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Saluja S, Qiu L, Wang AR, Campos G, Seilheimer R, McNab JA, Haber SN, Barbosa DAN, Halpern CH. Diffusion Magnetic Resonance Imaging Tractography Guides Investigation of the Zona Incerta: A Novel Target for Deep Brain Stimulation. Biol Psychiatry 2024:S0006-3223(24)01105-3. [PMID: 38401802 DOI: 10.1016/j.biopsych.2024.02.1004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 02/02/2024] [Accepted: 02/16/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND The zona incerta (ZI) is a subcortical structure primarily investigated in rodents that is implicated in various behaviors, ranging from motor control to survival-associated activities, partly due to its integration in multiple neural circuits. In the current study, we used diffusion magnetic resonance imaging tractography to segment the ZI and gain insight into its connectivity in various circuits in humans. METHODS We performed probabilistic tractography in 7T diffusion MRI on 178 participants from the Human Connectome Project to validate the ZI's anatomical subdivisions and their respective tracts. K-means clustering segmented the ZI based on each voxel's connectivity profile. We further characterized the connections of each ZI subregion using probabilistic tractography with each subregion as a seed. RESULTS We identified 2 dominant clusters that delineated the whole ZI into rostral and caudal subregions. The caudal ZI primarily connected with motor regions, while the rostral ZI received a topographic distribution of projections from prefrontal areas, notably the anterior cingulate and medial prefrontal cortices. We generated a probabilistic ZI atlas that was registered to a patient-participant's magnetic resonance imaging scan for placement of stereoencephalographic leads for electrophysiology-guided deep brain stimulation to treat their obsessive-compulsive disorder. Rostral ZI stimulation improved the patient's core symptoms (mean improvement 21%). CONCLUSIONS We present a tractography-based atlas of the rostral and caudal ZI subregions constructed using high-resolution diffusion magnetic resonance imaging from 178 healthy participants. Our work provides an anatomical foundation to explore the rostral ZI as a novel target for deep brain stimulation to treat refractory obsessive-compulsive disorder and other disorders associated with dysfunctional reward circuitry.
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Affiliation(s)
- Sabir Saluja
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Liming Qiu
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Allan R Wang
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gustavo Campos
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert Seilheimer
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer A McNab
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Suzanne N Haber
- Department of Pharmacology & Physiology, University of Rochester School of Medicine and Dentistry, Rochester, New York; Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, Massachusetts
| | - Daniel A N Barbosa
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Casey H Halpern
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.
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Guedes F, Henriques VM, Torrão FL, Haikal NP, Sanches GE, Barbosa DAN, Marsicano FG, Rosa LAN, Siquara AC, Malessy MJA. When biopsy goes wrong: a case series of misdiagnoses and complications from biopsies of masses of unknown origin potentially originating from a peripheral nerve. J Neurosurg 2024; 140:480-488. [PMID: 37877976 DOI: 10.3171/2023.5.jns23385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 05/15/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVE Biopsies of peripheral nerve tumors (PNTs) are often used to plan an efficient treatment strategy. However, performing a biopsy is controversial when the mass is likely to be a benign PNT (BPNT). The aim of this study was to evaluate the side effects of biopsies in patients with potential PNTs. METHODS A retrospective and cross-sectional study was conducted on 24 patients who underwent biopsy of a mass of unknown origin potentially originating from a peripheral nerve (MUOPON), performed in nonspecialty services, and who were later referred to the authors' service for resection of their lesion between January 2005 and December 2022. The patients were evaluated for pain score, presence of a motor or sensory deficit, biopsy diagnosis, and definitive histopathological postsurgical diagnosis. RESULTS The location of the tumor was supraclavicular in 7 (29.2%) patients, in the axillary region in 3 (12.5%), in the upper limb in 7 (29.2%), and in the lower limb in 7 (29.2%). Twenty-one (87.5%) patients were evaluated by MRI before biopsy, and 3 (12.5%) underwent ultrasound. One patient did not have an examination before the procedure. Based on the biopsy findings, 12 (50%) analyses had an inconclusive histopathological result. The preexisting pain worsened, as measured 1 week after biopsy, in all patients and had remained unchanged at the first evaluation by the authors (median 3 months, range 2-4 months). In 1 case, the open biopsy had to be interrupted because the patient experienced excruciating pain. Four (16.7%) patients developed motor deficits. Subsequent surgery was hampered by scar formation and intratumoral hemorrhage in 5 (20.8%) patients. The initial diagnosis obtained by biopsy differed from the final histopathological diagnosis in all patients, of whom 21 (87.5%) had BPNTs, 2 (8.3%) malignant peripheral nerve sheath tumors, and 1 (4.2%) an ancient schwannoma. CONCLUSIONS Biopsies of PNTs are controversial and may result in misdiagnosis, neuropathic pain, or neurological deficit due to axonal damage, and they may also hinder microsurgical resection when if performed when not indicated. Indications for biopsy of an MUOPON must be carefully considered, especially if BPNT is a possible diagnosis.
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Affiliation(s)
- Fernando Guedes
- 1Department of Surgery, Neurosurgery Division, Gaffrée and Guinle University Hospital (HUGG), Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
- 2Peripheral Nerves Unit, Division of Neurosurgery, Pedro Ernesto University Hospital (HUPE), University of the State of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Vinícius M Henriques
- 1Department of Surgery, Neurosurgery Division, Gaffrée and Guinle University Hospital (HUGG), Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
| | - Francisco L Torrão
- 1Department of Surgery, Neurosurgery Division, Gaffrée and Guinle University Hospital (HUGG), Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
| | - Neder P Haikal
- 2Peripheral Nerves Unit, Division of Neurosurgery, Pedro Ernesto University Hospital (HUPE), University of the State of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Gabriel E Sanches
- 1Department of Surgery, Neurosurgery Division, Gaffrée and Guinle University Hospital (HUGG), Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
| | - Daniel A N Barbosa
- 3Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Felipe G Marsicano
- 1Department of Surgery, Neurosurgery Division, Gaffrée and Guinle University Hospital (HUGG), Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
| | - Livia A N Rosa
- 1Department of Surgery, Neurosurgery Division, Gaffrée and Guinle University Hospital (HUGG), Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
| | - Ana C Siquara
- 4Pathology Division, Antônio Pedro University Hospital (HUAP), Federal Fluminense University (UFF), Niterói, Rio de Janeiro, Brazil; and
| | - Martijn J A Malessy
- 5Department of Nerve Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Nho YH, Rolle CE, Topalovic U, Shivacharan RS, Cunningham TN, Hiller S, Batista D, Feng A, Espil FM, Kratter IH, Bhati MT, Kellogg M, Raslan AM, Williams NR, Garnett J, Pesaran B, Oathes DJ, Suthana N, Barbosa DAN, Halpern CH. Responsive deep brain stimulation guided by ventral striatal electrophysiology of obsession durably ameliorates compulsion. Neuron 2024; 112:73-83.e4. [PMID: 37865084 PMCID: PMC10841397 DOI: 10.1016/j.neuron.2023.09.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 08/12/2023] [Accepted: 09/26/2023] [Indexed: 10/23/2023]
Abstract
Treatment-resistant obsessive-compulsive disorder (OCD) occurs in approximately one-third of OCD patients. Obsessions may fluctuate over time but often occur or worsen in the presence of internal (emotional state and thoughts) and external (visual and tactile) triggering stimuli. Obsessive thoughts and related compulsive urges fluctuate (are episodic) and so may respond well to a time-locked brain stimulation strategy sensitive and responsive to these symptom fluctuations. Early evidence suggests that neural activity can be captured from ventral striatal regions implicated in OCD to guide such a closed-loop approach. Here, we report on a first-in-human application of responsive deep brain stimulation (rDBS) of the ventral striatum for a treatment-refractory OCD individual who also had comorbid epilepsy. Self-reported obsessive symptoms and provoked OCD-related distress correlated with ventral striatal electrophysiology. rDBS detected the time-domain area-based feature from invasive electroencephalography low-frequency oscillatory power fluctuations that triggered bursts of stimulation to ameliorate OCD symptoms in a closed-loop fashion. rDBS provided rapid, robust, and durable improvement in obsessions and compulsions. These results provide proof of concept for a personalized, physiologically guided DBS strategy for OCD.
