Deep Brain Stimulation for Obsessive-Compulsive Disorder: Optimal Stimulation Sites

BACKGROUND

Deep brain stimulation (DBS) is a promising treatment option for treatment-refractory obsessive-compulsive disorder (OCD). Several stimulation targets have been used, mostly in and around the anterior limb of the internal capsule and ventral striatum. However, the precise target within this region remains a matter of debate.

METHODS

Here, we retrospectively studied a multicenter cohort of 82 patients with OCD who underwent DBS of the ventral capsule/ventral striatum and mapped optimal stimulation sites in this region.

RESULTS

DBS sweet-spot mapping performed on a discovery set of 58 patients revealed 2 optimal stimulation sites associated with improvements on the Yale-Brown Obsessive Compulsive Scale, one in the anterior limb of the internal capsule that overlapped with a previously identified OCD-DBS response tract and one in the region of the inferior thalamic peduncle and bed nucleus of the stria terminalis. Critically, the nucleus accumbens proper and anterior commissure were associated with beneficial but suboptimal clinical improvements. Moreover, overlap with the resulting sweet- and sour-spots significantly estimated variance in outcomes in an independent cohort of 22 patients from 2 additional DBS centers. Finally, beyond obsessive-compulsive symptoms, stimulation of the anterior site was associated with optimal outcomes for both depression and anxiety, while the posterior site was only associated with improvements in depression.

CONCLUSIONS

Our results suggest how to refine targeting of DBS in OCD and may be helpful in guiding DBS programming in existing patients.

Cerebellar Volume and Disease Staging in Parkinson's Disease: An ENIGMA-PD Study

BACKGROUND

Increasing evidence points to a pathophysiological role for the cerebellum in Parkinson's disease (PD). However, regional cerebellar changes associated with motor and non-motor functioning remain to be elucidated.

OBJECTIVE

To quantify cross-sectional regional cerebellar lobule volumes using three dimensional T1-weighted anatomical brain magnetic resonance imaging from the global ENIGMA-PD working group.

METHODS

Cerebellar parcellation was performed using a deep learning-based approach from 2487 people with PD and 1212 age and sex-matched controls across 22 sites. Linear mixed effects models compared total and regional cerebellar volume in people with PD at each Hoehn and Yahr (HY) disease stage, to an age- and sex- matched control group. Associations with motor symptom severity and Montreal Cognitive Assessment scores were investigated.

RESULTS

Overall, people with PD had a regionally smaller posterior lobe (dmax  = -0.15). HY stage-specific analyses revealed a larger anterior lobule V bilaterally (dmax  = 0.28) in people with PD in HY stage 1 compared to controls. In contrast, smaller bilateral lobule VII volume in the posterior lobe was observed in HY stages 3, 4, and 5 (dmax  = -0.76), which was incrementally lower with higher disease stage. Within PD, cognitively impaired individuals had lower total cerebellar volume compared to cognitively normal individuals (d = -0.17).

CONCLUSIONS

We provide evidence of a dissociation between anterior "motor" lobe and posterior "non-motor" lobe cerebellar regions in PD. Whereas less severe stages of the disease are associated with larger motor lobe regions, more severe stages of the disease are marked by smaller non-motor regions. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

The Role of Apathy in Spontaneous Verbal and Nonverbal Behaviors: A Transdiagnostic Pilot Study in Neurodegeneration

BACKGROUND

Apathy, characterized by a quantifiable reduction in motivation or goal-directed behavior, is a multidimensional syndrome that has been observed across many neurodegenerative diseases.

OBJECTIVE

To develop a novel task measuring spontaneous action initiation (ie, a nonverbal equivalent to spontaneous speech tasks) and to investigate the association between apathy and executive functions such as the voluntary initiation of speech and actions and energization (ie, ability to initiate and sustain a response).

METHOD

We compared the energization and executive functioning performance of 10 individuals with neurodegenerative disease and clinically significant apathy with that of age-matched healthy controls (HC). We also investigated the association between self-reported scores on the Apathy Evaluation Scale (AES) and performance on energization tasks.

RESULTS

The individuals with apathy made significantly fewer task-related actions than the HC on the novel spontaneous action task, and their scores on the AES were negatively correlated with spontaneous task-related actions, providing preliminary evidence for the task's construct validity. In addition, the individuals with apathy performed more poorly than the HC on all of the energization tasks, regardless of task type or stimulus modality, suggesting difficulty in sustaining voluntary responding over time. Most of the tasks also correlated negatively with the AES score. However, the individuals with apathy also performed more poorly on some of the executive function tasks, particularly those involving self-monitoring.

CONCLUSION

Our work presents a novel experimental task for measuring spontaneous action initiation-a key symptom of apathy-and suggests a possible contribution of apathy to neuropsychological deficits such as poor energization.

Left Prefrontal Connectivity Links Subthalamic Stimulation with Depressive Symptoms

OBJECTIVE

Subthalamic nucleus deep brain stimulation (STN-DBS) in Parkinson's disease (PD) not only stimulates focal target structures but also affects distributed brain networks. The impact this network modulation has on non-motor DBS effects is not well-characterized. By focusing on the affective domain, we systematically investigate the impact of electrode placement and associated structural connectivity on changes in depressive symptoms following STN-DBS, which have been reported to improve, worsen, or remain unchanged.

