Surgical neuroanatomy and programming in deep brain stimulation for obsessive compulsive disorder

Abstract

Objectives: Deep brain stimulation (DBS) has been established as a safe, effective therapy for movement disorders (Parkinson's disease, essential tremor, etc.), and its application is expanding to the treatment of other intractable neuropsychiatric disorders including depression and obsessive-compulsive disorder (OCD). Several published studies have supported the efficacy of DBS for severely debilitating OCD. However, questions remain regarding the optimal anatomic target and the lack of a bedside programming paradigm for OCD DBS. Management of OCD DBS can be highly variable and is typically guided by each center's individual expertise. In this paper, we review the various approaches to targeting and programming for OCD DBS. We also review the clinical experience for each proposed target and discuss the relevant neuroanatomy.

Materials and methods: A PubMed review was performed searching for literature on OCD DBS and included all articles published before March 2012. We included all available studies with a clear description of the anatomic targets, programming details, and the outcomes.

Results: Six different DBS approaches were identified. High-frequency stimulation with high voltage was applied in most cases, and predictive factors for favorable outcomes were discussed in the literature.

Conclusion: DBS remains an experimental treatment for medication refractory OCD. Target selection and programming paradigms are not yet standardized, though an improved understanding of the relationship between the DBS lead and the surrounding neuroanatomic structures will aid in the selection of targets and the approach to programming. We propose to form a registry to track OCD DBS cases for future clinical study design.

Keywords: Deep brain stimulation; inferior thalamic peduncle; obsessive compulsive disorder; subthalamic nucleus; ventral capsule/ventral striatum.

Figure 1. Anterior view of coronal sections of deep nuclear areas of the left hemisphere showing five different approaches for OCD DBS

Left. Electrode placement in ALIC (A) for deep brain stimulation. Middle. Electrode placement targeting NAcc through ALIC utilizing three, different trajectories (B, C, and D). Right. Modified VC/VS trajectory (E) A: The ALIC trajectory (Anderson and Ahmed (2003) and Abelson et al. (2005)). B: Medial trajectory through the caudate nucleus to the nucleus accumbens (NAcc) utilizing Medtronic model 3387 electrode (each contact length = 1.5 mm, inter-electrode spacing = 1.5 mm) by Aouizerate et al. (2004, 2007). C: VC/VS stimulation trajectory through the ALIC to the NAcc using a shorter length of stimulating electrode (Medtronic model 3389: each contact length = 1.5 mm, inter-electrode spacing = 0.5 mm) by Denys et al. (2010). D: VC/VS trajectory through ALIC to the NAcc using a longer length of stimulating electrode (Medtronic model 3387 IES/3887: each contact length = 3 mm, inter-electrode spacing = 4 mm) by Greenberg et al. (2006). E. VC/VS trajectory through ALIC to the NAcc using a longer length of stimulating electrode (Medtronic model 3387 IES/3887: each contact length = 3 mm, inter-electrode spacing = 4 mm) by Greenberg et al. (2010). ACA = anterior cerebral artery, ALIC = anterior limb of the internal capsule, AN = anterior nucleus of the thalamus, AntCom = anterior commissure, BN = bed nucleus, CC = corpus callosum, CL = claustrum, CN = caudate nucleus, DiaBd = diagonal band of Broca, EC = external capsule, EX = extreme capsule, GP = globus pallidus, LOS = lateral olfactory stria, MCA = middle cerebral artery, MFB = medial forebrain bundle, MD = mediodorsal nucleus of the thalamus, MOS = medial olfactory stria, NA = amygdala, NAcc = nucleus accumbens, OpCh =Optic Chiasm, Pu = putamen, Sep = septum pellucidum, SN = septal nucleus, STN = subthalamic nucleus