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Affiliation(s)
- Young-Hoon Nho
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Camarin E Rolle
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Uros Topalovic
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, USA
| | - Rajat S Shivacharan
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Tricia N Cunningham
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Sonja Hiller
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, USA
| | - Daniel Batista
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, USA
| | - Austin Feng
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Flint M Espil
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Ian H Kratter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Mahendra T Bhati
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Marissa Kellogg
- Oregon Health and Science University Comprehensive Epilepsy Center, Portland, OR, USA
| | - Ahmed M Raslan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Nolan R Williams
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - John Garnett
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Bijan Pesaran
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Desmond J Oathes
- Department of Psychiatry, Center for Neuromodulation in Depression and Stress, Brain Science, Translation, Innovation, and Modulation Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Nanthia Suthana
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, USA
| | - Daniel A N Barbosa
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA.
| | - Casey H Halpern
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA; Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.
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Rijsketic DR, Casey AB, Barbosa DAN, Zhang X, Hietamies TM, Ramirez-Ovalle G, Pomrenze MB, Halpern CH, Williams LM, Malenka RC, Heifets BD. UNRAVELing the synergistic effects of psilocybin and environment on brain-wide immediate early gene expression in mice. Neuropsychopharmacology 2023; 48:1798-1807. [PMID: 37248402 PMCID: PMC10579391 DOI: 10.1038/s41386-023-01613-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/25/2023] [Accepted: 05/15/2023] [Indexed: 05/31/2023]
Abstract
The effects of context on the subjective experience of serotonergic psychedelics have not been fully examined in human neuroimaging studies, partly due to limitations of the imaging environment. Here, we administered saline or psilocybin to mice in their home cage or an enriched environment, immunofluorescently-labeled brain-wide c-Fos, and imaged iDISCO+ cleared tissue with light sheet fluorescence microscopy (LSFM) to examine the impact of environmental context on psilocybin-elicited neural activity at cellular resolution. Voxel-wise analysis of c-Fos-immunofluorescence revealed clusters of neural activity associated with main effects of context and psilocybin-treatment, which were validated with c-Fos+ cell density measurements. Psilocybin increased c-Fos expression in subregions of the neocortex, caudoputamen, central amygdala, and parasubthalamic nucleus while it decreased c-Fos in the hypothalamus, cortical amygdala, striatum, and pallidum in a predominantly context-independent manner. To gauge feasibility of future mechanistic studies on ensembles activated by psilocybin, we confirmed activity- and Cre-dependent genetic labeling in a subset of these neurons using TRAP2+/-;Ai14+ mice. Network analyses treating each psilocybin-sensitive cluster as a node indicated that psilocybin disrupted co-activity between highly correlated regions, reduced brain modularity, and dramatically attenuated intermodular co-activity. Overall, our results indicate that main effects of context and psilocybin were robust, widespread, and reorganized network architecture, whereas context×psilocybin interactions were surprisingly sparse.
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Affiliation(s)
- Daniel Ryskamp Rijsketic
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Austen B Casey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Daniel A N Barbosa
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Xue Zhang
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, 94305, USA
| | - Tuuli M Hietamies
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Grecia Ramirez-Ovalle
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Matthew B Pomrenze
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, 94305, USA
- Nancy Pritzker Laboratory, Stanford University, Stanford, CA, 94305, USA
| | - Casey H Halpern
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Leanne M Williams
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, 94305, USA
- Sierra-Pacific Mental Illness Research, Education, and Clinical Center (MIRECC) Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Robert C Malenka
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, 94305, USA
- Nancy Pritzker Laboratory, Stanford University, Stanford, CA, 94305, USA
| | - Boris D Heifets
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA.
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, 94305, USA.
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5
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Eisinger RS, Okun MS, Cernera S, Cagle J, Beke M, Ramirez-Zamora A, Kim BH, Barbosa DAN, Qiu L, Vaswani P, Aamodt WW, Halpern CH, Foote KD, Gunduz A, Almeida L. Weight and survival after deep brain stimulation for Parkinson's disease. Parkinsonism Relat Disord 2023; 115:105810. [PMID: 37660542 PMCID: PMC10664863 DOI: 10.1016/j.parkreldis.2023.105810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/05/2023] [Accepted: 08/13/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Weight loss in Parkinson's disease (PD) is common and associated with increased mortality. The clinical significance of weight changes following deep brain stimulation (DBS) of the subthalamic nucleus (STN) and globus pallidus internus (GPi) is unclear. OBJECTIVES To address (1) whether PD patients exhibit progressive weight loss, (2) whether staged DBS surgery is associated with weight changes, and (3) whether survival after DBS correlates with post-DBS weight. METHODS This is a single-center, longitudinal, retrospective cohort study of 1625 PD patients. We examined trends in weight over time and the relationship between weight and years survival after DBS using regression and mixed model analyses. RESULTS There was a decline in body weight predating motor symptom onset (n = 756, 0.70 ± 0.03% decrease per year, p < 0.001). Weight decline accelerated in the decade preceding death (n = 456, 2.18 ± 0.31% decrease per year, p < 0.001). DBS patients showed a weight increase of 2.0 ± 0.33% at 1 year following the first DBS lead implant (n = 455) and 2.68 ± 1.1% at 3 years if a contralateral DBS lead was placed (n = 249). The bilateral STN DBS group gained the most weight after surgery during 6 years of follow up (vs bilateral GPi, 3.03 ± 0.45% vs 1.89 ± 0.31%, p < 0.01). An analysis of the DBS cohort with date of death available (n = 72) revealed that post-DBS weight (0-12 months after the first or 0-36 months after the second surgery) was positively associated with survival (R2 = 0.14, p < 0.001). DISCUSSION Though PD is associated with significant weight loss, DBS patients gained weight following surgery. Higher post-operative weight was associated with increased survival. These results should be replicated in other cohorts.
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Affiliation(s)
- Robert S Eisinger
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, USA; Department of Neurology, Hospital of the University of Pennsylvania, USA.
| | - Michael S Okun
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, USA; Department of Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, USA
| | - Stephanie Cernera
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, USA; Department of Neurosurgery, University of California, San Francisco, USA
| | - Jackson Cagle
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, USA
| | - Matthew Beke
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, USA; Food Science and Human Nutrition Department, University of Florida, USA
| | - Adolfo Ramirez-Zamora
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, USA
| | - B Hope Kim
- Department of Neurology, Hospital of the University of Pennsylvania, USA
| | - Daniel A N Barbosa
- Department of Neurosurgery, Hospital of the University of Pennsylvania, USA
| | - Liming Qiu
- Department of Neurosurgery, Hospital of the University of Pennsylvania, USA
| | - Pavan Vaswani
- Department of Neurology, Hospital of the University of Pennsylvania, USA
| | - Whitley W Aamodt
- Department of Neurology, Hospital of the University of Pennsylvania, USA
| | - Casey H Halpern
- Department of Neurosurgery, Hospital of the University of Pennsylvania, USA; Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, PA, Philadelphia, USA
| | - Kelly D Foote
- Department of Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, USA
| | - Aysegul Gunduz
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, USA; Department of Biomedical Engineering, University of Florida, USA
| | - Leonardo Almeida
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, USA; Department of Neurology, University of Minnesota, Minneapolis, MN, USA
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Rolle CE, Ng GY, Nho YH, Barbosa DAN, Shivacharan RS, Gold JI, Bassett DS, Halpern CH, Buch V. Accumbens connectivity during deep-brain stimulation differentiates loss of control from physiologic behavioral states. Brain Stimul 2023; 16:1384-1391. [PMID: 37734587 PMCID: PMC10811591 DOI: 10.1016/j.brs.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 09/10/2023] [Accepted: 09/11/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Loss of control (LOC) eating, the subjective sense that one cannot control what or how much one eats, characterizes binge-eating behaviors pervasive in obesity and related eating disorders. Closed-loop deep-brain stimulation (DBS) for binge eating should predict LOC and trigger an appropriately timed intervention. OBJECTIVE/HYPOTHESIS This study aimed to identify a sensitive and specific biomarker to detect LOC onset for DBS. We hypothesized that changes in phase-locking value (PLV) predict the onset of LOC-associated cravings and distinguish them from potential confounding states. METHODS Using DBS data recorded from the nucleus accumbens (NAc) of two patients with binge eating disorder (BED) and severe obesity, we compared PLV between inter- and intra-hemispheric NAc subregions for three behavioral conditions: craving (associated with LOC eating), hunger (not associated with LOC), and sleep. RESULTS In both patients, PLV in the high gamma frequency band was significantly higher for craving compared to sleep and significantly higher for hunger compared to craving. Maximum likelihood classifiers achieved accuracies above 88% when differentiating between the three conditions. CONCLUSIONS High-frequency inter- and intra-hemispheric PLV in the NAc is a promising biomarker for closed-loop DBS that differentiates LOC-associated cravings from physiologic states such as hunger and sleep. Future trials should assess PLV as a LOC biomarker across a larger cohort and a wider patient population transdiagnostically.
