1
|
Carrillo-Ruiz JD, Carrillo-Márquez JR, Beltrán JQ, Jiménez-Ponce F, García-Muñoz L, Navarro-Olvera JL, Márquez-Franco R, Velasco F. Innovative perspectives in limbic surgery using deep brain stimulation. Front Neurosci 2023; 17:1167244. [PMID: 37274213 PMCID: PMC10233042 DOI: 10.3389/fnins.2023.1167244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/24/2023] [Indexed: 06/06/2023] Open
Abstract
Limbic surgery is one of the most attractive and retaken fields of functional neurosurgery in the last two decades. Psychiatric surgery emerged from the incipient work of Moniz and Lima lesioning the prefrontal cortex in agitated patients. Since the onset of stereotactic and functional neurosurgery with Spiegel and Wycis, the treatment of mental diseases gave attention to refractory illnesses mainly with the use of thalamotomies. Neurosis and some psychotic symptoms were treated by them. Several indications when lesioning the brain were included: obsessive-compulsive disorder, depression, and aggressiveness among others with a diversity of targets. The indiscriminately use of anatomical sites without enough scientific evidence, and uncertainly defined criteria for selecting patients merged with a deficiency in ethical aspects, brought a lack of procedures for a long time: only select clinics allowed this surgery around the world from 1950 to the 1990s. In 1999, Nuttin et al. began a new chapter in limbic surgery with the use of Deep Brain Stimulation, based on the experience of pain, Parkinson's disease, and epilepsy. The efforts were focused on different targets to treat depression and obsessive-compulsive disorders. Nevertheless, other diseases were added to use neuromodulation. The goal of this article is to show the new opportunities to treat neuropsychiatric diseases.
Collapse
Affiliation(s)
- José Damián Carrillo-Ruiz
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
- Research Direction, Mexico General Hospital, Mexico City, Mexico
- Neuroscience Coordination, Psychology Faculty, Anahuac University, Mexico City, Mexico
| | - José Rodrigo Carrillo-Márquez
- Faculty of Health Sciences, Anahuac University, Mexico City, Mexico
- Alpha Health Sciences Leadership Program, Anahuac University, Mexico City, Mexico
| | - Jesús Quetzalcóatl Beltrán
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
| | - Fiacro Jiménez-Ponce
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
| | - Luis García-Muñoz
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
| | - José Luis Navarro-Olvera
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
| | - René Márquez-Franco
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
| | - Francisco Velasco
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
| |
Collapse
|
2
|
Yan H, Siegel L, Breitbart S, Gorodetsky C, Fasano A, Rahim A, Loh A, Kulkarni AV, Ibrahim GM. An open-label prospective pilot trial of nucleus accumbens deep brain stimulation for children with autism spectrum disorder and severe, refractory self-injurious behavior: study protocol. Pilot Feasibility Stud 2022; 8:24. [PMID: 35109924 PMCID: PMC8808966 DOI: 10.1186/s40814-022-00988-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 01/20/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Children and youth with autism spectrum disorder (ASD) may manifest self-injurious behaviors (SIB) that may become severe and refractory with limited pharmacologic or behavioral treatment options. Here, we present the protocol of a prospective, mixed-methods study to assess the safety and efficacy of deep brain stimulation (DBS) of the nucleus accumbens (NAcc) for children and youth with ASD and severe, refractory SIB. METHODS This is a prospective, single-center, single-cohort, open-label, non-randomized pilot trial of 6 patients. Participants will be recruited through specialized behavioral clinics with persistent severe and refractory SIB following standard and intensive interventions. Following NAcc-DBS, participants will be enrolled in the study for 12 months. The primary objectives of the study are safety and feasibility, assessed by rate of recruitment and identification of factors impacting adherence to follow-up and study protocol. Potential treatment efficacy will be assessed by changes in the Children's Yale-Brown Obsessive-Compulsive Scale in ASD (CYBOCS-ASD), the Behavior Problems Index (BPI), the Inventory of Statements about Self-Injury (ISAS) and the Repetitive Behavior Scale-Revised (RBS-R) questionnaires. Additional clinical outcomes will be assessed, including measures of participant and caregiver quality of life, actigraph measurements, and positron emission tomography (PET) changes following DBS. DISCUSSION This study will be the first to evaluate the effect of DBS of the NAcc on a pediatric population in a controlled, prospective trial. Secondary outcomes will improve the understanding of behavioral, neuro-imaging, and electrophysiologic changes in children with ASD and SIB treated with DBS. This trial will provide an estimated effect size of NAcc-DBS for severe refractory SIB in children with ASD in preparation for future comparative trials. TRIAL REGISTRATION Registration on ClinicalTrials.gov was completed on 12 June 2019 with the Identifier: NCT03982888 .
