Deep Brain Stimulation (DBS) for Obsessive-Compulsive Disorder (OCD)
Description: A 40-year-old male presents with treatment-resistant OCD to Mount Sinai. His symptoms began as tics in childhood, which progressed into fears of self-harm and harming others, and later, compulsive urges to poke his eyes. He would spend hours consumed with intrusive thoughts to neutralize these urges. In such severe cases, surgical neuromodulation is considered. With a Yale-Brown OCD score of 30/40, his failed treatments included clomipramine, transcranial magnetic stimulation, electroconvulsive therapy, exposure and response prevention, and other pharmacological therapy. DBS for OCD has been approved since 2009 by the U.S. Food and Drug Administration under a humanitarian device exemption. Brian H. Kopell, MD, Director of Mount Sinai’s Center for Neuromodulation, collaborated on this case with Martijn Figee, MD, PhD, Director of the Mount Sinai Interventional Psychiatry Program. They are part of a large team working within the Nash Center for Advanced Circuit Therapeutics (C-ACT), which was established as a hub to bring neurosurgeons, neurologists, psychiatrists, and psychologists together with neuroimaging specialists, electrophysiologists, data scientists, engineers, and basic neuroscientists to specifically rethink the way neuromodulation treatments are developed, personalized, and delivered to patients. Its founding director Helen S. Mayberg, MD, is internationally renowned for her study of brain circuits and her pioneering research into DBS. In a narrated video, Drs. Kopell and Figee describe the preoperative planning, the surgical approach, the postoperative programming, and the outcome, which shows at 6-month follow-up the patient is almost free of OCD and has no eye-poking compulsions. Residual habitual rituals persist, they report, but they are shorter and unrelated to obsessions or strong urges.
Deep brain stimulation for obsessive compulsive disorder, brian copal and more times he gave. So we're gonna talk about obsessive compulsive disorder and what we can do for it surgically. So this is a very serious neuropsychiatric condition with intrusive thoughts so thoughts that the patient doesn't want but can't think of something else and and responding to it with this irresistible urge to neutralize the thoughts or to check whether the thought was true or not. This is a disorder that can happen in patients that are completely completely aware of the irrationality of these thoughts and these behaviors but nevertheless they can't stop it. So it's obsessions and compulsions. It's very common in the general population. And an estimate of two million people in the US. Um an estimate of 200,000 new patients every year. And we're gonna look at how we can treat this with surgical surgical interventions. So the most effective treatment for O. C. D. Is behavioral therapy and medications E. R. P. This is exposure and response prevention where the patient is invited to think about the obsession which is the exposure part without giving into the compulsions. For example touching the contaminated been without washing their hands and that creates anxiety but eventually the anxiety will be extinguished and the patient can continue if that doesn't work. It needs to be assisted with medication usually serotonin ergic or dope man ergic agents. But if that doesn't work. And there's actually a substantial fraction of all patients that don't respond to these first line treatments. Deep brain stimulation is an option. We assess the patient for deep brain stimulation. He was a 40 year old male and he had had O. C. D. Along with dicks which is occurring very commonly together since childhood. These were mostly obsessions which are very typical for O. C. D. Of harming someone else for harm harming himself more specifically through poking his eyes. And he felt the constant anxiety or urge to potentially poke his eyes. And then he had to compulsively ritual eyes neutralize these urges and these anxieties for hours and hours. And this significantly decreased his daily life quality. He was unable to live in his own house because everything was contaminated. He had to stop working and he had a very high score of 30 out of a max of 40 on the while. The Yale Brown obsessive compulsive skill, the white box. So we try to treat him with all different treatments including medications also called transcranial magnetic stimulation which is another form of noninvasive neuromodulation. Even electroshocks which doesn't generally help for O. C. D. But it can alleviate the secondary depressive symptoms and of course also exposure and response prevention. We assessed him including his treatment history um because he was completely refractory and had a clear picture of O. C. D. We consented him for deep brain stimulation. The reason that we choose is the interior limp of the internal capsule and and brian koppel will talk more about that over the years. There have been several targets in this region that have been explored for the treatment of O. C. D. From a surgical basis. In our group at Mount Sinai we use the anterior limb of the internal capsule or a lick for short. Prior to the surgery, the patient undergoes a high resolution volumetric mapping M. R. I. And volumetric cT scan under general anesthesia to minimize any motion utilizing