title: Deep brain stimulation of the lateral habenular complex in treatment-resistant depression: traps and pitfalls of trajectory choice.
abstract: BACKGROUND
  Deep brain stimulation (DBS) has recently been discussed as a promising treatment option for severe cases of major depression. Experimental data have suggested that the lateral habenular complex (LHb-c) is a central region of depression-related neuronal circuits. Because of its location close to the midline, stereotactic targeting of the LHb-c presents surgeons with distinct challenges.
  
  
  OBJECTIVE
  To define the obstacles of DBS surgery for stimulation of the LHb-c and thus to establish safe trajectories.
  
  
  METHODS
  Stereotactic magnetic resonance imaging data sets of 54 hemispheres originating from 27 DBS patients were taken for analysis on a stereotactic planning workstation. After alignment of images according to the anterior commissure--posterior commissure definition, analyses focused on vessels and enlarged ventricles interfering with trajectories.
  
  
  RESULTS
  As major trajectory obstacles, enlarged ventricles and an interfering superior thalamic vein were found. A standard frontal trajectory (angle > 40° relative to the anterior commissure--posterior commissure in sagittal images) for bilateral stimulation was safely applicable in 48% of patients, whereas a steeper frontal trajectory (angle <40 relative to the anterior commissure--posterior commissure in sagittal images) for bilateral stimulation was possible in 96%. Taken together, safe bilateral targeting of the LHb-c was possible in 98% of all patients.
  
  
  CONCLUSIONS
  Targeting LHb-c is a feasible and safe technique in the majority of patients undergoing surgery for DBS. However, meticulous individual planning to avoid interference with ventricles and thalamus-related veins is mandatory because an alternative steep frontal entry point has to be considered in about half of the patients.
authors.affiliation: Division of Stereotactic Neurosurgery, Department of Neurosurgery, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, Heidelberg, Germany.
authors.forename: Till M
authors.initials: TM
authors.lastname: Schneider
authors.forename: Christopher
authors.initials: C
authors.lastname: Beynon
authors.forename: Alexander
authors.initials: A
authors.lastname: Sartorius
authors.forename: Andreas W
authors.initials: AW
authors.lastname: Unterberg
authors.forename: Karl L
authors.initials: KL
authors.lastname: Kiening
mesh_terms: D000293:Adolescent; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D046690:Deep Brain Stimulation / Q000379:methods*; D061218:Depressive Disorder, Treatment-Resistant / Q000628:therapy*; D004567:Electrodes, Implanted; D005260:Female; D019262:Habenula; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D013238:Stereotaxic Techniques