertaken and distributed among participants together with a list of relevant discussion topics. Special emphasis was put on current experience and practice, and areas of controversy regarding clinical application of MRgHiFUS for functional neurosurgery. Results: The recommendations addressed lesioning for treatment of brain disorders in general, and with respect to MRgHiFUS indications, stereotactic targets, treatment alternatives, patient selection and management, standardization of reporting and follow-up, and initialization of a national registry for interventional therapies of movement disorders. Good clinical evidence is presently only available for unilateral thalamic lesioning in treating essential tremor or tremor-dominant Parkinson's disease and, to a minor extent, for unilateral subthalamotomy for Parkinson's disease motor features. However, the workgroup unequivocally recommends further exploration and adaptation of MRgHiFUS-based functional lesioning interventions and confirms the need for outcome-based evaluation of these approaches based on a unified registry. MRgHiFUS and DBS should be evaluated by experts familiar with both methods, as they are mutually complementing therapy options to be appreciated for their distinct advantages and potential. Conclusion: This multidisciplinary consensus paper is a representative current recommendation for safe implementation and standardized practice of MRgHiFUS treatments for functional neurosurgery in Switzerland.
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Affiliation(s)
| | - Markus F Oertel
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Ettore A Accolla
- Neurology Unit, Department of Internal Medicine, Hôpital Fribourgeois (HFR)-Cantonal Hospital Fribourg, University of Fribourg, Fribourg, Switzerland
| | - Julien Bally
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Department of Neurology, Geneva University Hospital and University of Geneva, Geneva, Switzerland
| | - Roland Bauer
- Department of Neurosurgery, Cantonal Hospital Aarau, Aarau, Switzerland
| | | | - David Benninger
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Stephan Bohlhalter
- Neurocenter, Lucerne Cantonal Hospital, University of Zurich, Zurich, Switzerland
| | - Fabian Büchele
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Stefan Hägele-Link
- Department of Neurology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Georg Kägi
- Department of Neurology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Paul Krack
- Department of Neurology, Inselspital, University Bern, Bern, Switzerland
| | - Marie T Krüger
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Sujitha Mahendran
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - J Carsten Möller
- Parkinson Center, Center for Neurological Rehabilitation, Zihlschlacht, Switzerland
| | - Veit Mylius
- Department of Neurology, Center for Neurorehabilitation, Valens, Switzerland
| | - Tobias Piroth
- Department of Neurology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Beat Werner
- Center for Magnetic Resonance (MR) Research, University Children's Hospital Zurich, Zurich, Switzerland
| | - Alain Kaelin-Lang
- Department of Neurology, Inselspital, University Bern, Bern, Switzerland.,Neurocenter of Southern Switzerland Ente Ospedaliero Cantonale (EOC), Regional Hospital Lugano, Lugano, Switzerland.,Faculty of Biomedical Neurosciences, Università Della Svizzera Italiana, Lugano, Switzerland
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Guglielmi G, Eschbach KL, Alexander AL. Smaller Knife, Fewer Seizures? Recent Advances in Minimally Invasive Techniques in Pediatric Epilepsy Surgery. Semin Pediatr Neurol 2021; 39:100913. [PMID: 34620456 DOI: 10.1016/j.spen.2021.100913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 02/02/2023]
Abstract
Children with drug-resistant epilepsy are at high risk for developmental delay, increased mortality, psychiatric comorbidities, and requiring assistance with activities of daily living. Despite the advent of new and effective pharmacologic therapies, about one in 5 children will develop drug-resistant epilepsy, and most of these children continue to have seizures despite trials of other medication. Epilepsy surgery is often a safe and effective option which may offer seizure freedom or at least a significant reduction in seizure burden in many children. However, despite published evidence of safety and efficacy, epilepsy surgery remains underutilized in the pediatric population. Patient and family fears about the risks of surgery may contribute to this gap. Less invasive surgical techniques may be more palatable to children with epilepsy and their caregivers. In this review, we present recent advances in minimally invasive techniques for the surgical treatment of epilepsy as well as intriguing possibilities for the future. We describe the indications for, benefits of, and limits to minimally-invasive techniques including Stereo-encephalography, laser interstitial thermal ablation, deep brain stimulation, focused ultrasound, stereo-encephalography-guided radiofrequency ablation, endoscopic disconnections, and responsive neurostimulation.