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Affiliation(s)
- Camarin E Rolle
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania Hospital, Spruce Building 3rd Floor, 801 Spruce Street, Philadelphia, PA 19107, USA; Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94304, USA
| | - Grace Y Ng
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania Hospital, Spruce Building 3rd Floor, 801 Spruce Street, Philadelphia, PA 19107, USA; Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA; Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Young-Hoon Nho
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania Hospital, Spruce Building 3rd Floor, 801 Spruce Street, Philadelphia, PA 19107, USA; Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
| | - Daniel A N Barbosa
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania Hospital, Spruce Building 3rd Floor, 801 Spruce Street, Philadelphia, PA 19107, USA; Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
| | - Rajat S Shivacharan
- Department of Neurosurgery, Stanford University School of Medicine, 453 Quarry Road Office 245C, Stanford, CA 94304, USA
| | - Joshua I Gold
- Department of Neuroscience, University of Pennsylvania, 3700 Hamilton Walk, Richards D407, Philadelphia, PA 19104, USA
| | - Dani S Bassett
- Departments of Bioengineering, Physics and Astronomy, Electrical and Systems Engineering, Neurology, and Psychiatry, University of Pennsylvania, 210 S. 33rd St, Skirkanich Hall 240, Philadelphia, PA 19104, USA; Santa Fe Institute, 1399 Hyde Park Rd, Santa Fe, NM 87501, USA
| | - Casey H Halpern
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania Hospital, Spruce Building 3rd Floor, 801 Spruce Street, Philadelphia, PA 19107, USA; Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
| | - Vivek Buch
- Department of Neurosurgery, Stanford University School of Medicine, 453 Quarry Road Office 245C, Stanford, CA 94304, USA.
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Barbosa DAN, Gattas S, Salgado JS, Kuijper FM, Wang AR, Huang Y, Kakusa B, Leuze C, Luczak A, Rapp P, Malenka RC, Hermes D, Miller KJ, Heifets BD, Bohon C, McNab JA, Halpern CH. An orexigenic subnetwork within the human hippocampus. Nature 2023; 621:381-388. [PMID: 37648849 PMCID: PMC10499606 DOI: 10.1038/s41586-023-06459-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 07/20/2023] [Indexed: 09/01/2023]
Abstract
Only recently have more specific circuit-probing techniques become available to inform previous reports implicating the rodent hippocampus in orexigenic appetitive processing1-4. This function has been reported to be mediated at least in part by lateral hypothalamic inputs, including those involving orexigenic lateral hypothalamic neuropeptides, such as melanin-concentrating hormone5,6. This circuit, however, remains elusive in humans. Here we combine tractography, intracranial electrophysiology, cortico-subcortical evoked potentials, and brain-clearing 3D histology to identify an orexigenic circuit involving the lateral hypothalamus and converging in a hippocampal subregion. We found that low-frequency power is modulated by sweet-fat food cues, and this modulation was specific to the dorsolateral hippocampus. Structural and functional analyses of this circuit in a human cohort exhibiting dysregulated eating behaviour revealed connectivity that was inversely related to body mass index. Collectively, this multimodal approach describes an orexigenic subnetwork within the human hippocampus implicated in obesity and related eating disorders.
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Affiliation(s)
- Daniel A N Barbosa
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sandra Gattas
- Department of Electrical Engineering and Computer Science, University of California, Irvine, Irvine, CA, USA
| | - Juliana S Salgado
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Fiene Marie Kuijper
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
- Université Paris Cité, Paris, France
- Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Allan R Wang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Yuhao Huang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Bina Kakusa
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Christoph Leuze
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Artur Luczak
- Canadian Centre for Behavioral Neuroscience, University of Lethbridge, Lethbridge, Alberta, Canada
| | - Paul Rapp
- Department of Military & Emergency Medicine, Uniformed Services University, Bethesda, MD, USA
| | - Robert C Malenka
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
- Nancy Pritzker Laboratory, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Dora Hermes
- Department of Physiology & Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
| | - Kai J Miller
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Boris D Heifets
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Cara Bohon
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Jennifer A McNab
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Casey H Halpern
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.
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Qiu L, Halpern CH, Barbosa DAN. Are we getting closer to offering deep brain stimulation for treatment-resistant depression in clinical practice? Mol Psychiatry 2023; 28:2627-2629. [PMID: 37106119 DOI: 10.1038/s41380-023-02078-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- Liming Qiu
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Casey H Halpern
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Daniel A N Barbosa
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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9
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Wang AR, Kuijper FM, Barbosa DAN, Hagan KE, Lee E, Tong E, Choi EY, McNab JA, Bohon C, Halpern CH. Human habit neural circuitry may be perturbed in eating disorders. Sci Transl Med 2023; 15:eabo4919. [PMID: 36989377 DOI: 10.1126/scitranslmed.abo4919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/03/2023] [Indexed: 03/31/2023]
Abstract
Circuit-based mechanisms mediating the development and execution of habitual behaviors involve complex cortical-striatal interactions that have been investigated in animal models and more recently in humans. However, how human brain circuits implicated in habit formation may be perturbed in psychiatric disorders remains unclear. First, we identified the locations of the sensorimotor putamen and associative caudate in the human brain using probabilistic tractography from Human Connectome Project data. We found that multivariate connectivity of the sensorimotor putamen was altered in humans with binge eating disorder and bulimia nervosa and that the degree of alteration correlated with severity of disordered eating behavior. Furthermore, the extent of this circuit aberration correlated with mean diffusivity in the sensorimotor putamen and decreased basal dopamine D2/3 receptor binding potential in the striatum, consistent with previously reported microstructural changes and dopamine signaling mediating habit learning in animal models. Our findings suggest a neural circuit that links habit learning and binge eating behavior in humans, which could, in part, explain the treatment-resistant behavior common to eating disorders and other psychiatric conditions.
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Affiliation(s)
- Allan R Wang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Fiene Marie Kuijper
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
- Université Paris Cité, Paris 75006, France
- Assistance Publique des Hôpitaux de Paris, Paris 75012, France
| | - Daniel A N Barbosa
- Department of Neurosurgery, Perelman School of Medicine, Richards Medical Research Laboratories, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kelsey E Hagan
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Eric Lee
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Elizabeth Tong
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, 94305 USA
| | - Eun Young Choi
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Jennifer A McNab
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, 94305 USA
| | - Cara Bohon
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Casey H Halpern
- Department of Neurosurgery, Perelman School of Medicine, Richards Medical Research Laboratories, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
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Parker JJ, Rolle CE, Shivacharan RS, Barbosa DAN, Feng A, Huang Y, Kakusa BW, Prieto T, Jaffe RA, Williams NR, Halpern CH. Appetitive Mapping of the Human Nucleus Accumbens. Biol Psychiatry 2023; 93:e15-e19. [PMID: 36509559 DOI: 10.1016/j.biopsych.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/09/2022] [Accepted: 09/16/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Jonathon J Parker
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Cammie E Rolle
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Rajat S Shivacharan
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Daniel A N Barbosa
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Austin Feng
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Yuhao Huang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Bina W Kakusa
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Tom Prieto
- Department of Neurology, Stanford University School of Medicine, Stanford, California
| | - Richard A Jaffe
- Department of Anesthesia, Stanford University School of Medicine, Stanford, California
| | - Nolan R Williams
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Casey H Halpern
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.
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Gelineau-Morel R, Kruer MC, Garris JF, Libdeh AA, Barbosa DAN, Coffman KA, Moon D, Barton C, Vera AZ, Bruce AB, Larsh T, Wu SW, Gilbert DL, O’Malley JA. Deep Brain Stimulation for Pediatric Dystonia: A Review of the Literature and Suggested Programming Algorithm. J Child Neurol 2022; 37:813-824. [PMID: 36053123 PMCID: PMC9912476 DOI: 10.1177/08830738221115248] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Deep brain stimulation (DBS) is an established intervention for use in pediatric movement disorders, especially dystonia. Although multiple publications have provided guidelines for deep brain stimulation patient selection and programming in adults, there are no evidence-based or consensus statements published for pediatrics. The result is lack of standardized care and underutilization of this effective treatment. To this end, we assembled a focus group of 13 pediatric movement disorder specialists and 1 neurosurgeon experienced in pediatric deep brain stimulation to review recent literature and current practices and propose a standardized approach to candidate selection, implantation target site selection, and programming algorithms. For pediatric dystonia, we provide algorithms for (1) programming for initial session and follow-up sessions, and (2) troubleshooting side effects encountered during programming. We discuss common side effects, how they present, and recommendations for management. This topical review serves as a resource for movement disorders specialists interested in using deep brain stimulation for pediatric dystonia.
