Deep brain stimulation of the subcallosal cingulate gyrus for depression: anatomical location of active contacts in clinical responders and a suggested guideline for targeting

Clinical article

Clement Hamani Division of Neurosurgery, Toronto Western Hospital, and

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Helen Mayberg Departments of Psychiatry and Neurology, Emory University School of Medicine, Atlanta, Georgia

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Brian Snyder Division of Neurosurgery, Toronto Western Hospital, and

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Peter Giacobbe Department of Psychiatry, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; and

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Sidney Kennedy Department of Psychiatry, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; and

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Andres M. Lozano Division of Neurosurgery, Toronto Western Hospital, and

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Object

Deep brain stimulation (DBS) of the subcallosal cingulate gyrus (SCG), including Brodmann area 25, is currently being investigated for the treatment of major depressive disorder (MDD). As a potential emerging therapy, optimal target selection within the SCG has still to be determined. The authors compared the location of the electrode contacts in responders and nonresponders to DBS of the SCG and correlated the results with clinical outcome to help in identifying the optimal target within the region. Based on the location of the active contacts used for long-term stimulation in responders, the authors suggest a standardized method of targeting the SCG in patients with MDD.

Methods

Postoperative MR imaging studies of 20 patients with MDD treated with DBS of the SCG were analyzed. The authors assessed the location of the active contacts relative to the midcommissural point and in relation to anatomical landmarks within the medial aspect of the frontal lobe. For this, a grid with 2 main lines was designed, with 1 line in the anterior-posterior and 1 line in the dorsal-ventral axis. Each of these lines was divided into 100 units, and data were converted into percentages. The anterior-posterior line extended from the anterior commissure (AC) to the projection of the anterior aspect of the corpus callosum (CCa). The dorsal-ventral line extended from the inferior portion of the CC (CCi) to the most ventral aspect of the frontal lobe (abbreviated “Fr” for the formula).

Results

Because the surgical technique did not vary across patients, differences in stereotactic coordinates between responders and nonresponders did not exceed 1.5 mm in any axis (x, y, or z). In patients who responded to the procedure, contacts used for long-term stimulation were in close approximation within the SCG. In the anterior-posterior line, these contacts were located within a 73.2 ± 7.7 percentile distance from the AC (with the AC center being 0% and the line crossing the CCa being 100%). In the dorsal-ventral line, active contacts in responders were located within a 26.2 ± 13.8 percentile distance from the CCi (with the CCi edge being 0% and the Fr inferior limit being 100%). In the medial-lateral plane, most electrode tips were in the transition between the gray and white matter of SCG.

Conclusions

Active contacts in patients who responded to DBS were relatively clustered within the SCG. Because of the anatomical variability in the size and shape of the SCG, the authors developed a method to standardize the targeting of this region.

Abbreviations used in this paper:

AC = anterior commissure; CC = corpus callosum; CCa = anterior aspect of the CC; CCi = inferior portion of the CC; DBS = deep brain stimulation; HAMD-17 = Hamilton depression scale; MCP = midcommissural point; MDD = major depressive disorder; PC = posterior commissure; SCG = subcallosal cingulate gyrus; SPGR = spoiled gradient–recalled acquisition.
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