METHODS

Depressive symptoms before and after STN-DBS surgery were documented in 116 patients with PD from 3 DBS centers (Berlin, Queensland, and Cologne). Based on individual electrode reconstructions, the volumes of tissue activated (VTAs) were estimated and combined with normative connectome data to identify structural connections passing through VTAs. Berlin and Queensland cohorts formed a training and cross-validation dataset used to identify structural connectivity explaining change in depressive symptoms. The Cologne data served as the test-set for which depressive symptom change was predicted.

RESULTS

Structural connectivity was linked to depressive symptom change under STN-DBS. An optimal connectivity map trained on the Berlin cohort could predict changes in depressive symptoms in Queensland patients and vice versa. Furthermore, the joint training-set map predicted changes in depressive symptoms in the independent test-set. Worsening of depressive symptoms was associated with left prefrontal connectivity.

INTERPRETATION

Fibers connecting the electrode with left prefrontal areas were associated with worsening of depressive symptoms. Our results suggest that for the left STN-DBS lead, placement impacting fibers to left prefrontal areas should be avoided to maximize improvement of depressive symptoms. ANN NEUROL 2020;87:962-975.

P1-06-17: A New Pathological Response Index (PRI) for Neoadjuvant Chemotherapy Accurately Predicts Clinical Outcomes of Locally Advanced Breast Cancers (LAPBC)

Pathological complete response (pCR) after neoadjuvant chemotherapy predicts overall survival that is independent of treatment regimen. However; pCR is not a perfect surrogate for overall survival, given that a significant number of patients who did not achieve pCR also have a good prognosis and a small number of patients with pCR still develop recurrences. Furthermore, residual cancer cells after neoadjuvant therapy includes a wide range of responses from near pCR to complete resistance.

In this study we performed a comprehensive pathological assessment for 245 surgical specimens of LAPBC, treated at a single institution, removed after receiving neoadjuvant anthracycline combination chemotherapy only (n=152) or with Taxane (n=93) with median follow up 42 months. Progression free survival (PFS) was used as the study endpoint. For comparison, residual cancer burden (RCB) was calculated using web calculator at www.mdanderson,org/breast_BCR. A multivariate Cox regression model revealed that size of the residual invasive carcinoma (OR; 3.2, CI 95%; 1.6−6.1, p=0.001), presence of lympho-vascular invasion (OR; 2.4, CI 95%; 1.3−4.3, p=0.004), absence of any pathological evidence of response at the site of the primary tumour or axillary lymph nodes after CT (OR; 3.2, CI 95%; 2.2−8.0, p=0.00001), and presence of at least one apical lymph node metastases (OR; 4.2, CI 95%; 1.5−6.8, p=0.003) at surgery were significantly associated with shorter PFS. These results were used to develop a pathological response index (PRI) from which 5 prognostic subgroups with distinct clinical outcomes were identified. Patients with PRI-PG1 (n=110; 49%) had a good clinical outcomes in both ER+ (3-year PFS; 91%) and ER- tumours (3-year PFS; 84%). Moreover, patients with PRI-PGI who did not show pCR (n=69) had equivalent overall and PFS as those with PRI-PG1 who achieved pCR (n=41); p=NS. Patients with PRI-PG2-5, had a 5 fold increase in the risk of progression compared to those with PRI-PG1 (HR; 5.2, CI 95%; 2.9−9.6, p≤0.0001). ER+ patients with PRI-PG3-5 (25% of ER+ cases) had shorter 3-year PFS 30%) compared to those ER+ with PRI PG1-2 (91%) despite treatment with adjuvant hormonal therapy (HR=6.5, CI 95%; 2.8−14.7, p<0.0001). Similarly, HER2 positive patients with PRI- PG3-5 (20% of HER2+ patients) showed very rapid progression within < 3 years (PFS; 10%) vs. those with PRI-PG1-2 (PFS; 82%) despite trastuzumab treatment (HR=8.4; CI 95%; 2.8−25.0, p<0.0001).

In conclusion, a pathological response index including size of residual tumour, post chemotherapy lymph node pathological stage, lympho-vascular invasion and any evidence of fibrotic/response reaction following neoadjuvant chemotherapy may accurately predict the chance of disease progression, identify a greater proportion of patients (>twice as many as pCR) who could potentially benefit from the neoadjuvant chemotherapy and may be able to spared further adjuvant therapy. Furthermore this new PRI may help to improve the sensitivity of pathological response as a study end-point for predicting tumours response to a given neoadjuvant regimen and enable biological markers to be studied in a good prognostic group in additional to pCR.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-06-17.

Development and description of two new instruments for measuring the impact of coordinated social services for children

The Boston Family Reunification Network provides two innovative services designed to help children return to their families as soon as possible. A team developed two new instruments to measure process and clinical outcomes of the initiatives. This article describes the instruments, the two-year development process, and the points considered during the instruments' development. Suggestions for other social welfare groups planning to create and implement outcome tools are included.