Academic journal article Indian Journal of Psychiatry

Deep Brain Stimulation of Ventral Internal Capsule for Refractory Obsessive-Compulsive Disorder

Academic journal article Indian Journal of Psychiatry

Deep Brain Stimulation of Ventral Internal Capsule for Refractory Obsessive-Compulsive Disorder

Article excerpt

Byline: Alok. Gupta, Sumant. Khanna, Rahul. Jain

The main objective of this study is to assess the effectiveness of deep brain stimulation (DBS) of the ventral striatum (VS) of the anterior limb of internal capsule for patients suffering from refractory obsessive-compulsive disorder (OCD) and to compare its result with traditional anterior capsulotomy. The present study consisted of two patients subjected to stimulation of ventral capsule (VC)/VS region of internal capsule for refractory OCD. Leads were implanted on both sides stereotactically using fused images of magnetic resonance imaging and computed tomography scan brain and connected to pulse generator (Medtronic). Outcome of both the patients was measured by Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Beck Depression Inventory (BDI), and Mini-Mental Status Examination. The first case was followed for 4 years and 6 months, while the second case was followed for 2 years and 6 months. Both the patients responded very well to stimulation with reduction of Y-BOCS from 38 to 12 (68.42% improvement) in the first patient and 38 to 10 (78.68% improvement) in the second patient after 1 year. BDI also improved in both the patients with no significant change in mental state. No adverse effect was seen in any of the patient. The beneficial effect of DBS persisted in both the patients till follow-up and was much superior to the beneficial effect of anterior capsulotomy. We conclude that DBS of VC/VS complex is very safe and effective in refractory OCD and shows considerable promise for the future. The result of two treated patients was much better as compared to lesioning (anterior capsulotomy) and the beneficial effect persisted for long time.

Introduction

Obsessive-compulsive disorder (OCD) is generally believed to be one of the most distressing of all anxiety disorders. Clinical experience with patients suggests that it affects the quality of life in many ways in the form of troubled relationship, work distraction. Patient feels bonded by obsession and compulsions, and they spent lot of time on compulsive rituals.[1] OCD patients are more likely to have divorce then non-OCD individual.[2]

Both pharmacological and cognitive behavioral therapy (CBT) has proven to be effective treatment in OCD.[3] However, full or partial remission is seen in 60%-80% patients and the remaining patients experience only a minimum or no response.

Despite medications and CBT, some OCD patients remain refractory and run a chronic deteriorating course.[4] In a follow-up of patients who have never undergone surgical intervention for different reason, their condition remained the same and some of them committed suicide.[5]

Therapeutic option in this group was initially limited to ablative surgeries such as anterior capsulotomy[6] or anterior cingulotomy.[7] The observation that lesion effect can be achieved by electrical current delivered at that level led to the development of implantable stimulation system to treat neurological disorder. Since deep brain stimulation (DBS) system consists of delivering high-frequency current at the target region without resulting in any neuronal injury led to the initiation of its use for patients who need capsulotomy for OCD. The effectiveness of DBS for OCD was established in various publications[8],[9],[10],[11] where anterior limb of internal capsule (ALIC) was used for stimulation. They used stimulation of ALIC 3-4 mm anterior to anterior commissure. A more posterior and ventral target was found to be more effective for controlling symptoms of OCD.[12] In a review article published in 2014, the effectiveness of various target for OCD was compared. The study was sponsored by the American Society of Stereotactic and Functional Neurosurgery and Congress of Neurological Surgeon and endorsed by the American Association of Neurological Surgeon. They found significant improvement after bilateral nucleus accumbens stimulation for medically refractive OCD and recommended it a reasonable therapeutic option in patient with severe treatment-refractory OCD. …

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