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Affiliation(s)
- Rose Gelineau-Morel
- Division of Neurology, Department of Pediatrics, Children’s Mercy Hospital, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City, Missouri, 64108
| | - Michael C Kruer
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children’s Hospital & University of Arizona College of Medicine - Phoenix, Phoenix, AZ, 85016
| | - Jordan F Garris
- Division of Pediatric Neurology, Department of Neurology, University of Virginia, PO Box 800394, Charlottesville, VA, 22908−0394
| | - Amal Abu Libdeh
- Division of Pediatric Neurology, Department of Neurology, University of Virginia, PO Box 800394, Charlottesville, VA, 22908−0394
| | - Daniel A N Barbosa
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Edwards Bldg, Stanford, CA, 94305
| | - Keith A Coffman
- Division of Neurology, Department of Pediatrics, Children’s Mercy Hospital, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City, Missouri, 64108
| | - David Moon
- Department of Child Neurology, Division of Neurosciences, Helen DeVos Children’s Hospital, 100 Michigan St NE, Grand Rapids, MI 49503
| | - Christopher Barton
- Department of Neurology, University of Louisville School of Medicine, Louisville, Kentucky; Division of Child Neurology, Norton Children’s Medical Group, 231 E Chestnut St, Louisville, KY 40202
| | - Alonso Zea Vera
- Department of Neurology, Children’s National Hospital, 111 Michigan Ave NW, Washington, DC, 20010
| | - Adrienne B Bruce
- Division of Pediatric Neurology, Department of Pediatrics, Prisma Health, 200 Patewood Drive A350, Greenville, SC, USA 29615; University of South Carolina School of Medicine Greenville, 607 Grove Road, Greenville, SC, 29605
| | - Travis Larsh
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, 3333 Burnet Ave, Location E4, Suite 110, Cincinnati, OH 45229
| | - Steve W Wu
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, 3333 Burnet Ave, Location E4, Suite 110, Cincinnati, OH 45229
| | - Donald L Gilbert
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, 3333 Burnet Ave, Location E4, Suite 110, Cincinnati, OH 45229
| | - Jennifer A O’Malley
- Department of Neurology, Division of Child Neurology, Stanford University School of Medicine, 750 Welch Road, Suite 317, Palo Alto, California, 94304
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Barbosa DAN, Kuijper FM, Duda J, Wang AR, Cartmell SCD, Saluja S, Cunningham T, Shivacharan RS, Bhati MT, Safer DL, Lock JD, Malenka RC, de Oliveira-Souza R, Williams NR, Grossman M, Gee JC, McNab JA, Bohon C, Halpern CH. Aberrant impulse control circuitry in obesity. Mol Psychiatry 2022; 27:3374-3384. [PMID: 35697760 PMCID: PMC9192250 DOI: 10.1038/s41380-022-01640-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 05/11/2022] [Accepted: 05/18/2022] [Indexed: 01/09/2023]
Abstract
The ventromedial prefrontal cortex (vmPFC) to nucleus accumbens (NAc) circuit has been implicated in impulsive reward-seeking. This disinhibition has been implicated in obesity and often manifests as binge eating, which is associated with worse treatment outcomes and comorbidities. It remains unclear whether the vmPFC-NAc circuit is perturbed in impulsive eaters with obesity. Initially, we analyzed publicly available, high-resolution, normative imaging data to localize where vmPFC structural connections converged within the NAc. These structural connections were found to converge ventromedially in the presumed NAc shell subregion. We then analyzed multimodal clinical and imaging data to test the a priori hypothesis that the vmPFC-NAc shell circuit is linked to obesity in a sample of female participants that regularly engaged in impulsive eating (i.e., binge eating). Functionally, vmPFC-NAc shell resting-state connectivity was inversely related to body mass index (BMI) and decreased in the obese state. Structurally, vmPFC-NAc shell structural connectivity and vmPFC thickness were inversely correlated with BMI; obese binge-prone participants exhibited decreased vmPFC-NAc structural connectivity and vmPFC thickness. Finally, to examine a causal link to binge eating, we directly probed this circuit in one binge-prone obese female using NAc deep brain stimulation in a first-in-human trial. Direct stimulation of the NAc shell subregion guided by local behaviorally relevant electrophysiology was associated with a decrease in number of weekly episodes of uncontrolled eating and decreased BMI. This study unraveled vmPFC-NAc shell circuit aberrations in obesity that can be modulated to restore control over eating behavior in obesity.
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Affiliation(s)
- Daniel A N Barbosa
- Department of Neurosurgery, Pennsylvania Hospital, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Fiene Marie Kuijper
- Department of Neurosurgery, Pennsylvania Hospital, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey Duda
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Allan R Wang
- Department of Neurosurgery, Pennsylvania Hospital, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Samuel C D Cartmell
- Department of Neurosurgery, Pennsylvania Hospital, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sabir Saluja
- Department of Neurosurgery, Pennsylvania Hospital, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tricia Cunningham
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Rajat S Shivacharan
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Mahendra T Bhati
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Debra L Safer
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - James D Lock
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Robert C Malenka
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
- Nancy Pritzker Laboratory, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Ricardo de Oliveira-Souza
- Department of Specialized Medicine, Gaffrée e Guinle University Hospital, The Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Nolan R Williams
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Murray Grossman
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - James C Gee
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer A McNab
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Cara Bohon
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Casey H Halpern
- Department of Neurosurgery, Pennsylvania Hospital, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, PA, Philadelphia, USA.
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13
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Zhang X, Zhang H, Lin Z, Barbosa DAN, Lai Y, Halpern CH, Voon V, Li D, Zhang C, Sun B. Effects of Bilateral Subthalamic Nucleus Stimulation on Depressive Symptoms and Cerebral Glucose Metabolism in Parkinson's Disease: A 18F-Fluorodeoxyglucose Positron Emission Tomography/Computerized Tomography Study. Front Neurosci 2022; 16:843667. [PMID: 35720690 PMCID: PMC9200334 DOI: 10.3389/fnins.2022.843667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 03/10/2022] [Indexed: 02/02/2023] Open
Abstract
Subthalamic nucleus (STN) deep brain stimulation (DBS) can improve motor symptoms in Parkinson's disease (PD), as well as potentially improving otherwise intractable comorbid depressive symptoms. To address the latter issue, we evaluated the severity of depressive symptoms along with the severity of motor symptoms in 18 PD patients (mean age, 58.4 ± 5.4 years; 9 males, 9 females; mean PD duration, 9.4 ± 4.4 years) with treatment-resistant depression (TRD) before and after approximately 1 year of STN-DBS treatment. Moreover, to gain more insight into the brain mechanism mediating the therapeutic action of STN-DBS, we utilized 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) to assess cerebral regional glucose metabolism in the patients at baseline and 1-year follow-up. Additionally, the baseline PET data from patients were compared with PET data from an age- and sex-matched control group of 16 healthy volunteers. Among them, 12 PD patients underwent post-operative follow-up PET scans. Results showed that the severity of both motor and depressive symptoms in patients with PD-TRD was reduced significantly at 1-year follow-up. Also, patients used significantly less antiparkinsonian medications and antidepressants at 1-year follow-up, as well as experiencing improved daily functioning and a better quality of life. Moreover, relative to the PET data from healthy controls, PD-TRD patients displayed widespread abnormalities in cerebral regional glucose metabolism before STN-DBS treatment, which were partially recovered at 1-year follow-up. Additionally, significant correlations were observed between the patients' improvements in depressive symptoms following STN-DBS and post-operative changes in glucose metabolism in brain regions implicated in emotion regulation. These results support the view that STN-DBS provides a promising treatment option for managing both motor and depressive symptoms in patients who suffer from PD with TRD. However, the results should be interpreted with caution due to the observational nature of the study, small sample size, and relatively short follow-up.