a surgical planning station. The targets are selected and guided by tractor graphic analysis. On the day of the surgery, a stereotype Actiq head frame is placed under local anesthesia and an inter operative ct registration scan is obtained. This is in turn fused with the preoperative M. R. I. Containing the selected targets. I will now talk about the current targeting strategy with our group. There are two major subdivisions within the anterior limb of the internal capsule, a medial segment that is biased towards the thalamus and the medial prefrontal cortex, a lateral segment that is biased towards the ventral lateral prefrontal cortex at the very bottom of the anterior limb of the internal capsule. There exists another fiber track known as the palace all thalamic tract which is an outflow tract from the globus palace. Going towards the thalamus. Our strategy involves a patient specific connect atomic based targeting method. In this methodology we identify these medial and lateral segments that are very specific to a patient's anatomy. Furthermore we identify an anchor point just in the anterior medial G. P. E, which corresponds to the outflow pal. It'll fill Amick tract by putting these all together. This ensures engagement with all key anatomical regions. We put this together by combining the connectivity mapping strategy using fiber track or track to graphic analysis along with volume of tissue activation model that identify areas within the eventual capsule that results in the most profound effects on the obsessive compulsive phenotype Together, this is an example of how the strategy is placed or utilized in the operating room. The blue and green lines represents the trajectories towards the target. The white spot scene in this particular region here on the right side and on the left side represents the intended initial segment of activation in the postoperative period. The placement of the dBS electrodes and impulse generator is done in a stage fashion. On the day of the surgery. Once again, the head frame is placed under local anesthesia and the imaging is obtained. This is in turn fused with the preoperative imaging. As discussed, This plan is fused within the surgical planning station. Initially a micro electrode recording electrode is first placed along the targeting trajectory. Another CT scan is confirmed the actual placement of this micro electrode. When this is considered within tolerance of where we wish to place the DBS lead, the final dBS electrode is placed, The patient is typically discharged home the following day and a second electrode is placed one month followed by the impulse generator. The beauty about this implantation technique and about modern technology with segmented leads is that you now can stimulate in specific directions and if you map that on the track topography of the pre operative scans fused with the post post operative city. You can actually steer the stimulation towards connections that we know are involved in different aspects different symptoms of O. C. D. So to develop a very personalized strategy for specific patients with a specific set of obsessions and compulsions and mood and anxiety symptoms. And this is what we applied for this patient. Based on this mapping, we we decided that the second contact you can see depicted here from the top was gonna be most strategically situated in these connections. Um We tested nevertheless each contact in each segment separately interestingly. He started improving most and very acutely um at contact one but that may still be an after effect of the prior stimulation in the contact to which was also the one that we defined, defined based on art photography to be the most effective one. So we sent the patient home on with the stimulation on that second contact. Unfortunately the first month I didn't notice any improvement. In fact, he became very desperate because this was his last hope. So when he came in next month we increased the amplitude in the same location, we titrate it up in steps of half a million up to six million. And then he immediately started to improve. He started to immediately feel less anxious, calmer and in the month or after he was able to go back to his all house. He started socializing, started dating, even resumed working and there were still some residual compulsions which is why the next visit we further increase the amplitude with just half a million. And that made him completely lose all of his residuals from these symptoms. Six months later he was almost still almost free of O. C. D. None of the eye poking composers anymore. Some habitual rituals for which we indicated him for additional cognitive behavioral therapy. As of today, he's still up and down struggling with some of these residual symptoms but otherwise he's doing great very well. And this is a great example of how DBS can Offer huge benefits for these otherwise completely treatment resistant patients. In general, we see that six out of 10 patients have a meaningful response, which is this patient overall this uh case vignette emphasizes the unique multidisciplinary talents of our center for neuromodulation, bringing together neurosurgeons, neuropsychiatrist and biomedical engineers to create a unique patient specific treatment plan around deep brain stimulation therapy for obsessive compulsive disorder