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Affiliation(s)
- Gina Guglielmi
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO
| | - Krista L Eschbach
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO
| | - Allyson L Alexander
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO.
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Focused ultrasound for functional neurosurgery. J Neurooncol 2021; 156:17-22. [PMID: 34383232 DOI: 10.1007/s11060-021-03818-3] [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: 07/23/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Brain lesioning is a fundamental technique in the functional neurosurgery world. It has been investigated for decades and presented promising results long before novel pharmacological agents were introduced to treat movement disorders, psychiatric disorders, pain, and epilepsy. Ablative procedures were replaced by effective drugs during the 1950s and by Deep Brain Stimulation (DBS) in the 1990s as a reversible neuromodulation technique. In the last decade, however, the popularity of brain lesioning has increased again with the introduction of magnetic resonance-guided focused ultrasound (MRgFUS). OBJECTIVE In this review, we will cover the current and emerging role of MRgFUS in functional neurosurgery. METHODS Literature review from PubMed and compilation. RESULTS Investigated since 1930, MRgFUS is a technology enabling targeted energy delivery at the convergence of mechanical sound waves. Based on technological advancements in phased array ultrasound transducers, algorithms accounting for skull penetration by sound waves, and MR imaging for targeting and thermometry, MRgFUS is capable of brain lesioning with sub-millimeter precision and can be used in a variety of clinical indications. CONCLUSION MRgFUS is a promising technology evolving as a dominant tool in different functional neurosurgery procedures in movement disorders, psychiatric disorders, epilepsy, among others.
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Meng Y, Pople CB, Lea-Banks H, Hynynen K, Lipsman N, Hamani C. Focused ultrasound neuromodulation. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2021; 159:221-240. [PMID: 34446247 DOI: 10.1016/bs.irn.2021.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Focused ultrasound (FUS) is an emerging modality for performing incisionless neurosurgical procedures including thermoablation and blood-brain barrier (BBB) modulation. Emerging evidence suggests that low intensity FUS can also be used for neuromodulation with several benefits, including high spatial precision and the possibility of targeting deep brain regions. Here we review the existing data regarding the biological mechanisms of FUS neuromodulation, the characteristics of neuronal activity altered by FUS, emerging indications for FUS neuromodulation, as well as the strengths and limitations of this approach.
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Affiliation(s)
- Ying Meng
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Christopher B Pople
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Harriet Lea-Banks
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Kullervo Hynynen
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Nir Lipsman
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada
| | - Clement Hamani
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada.
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Davidson B, Mithani K, Huang Y, Jones RM, Goubran M, Meng Y, Snell J, Hynynen K, Hamani C, Lipsman N. Technical and radiographic considerations for magnetic resonance imaging-guided focused ultrasound capsulotomy. J Neurosurg 2021; 135:291-299. [PMID: 32977311 DOI: 10.3171/2020.6.jns201302] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/04/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Magnetic resonance imaging-guided focused ultrasound (MRgFUS) is an emerging treatment modality that enables incisionless ablative neurosurgical procedures. Bilateral MRgFUS capsulotomy has recently been demonstrated to be safe and effective in treating obsessive-compulsive disorder (OCD) and major depressive disorder (MDD). Preliminary evidence has suggested that bilateral MRgFUS capsulotomy can present increased difficulties in reaching lesional temperatures as compared to unilateral thalamotomy. The authors of this article aimed to study the parameters associated with successful MRgFUS capsulotomy lesioning and to present longitudinal radiographic findings following MRgFUS capsulotomy. METHODS Using data from 22 attempted MRgFUS capsulotomy treatments, the authors investigated the relationship between various sonication parameters and the maximal temperature achieved at the intracranial target. Lesion volume and morphology were analyzed longitudinally using structural and diffusion tensor imaging. A retreatment procedure was attempted in one patient, and their postoperative imaging is presented. RESULTS Skull density ratio (SDR), skull thickness, and angle of incidence were significantly correlated with the maximal temperature achieved. MRgFUS capsulotomy lesions appeared similar to those following MRgFUS thalamotomy, with three concentric zones observed on MRI. Lesion volumes regressed substantially over time following MRgFUS. Fractional anisotropy analysis revealed a disruption in white matter integrity, followed by a gradual return to near-baseline levels concurrent with lesion regression. In the patient who underwent retreatment, successful bilateral lesioning was achieved, and there were no adverse clinical or radiographic events. CONCLUSIONS With the current iteration of MRgFUS technology, skull-related parameters such as SDR, skull thickness, and angle of incidence should be considered when selecting patients suitable for MRgFUS capsulotomy. Lesions appear to follow morphological patterns similar to what is seen following MRgFUS thalamotomy. Retreatment appears to be safe, although additional cases will be necessary to further evaluate the associated safety profile.
