Three-Year Outcomes in Deep Brain Stimulation for Highly Resistant Obsessive–Compulsive Disorder

Abstract

Deep brain stimulation (DBS) of the anterior limb of the internal capsule has been shown to be beneficial in the short term for obsessive-compulsive disorder (OCD) patients who exhaust conventional therapies. Nuttin et al, who published the first DBS for OCD series, found promising results using a capsule target immediately rostral to the anterior commissure extending into adjacent ventral capsule/ventral striatum (VC/VS). Published long-term outcome data are limited to four patients. In this collaborative study, 10 adult OCD patients meeting stringent criteria for severity and treatment resistance had quadripolar stimulating leads implanted bilaterally in the VC/VS. DBS was activated openly 3 weeks later. Eight patients have been followed for at least 36 months. Group Yale-Brown Obsessive Compulsive Scale (YBOCS) scores decreased from 34.670.6 (mean7SEM) at baseline (severe) to 22.372.1 (moderate) at 36 months (po0.001). Four of eight patients had a X35% decrease in YBOCS severity at 36 months; in two patients, scores declined between 25 and 35%. Global Assessment of Functioning scores improved from 36.671.5 at baseline to 53.872.5 at 36 months (po0.001). Depression and anxiety also improved, as did self-care, independent living, and work, school, and social functioning. Surgical adverse effects included an asymptomatic hemorrhage, a single seizure, and a superficial infection. Psychiatric adverse effects included transient hypomanic symptoms, and worsened depression and OCD when DBS was interrupted by stimulator battery depletion. This open study found promising long-term effects of DBS in highly treatment-resistant OCD.

Deep brain stimulation in Parkinson disease—what went wrong?

“…The following observations should be considered to better understand the action of DBS: (i) HFS of sensory fibres or corticospinal motor fibres evokes continuous pain or muscle contractions [76] and (ii) the time course of the clinical effect of DBS differ, depending on the symptom targeted. Whereas the maximum beneficial effect on tremor and rigidity is reached within minutes, the delay for maximal improvement in akinesia is minutes to hours and the improvement in dystonia, OCD or depression gradually develops over several weeks [76][77][78][79]. It is thus possible that the latter cases are the result of plasticity changes in the network affected by DBS, whereas the short-term improvements result from the immediate effect of DBS on the network.…”

Dianas quirúrgicas en el tratamiento de enfermedades psiquiátricas. Desde el movimiento a las emociones

“…También los pacientes con TOC con esta diana quirúrgica mejoran tras la intervención la depresión, evaluados con la escala de Hamilton y la ansiedad, que son problemas coadyuvantes en esta patología. Sin embargo, la diana exacta es variable según los diferentes autores, así unos colocan el electrodo en la cápsula interna (CI) 1,7,84,85 y otros en VS/CI, o bien Nacc/CI, aunque esta estructura formaría parte del VS 8,37,41,42,43,44,56,107 . Así, en algunos estudios clínicos, colocan los contactos de estimulación dorsales (contactos 2 y 3) en la CI, mientras los más ventrales (contactos 0 y 1) en el VS o bien Nacc, sin llegar a especificar los contactos clínicamente activos en las diferentes publicaciones 8,43,107 .…”

“…Los parámetros de estimulación, en las distintas publicaciones, son muy variables, entre 4-10 voltios, según los distintos autores 1,8,37,41,43,60,85,107 . Así Goodman y cols estimularon con 8 voltios y Abelson con 10 voltios en CI, por lo que se debe asumir que el campo de estimulación es grande y puede alcanzar diferentes estructuras anatómicas además de la deseada 1,41 .…”

“…Para la depresión refractaria sería el área subgenual (área 25 de Brodmann) y la región VS/NAcc. Para el Guille de la Tourette la diana sería el Voi y el CM/Pfs del tálamo y el GPi 2,19,43,66,71,75,76,79,97,100,107,113 . La actuación sobre cada una de estas dianas, induce cambios corticales evaluados en PET, así en los pacientes con TOC que son intervenidos con buena respuesta clínica, la hiperactividad del COF y del área cingular muestra una reducción 91,92 y los pacientes con depresión con reducción en la escala de Hamilton tienen un hipoactividad del área subgenual 78 .…”

Deep Brain Stimulation for Psychiatric Disorders

“…An apparent exacerbation of depressive symptoms after loss of stimulation and a lead fracture was also seen in this patient, adding to concerns other investigators have had over short battery life and sudden cessation of therapy in this patient population. 5,39 Others have explored the ventral region of the capsule and the accumbens in an effort to find a more effective target. Several groups have made the observation that lesions made more ventral in the AIC are more clinically effective, and that the high stimulation levels and use of ventral negative contacts in the study from Belgium might be stimulating the NAcc.…”