Laboratory Studies

Routine pre-surgical laboratory studies include a CBC and urinalysis to evaluate for evidence of infection, a coagulation panel to ensure normal clotting function, and a renal function panel prior to obtaining contrasted imaging studies to minimize the risks associated with administration of iodinated or gadolinium contrast media.

Imaging Studies

A volumetric, high resolution MRI of the brain with and without intravenous gadolinium constrast is typically obtained as part of the pre-surgical evaluation prior to DBS implantation. Functional MRI may be obtained as part of a research protocol depending on institutional practices.

Other Tests

Neuropsychiatric testing to establish a pre-implantation baseline should be strongly considered for all potential DBS patients. This allows for assessment of any adverse effects of stimulation, and can also help assess for functional benefit of therapy. Particularly given the paucity of data surrounding DBS for psychiatric indications, this testing can be very useful from a research perspective.

Treatment & Management

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Media Gallery

Cingulotomy. The position of the lesion is shown.
Anterior capsulotomy. The position of the lesion is shown.
Subcaudate tractotomy. The position of the lesion is shown.
The Papez circuit.
The orbitofrontal cortex. Adapted from an image from Professor Mark Dubin, University of Colorado.
The dorsolateral prefrontal cortex. Adapted from an image from Professor Mark Dubin, University of Colorado.
The cingulate gyrus (Cg25; in green). Adapted from an image from Professor Mark Dubin, University of Colorado.
The dorsal "compartment" of the frontal lobe. Adapted from an image from Professor Mark Dubin, University of Colorado.
The ventral "compartment" of the frontal lobe. Adapted from an image from Professor Mark Dubin, University of Colorado.
The limbic thalamocortical loop. MOFC = medial orbitofrontal cortex. DMmc = dorsomedial thalamic nucleus, magnocellular portion.
The cortico-striato-thalamocortical loop (CSTC loop) as it relates to neuromodulation for psychiatry. DLPFC = dorsolateral prefrontal cortex. LOFC = lateral orbitofrontal cortex. MOFC = medial orbitofrontal cortex. GPe = globus pallidus pars externa. GPi = globus pallidus pars interna. STN = subthalamic nucleus. SNc = substantia nigra pars compacta. SNr = substantia nigra pars reticularis. VTA = ventral tegmental area.
The associative thalamocortical loop. DLPFC = dorsolateral prefrontal cortex. LOFC = lateral orbitofrontal cortex. VApc = ventral anterior thalamic nucleus, parvocellular portion. VAmc = ventral anterior thalamic nucleus, magnocellular portion. DMpc = dorsomedial thalamic nucleus, parvocellular portion.
The hypothalamic-pituitary axis as it relates to the aforementioned circuitry. OFC = orbitofrontal cortex.
How neuromodulation at the cingulate gyrus (Cg25) interacts at the aforementioned circuitries. The highlighted area represents Cg25.
How neuromodulation at cingulate gyrus (Cg25) interacts at the aforementioned circuitries. The highlighted area represents Cg25.
How neuromodulation at the anterior internal capsule (AIC) interacts at the aforementioned circuitries. The highlighted area represents AIC.
How neuromodulation at the anterior internal capsule (AIC) interacts at the aforementioned circuitries. The highlighted area represents AIC.
How neuromodulation at the nucleus accumbens (NA) shell interacts at the aforementioned circuitries. The highlighted area represents the NA shell.
How neuromodulation at the nucleus accumbens (NA) shell interacts at the aforementioned circuitries. The highlighted area represents the NA shell.
How neuromodulation at the ventral striatum (VS) interacts at the aforementioned circuitries. The highlighted area represents VS.
How neuromodulation at the ventral striatum (VS) interacts at the aforementioned circuitries. The highlighted area represents VS.
How neuromodulation at the inferior thalamic peduncle (ITP) interacts at the aforementioned circuitries. The highlighted area represents ITP.
How neuromodulation at the inferior thalamic peduncle (ITP) interacts at the aforementioned circuitries. The highlighted area represents ITP.
Examples of deep brain stimulation (DBS) leads.
Example of implantable neurostimulator for deep brain stimulation (DBS) leads (implantable pulse generator, IPG).

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Author

Jonathan P Miller, MD Director, Functional and Restorative Neurosurgery, Director of Epilepsy Surgery, Attending Neurosurgeon, University Hospitals Cleveland Medical Center; Director, Functional and Restorative Neurosurgery Center, UH Cleveland Medical Center Neurological Institute; Associate Professor of Neurosurgery, Fellowship Director, Functional and Stereotactic Neurosurgery, Associate Residency Program Director, Department of Neurosurgery, Surgical Director, Neuromodulation Center, Case Western Reserve University School of Medicine

Jonathan P Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, American Epilepsy Society, American Society for Stereotactic and Functional Neurosurgery, Congress of Neurological Surgeons, International Neuromodulation Society, North American Neuromodulation Society, Ohio State Neurosurgical Society, Society of Neurological Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Charles N Munyon, MD Clinical Fellow in Functional and Stereotactic Neurosurgery, University Hospitals Case Medical Center; Clinical Instructor, Case Western Reserve University School of Medicine

Charles N Munyon, MD is a member of the following medical societies: American Association of Neurological Surgeons, Phi Beta Kappa, Sigma Xi, The Scientific Research Honor Society, Congress of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery

Disclosure: Nothing to disclose.

Jennifer A Sweet, MD Stereotactic and Functional Neurosurgeon, University Hospitals Case Medical Center; Assistant Professor of Neurological Surgery, Case Western Reserve University School of Medicine

Jennifer A Sweet, MD is a member of the following medical societies: American Association of Neurological Surgeons, American Medical Association, Congress of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery, Women in Neurosurgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Brian H Kopell, MD Associate Professor, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai

Brian H Kopell, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery, Congress of Neurological Surgeons, International Parkinson and Movement Disorder Society, North American Neuromodulation Society

Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from Abbott Neuromodulation for consulting.

Additional Contributors

Michael G Nosko, MD, PhD Associate Professor of Surgery, Chief, Division of Neurosurgery, Medical Director, Neuroscience Unit, Medical Director, Neurosurgical Intensive Care Unit, Director, Neurovascular Surgery, Rutgers Robert Wood Johnson Medical School

Michael G Nosko, MD, PhD is a member of the following medical societies: Academy of Medicine of New Jersey, Congress of Neurological Surgeons, Canadian Neurological Sciences Federation, Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, American Heart Association, American Medical Association, New York Academy of Sciences, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors are deeply indebted to Dr. Jerry Halverson, MD and Dr. Brian Kopell, MD, for their work on the first version of this article, on which this update was based.

Jerry L Halverson, MD Medical Director of Adult Services, Rogers Memorial Hospital; Voluntary Clinical Assistant Professor, Department of Psychiatry, University of Wisconsin School of Medicine and Public Health; Clinical Assistant Professor of Psychiatry, Department of Psychiatry and Behavioral Sciences, Medical College of Wisconsin

Jerry L Halverson, MD is a member of the following medical societies: American College of Psychiatrists, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Brian H Kopell, MD Associate Professor, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai

Brian H Kopell, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American Society of Stereotactical and Functional Neurosurgery, Congress of Neurological Surgeons, Movement Disorders Society, and North American Neuromodulation Society

Disclosure: Nothing to disclose.

Sections Neuromodulation Surgery for Psychiatric Disorders
Overview
Workup
Treatment
Media Gallery
References

Neuromodulation Surgery for Psychiatric Disorders Workup

Laboratory Studies

Imaging Studies

Other Tests

References

Tables

Contributor Information and Disclosures

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