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Affiliation(s)
- Benjamin Davidson
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program
- 3Sunnybrook Research Institute
| | - Karim Mithani
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program
- 3Sunnybrook Research Institute
| | - Yuexi Huang
- 3Sunnybrook Research Institute
- 4Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Ryan M Jones
- 3Sunnybrook Research Institute
- 4Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Maged Goubran
- 2Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program
- 3Sunnybrook Research Institute
- 4Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
- 7Department of Medical Biophysics, University of Toronto; and
| | - Ying Meng
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program
- 3Sunnybrook Research Institute
| | - John Snell
- 5The Focused Ultrasound Foundation, Charlottesville
- 6Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Kullervo Hynynen
- 2Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program
- 3Sunnybrook Research Institute
- 4Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
- 7Department of Medical Biophysics, University of Toronto; and
- 8Institute of Biomaterials and Biomedical Engineering, Toronto, Ontario, Canada
| | - Clement Hamani
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program
- 3Sunnybrook Research Institute
| | - Nir Lipsman
- 1Division of Neurosurgery, Sunnybrook Health Sciences Centre
- 2Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program
- 3Sunnybrook Research Institute
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Zibly Z, Averbuch S. MR-Guided High-Intensity Focused Ultrasound Lesioning: MRgHIFU Breathing Life in the Lost Art of Lesioning for Movement Disorders. Neurol India 2021; 68:S202-S205. [PMID: 33318351 DOI: 10.4103/0028-3886.302452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU) is a well-established technology that has been developed during the last decade and is currently used in the treatment of a diverse range of neurodegenerative brain disorders and neuropsychiatric diseases. This innovative noninvasive technology uses nonionizing ultrasound waves to heat and thus ablate brain tissue in selected targets. In comparison with other lesioning and surgical techniques, MRgHIFU has the following advantages: noninvasive, an immediate clinical outcome with no risk of long-standing ionizing radiation injury, no need for general anesthesia, and no device implantation.
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Affiliation(s)
- Zion Zibly
- Department of Neurosurgery, The Functional Neurosurgery Unit, The Focused Ultrasound Institute and Sackler School of Medicine, Tel Aviv University, Israel
| | - Shay Averbuch
- Sackler School of Medicine, Tel Aviv University, Israel
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Germann J, Elias GJB, Neudorfer C, Boutet A, Chow CT, Wong EHY, Parmar R, Gouveia FV, Loh A, Giacobbe P, Kim SJ, Jung HH, Bhat V, Kucharczyk W, Chang JW, Lozano AM. Potential optimization of focused ultrasound capsulotomy for obsessive compulsive disorder. Brain 2021; 144:3529-3540. [PMID: 34145884 DOI: 10.1093/brain/awab232] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/19/2021] [Accepted: 05/21/2021] [Indexed: 11/13/2022] Open
Abstract
Obsessive-compulsive disorder is a debilitating and often refractory psychiatric disorder. Magnetic resonance-guided focused ultrasound is a novel, minimally invasive neuromodulatory technique that has shown promise in treating this condition. We investigated the relationship between lesion location and long-term outcome in obsessive-compulsive disorder patients treated with focused ultrasound to discern the optimal lesion location and elucidate the efficacious network underlying symptom alleviation. Postoperative images of eleven patients who underwent focused ultrasound capsulotomy were used to correlate lesion characteristics with symptom improvement at one year follow-up. Normative resting-state functional MRI and normative diffusion MRI-based tractography analyses were used to determine the networks associated with successful lesions. Obsessive-compulsive disorder patients treated with inferior thalamic peduncle deep brain stimulation (n = 5) and lesions from the literature implicated in obsessive-compulsive disorder (n = 18) were used for external validation. Successful long-term relief of obsessive-compulsive disorder was associated with lesions that included a specific area in the dorsal anterior limb of the internal capsule. Normative resting-state functional MRI analysis showed that lesion engagement of areas 24 and 46 was significantly associated with clinical outcomes (R = 0.79, p = 0.004). The key role of areas 24 and 46 was confirmed by (1) normative diffusion MRI-based tractography analysis showing that streamlines associated with better outcome projected to these areas, (2) association of these areas with inferior thalamic peduncle deep brain stimulation patients' outcome (R = 0.83, p = 0.003); (3) the connectedness of these areas to obsessive-compulsive disorder-causing lesions, as identified using literature-based lesion network mapping. These results provide considerations for target improvement, outlining the specific area of the internal capsule critical for successful magnetic resonance-guided focused ultrasound outcome and demonstrating that discrete frontal areas are involved in symptom relief. This could help refine focused ultrasound treatment for obsessive-compulsive disorder and provide a network-based rationale for potential alternative targets.