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Affiliation(s)
- Xiaoxiao Zhang
- Department of Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Huiwei Zhang
- PET Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhengyu Lin
- Department of Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Daniel A. N. Barbosa
- Department of Neurosurgery, School of Medicine, Stanford University, Stanford, CA, United States
| | - Yijie Lai
- Department of Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Casey H. Halpern
- Department of Neurosurgery, School of Medicine, Stanford University, Stanford, CA, United States
| | - Valerie Voon
- Department of Psychiatry, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Dianyou Li
- Department of Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chencheng Zhang
- Department of Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,*Correspondence: Chencheng Zhang,
| | - Bomin Sun
- Department of Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,Bomin Sun,
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Zhu Z, Hubbard E, Guo X, Barbosa DAN, Popal AM, Cai C, Jiang H, Zheng Z, Lin J, Gao W, Zhang J, Bartas K, Macchia D, Derdeyn P, Halpern CH, Mayberg HS, Beier KT, Zhu J, Wu H. A connectomic analysis of deep brain stimulation for treatment-resistant depression. Brain Stimul 2021; 14:1226-1233. [PMID: 34400379 DOI: 10.1016/j.brs.2021.08.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 08/11/2021] [Accepted: 08/11/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Deep brain stimulation (DBS) has been used as a treatment of last resort for treatment-resistant depression (TRD) for more than a decade. Many DBS targets have been proposed and tested clinically, but the underlying circuit mechanisms remain unclear. Uncovering white matter tracts (WMT) activated by DBS targets may provide crucial information about the circuit substrates mediating DBS efficacy in ameliorating TRD. METHODS We performed probabilistic tractography using diffusion magnetic resonance imaging datas from 100 healthy volunteers in Human Connectome Project datasets to analyze the structural connectivity patterns of stimulation targeting currently-used DBS target for TRD. We generated mean and binary fiber distribution maps and calculated the numbers of WMT streamlines in the dataset. RESULTS Probabilistic tracking results revealed that activation of distinct DBS targets demonstrated modulation of overlapping but considerably distinct pathways. DBS targets were categorized into 4 groups: Cortical, Striatal, Thalamic, and Medial Forebrain Bundle according to their main modulated WMT and brain areas. Our data also revealed that Brodmann area 10 and amygdala are hub structures that are associated with all DBS targets. CONCLUSIONS Our results together suggest that the distinct mechanism of DBS targets implies individualized target selection and formulation in the future of DBS treatment for TRD. The modulation of Brodmann area 10 and amygdala may be critical for the efficacy of DBS-mediated treatment of TRD.
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Affiliation(s)
- Zhoule Zhu
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, 310009, China
| | - Elizabeth Hubbard
- Department of Physiology and Biophysics, University of California, Irvine, CA, 92697-4560, USA
| | - Xinxia Guo
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, 310009, China
| | - Daniel A N Barbosa
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Abdul Malik Popal
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, 310009, China
| | - Chengwei Cai
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, 310009, China
| | - Hongjie Jiang
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, 310009, China
| | - Zhe Zheng
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, 310009, China
| | - Jingquan Lin
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, 310009, China
| | - Wei Gao
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, 310009, China
| | - Jianmin Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, 310009, China
| | - Katrina Bartas
- Program in Mathematical, Computational, and Systems Biology, University of California, Irvine, CA, 92697-4560, USA
| | - Desiree Macchia
- Department of Physiology and Biophysics, University of California, Irvine, CA, 92697-4560, USA
| | - Pieter Derdeyn
- Program in Mathematical, Computational, and Systems Biology, University of California, Irvine, CA, 92697-4560, USA
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Helen S Mayberg
- Departments of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Kevin T Beier
- Department of Physiology and Biophysics, University of California, Irvine, CA, 92697-4560, USA; Department of Neurobiology and Behavior, University of California, Irvine, CA, 92697-4560, USA; Department of Biomedical Engineering, University of California, Irvine, CA, 92697-4560, USA; Department of Pharmaceutical Sciences, University of California, Irvine, CA, 92697-4560, USA; Center for the Neurobiology of Learning and Memory, University of California, Irvine, CA, 92697, USA.
| | - Junming Zhu
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, 310009, China.
| | - Hemmings Wu
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, 310009, China.
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15
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Kuijper FM, Mahajan UV, Ku S, Barbosa DAN, Alessi SM, Stein SC, Kampman KM, Bentzley BS, Halpern CH. Deep Brain Stimulation Compared With Contingency Management for the Treatment of Cocaine Use Disorders: A Threshold and Cost-Effectiveness Analysis. Neuromodulation 2021; 25:253-262. [PMID: 34028131 DOI: 10.1111/ner.13410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 03/13/2021] [Accepted: 04/05/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Cocaine is the second most frequently used illicit drug worldwide (after cannabis), and cocaine use disorder (CUD) related deaths increased globally by 80% from 1990 to 2013. There is yet to be a regulatory-approved treatment. Emerging preclinical evidence indicates that deep brain stimulation (DBS) of the nucleus accumbens may be a therapeutic option. Prior to expanding the costly investigation of DBS for treatment of CUD, it is important to ensure societal cost-effectiveness. AIMS We conducted a threshold and cost-effectiveness analysis to determine the success rate at which DBS would be equivalent to contingency management (CM), recently identified as the most efficacious therapy for treatments of CUDs. MATERIALS AND METHODS Quality of life, efficacy, and safety parameters for CM were obtained from previous literature. Costs were calculated from a societal perspective. Our model predicted the utility benefit based on quality-adjusted-life-years (QALYs) and incremental-cost-effectiveness-ratio resulting from two treatments on a one-, two-, and five-year timeline. RESULTS On a one-year timeline, DBS would need to impart a success rate (i.e., cocaine free) of 70% for it to yield the same utility benefit (0.492 QALYs per year) as CM. At no success rate would DBS be more cost-effective (incremental-cost-effectiveness-ratio <$50,000) than CM during the first year. Nevertheless, as DBS costs are front-loaded, DBS would need to achieve success rates of 74% and 51% for its cost-effectiveness to exceed that of CM over a two- and five-year period, respectively. CONCLUSIONS We find DBS would not be cost-effective in the short-term (one year) but may be cost-effective in longer timelines. Since DBS holds promise to potentially be a cost-effective treatment for CUDs, future randomized controlled trials should be performed to assess its efficacy.
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Affiliation(s)
- Fiene Marie Kuijper
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Uma V Mahajan
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Seul Ku
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Daniel A N Barbosa
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Sherman C Stein
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kyle M Kampman
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brandon S Bentzley
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
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16
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Kakusa B, Saluja S, Barbosa DAN, Cartmell S, Espil FM, Williams NR, McNab JA, Halpern CH. Evidence for the role of the dorsal ventral lateral posterior thalamic nucleus connectivity in deep brain stimulation for Gilles de la Tourette syndrome. J Psychiatr Res 2021; 132:60-64. [PMID: 33045620 DOI: 10.1016/j.jpsychires.2020.09.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 09/08/2020] [Accepted: 09/25/2020] [Indexed: 12/16/2022]
Abstract
Gilles de la Tourette syndrome (GTS) can manifest as debilitating, medically-refractory tics for which deep brain stimulation (DBS) of the centromedian-parafascicular complex (CM) can provide effective treatment. However, patients have reported benefit with activation of contacts dorsal to the CM and likely in the ventro-lateral thalamus (VL). At our institution, a case of a robust and durable response in a GTS patient required stimulation in the CM and more dorsally. We explore the structural connectivity of thalamic subregions associated with GTS using diffusion MRI tractography. Diffusion weighted images from 40 healthy Human Connectome Project (HCP) subjects and our GTS patient were analyzed. The VL posterior nucleus (VLp) and the CM were used as seeds for whole-brain probabilistic tractography. Leads were localized via linear registration of pre-/post-operative imaging and cross-referenced with the DBS Intrinsic Template Atlas. Tractography revealed high streamline probability from the CM and VLp to the superior frontal gyrus, rostral middle frontal gyrus, brainstem, and ventral diencephalon. Given reported variable responses to DBS along the thalamus, we segmented the VLp based on its connectivity profile. Ventral and dorsal subdivisions emerged, with streamline probability patterns differing between the dorsal VLp and CM. The CM, the most reported DBS target for GTS, and the dorsal VLp have different but seemingly complimentary connectivity profiles as evidenced by our patient who, at 1-year post-operatively, had significant therapeutic benefit. Stimulation of both regions may better target reward and motor circuits, resulting in enhanced symptom control for GTS.
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Affiliation(s)
- Bina Kakusa
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Sabir Saluja
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Daniel A N Barbosa
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Sam Cartmell
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Flint M Espil
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Nolan R Williams
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Jennifer A McNab
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, 94305, USA.
