Deep brain stimulation for the treatment of severe, medically refractory obsessive-compulsive disorder

Abstract

Deep brain stimulation is a rapidly expanding therapy initially designed for the treatment of movement disorders and pain syndromes. The therapy includes implantation of electrodes in specific targets of the brain, delivering programmable small and safe electric impulses, like a pacemaker, that modulates both local and broad neurologic networks. The effects are thought to primarily involve a focus in the brain, probably inhibitory, which then restores a network of neural circuitry. Psychiatric diseases can be refractory and severe, leading to high medical costs, significant morbidity, and even death. Whereas surgery for psychiatric disease used to include destructive procedures, deep brain stimulation allows safe, reversible, and adjustable treatment that can be tailored for each patient. Deep brain stimulation offers new hope for these unfortunate patients, and the preliminary results are promising.

Figure 1.

Diffusion tensor image demonstrating connections between prefrontal cortex regions and the ventral portion of the anterior limb of the internal capsule (ALIC) and the adjacent ventral capsule ventral striatum (VC/VS). Yellow box in upper left corner is a 3×3mm voxel seed point. Tractography was set at threshold of 0.15 and minimal fiber length of 15mm. Intense orbitofrontal connections are seen. Other fiber pathways include dorsolateral prefrontal cortex, supplementary motor, sensorimotor, uncinate fasciculus, inferior occipitofrontal fasciculus, thalamus, and various dorsal mesencephalic pathways.

Figure 2.

Frontal section through the target area, giving the topographic relations between internal capsule, nucleus accumbens, and bed nucleus of stria terminalis. Target point: 3 mm rostral CA, 7 mm right lateral of midline. 3–4 mm ventral of AC-PC line. Green: rostral edge of bed nucleus of stria terminalis. White: caudal part of anterior limb of internal capsule.