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Affiliation(s)
- Jürgen Germann
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Gavin J B Elias
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Clemens Neudorfer
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Alexandre Boutet
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada.,Joint Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Clement T Chow
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Emily H Y Wong
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Roohie Parmar
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Flavia Venetucci Gouveia
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Aaron Loh
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Peter Giacobbe
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Se Joo Kim
- Department of Psychiatry, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Ho Jung
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Venkat Bhat
- Centre for Mental Health and Krembil Research Centre, University Health Network, Toronto, Canada
| | - Walter Kucharczyk
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada.,Joint Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Jin Woo Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
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Hageman SB, van Rooijen G, Bergfeld IO, Schirmbeck F, de Koning P, Schuurman PR, Denys D. Deep brain stimulation versus ablative surgery for treatment-refractory obsessive-compulsive disorder: A meta-analysis. Acta Psychiatr Scand 2021; 143:307-318. [PMID: 33492682 DOI: 10.1111/acps.13276] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/05/2020] [Accepted: 01/10/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Ablative surgery (ABL) and deep brain stimulation (DBS) are last-resort treatment options for patients suffering from treatment-refractory obsessive-compulsive disorder (OCD). The aim of this study was to conduct an updated meta-analysis comparing the clinical outcomes of the ablative procedures capsulotomy and cingulotomy and deep brain stimulation. METHODS We conducted a PubMed search to identify all clinical trials on capsulotomy, cingulotomy, and DBS. Random effects meta-analyses were performed on 38 articles with a primary focus on efficacy in reducing OCD symptoms as measured by a reduction in the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score and the responder rate (≥35% reduction in Y-BOCS score). RESULTS With responder rates of 48% and 53% after 12-16 months and 56% and 57% at last follow-up for ABL and DBS, respectively, and large effect sizes in the reduction in Y-BOCS scores, both surgical modalities show effectiveness in treating refractory OCD. Meta-regression did not show a statistically significant difference between ABL and DBS regarding these outcomes. Regarding adverse events, a statistically significant higher rate of impulsivity is reported in studies on DBS. CONCLUSION This meta-analysis shows equal efficacy of ABL and DBS in the treatment of refractory OCD. For now, the choice of intervention should, therefore, rely on factors such as risk of developing impulsivity, patient preferences, and experiences of psychiatrist and neurosurgeon. Future research should provide more insight regarding differences between ABL and DBS and response prediction following direct comparisons between the surgical modalities, to enable personalized and legitimate choices between ABL and DBS.
