Reduced limbic connections may contraindicate subgenual cingulate deep brain stimulation for intractable depression

Case report

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In this study, the authors performed deep brain stimulation (DBS) of the subgenual anterior cingulate cortex (SACC) in a patient with a history of bipolar disorder. After a right thalamic stroke, intractable depression without mood elevation or a mixed state developed in this patient. He underwent bilateral SACC DBS and died 16 months afterwards. Anatomical connections were studied in this patient preoperatively and postmortem using diffusion tractography (DT). A comparison of in vivo and high resolution ex vivo connectivity patterns was performed as a measure of the utility of in vivo DT in presurgical planning for DBS. Diagnostic measures included neuropsychological testing, preoperative and ex vivo DT, and macroscopic neuropathological assessment. Post-DBS depression rating scores did not improve. In vivo and ex vivo DT revealed markedly reduced limbic projections from the thalamus and SACC to the amygdala in the right (stroke-affected) hemisphere. A highly selective right mediothalamic lesion was associated with the onset of refractory depression. Reduced amygdalar-thalamic and amygdalar-SACC connections could be a contraindication to DBS for depression. Correspondence between preoperative and higher resolution ex vivo DT supports the validity of DT as a presurgical planning tool for DBS.

Abbreviations used in this paper:DBS = deep brain stimulation; DT = diffusion tractography; SACC = subgenual anterior cingulate cortex.

Article Information

Address correspondence to: Jennifer A. McNab, M.Sc., Oxford Centre for Functional Magnetic Resonance Imaging of the Brain, John Radcliffe Hospital, Headington, Oxford OX3 9DU, United Kingdom. email:jmcnab@fmrib.ox.ac.uk.

Please include this information when citing this paper: published online March 13, 2009; DOI: 10.3171/2009.2.JNS081299.

© AANS, except where prohibited by US copyright law.

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Figures

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    In vivo structural images showing the right thalamic infarct (a) and the 4 electrode contact sites in the left (b) and right (c) hemispheres. Enlarged views (d–f) of the regions of interest in (a–c) are shown. The red arrow identifies the infarct in (d).

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    In vivo (a and b) and ex vivo (c and d) diffusion tractography of thalamic amygdalar projections. Both in vivo and ex vivo data failed to show paths between the right thalamic infarct and the amygdala, despite clear pathways in homologous structures of the left hemisphere.

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    In vivo (a–c) and ex vivo (d–f) diffusion tractography showing anatomical connections with the SACC DBS sites in the left (yellow) and right (blue) hemispheres.

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    Images of the right thalamic infarct. Structural MR images of the ex vivo brain in the axial a) and coronal (b) planes. A photograph of a coronal slice of the ex vivo brain (c) depicting part of the infarct. Yellow arrows indicate the infarct.

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