Tractography-Guided Deep Brain Stimulation of the Anteromedial Globus Pallidus Internus for Refractory Obsessive-Compulsive Disorder: Case Report

Abstract

BACKGROUND AND IMPORTANCEObsessive-compulsive disorder (OCD) is a disabling psychiatric disorder, mainly treated with psychotherapy and pharmacotherapy. Surgical intervention may be appropriate for patients with treatment-refractory OCD. Deep brain stimulation (DBS) is an alternative for previously common ablative surgical procedures. Tractography has been proposed as a method for individualizing DBS treatment and may have the potential to improve efficacy.CLINICAL PRESENTATIONWe present a patient with treatment-refractory OCD previously treated with bilateral leucotomies, who underwent DBS surgery with targeting informed by tractography. Preoperative tractography to identify suitable DBS targets was undertaken. Structural images were also utilized for standard stereotactic surgical planning. The anteromedial globus pallidus internus (amGPi) was chosen as the target bilaterally after consideration of white matter projections to frontal cortical regions and neurosurgical approach. Bilateral amGPi DBS surgery was undertaken without adverse events. At 16-mo follow-up, there was a 48.5% reduction in OCD symptom severity as measured by the Yale-Brown Obsessive Compulsive Scale.CONCLUSIONThe amGPi can be a successful DBS target for OCD. This is the first known case to report on DBS surgery postleucotomies for OCD and highlights the utility of tractography for surgical planning in OCD.

Four Deep Brain Stimulation Targets for Obsessive-Compulsive Disorder: Are They Different?

“…These comparisons form the basis for cross evaluation of therapeutic outcomes and for understanding the underlying mechanisms of those outcomes. Diffusion magnetic resonance imaging (dMRI) tractography is increasingly being used to model or position electrodes for DBS (9,(13)(14)(15)(16)(17)(18)(19) which raises an additional issue regarding the accuracy of diffusion tractography to correctly label connections.…”

Neurocircuitry of Deep Brain Stimulation for Obsessive-Compulsive Disorder as Revealed by Tractography: A Systematic Review

“…Forty studies were excluded based on titles and abstracts, resulting in 20 full-text papers for detailed evaluation. Of those, 12 articles were excluded for the following reasons: (i) connectivity was not assessed with tractography ( 28 , 29 ); (ii) DBS outcomes were not considered ( 30 – 33 ); (iii) no description of WMP was provided according to our defined criteria ( 34 , 35 ); referred studies were duplicate in other selected articles ( 36 ). The eight studies included were published between 2016 and 2020 and originated from Spain ( N = 1), Netherlands ( N = 1), Germany ( N = 3), United Kingdom ( N = 1), and the United States ( N = 2) ( 17 , 20 – 23 , 37 – 39 ) ( Table 1 ).…”

Effects of stereotactic radiofrequency thermocoagulation in the globus pallidus internus on refractory tic disorders

“…Because Kurlan et al and Sun et al had applied radiofrequency thermocoagulation in the gyri cinguli and anterior capsule interna for the treatment of TS or refractory tic disorders [5,18], we hypothesized that the use of radiofrequency thermocoagulation in the globus pallidus internus could be more effective for refractory tic disorders. This is because high-frequency deep brain stimulation in the globus pallidus internus is effective in the treatment of medically intractable Parkinson's disease, TS, and refractory obsessivecompulsive disorder [10][11][12][13], and destruction of this structure can block the basal-ganglia-thalamocortical circuit or pathway, thus achieving better treatment effects. Our study revealed that a higher proportion of patients with refractory tic disorders benefited from this approach, with a total efficacy rate of 92.5% and a rate of 70% of excellent or marked improvement.…”

“…The thalamus, globus pallidus, and anterior limb of the internal capsule/nucleus have been reported in some studies as surgical targets for treatment of refractory TS and obsessivecompulsive disorder [9]. High-frequency deep brain stimulation has been performed in the internal globus pallidus for treatment of medically intractable Parkinson's disease, TS, and refractory obsessive-compulsive disorder [10][11][12][13]; in the thalamus for treating medically refractory TS [14]; and in the internal capsule and nucleus accumbens for treating refractory obsessive-compulsive disorder [15]. For TS, it has been reported that when high-frequency stimulation is applied in the anteromedial globus pallidus internus, the amplitude of tic-associated phasic changes in the globus pallidus internus is reduced [2].…”

“…In 2005, Sun et al reported the use of radiofrequency thermocoagulation guided by high-resolution magnetic resonance imaging (MRI) in bilateral anterior capsulotomy for the treatment of refractory tic disorder [5], achieving 50% symptom improvement on the tic severity scale in patients receiving thermocoagulation in the posterior one-third of the anterior limb of the internal capsule, compared to 80% in the anterior one-third of the anterior limb of the internal capsule. As high-frequency deep brain stimulation in the globus pallidus internus is effective for the treatment of medically intractable Parkinson's disease, TS, and refractory obsessive-compulsive disorder [10][11][12][13], it was hypothesized that radiofrequency thermocoagulation to destroy the structure of this area could be more effective in treating refractory tic disorders. Because the globus pallidus internus is located in the basal-ganglia-thalamocortical circuit or pathway, blocking this circuit or pathway would interrupt the nervous transmission of vocal and motor tics, achieving the treatment effect.…”