Attenuating side effects of deep brain stimulation in the bed nucleus of the stria terminalis for obsessive compulsive disorder using current-steering strategies

Abstract

Deep brain stimulation (DBS) targeting the anterior limb of the internal capsule (ALIC) is effective for severe, treatment-resistant obsessive-compulsive disorder (trOCD), with approval under a humanitarian device exemption from the U.S. FDA [[1]Shofty B. Gadot R. Viswanathan A. Provenza N.R. Storch E.A. McKay S.A. et al.Intraoperative valence testing to adjudicate between ventral capsule/ventral striatum and bed nucleus of the stria terminalis target selection in deep brain stimulation for obsessive-compulsive disorder.J Neurosurg. 2022; 1: 1-9https://doi.org/10.3171/2022.10.JNS221683Crossref Scopus (1) Google Scholar,[2]Gadot R. Najera R. Hirani S. Anand A. Storch E. Goodman W.K. et al.Efficacy of deep brain stimulation for treatment-resistant obsessive-compulsive disorder: systematic review and meta-analysis.J Neurol Neurosurg Psychiatry. 2022; (jnnp-2021-328738)https://doi.org/10.1136/JNNP-2021-328738Crossref PubMed Google Scholar]. Over the past two decades, this DBS target has evolved posteriorly, from several millimeters anterior to the anterior commissure (AC) to closer or just posterior to the AC [[2]Gadot R. Najera R. Hirani S. Anand A. Storch E. Goodman W.K. et al.Efficacy of deep brain stimulation for treatment-resistant obsessive-compulsive disorder: systematic review and meta-analysis.J Neurol Neurosurg Psychiatry. 2022; (jnnp-2021-328738)https://doi.org/10.1136/JNNP-2021-328738Crossref PubMed Google Scholar]. The subjacent gray matter anterior to the AC is the ventral striatum, designating this target as the ventral capsule/ventral striatum (VC/VS). Posterior to the AC, the subjacent gray matter is the bed nucleus of the stria terminalis (BNST). Targeting the BNST has been effective in a number of case series, with response rates of 67–100% [[1]Shofty B. Gadot R. Viswanathan A. Provenza N.R. Storch E.A. McKay S.A. et al.Intraoperative valence testing to adjudicate between ventral capsule/ventral striatum and bed nucleus of the stria terminalis target selection in deep brain stimulation for obsessive-compulsive disorder.J Neurosurg. 2022; 1: 1-9https://doi.org/10.3171/2022.10.JNS221683Crossref Scopus (1) Google Scholar,[2]Gadot R. Najera R. Hirani S. Anand A. Storch E. Goodman W.K. et al.Efficacy of deep brain stimulation for treatment-resistant obsessive-compulsive disorder: systematic review and meta-analysis.J Neurol Neurosurg Psychiatry. 2022; (jnnp-2021-328738)https://doi.org/10.1136/JNNP-2021-328738Crossref PubMed Google Scholar]. Side effects of stimulation, which can limit therapy delivery, include insomnia, hypomania, and weight gain [[3]Luyten L. Hendrickx S. Raymaekers S. Gabriëls L. Nuttin B. Electrical stimulation in the bed nucleus of the stria terminalis alleviates severe obsessive-compulsive disorder.Mol Psychiatr. 2015; 21 (2016 21:9): 1272-1280https://doi.org/10.1038/mp.2015.124Crossref PubMed Scopus (145) Google Scholar,[4]Baldermann J.C. Hahn L. Dembek T.A. Kohl S. Kuhn J. Visser-Vandewalle V. et al.Weight change after striatal/capsule deep brain stimulation relates to connectivity to the bed nucleus of the stria terminalis and hypothalamus.Brain Sci. 2019; 9https://doi.org/10.3390/BRAINSCI9100264Crossref Google Scholar]. Some side effects may result from off-target activation of surrounding tissue and functionally connected structures [[4]Baldermann J.C. Hahn L. Dembek T.A. Kohl S. Kuhn J. Visser-Vandewalle V. et al.Weight change after striatal/capsule deep brain stimulation relates to connectivity to the bed nucleus of the stria terminalis and hypothalamus.Brain Sci. 2019; 9https://doi.org/10.3390/BRAINSCI9100264Crossref Google Scholar]. Here, we report amelioration of an unusual constellation of adverse effects from off-target BNST stimulation, achieved by testing an anatomically-derived hypothesis regarding their origin using electrical current-steering with segmented DBS leads. The patient is a 23-year-old male who underwent BNST DBS for trOCD. Before DBS, the patient suffered from severe