Collapse
Affiliation(s)
- Han Yan
- Division of Neurosurgery, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada.,Institute of Health of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Lauren Siegel
- Neurosciences and Mental Health Program, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada
| | - Sara Breitbart
- Division of Neurosurgery, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada.,Neurosciences and Mental Health Program, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada
| | | | - Alfonso Fasano
- Division of Neurology, The Hospital for Sick Children, Toronto, Canada.,Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, Ontario, Canada. Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Brain Institute, Toronto, Ontario, Canada.,CenteR for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, ON, Canada
| | - Aliya Rahim
- Neurosciences and Mental Health Program, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada.,Surrey Place, Toronto, Ontario, Canada
| | - Alvin Loh
- Surrey Place, Toronto, Ontario, Canada.,Division of Developmental Paediatrics, Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Abhaya V Kulkarni
- Division of Neurosurgery, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada.,Institute of Health of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - George M Ibrahim
- Division of Neurosurgery, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada. .,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada. .,Institute of Biomedical Engineering, University of Toronto, Toronto, Canada. .,Institute of Medical Science, University of Toronto, Toronto, Canada.
| |
Collapse
|
3
|
Mahajan UV, Ojukwu DI, Azagury DE, Safer DL, Cunningham T, Halpern CH. Can responsive deep brain stimulation be a cost-effective treatment for severe obesity? Obesity (Silver Spring) 2022; 30:338-346. [PMID: 35088556 DOI: 10.1002/oby.23324] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/29/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE A first-in-human responsive deep brain stimulation (rDBS) trial (NCT03868670) for obesity is under way, which is based on promising preclinical evidence. Given the upfront costs of rDBS, it is prudent to examine the success threshold for cost-effectiveness compared with laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS Efficacy and safety data on LRYGB and safety data on rDBS were collected for established indications through a literature search. The success threshold was defined as minimum BMI reduction. Treatment costs were calculated via Medicare national reimbursement data. RESULTS LRYGB had a mean BMI reduction of 13.75 kg/m2 . Based on adverse events, LRYGB was a less-preferred health state (overall adverse event utility of 0.96 [0.02]) than rDBS (0.98 [0.01]), but LRYGB ($14,366 [$6,410]) had a significantly lower treatment cost than rDBS ($29,951 [$4,490]; p < 0.0001). Therefore, for rDBS to be cost-effective compared with LRYGB, the multiple models yielded a success threshold range of 13.7 to 15.2 kg/m2 . CONCLUSIONS This study established a preliminary efficacy success threshold for rDBS to be cost-effective for severe obesity, and results from randomized controlled trials are needed. This analysis allows for interpretation of the economic impact of advancing rDBS for obesity in light of ongoing trial results and suggests an attainable threshold is needed for cost-effectiveness.