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17
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Wu H, Adler S, Azagury DE, Bohon C, Safer DL, Barbosa DAN, Bhati MT, Williams NR, Dunn LB, Tass PA, Knutson BD, Yutsis M, Fraser A, Cunningham T, Richardson K, Skarpaas TL, Tcheng TK, Morrell MJ, Roberts LW, Malenka RC, Lock JD, Halpern CH. Brain-Responsive Neurostimulation for Loss of Control Eating: Early Feasibility Study. Neurosurgery 2020; 87:1277-1288. [PMID: 32717033 PMCID: PMC8599841 DOI: 10.1093/neuros/nyaa300] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 05/02/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Loss of control (LOC) is a pervasive feature of binge eating, which contributes significantly to the growing epidemic of obesity; approximately 80 million US adults are obese. Brain-responsive neurostimulation guided by the delta band was previously found to block binge-eating behavior in mice. Following novel preclinical work and a human case study demonstrating an association between the delta band and reward anticipation, the US Food and Drug Administration approved an Investigational Device Exemption for a first-in-human study. OBJECTIVE To assess feasibility, safety, and nonfutility of brain-responsive neurostimulation for LOC eating in treatment-refractory obesity. METHODS This is a single-site, early feasibility study with a randomized, single-blinded, staggered-onset design. Six subjects will undergo bilateral brain-responsive neurostimulation of the nucleus accumbens for LOC eating using the RNS® System (NeuroPace Inc). Eligible participants must have treatment-refractory obesity with body mass index ≥ 45 kg/m2. Electrophysiological signals of LOC will be characterized using real-time recording capabilities coupled with synchronized video monitoring. Effects on other eating disorder pathology, mood, neuropsychological profile, metabolic syndrome, and nutrition will also be assessed. EXPECTED OUTCOMES Safety/feasibility of brain-responsive neurostimulation of the nucleus accumbens will be examined. The primary success criterion is a decrease of ≥1 LOC eating episode/week based on a 28-d average in ≥50% of subjects after 6 mo of responsive neurostimulation. DISCUSSION This study is the first to use brain-responsive neurostimulation for obesity; this approach represents a paradigm shift for intractable mental health disorders.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Casey H Halpern
- Correspondence: Casey H. Halpern, MD, Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive (R-227), Stanford, CA 94305-5327, USA.
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18
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Erickson-DiRenzo E, Kuijper FM, Barbosa DAN, Lim EA, Lin PT, Lising MA, Huang Y, Sung CK, Halpern CH. Multiparametric laryngeal assessment of the effect of thalamic deep brain stimulation on essential vocal tremor. Parkinsonism Relat Disord 2020; 81:106-112. [PMID: 33120071 DOI: 10.1016/j.parkreldis.2020.10.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE EVT is a refractory voice disorder that significantly affects quality of life. This work aims to conduct a multiparametric assessment of the effect of deep brain stimulation (DBS) of the thalamic ventral intermediate nucleus (VIM) on essential vocal tremor (EVT) and investigate the relation between DBS lead location and EVT outcomes. METHODS Nine participants underwent DBS for essential tremor and were diagnosed with co-occurring EVT in this prospective cohort study. Objective measurements including acoustic evaluation of vocal fundamental frequency (F0) and intensity modulation and subjective measurements including physiologic evaluation of the oscillatory movement of the laryngeal muscles and vocal tract and perceptual ratings of tremor severity were collected PRE and POST DBS. Finally, we investigated the relation between DBS lead location and EVT outcomes. RESULTS Acoustic modulations of F0 and intensity were significantly improved POST DBS. Physiologic assessment showed a POST DBS reduction of oscillatory movement in the laryngeal muscles and vocal tract, but not significantly. Listener and participant perception, of EVT severity was also significantly reduced. Finally, our results indicate better EVT control with increased distance to midline of left VIM thalamic stimulation. CONCLUSIONS By employing a battery of objective and subjective measures, our study supports the benefit of DBS for the treatment of EVT and specifies the acoustic and physiologic mechanisms that mediate its positive effect. We further provide preliminary results on the relation between lead location and EVT outcomes, laying the foundation for future studies to clarify the optimal DBS target for the treatment of EVT.
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Affiliation(s)
- Elizabeth Erickson-DiRenzo
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Fiene Marie Kuijper
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Daniel A N Barbosa
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Erika A Lim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Peter T Lin
- Valley Parkinson Clinic, 800 Pollard Road, Suite C-30, Los Gatos, CA, USA
| | - Melanie A Lising
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Yuhao Huang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - C Kwang Sung
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.
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Abstract
Because of a recent politically-biased Lancet editorial, the world’s opinion has been directed against the Brazilian government over the rising numbers of COVID-19 cases in the country. This is an example of reporting data without accounting for important covariates. Epidemiological figures should always be corrected for population size. In fact, Brazil is not even on the list of the 10 countries with the highest number of deaths per 100,000 people. Belgium, the United Kingdom, and Spain are the most affected countries in this regard. The disinformation presented by a renowned medical journal has ignited severe criticisms against a Chief-of-State for not promoting a generalized lockdown in a country of continental size. As scientists, we have a duty to stress the caveats of science instead of fueling political attacks, and we should refrain from jumping to uninformed conclusions without considering well-analyzed data. Moreover, while there is no evidence to endorse the efficacy of a generalized lockdown in socioeconomically vulnerable populations, it is undoubtedly associated with severe nationwide adverse effects.
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Saluja S, Barbosa DAN, Parker JJ, Huang Y, Jensen MR, Ngo V, Santini VE, Pauly KB, Ghanouni P, McNab JA, Halpern CH. Case Report on Deep Brain Stimulation Rescue After Suboptimal MR-Guided Focused Ultrasound Thalamotomy for Essential Tremor: A Tractography-Based Investigation. Front Hum Neurosci 2020; 14:191. [PMID: 32676015 PMCID: PMC7333679 DOI: 10.3389/fnhum.2020.00191] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/28/2020] [Indexed: 12/15/2022] Open
Abstract
Essential tremor (ET) is the most prevalent movement disorder in adults, and can often be medically refractory, requiring surgical intervention. MRI-guided focused ultrasound (MRgFUS) is a less invasive procedure that uses ultrasonic waves to induce lesions in the ventralis intermedius nucleus (VIM) to treat refractory ET. As with all procedures for treating ET, optimal targeting during MRgFUS is essential for efficacy and durability. Various studies have reported cases of tremor recurrence following MRgFUS and long-term outcome data is limited to 3–4 years. We present a tractography-based investigation on a case of DBS rescue for medically refractory ET that was treated with MRgFUS that was interrupted due to the development of dysarthria during the procedure. After initial improvement, her hand tremor started to recur within 6 months after treatment, and bilateral DBS was performed targeting the VIM 24 months after MRgFUS. DBS induced long-term tremor control with monopolar stimulation. Diffusion MRI tractography was used to reconstruct the dentatorubrothalamic (DRTT) and corticothalmic (CTT) tracts being modulated by the procedures to understand the variability in efficacy between MRgFUS and DBS in treating ET in our patient. By comparing the MRgFUS lesion and DBS volume of activated tissue (VAT), we found that the MRgFUS lesion was located ventromedially to the VAT, and was less than 10% of the size of the VAT. While the lesion encompassed the same proportion of DRTT streamlines, it encompassed fewer CTT streamlines than the VAT. Our findings indicate the need for further investigation of targeting the CTT when using neuromodulatory procedures to treat refractory ET for more permanent tremor relief.
