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Case Presentation: DBS for Depression

Case Presentation: DBS for Depression. Robert McGovern, MS-IV Neurosurgery Grand Rounds, Massachusetts General Hospital July 16 th , 2009. Patient H&P. 43 y/o M with hx of severe, medically intractable depression On multiple medications 15 ECT trials Placement of VNS without success

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Case Presentation: DBS for Depression

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  1. Case Presentation: DBS for Depression Robert McGovern, MS-IV Neurosurgery Grand Rounds, Massachusetts General Hospital July 16th, 2009

  2. Patient H&P • 43 y/o M with hx of severe, medically intractable depression • On multiple medications • 15 ECT trials • Placement of VNS without success • Placement of epidural prefrontal cortical stimulator without success • Presents for placement of deep brain stimulating (DBS) electrodes in Ventral Capsule/Ventral Striatum (VC/VS)

  3. Depression • WHO estimates 121 million people worldwide • Leading cause of disability worldwide • 4th leading contributor to global burden of disease • Affects almost 1 in 5 persons in US • ~ 20% of patients are treatment-resistant • Alternative therapies are needed • Electroconvulsive therapy (ECT) • Vagal Nerve Stimulation (VNS) • Transcranial Magnetic Stimulation (TMS) • Deep Brain Stimulation (DBS)

  4. Neuroanatomy of Depression

  5. Rationale for Targeting the Ventral Capsule/Ventral Striatum VS is a central node in the limbic-cortical-subcortical network thought to be involved in emotional processing VS is central in processing reward and pleasure information VS is ideally suited to modulate reward-motivated behavior VC contains white matter tracts connecting VS to areas mentioned above

  6. Targeting the VC/VS Caudate Caudate IC IC Putamen Putamen GP

  7. Operative Procedure • Stereotactic frame placed • Electrodes inserted under local anesthesia • Intra-operative testing • Subjective mood, anxiety, energy level ratings • Placement of batteries under clavicle

  8. Electrode Placement

  9. Operative Results and Post-op Management • Immediate feeling of a “smile” or “giggle” when stimulator turned on • Increase in subjective mood immediately, decrease in anxiety • Described pattern of both short term and long tern changes leading to improvement • Continued on home medications, recovery period, discharged on POD 3

  10. Long Term Follow-Up • Depression rating scales • Hamilton depression and anxiety scores (HAM) • Montgomery Asberg Depression Rating scale (MADRS) • Global Assessment of functioning (GAF) • Detailed neuropsych batter • Complications

  11. Conclusions • DBS offers a safe and effective method of modulating specific brain regions • DBS may become a therapeutic alternative for treatment-resistant depression • Continued research into the structural and functional basis of depression will enable us to further refine our treatment methods

  12. Acknowledgments • Dr. Emad Eskandar

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