Collapse
Affiliation(s)
- Uma V Mahajan
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Disep I Ojukwu
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Dan E Azagury
- Section of Minimally Invasive and Bariatric Surgery, Department of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Debra L Safer
- Stanford Adult Eating and Weight Disorders Program, Department of Psychiatry, Stanford University Medical Center, Stanford, California, USA
| | - Tricia Cunningham
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
- Department of Neurosurgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| |
Collapse
|
4
|
Wu H, Adler S, Azagury DE, Bohon C, Safer DL, Barbosa DAN, Bhati MT, Williams NR, Dunn LB, Tass PA, Knutson BD, Yutsis M, Fraser A, Cunningham T, Richardson K, Skarpaas TL, Tcheng TK, Morrell MJ, Roberts LW, Malenka RC, Lock JD, Halpern CH. Brain-Responsive Neurostimulation for Loss of Control Eating: Early Feasibility Study. Neurosurgery 2020; 87:1277-1288. [PMID: 32717033 PMCID: PMC8599841 DOI: 10.1093/neuros/nyaa300] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 05/02/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Loss of control (LOC) is a pervasive feature of binge eating, which contributes significantly to the growing epidemic of obesity; approximately 80 million US adults are obese. Brain-responsive neurostimulation guided by the delta band was previously found to block binge-eating behavior in mice. Following novel preclinical work and a human case study demonstrating an association between the delta band and reward anticipation, the US Food and Drug Administration approved an Investigational Device Exemption for a first-in-human study. OBJECTIVE To assess feasibility, safety, and nonfutility of brain-responsive neurostimulation for LOC eating in treatment-refractory obesity. METHODS This is a single-site, early feasibility study with a randomized, single-blinded, staggered-onset design. Six subjects will undergo bilateral brain-responsive neurostimulation of the nucleus accumbens for LOC eating using the RNS® System (NeuroPace Inc). Eligible participants must have treatment-refractory obesity with body mass index ≥ 45 kg/m2. Electrophysiological signals of LOC will be characterized using real-time recording capabilities coupled with synchronized video monitoring. Effects on other eating disorder pathology, mood, neuropsychological profile, metabolic syndrome, and nutrition will also be assessed. EXPECTED OUTCOMES Safety/feasibility of brain-responsive neurostimulation of the nucleus accumbens will be examined. The primary success criterion is a decrease of ≥1 LOC eating episode/week based on a 28-d average in ≥50% of subjects after 6 mo of responsive neurostimulation. DISCUSSION This study is the first to use brain-responsive neurostimulation for obesity; this approach represents a paradigm shift for intractable mental health disorders.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Casey H Halpern
- Correspondence: Casey H. Halpern, MD, Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive (R-227), Stanford, CA 94305-5327, USA.
| |
Collapse
|
5
|
Ramadi KB, Srinivasan SS, Traverso G. Electroceuticals in the Gastrointestinal Tract. Trends Pharmacol Sci 2020; 41:960-976. [PMID: 33127099 DOI: 10.1016/j.tips.2020.09.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/25/2020] [Accepted: 09/30/2020] [Indexed: 02/08/2023]
Abstract
The field of electroceuticals has attracted considerable attention over the past few decades as a novel therapeutic modality. The gastrointestinal (GI) tract (GIT) holds significant potential as a target for electroceuticals as the intersection of neural, endocrine, and immune systems. We review recent developments in electrical stimulation of various portions of the GIT (including esophagus, stomach, and small and large intestine) and nerves projecting to the GIT and supportive organs. This has been tested with varying degrees of success for several dysmotility, inflammatory, hormonal, and neurologic disorders. We outline a vision for the future of GI electroceuticals, building on advances in mechanistic understanding of GI physiology coupled with novel ingestible technologies. The next wave of electroceutical therapies will be minimally invasive and more targeted than current approaches, making them an indispensable tool in the clinical armamentarium.
Collapse
Affiliation(s)
- Khalil B Ramadi
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA; David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Shriya S Srinivasan
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA; David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Giovanni Traverso
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA; David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.
