- Department of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
Correspondence Address:
Clement Hamani
Department of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
DOI:10.4103/2152-7806.91607
Copyright: © 2012 Sankar T. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.How to cite this article: Sankar T, Tierney TS, Hamani C. Novel applications of deep brain stimulation. Surg Neurol Int 14-Jan-2012;3:
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Abstract
The success of deep brain stimulation (DBS) surgery in treating medically refractory symptoms of some movement disorders has inspired further investigation into a wide variety of other treatment-resistant conditions. These range from disorders of gait, mood, and memory to problems as diverse as obesity, consciousness, and addiction. We review the emerging indications, rationale, and outcomes for some of the most promising new applications of DBS in the treatment of postural instability associated with Parkinson's disease, depression, obsessive–compulsive disorder, obesity, substance abuse, epilepsy, Alzheimer′s-type dementia, and traumatic brain injury. These studies reveal some of the excitement in a field at the edge of a rapidly expanding frontier. Much work still remains to be done on basic mechanism of DBS, optimal target and patient selection, and long-term durability of this technology in treating new indications.
Keywords: Alzheimer's disease, deep brain stimulation, depression, epilepsy, movement disorders, psychiatry
INTRODUCTION
The modern application of deep brain stimulation (DBS) to the treatment of neurological illness began in the late 1980s with the pioneering work of Benabid and colleagues,[
GAIT IMPAIRMENT AND POSTURAL INSTABILITY IN PD
A number of recent studies have provided convincing evidence that both pallidal (globus pallidus internus or GPi) and subthalamic nucleus (STN) DBS are highly effective in treating PD. DBS improves the cardinal motor symptoms of PD including tremor,[
As a result, there has been renewed interest in understanding the neuroanatomical substrates of locomotion and their relevance in PD. Early work on decerebrate cats first suggested that electrical stimulation in the brainstem could initiate or enhance locomotive behavior.[
TREATMENT RESISTANT DEPRESSION
The notion of neurosurgery for psychiatric disorders evokes memories of a troubled past. The misguided and indiscriminant application of lobotomy with its unacceptable rate of morbidity, coupled with the development of effective psychotropic medications nearly led to the demise of psychiatric surgical procedures by the 1960s.[
Major depressive disorder (MDD) is a prevalent and costly illness. Recent data suggest that it afflicts more than 121 million people worldwide.[
DBS is now being used to target nodes within dysregulated mood circuits. Among these, a commonly studied region is the subcallosal cingulate gyrus (SCG). Functional imaging studies demonstrate SCG overactivity in depressed patients, accompanied by corresponding reductions in activity in associated prefrontal and premotor cortical areas (areas 9 and 46).[
Long-term follow-up data from an extended cohort of 20 patients treated with SCG DBS have now been published.[
Several other targets for DBS in depression other than the SCG have now emerged. Preliminary data from pilot studies of bilateral DBS of the ventral caudate/ventral striatum (VC/VS),[
OTHER PSYCHIATRIC DISORDERS: TOURETTE'S SYNDROME, OBSESSIVE-COMPULSIVE DISORDER, ADDICTION
Gilles de la Tourette syndrome (TS) is characterized by the childhood onset of intrusive and chronic motor or vocal tics.[
Obsessive-compulsive disorder (OCD) is an anxiety disorder in which unwanted and repeated thoughts, feelings, ideas, or sensations (obsessions) result in patients feeling compelled to perform certain repetitive behaviors (compulsions). Functionally disabling in 40% and medically intractable in 10% of sufferers, OCD has long been treated with ablative neurosurgical procedures including cingulotomy and anterior capsulotomy, with some success.[
The well-established importance of dopamine release in the NAcc to the reward system of the brain[
EPILEPSY
It is estimated that 1% of all adults suffer from epilepsy, with close to 30% of cases being refractory to conventional antiepileptic therapy.[
Outside the cerebellum, direct stimulation of the hippocampus has also been investigated in epilepsy. Structures of the mesial temporal lobe are a natural target for neuromodulation in view of the proven effectiveness of mesiotemporal resective surgery in patients with temporal lobe epilepsy.[
Thalamic DBS has increasingly gained importance in the treatment of epilepsy. Following an initial report of success with centromedian (CM) nucleus stimulation,[
Other recent novel developments include the responsive neurostimulator, which is an implanted device designed to detect early epileptiform activity and responds – much like a cardiac defibrillator – by delivering pulses of abortive electrical stimulation.[
ALZHEIMER'S DISEASE
With 27 million people currently afflicted worldwide, and a predicted increase in accrual of cases as the world population ages, Alzheimer's Disease (AD) is the most prevalent of neurodegenerative dementias.[
Based on the serendipitous observation of memory enhancement due to electrical stimulation of the hypothalamic/forniceal region in a patient being treated for obesity,[
MINIMALLY CONSCIOUS STATE
Using neuromodulation to reverse disorders of consciousness caused by traumatic brain injury has been attempted since the 1950s. These early attempts were confounded by the initiation of stimulation in the period soon after brain injury, when some degree of spontaneous recovery is expected, and further weakened by a very limited understanding of the differences in impaired states of consciousness, which may impact recovery and outcome.[
CONCLUSION
DBS has been shown to be a safe and effective surgical option for a number of movement disorders including essential tremor, PD, and the dystonias. Neural modulation of non-motor circuits is now being investigated for the treatment of several other refractory neurological and psychiatric diseases. Rigorous clinical trials providing robust outcome measures will be needed to establish the safety and efficacy of DBS for these emerging indications.
Publication of this manuscript has been made possible by an educational grant from
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