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Affiliation(s)
- Sarah Babette Hageman
- Department of Psychiatry, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Geeske van Rooijen
- Department of Psychiatry, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Isidoor O Bergfeld
- Department of Psychiatry, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Frederike Schirmbeck
- Department of Psychiatry, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Arkin Institute for Mental Health, Amsterdam, the Netherlands
| | - Pelle de Koning
- Department of Psychiatry, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - P Rick Schuurman
- Department of Neurosurgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Damiaan Denys
- Department of Psychiatry, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Amsterdam, The Netherlands.,Amsterdam Brain and Cognition, University of Amsterdam, Amsterdam, The Netherlands.,The Netherlands Institute for Neuroscience, an Institute of the Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
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43
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Alternatives to Pharmacological and Psychotherapeutic Treatments in Psychiatric Disorders. PSYCHIATRY INTERNATIONAL 2021. [DOI: 10.3390/psychiatryint2010001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Nowadays, most of the patients affected by psychiatric disorders are successfully treated with psychotherapy and pharmacotherapy. Nevertheless, according to the disease, a variable percentage of patients results resistant to such modalities, and alternative methods can then be considered. The purpose of this review is to summarize the techniques and results of invasive modalities for several treatment-resistant psychiatric diseases. A literature search was performed to provide an up-to-date review of advantages, disadvantages, efficacy, and complications of Deep-Brain Stimulation, Magnetic Resonance-guided Focused-Ultrasound, radiofrequency, and radiotherapy lesioning for depression, obsessive-compulsive disorder, schizophrenia, addiction, anorexia nervosa, and Tourette’s syndrome. The literature search did not strictly follow the criteria for a systematic review: due to the large differences in methodologies and patients’ cohort, we tried to identify the highest quality of available evidence for each technique. We present the data as a comprehensive, narrative review about the role, indication, safety, and results of the contemporary instrumental techniques that opened new therapeutic fields for selected patients unresponsive to psychotherapy and pharmacotherapy.
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44
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Transcranial Magnetic Resonance Imaging-Guided Focused Ultrasound with a 1.5 Tesla Scanner: A Prospective Intraindividual Comparison Study of Intraoperative Imaging. Brain Sci 2021; 11:brainsci11010046. [PMID: 33406708 PMCID: PMC7823499 DOI: 10.3390/brainsci11010046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/16/2020] [Accepted: 12/28/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND High-quality intraoperative imaging is needed for optimal monitoring of patients undergoing transcranial MR-guided Focused Ultrasound (tcMRgFUS) thalamotomy. In this paper, we compare the intraoperative imaging obtained with dedicated FUS-Head coil and standard body radiofrequency coil in tcMRgFUS thalamotomy using 1.5-T MR scanner. METHODS This prospective study included adult patients undergoing tcMRgFUS for treatment of essential tremor. Intraoperative T2-weighted FRFSE sequences were acquired after the last high-energy sonication using a dedicated two-channel FUS-Head (2ch-FUS) coil and body radiofrequency (body-RF) coil. Postoperative follow-ups were performed at 48 h using an eight-channel phased-array (8ch-HEAD) coil. Two readers independently assessed the signal-to-noise ratio (SNR) and evaluated the presence of concentric lesional zones (zone I, II and III). Intraindividual differences in SNR and lesional findings were compared using the Wilcoxon signed rank sum test and McNemar test. RESULTS Eight patients underwent tcMRgFUS thalamotomy. Intraoperative T2-weighted FRFSE images acquired using the 2ch-FUS coil demonstrated significantly higher SNR (R1 median SNR: 10.54; R2: 9.52) compared to the body-RF coil (R1: 2.96, p < 0.001; R2: 2.99, p < 0.001). The SNR was lower compared to the 48-h follow-up (p < 0.001 for both readers). Intraoperative zone I and zone II were more commonly visualized using the 2ch-FUS coil (R1, p = 0.031 and p = 0.008, R2, p = 0.016, p = 0.008), without significant differences with 48-h follow-up (p ≥ 0.063). The inter-reader agreement was almost perfect for both SNR (ICC: 0.85) and lesional findings (k: 0.82-0.91). CONCLUSIONS In the study population, the dedicated 2ch-FUS coil significantly improved the SNR and visualization of lesional zones on intraoperative imaging during tcMRgFUS performed with a 1.5-T MR scanner.