| |
Collapse
|
6
|
Khan IS, D'Agostino EN, Calnan DR, Lee JE, Aronson JP. Deep Brain Stimulation for Memory Modulation: A New Frontier. World Neurosurg 2019; 126:638-646. [DOI: 10.1016/j.wneu.2018.12.184] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 12/18/2018] [Accepted: 12/20/2018] [Indexed: 12/30/2022]
|
7
|
Formolo DA, Gaspar JM, Melo HM, Eichwald T, Zepeda RJ, Latini A, Okun MS, Walz R. Deep Brain Stimulation for Obesity: A Review and Future Directions. Front Neurosci 2019; 13:323. [PMID: 31057350 PMCID: PMC6482165 DOI: 10.3389/fnins.2019.00323] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 03/21/2019] [Indexed: 01/01/2023] Open
Abstract
The global prevalence of obesity has been steadily increasing. Although pharmacotherapy and bariatric surgeries can be useful adjuvants in the treatment of morbid obesity, they may lose long-term effectiveness. Obesity result largely from unbalanced energy homeostasis. Palatable and densely caloric foods may affect the brain overlapped circuits involved with homeostatic hypothalamus and hedonic feeding. Deep brain stimulation (DBS) consists of delivering electrical impulses to specific brain targets to modulate a disturbed neuronal network. In selected patients, DBS has been shown to be safe and effective for movement disorders. We review all the cases reports and series of patients treated with DBS for obesity using a PubMed search and will address the following obesity-related issues: (i) the hypothalamic regulation of homeostatic feeding; (ii) the reward mesolimbic circuit and hedonic feeding; (iii) basic concepts of DBS as well as the rationale for obesity treatment; (iv) perspectives and challenges in obesity DBS. The small number of cases provides preliminary evidence for the safety and the tolerability of a potential DBS approach. The ventromedial (n = 2) and lateral (n = 8) hypothalamic nuclei targets have shown mixed and disappointing outcomes. Although nucleus accumbens (n = 7) targets were more encouraging for the outcomes of body weight reduction and behavioral control for eating, there was one suicide reported after 27 months of follow-up. The authors did not attribute the suicide to DBS therapy. The identification of optimal brain targets, appropriate programming strategies and the development of novel technologies will be important as next steps to move DBS closer to a clinical application. The identification of electrical control signals may provide an opportunity for closed-loop adaptive DBS systems to address obesity. Metabolic and hormonal sensors such as glycemic levels, leptin, and ghrelin levels are candidate control signals for DBS. Focused excitation or alternatively inhibition of regions of the hypothalamus may provide better outcomes compared to non-selective DBS. Utilization of the NA delta oscillation or other physiological markers from one or multiple regions in obesity-related brain network is a promising approach. Experienced multidisciplinary team will be critical to improve the risk-benefit ratio for this approach.
Collapse
Affiliation(s)
- Douglas A Formolo
- Center for Applied Neuroscience, University Hospital, Federal University of Santa Catarina, Florianópolis, Brazil.,Graduate Program in Neuroscience, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Joana M Gaspar
- Laboratory of Bioenergetics and Oxidative Stress, Department of Biochemistry, Federal University of Santa Catarina, Florianópolis, Brazil.,Graduate Program in Biochemistry, Department of Biochemistry, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Hiago M Melo
- Center for Applied Neuroscience, University Hospital, Federal University of Santa Catarina, Florianópolis, Brazil.,Graduate Program in Neuroscience, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Tuany Eichwald
- Laboratory of Bioenergetics and Oxidative Stress, Department of Biochemistry, Federal University of Santa Catarina, Florianópolis, Brazil.,Graduate Program in Biochemistry, Department of Biochemistry, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Ramiro Javier Zepeda
- Department of Neuroscience, Faculty of Medicine, Chile University and Health Science Institute, O'Higgins University, Santiago, Chile
| | - Alexandra Latini
- Laboratory of Bioenergetics and Oxidative Stress, Department of Biochemistry, Federal University of Santa Catarina, Florianópolis, Brazil.,Graduate Program in Biochemistry, Department of Biochemistry, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Michael S Okun
- Fixel Institute for Neurological Diseases, Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Roger Walz
- Center for Applied Neuroscience, University Hospital, Federal University of Santa Catarina, Florianópolis, Brazil.,Graduate Program in Neuroscience, Federal University of Santa Catarina, Florianópolis, Brazil.,Fixel Institute for Neurological Diseases, Department of Neurology, University of Florida, Gainesville, FL, United States.,Graduate Program in Medical Sciences, Federal University of Santa Catarina, Florianópolis, Brazil.,Department of Internal Medicine, University Hospital, Federal University of Santa Catarina, Florianópolis, Brazil
| |
Collapse
|