title: Reduced limbic connections may contraindicate subgenual cingulate deep brain stimulation for intractable depression.
abstract: 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.
authors.affiliation: Oxford Centre for Functional Magnetic Resonance Imaging of the Brain, Department of Clinical Neurology, University of Oxford, UK. jmcnab@fmrib.ox.ac.uk
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: McNab
authors.forename: Natalie L
authors.initials: NL
authors.lastname: Voets
authors.forename: Ned
authors.initials: N
authors.lastname: Jenkinson
authors.forename: Waney
authors.initials: W
authors.lastname: Squier
authors.forename: Karla L
authors.initials: KL
authors.lastname: Miller
authors.forename: Guy M
authors.initials: GM
authors.lastname: Goodwin
authors.forename: Tipu Z
authors.initials: TZ
authors.lastname: Aziz
mesh_terms: D000679:Amygdala / Q000473:pathology / Q000503:physiopathology*; D000075202:Contraindications; D046690:Deep Brain Stimulation; D003863:Depression / Q000503:physiopathology / Q000523:psychology / Q000628:therapy*; D038524:Diffusion Magnetic Resonance Imaging; D006179:Gyrus Cinguli / Q000473:pathology / Q000503:physiopathology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009483:Neuropsychological Tests; D013788:Thalamus / Q000473:pathology / Q000503:physiopathology*