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Affiliation(s)
- Sabir Saluja
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Daniel A N Barbosa
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Jonathon J Parker
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Yuhao Huang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Michael R Jensen
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Vyvian Ngo
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Veronica E Santini
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Kim Butts Pauly
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, United States
| | - Pejman Ghanouni
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, United States
| | - Jennifer A McNab
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, United States
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
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21
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Kakusa B, Saluja S, Dadey DYA, Barbosa DAN, Gattas S, Miller KJ, Cowan RP, Kouyoumdjian Z, Pouratian N, Halpern CH. Electrophysiology and Structural Connectivity of the Posterior Hypothalamic Region: Much to Learn From a Rare Indication of Deep Brain Stimulation. Front Hum Neurosci 2020; 14:164. [PMID: 32670034 PMCID: PMC7326144 DOI: 10.3389/fnhum.2020.00164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 04/15/2020] [Indexed: 12/18/2022] Open
Abstract
Cluster headache (CH) is among the most common and debilitating autonomic cephalalgias. We characterize clinical outcomes of deep brain stimulation (DBS) to the posterior hypothalamic region through a novel analysis of the electrophysiological topography and tractography-based structural connectivity. The left posterior hypothalamus was targeted ipsilateral to the refractory CH symptoms. Intraoperatively, field potentials were captured in 1 mm depth increments. Whole-brain probabilistic tractography was conducted to assess the structural connectivity of the estimated volume of activated tissue (VAT) associated with therapeutic response. Stimulation of the posterior hypothalamic region led to the resolution of CH symptoms, and this benefit has persisted for 1.5-years post-surgically. Active contacts were within the posterior hypothalamus and dorsoposterior border of the ventral anterior thalamus (VAp). Delta- (3 Hz) and alpha-band (8 Hz) powers increased and peaked with proximity to the posterior hypothalamus. In the posterior hypothalamus, the delta-band phase was coupled to beta-band amplitude, the latter of which has been shown to increase during CH attacks. Finally, we identified that the VAT encompassing these regions had a high proportion of streamlines of pain processing regions, including the insula, anterior cingulate gyrus, inferior parietal lobe, precentral gyrus, and the brainstem. Our unique case study of posterior hypothalamic region DBS supports durable efficacy and provides a platform using electrophysiological topography and structural connectivity, to improve mechanistic understanding of CH and this promising therapy.
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Affiliation(s)
- Bina Kakusa
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Sabir Saluja
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - David Y A Dadey
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Daniel A N Barbosa
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Sandra Gattas
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Kai J Miller
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Robert P Cowan
- Department of Neurology and Neurosciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Zepure Kouyoumdjian
- Department of Neurology, South Valley Neurology, Morgan Hill, CA, United States
| | - Nader Pouratian
- Department of Neurosurgery, School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
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22
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Guedes F, Brown RS, Torrão-Junior FJL, Barbosa DAN, Ravanini GDAG, Amorim RMP. Pediatric peripheral nerve tumors: clinical and surgical aspects. Childs Nerv Syst 2019; 35:2289-2297. [PMID: 31346736 DOI: 10.1007/s00381-019-04306-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 07/10/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Pediatric peripheral nerve tumors (PNTs) are rare. Most are related to neurofibromatosis type 1 (NF1) with the potential for malignancy. An ongoing debate occurs about the best approach to such patients. This study describes a cohort of pediatric patients with PNTs and discusses clinical characteristics and surgical treatment. METHODS We retrospectively reviewed the charts of seven pediatric patients with eight PNTs surgically treated from 2007 to 2018. Information concerning patient demographics, clinical presentation, PNTs characteristics, treatment choice, and outcome were recorded. RESULTS All children presented with intense pain and a palpable mass. Three of the eight tumors were associated with a neurological deficit. Among the four patients with NF1, two had a neurofibroma and two a malignant peripheral nerve sheath tumor (MPNST). Histologically, three of the lesions were a benign peripheral nerve sheath tumor (BPNST), three a MPNST, and one each a desmoid tumor and Ewing's sarcoma. Two of the eight tumors underwent partial tumor excision and six gross total excisions. CONCLUSIONS Intense pain at rest, day, and/or night, preventing normal activities; a palpable, hard, immobile mass; an intense Tinel's sign related to the lump; clinical evidence of NF1; and high-speed growth of a tumor in the trajectory of the nerve or plexus should alert the clinician to the potential for malignancy. Preoperative biopsy is not indicated when clinical and imaging findings suggest a benign tumor. The surgical management of PNTs must be to achieve total resection, including wide margins with malignant tumors, though this is not always possible.
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Affiliation(s)
- Fernando Guedes
- Department of Surgery, Division of Neurosurgery, Gaffrée e Guinle University Hospital, School of Medicine, Federal University of Rio de Janeiro State (UNIRIO), 775 Mariz e Barros Street, Rio de Janeiro, RJ, Brazil
| | - Rosana Siqueira Brown
- Department of Surgery, Division of Neurosurgery, Gaffrée e Guinle University Hospital, School of Medicine, Federal University of Rio de Janeiro State (UNIRIO), 775 Mariz e Barros Street, Rio de Janeiro, RJ, Brazil.
| | - Francisco José Lourenço Torrão-Junior
- Department of Surgery, Division of Neurosurgery, Gaffrée e Guinle University Hospital, School of Medicine, Federal University of Rio de Janeiro State (UNIRIO), 775 Mariz e Barros Street, Rio de Janeiro, RJ, Brazil
| | - Daniel A N Barbosa
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Guilherme de Andrade Gagheggi Ravanini
- Department of Surgery, Division of Surgical Oncology, Gaffrée e Guinle University Hospital, School of Medicine, Federal University of Rio de Janeiro State (UNIRIO), 775 Mariz e Barros Street, Rio de Janeiro, RJ, Brazil
| | - Rogério Martin Pires Amorim
- Department of Surgery, Division of Neurosurgery, Gaffrée e Guinle University Hospital, School of Medicine, Federal University of Rio de Janeiro State (UNIRIO), 775 Mariz e Barros Street, Rio de Janeiro, RJ, Brazil
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23
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Povedano A, Brown RS, Barbosa DAN, Fiorelli RKA, Curcio DF, Laitman JT, Guedes‐Correa JF. Anatomical feasibility of a peripheral nerve transfer to reestablish the control of the external anal sphincter. FASEB J 2019. [DOI: 10.1096/fasebj.2019.33.1_supplement.768.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Andrea Povedano
- Federal University of the State of Rio de Janeiro ‐ UNIRIORio de JaneiroBrazil
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24
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Gorgulho AA, Fernandes F, Damiani LP, Barbosa DAN, Cury A, Lasagno CM, Bueno PRT, Santos BFO, Santos RHN, Berwanger O, Cavalcanti AB, Teixeira MJ, Moreno RA, De Salles AAF. Double Blinded Randomized Trial of Subcutaneous Trigeminal Nerve Stimulation as Adjuvant Treatment for Major Unipolar Depressive Disorder. Neurosurgery 2018; 85:717-728. [DOI: 10.1093/neuros/nyy420] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 08/07/2018] [Indexed: 12/28/2022] Open
Abstract
Abstract
BACKGROUND
More than 30% of major depressive disorder patients fail to respond to adequate trials of medications and psychotherapy. While modern neuromodulation approaches (ie, vagal nerve stimulation, deep brain stimulation) are yet to prove their efficacy for such cases in large randomized controlled trials, trigeminal nerve stimulation (TNS) has emerged as an alternative with promising effects on mood disorders.
OBJECTIVE
To assess efficacy, safety, tolerability, and placebo effect duration of continuous subcutaneous TNS (sTNS) in treatment-resistant depression (TRD).
METHODS
The TREND study is a single-center, double-blind, randomized, controlled, phase II clinical trial. Twenty unipolar TRD patients will receive V1 sTNS as adjuvant to medical therapy and randomized to active vs sham stimulation throughout a 24-wk period. An additional 24-wk open-label phase will follow. Data concerning efficacy, placebo response, relapse, and side effects related to surgery or electrical stimulation will be recorded. We will use the HDRS-17, BDI-SR, IDS_SR30, and UKU scales.
EXPECTED OUTCOMES
The main outcome measure is improvement in depression scores using HAM-17 under continuous sTNS as adjuvant to antidepressants. Active stimulation is expected to significantly impact response and remission rates. Minor side effects are expected due to the surgical procedure and electrical stimulation. The open-label phase should further confirm efficacy and tolerability.
DISCUSSION
This study protocol is designed to define efficacy of a novel adjuvant therapy for TRD. We must strive to develop safe, reproducible, predictable, and well-tolerated neuromodulation approaches for TRD patients impaired to manage their lives and contribute with society.