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Etherington LA, Matthews K, Akram H. New Directions for Surgical Ablation Treatment of Obsessive Compulsive Disorder. Curr Top Behav Neurosci 2021; 49:437-460. [PMID: 33565041 DOI: 10.1007/7854_2020_207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Although there are effective treatments available for many, probably most, patients with OCD, a significant number do not respond, or fail to experience a sustained beneficial response. For patients with such chronic, disabling and 'treatment-refractory' OCD, neurosurgical treatments may be considered. The best-established neurosurgical treatments are so-called ablative procedures, where targeted lesions are created with the intention of interrupting and modifying specific circuitry functions. There is a lengthy history of such procedures and a substantial literature although this is largely of an observational nature. However, both stereotactic radiosurgery (gamma knife) and MR-guided high intensity focused ultrasound are methods of lesion generation that lend themselves to the conduct of blinded randomised trial designs and these are beginning to be utilised. In this chapter, we present a narrative review of the key recent literature that describes the evidence for the safety and efficacy of lesion procedures for OCD. For context, we also consider the strength and quality of evidence relating to intensive residential treatment for OCD (sometimes proposed as an alternative to neurosurgery), furthermore, we also present some comparative data for lesion surgery and deep brain stimulation (DBS).
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Affiliation(s)
- Lori-An Etherington
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Keith Matthews
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK.
| | - Harith Akram
- Unit of Functional Neurosurgery, UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery (UCLH), London, UK
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46
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Blackmore DG, Turpin F, Palliyaguru T, Evans HT, Chicoteau A, Lee W, Pelekanos M, Nguyen N, Song J, Sullivan RKP, Sah P, Bartlett PF, Götz J. Low-intensity ultrasound restores long-term potentiation and memory in senescent mice through pleiotropic mechanisms including NMDAR signaling. Mol Psychiatry 2021; 26:6975-6991. [PMID: 34040151 PMCID: PMC8760044 DOI: 10.1038/s41380-021-01129-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 03/31/2021] [Accepted: 04/14/2021] [Indexed: 12/20/2022]
Abstract
Advanced physiological aging is associated with impaired cognitive performance and the inability to induce long-term potentiation (LTP), an electrophysiological correlate of memory. Here, we demonstrate in the physiologically aged, senescent mouse brain that scanning ultrasound combined with microbubbles (SUS+MB), by transiently opening the blood-brain barrier, fully restores LTP induction in the dentate gyrus of the hippocampus. Intriguingly, SUS treatment without microbubbles (SUSonly), i.e., without the uptake of blood-borne factors, proved even more effective, not only restoring LTP, but also ameliorating the spatial learning deficits of the aged mice. This functional improvement is accompanied by an altered milieu of the aged hippocampus, including a lower density of perineuronal nets, increased neurogenesis, and synaptic signaling, which collectively results in improved spatial learning. We therefore conclude that therapeutic ultrasound is a non-invasive, pleiotropic modality that may enhance cognition in elderly humans.
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Affiliation(s)
- Daniel G. Blackmore
- grid.1003.20000 0000 9320 7537Clem Jones Centre for Ageing Dementia Research, Queensland Brain Institute, The University of Queensland, Brisbane, QLD Australia
| | - Fabrice Turpin
- grid.1003.20000 0000 9320 7537Queensland Brain Institute, The University of Queensland, Brisbane, QLD Australia
| | - Tishila Palliyaguru
- grid.1003.20000 0000 9320 7537Clem Jones Centre for Ageing Dementia Research, Queensland Brain Institute, The University of Queensland, Brisbane, QLD Australia
| | - Harrison T. Evans
- grid.1003.20000 0000 9320 7537Clem Jones Centre for Ageing Dementia Research, Queensland Brain Institute, The University of Queensland, Brisbane, QLD Australia
| | - Antony Chicoteau
- grid.1003.20000 0000 9320 7537Clem Jones Centre for Ageing Dementia Research, Queensland Brain Institute, The University of Queensland, Brisbane, QLD Australia
| | - Wendy Lee
- grid.1003.20000 0000 9320 7537Clem Jones Centre for Ageing Dementia Research, Queensland Brain Institute, The University of Queensland, Brisbane, QLD Australia
| | - Matthew Pelekanos
- grid.1003.20000 0000 9320 7537Clem Jones Centre for Ageing Dementia Research, Queensland Brain Institute, The University of Queensland, Brisbane, QLD Australia
| | - Nghia Nguyen
- grid.1003.20000 0000 9320 7537Clem Jones Centre for Ageing Dementia Research, Queensland Brain Institute, The University of Queensland, Brisbane, QLD Australia
| | - Jae Song
- grid.1003.20000 0000 9320 7537Clem Jones Centre for Ageing Dementia Research, Queensland Brain Institute, The University of Queensland, Brisbane, QLD Australia
| | - Robert K. P. Sullivan
- grid.1003.20000 0000 9320 7537Queensland Brain Institute, The University of Queensland, Brisbane, QLD Australia
| | - Pankaj Sah
- grid.1003.20000 0000 9320 7537Queensland Brain Institute, The University of Queensland, Brisbane, QLD Australia ,grid.263817.90000 0004 1773 1790Joint Center for Neuroscience and Neural Engineering, and Department of Biology, Southern University of Science and Technology, Shenzhen, Guangdong Province P. R. China
| | - Perry F. Bartlett
- grid.1003.20000 0000 9320 7537Clem Jones Centre for Ageing Dementia Research, Queensland Brain Institute, The University of Queensland, Brisbane, QLD Australia ,grid.1003.20000 0000 9320 7537Queensland Brain Institute, The University of Queensland, Brisbane, QLD Australia ,grid.263817.90000 0004 1773 1790Joint Center for Neuroscience and Neural Engineering, and Department of Biology, Southern University of Science and Technology, Shenzhen, Guangdong Province P. R. China
| | - Jürgen Götz
- Clem Jones Centre for Ageing Dementia Research, Queensland Brain Institute, The University of Queensland, Brisbane, QLD, Australia.
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47
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Meng Y, Jones RM, Davidson B, Huang Y, Pople CB, Surendrakumar S, Hamani C, Hynynen K, Lipsman N. Technical Principles and Clinical Workflow of Transcranial MR-Guided Focused Ultrasound. Stereotact Funct Neurosurg 2020; 99:329-342. [PMID: 33302282 DOI: 10.1159/000512111] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/28/2020] [Indexed: 11/19/2022]
Abstract
Transcranial MR-guided focused ultrasound (MRgFUS) is a rapidly developing technology in neuroscience for manipulating brain structure and function without open surgery. The effectiveness of transcranial MRgFUS for thermoablation is well established, and the technique is actively employed worldwide for movement disorders including essential tremor. A growing number of centers are also investigating the potential of microbubble-mediated focused ultrasound-induced opening of the blood-brain barrier (BBB) for targeted drug delivery to the brain. Here, we provide a technical overview of the principles, clinical workflow, and operator considerations of transcranial MRgFUS procedures for both thermoablation and BBB opening.
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Affiliation(s)
- Ying Meng
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ryan M Jones
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin Davidson
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Yuexi Huang
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Christopher B Pople
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | | | - Clement Hamani
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kullervo Hynynen
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Nir Lipsman
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada, .,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada,
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Davidson B, Lipsman N, Meng Y, Rabin JS, Giacobbe P, Hamani C. The Use of Tractography-Based Targeting in Deep Brain Stimulation for Psychiatric Indications. Front Hum Neurosci 2020; 14:588423. [PMID: 33304258 PMCID: PMC7701283 DOI: 10.3389/fnhum.2020.588423] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/27/2020] [Indexed: 12/15/2022] Open
Abstract
Deep Brain Stimulation (DBS) has been investigated as a treatment option for patients with refractory psychiatric illness. Over the past two decades, neuroimaging developments have helped to advance the field, particularly the use of diffusion tensor imaging (DTI) and tractographic reconstruction of white-matter pathways. In this article, we review translational considerations and how DTI and tractography have been used to improve targeting during DBS surgery for depression, obsessive compulsive disorder (OCD) and post-traumatic stress disorder (PTSD).