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Affiliation(s)
| | - Fernando Fernandes
- Mood Disorders Unit (GRUDA), Department of Psychiatry, Faculty of Medicine, University of São Paulo (USP), São Paulo, São Paulo, Brazil
| | - Lucas P Damiani
- Research Institute (IP), Heart Hospital (HCor), São Paulo, São Paulo, Brazil
| | - Daniel A N Barbosa
- HCor Neuroscience Institute, Heart Hos-pital (HCor), São Paulo, São Paulo, Brazil
| | - Abrão Cury
- Internal Medicine Department, Federal University of São Paulo (UNIFESP), São Paulo, São Paulo, Brazil
| | - Camila M Lasagno
- Research Institute (IP), Heart Hospital (HCor), São Paulo, São Paulo, Brazil
| | - Priscila R T Bueno
- Research Institute (IP), Heart Hospital (HCor), São Paulo, São Paulo, Brazil
| | - Bruno F O Santos
- HCor Neuroscience Institute, Heart Hos-pital (HCor), São Paulo, São Paulo, Brazil
| | - Renato H N Santos
- Research Institute (IP), Heart Hospital (HCor), São Paulo, São Paulo, Brazil
| | - Otávio Berwanger
- Research Institute (IP), Heart Hospital (HCor), São Paulo, São Paulo, Brazil
| | | | - Manoel J Teixeira
- HCor Neuroscience Institute, Heart Hos-pital (HCor), São Paulo, São Paulo, Brazil
- Neurosurgery Discipline, Neurology Department, Faculty of Medicine, University of São Paulo (USP), São Paulo, São Paulo, Brazil
| | - Ricardo A Moreno
- Mood Disorders Unit (GRUDA), Department of Psychiatry, Faculty of Medicine, University of São Paulo (USP), São Paulo, São Paulo, Brazil
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De Salles AAF, Barbosa DAN, Fernandes F, Abucham J, Nazato DM, Oliveira JD, Cury A, Biasi A, Rossi R, Lasagno C, Bueno PT, Santos RHN, Damiani LP, Gorgulho AA. An Open-Label Clinical Trial of Hypothalamic Deep Brain Stimulation for Human Morbid Obesity: BLESS Study Protocol. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Human morbid obesity is increasing worldwide in an alarming way. The hypothalamus is known to mediate its mechanisms. Deep brain stimulation (DBS) of the ventromedial hypothalamus (VMH) may be an alternative to treat patients refractory to standard medical and surgical therapies.
OBJECTIVE
To assess the safety, identify possible side effects, and to optimize stimulation parameters of continuous VMH-DBS. Additionally, this study aims to determine if continuous VMH-DBS will lead to weight loss by causing changes in body composition, basal metabolism, or food intake control.
METHODS
The BLESS study is a feasibility study, single-center open-label trial. Six patients (body mass index > 40) will undergo low-frequency VMH-DBS. Data concerning timing, duration, frequency, severity, causal relationships, and associated electrical stimulation patterns regarding side effects or weight changes will be recorded.
EXPECTED OUTCOMES
We expect to demonstrate the safety, identify possible side effects, and to optimize electrophysiological parameters related to VMH-DBS. No clinical or behavioral adverse changes are expected. Weight loss ≥ 3% of the basal weight after 3 mo of electrical stimulation will be considered adequate. Changes in body composition and increase in basal metabolism are expected. The amount of food intake is likely to remain unchanged.
DISCUSSION
The design of this study protocol is to define the safety of the procedure, the surgical parameters important for target localization, and additionally the safety of long-term stimulation of the VMH in morbidly obese patients. Novel neurosurgical approaches to treat metabolic and autonomic diseases can be developed based on the data made available by this investigation.
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Affiliation(s)
- Antonio A F De Salles
- Neuroscience Institute—Heart Hospital (HCor Neuro), University of São Paulo (USP), São Paulo, Brazil
- Research Institute—Heart Hospital (HCor IEP), University of São Paulo (USP), São Paulo, Brazil
| | - Daniel A N Barbosa
- Neuroscience Institute—Heart Hospital (HCor Neuro), University of São Paulo (USP), São Paulo, Brazil
| | - Fernando Fernandes
- Neuroscience Institute—Heart Hospital (HCor Neuro), University of São Paulo (USP), São Paulo, Brazil
- Department of Psychiatry, University of São Paulo (USP), São Paulo, Brazil
| | - Julio Abucham
- Department of Medicine, University Federal of São Paulo (UNIFESP), São Paulo, Brazil
| | - Debora M Nazato
- Department of Medicine, University Federal of São Paulo (UNIFESP), São Paulo, Brazil
| | - Juliana D Oliveira
- Research Institute—Heart Hospital (HCor IEP), University of São Paulo (USP), São Paulo, Brazil
| | - Abrão Cury
- Department of Medicine, University Federal of São Paulo (UNIFESP), São Paulo, Brazil
| | - Alexandre Biasi
- Neuroscience Institute—Heart Hospital (HCor Neuro), University of São Paulo (USP), São Paulo, Brazil
| | - Ronaldo Rossi
- Research Institute—Heart Hospital (HCor IEP), University of São Paulo (USP), São Paulo, Brazil
| | - Camila Lasagno
- Research Institute—Heart Hospital (HCor IEP), University of São Paulo (USP), São Paulo, Brazil
| | - Priscila T Bueno
- Research Institute—Heart Hospital (HCor IEP), University of São Paulo (USP), São Paulo, Brazil
| | - Renato H N Santos
- Research Institute—Heart Hospital (HCor IEP), University of São Paulo (USP), São Paulo, Brazil
| | - Lucas P Damiani
- Research Institute—Heart Hospital (HCor IEP), University of São Paulo (USP), São Paulo, Brazil
| | - Alessandra A Gorgulho
- Neuroscience Institute—Heart Hospital (HCor Neuro), University of São Paulo (USP), São Paulo, Brazil
- Research Institute—Heart Hospital (HCor IEP), University of São Paulo (USP), São Paulo, Brazil
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26
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Barbosa DAN, de Oliveira-Souza R, Monte Santo F, de Oliveira Faria AC, Gorgulho AA, De Salles AAF. The hypothalamus at the crossroads of psychopathology and neurosurgery. Neurosurg Focus 2017; 43:E15. [DOI: 10.3171/2017.6.focus17256] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The neurosurgical endeavor to treat psychiatric patients may have been part of human history since its beginning. The modern era of psychosurgery can be traced to the heroic attempts of Gottlieb Burckhardt and Egas Moniz to alleviate mental symptoms through the ablation of restricted areas of the frontal lobes in patients with disabling psychiatric illnesses. Thanks to the adaptation of the stereotactic frame to human patients, the ablation of large volumes of brain tissue has been practically abandoned in favor of controlled interventions with discrete targets.Consonant with the role of the hypothalamus in the mediation of the most fundamental approach-avoidance behaviors, some hypothalamic nuclei and regions, in particular, have been selected as targets for the treatment of aggressiveness (posterior hypothalamus), pathological obesity (lateral or ventromedial nuclei), sexual deviations (ventromedial nucleus), and drug dependence (ventromedial nucleus). Some recent improvements in outcomes may have been due to the use of stereotactically guided deep brain stimulation and the change of therapeutic focus from categorical diagnoses (such as schizophrenia) to dimensional symptoms (such as aggressiveness), which are nonspecific in terms of formal diagnosis. However, agreement has never been reached on 2 related issues: 1) the choice of target, based on individual diagnoses; and 2) reliable prediction of outcomes related to individual targets. Despite the lingering controversies on such critical aspects, the experience of the past decades should pave the way for advances in the field. The current failure of pharmacological treatments in a considerable proportion of patients with chronic disabling mental disorders is reminiscent of the state of affairs that prevailed in the years before the early psychosurgical attempts.This article reviews the functional organization of the hypothalamus, the effects of ablation and stimulation of discrete hypothalamic regions, and the stereotactic targets that have most often been used in the treatment of psychopathological and behavioral symptoms; finally, the implications of current and past experience are presented from the perspective of how this fund of knowledge may usefully contribute to the future of hypothalamic psychosurgery.
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Affiliation(s)
- Daniel A. N. Barbosa
- 1Department of Clinical Neuroscience, D’Or Institute for Research and Education
- 2Division of Neurosurgery and
| | - Ricardo de Oliveira-Souza
- 1Department of Clinical Neuroscience, D’Or Institute for Research and Education
- 3Department of Neurology and Psychiatry, Gaffrée e Guinle University Hospital, Federal University of the State of Rio de Janeiro
| | - Felipe Monte Santo
- 1Department of Clinical Neuroscience, D’Or Institute for Research and Education
- 4Intensive Care Unit, Icaraí Hospital, Niteroi, RJ
| | - Ana Carolina de Oliveira Faria
- 1Department of Clinical Neuroscience, D’Or Institute for Research and Education
- 3Department of Neurology and Psychiatry, Gaffrée e Guinle University Hospital, Federal University of the State of Rio de Janeiro
| | - Alessandra A. Gorgulho
- 5HCor Neuroscience, São Paulo, Brazil; and
- 6Department of Neurosurgery and Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Antonio A. F. De Salles
- 5HCor Neuroscience, São Paulo, Brazil; and
- 6Department of Neurosurgery and Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, California
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