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Affiliation(s)
- Benjamin Davidson
- 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
| | - Nir Lipsman
- 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
| | - Ying Meng
- 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
| | - Jennifer S. Rabin
- Sunnybrook Research Institute, Toronto, ON, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Peter Giacobbe
- Sunnybrook Research Institute, Toronto, ON, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Clement Hamani
- 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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Davidson B, Hamani C, Meng Y, Baskaran A, Sharma S, Abrahao A, Richter MA, Levitt A, Giacobbe P, Lipsman N, Rabin JS. Examining cognitive change in magnetic resonance-guided focused ultrasound capsulotomy for psychiatric illness. Transl Psychiatry 2020; 10:397. [PMID: 33177508 PMCID: PMC7658970 DOI: 10.1038/s41398-020-01072-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 09/28/2020] [Accepted: 10/09/2020] [Indexed: 12/14/2022] Open
Abstract
Magnetic resonance-guided focused ultrasound (MRgFUS) anterior capsulotomy is a novel treatment option for patients with refractory obsessive compulsive disorder (OCD) or major depressive disorder (MDD). However, there is concern that lesional psychiatric surgery procedures may have adverse effects on cognition. In this study, we examined whether MRgFUS capsulotomy causes cognitive decline in patients with psychiatric illness. Ten patients with refractory OCD (n = 5) or MDD (n = 5) underwent MRgFUS capsulotomy. Cognitive functioning was measured at baseline as well as 6 months and 12 months postoperatively, with a battery of neuropsychological tests assessing domains of executive function, memory, and processing speed. Scores were analyzed at the individual-level, and changes ≥2 standard deviations were considered clinically significant. We also examined whether changes in clinical symptoms were associated with changes in cognitive performance. At baseline intellectual functioning was in the average to high-average range for the group. Following MRgFUS capsulotomy, there were no deteriorations in cognition that reached ≥2 standard deviations at 6 or 12 months. Eight out of ten patients demonstrated a ≥2 standard deviation improvement in at least one cognitive score at 6 or 12 months postoperatively. Improvements in clinical symptoms correlated significantly with self-reported improvements in frontal lobe function (p < 0.05), but not with objective measures of cognitive functioning. To summarize, MRgFUS capsulotomy did not result in cognitive decline in this cohort of patients with refractory OCD or MDD, suggesting that this procedure can be offered to patients with a very low risk of cognitive side effects.
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Affiliation(s)
- Benjamin Davidson
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada.
- Sunnybrook Research Institute, Toronto, ON, Canada.
| | - Clement Hamani
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Ying Meng
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Anusha Baskaran
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Sachie Sharma
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Agessandro Abrahao
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada
| | - Margaret Anne Richter
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
- Frederick W. Thompson Anxiety Disorders Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Anthony Levitt
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Peter Giacobbe
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Jennifer S Rabin
- Harquail Centre for Neuromodulation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada.
- Sunnybrook Research Institute, Toronto, ON, Canada.
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada.
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.
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50
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Horn A, Fox MD. Opportunities of connectomic neuromodulation. Neuroimage 2020; 221:117180. [PMID: 32702488 PMCID: PMC7847552 DOI: 10.1016/j.neuroimage.2020.117180] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 06/12/2020] [Accepted: 07/16/2020] [Indexed: 12/14/2022] Open
Abstract
The process of altering neural activity - neuromodulation - has long been used to treat patients with brain disorders and answer scientific questions. Deep brain stimulation in particular has provided clinical benefit to over 150,000 patients. However, our understanding of how neuromodulation impacts the brain is evolving. Instead of focusing on the local impact at the stimulation site itself, we are considering the remote impact on brain regions connected to the stimulation site. Brain connectivity information derived from advanced magnetic resonance imaging data can be used to identify these connections and better understand clinical and behavioral effects of neuromodulation. In this article, we review studies combining neuromodulation and brain connectomics, highlighting opportunities where this approach may prove particularly valuable. We focus on deep brain stimulation, but show that the same principles can be applied to other forms of neuromodulation, such as transcranial magnetic stimulation and MRI-guided focused ultrasound. We outline future perspectives and provide testable hypotheses for future work.
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Affiliation(s)
- Andreas Horn
- Neurology Department, Movement Disorders and Neuromodulation Sectio Charité - University Medicine Berlin,, Charitéplatz 1, D-10117 Berlin, Germany.
| | - Michael D Fox
- Berenson-Allen Center for Non-invasive Brain Stimulation, Department of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center, United States; Martinos Center for Biomedical Imaging, Departments of Neurology and Radiology, Harvard Medical School and Massachusetts General Hospital, United States; Center for Brain Circuit Therapeutics, Departments of Neurology, Psychiatry, and Radiology, Harvard Medical School and Brigham and Women's Hospital, United States.
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