T print simulation for obsessive compulsive disorder Brian kopel and Martin so we're going to talk about obsessive compulsive disorder and what we can do for it surgically so this is a very serious Neuropsychiatric condition with intrusive thoughts so thoughts that the patient doesn't want but can't think of something else and responding to it with this irresistible urge to neutralize the thought or to check whether they thought was true or not this is a disorder that can happen in patients that are complete completely aware of the irrationality of these thoughts and these behaviors but nevertheless they can't stop it so its obsessions and compulsions it's very common in the general population an estimate of two million people in the U.S um an estimate of 200 000 new patients every year and and we're going to look at how we can treat this with the surgical surgical interventions so the most effective treatment for OCD is uh behavioral therapy and medications Erp this is exposure and response prevention where the patient is invited to think about the obsession which is the exposure part without giving into the compulsions for example touching the contaminated bin without washing their hands and that creates anxiety but eventually the anxiety will be extinguished and the patient can continue okay if that doesn't work it needs to be assisted with medication usually serotonergic or dopaminergic agents but if that doesn't work and there's actually a substantial fraction of all patients that don't respond to these first line treatments deep brain stimulation is an option we assess the patient for the brain stimulation he was a 40 year old male and he had had OCD along with ticks which is occurring very commonly together since childhood these were mostly obsessions which are very typical for OCD of harming someone else or harming himself more specifically through poking his eyes and he felt the constant anxiety or urge to potentially poke his eyes and then he had to compulsively ritualize neutralize these urges and these anxieties for hours and hours and this significantly decreased his daily life quality he was unable to live in his own house because everything was contaminated he had to stop working and he had a very high score of 30 out of a Max of 40 on the while the yield Brown obsessive compulsive skill the white box so we try to treat him with all different treatments including medications also clomipramine transcranial magnetic stimulation which is another form of non-invasive neuromodulation even electroshocks which doesn't generally help for OCD but it can alleviate the secondary depressive symptoms and of course also exposure and response prevention we assessed him including his treatment history and because he was completely refractory and had a clear picture of OCD he consented him for deep brain stimulation the the region that we choose is the interior lymph of the internal capsule and and Brian Coppell will talk more about that foreign over the years there have been several Targets in this region that have been explored for the treatment of OCD from a surgical basis in our group at Mount Sinai we use the anterior limb of the internal capsule or alic for short prior to the surgery the patient undergoes a high resolution volumetric mapping MRI and volumetric CT scan under general anesthesia to minimize any motion utilizing a surgical planning station the targets are selected and guided by tractographic analysis on the day of the surgery a stereotactic head frame is placed under local anesthesia and an intraoperative CT registration scan is obtained this is in turn fused with the pre-operative MRI containing the selected targets I will now talk about the current targeting strategy with our group there are two major subdivisions within the anterior limb of the internal capsule a medial segment that is biased towards the thalamus and the medial prefrontal cortex a lateral segment that is biased towards the ventral lateral prefrontal cortex at the very bottom of the anterior limb of the internal capsule there exists another fiber tract known as the palatal thalamic tract which is an outflow tract from the Globus pallidus going towards the thalamus our strategy involves a patient-specific connectomic based targeting method in this methodology we identify these medial and lateral segments that are very specific to a patient's Anatomy furthermore we identify an anchor point just in the anterior medial gpe which corresponds to the outflow palatal thalamic tract by putting these all together this ensures engagement with all key anatomical regions we put this together by combining the connectivity mapping strategy using fiber tract or tractographic analysis along with volume of tissue activation models that identify areas within the ventral capsule that results in the most profound effects on the obsessive-compulsive phenotype together this is an example of how the strategy is placed or utilized in the operating room the blue and green lines represents the trajectories towards the target the white spot scene in this particular region here on the right side and on the left side represents the intended initial segment of activation in the post-operative period the placement of the DVS electrodes and impulse generator is done in a stage fashion on the day of the surgery once again the head frame is placed under local anesthesia and the Imaging is obtained this is in turn fused with the pre-operative Imaging as discussed this plan is fused within the surgical planning station initially a microelectrode recording electrode is first placed along the targeting trajectory another CT scan is confirmed the actual placement of this microelectrode when this is considered with intolerance of where we wish to place the DBS lead the final DBS electrode is placed the patient is typically discharged home the following day and a second electrode is placed one month followed by the impulse generator the beauty about this implantation technique and about modern technology with segmented leads is that you now can stimulate in specific directions and if you map that on the tractography of the pre-operative scans fuse with the post post-operative CT you can actually steer the stimulation towards specific connections that we know are involved in different aspects different symptoms of OCD so to develop a very personalized strategy for specific patients with a specific set of of obsessions and compulsions and mood and anxiety symptoms and this is what we applied for this patient based on this mapping we we decided that the the the second contact you can see depicted here from the top was going to be most strategically situated in these connections um we tested nevertheless each contact in each segment separately interestingly he started improving most and very acutely at contact one but that may still be an after effect of the prior stimulation in the contact 2 which was also the one that we defined defined based on our tractography to be the most effective one so we send the patient home on with the stimulation on that second contact unfortunately the first month didn't notice any improvements in fact he became very desperate because this was his last hope so when he came in next month we increased the amplitude in the same location we titrated it up in steps of half a milliamp up to six milliamp and then he immediately started to improve he started to immediately feel less anxious calmer and in the month thereafter he was able to go back to his old house he started socializing he started dating even resumed working and there were still some residual compulsions which is why the next visit we further increased the amplitude with just half a milliamp and that made him completely lose all of his residuals in these symptoms six months later he was almost still almost free of OCD none of the eye poking compulsions anymore some habitual rituals for which we indicated him for additional cognitive behavioral therapy as of today he's still up and down struggling with some of these residual symptoms but otherwise he's doing great and he's doing very well and this is a great example of how DBS can offer huge benefits for these otherwise completely treatment resistant patients in general we see that six out of 10 patients have a meaningful response which is this patient overall this uh case vignette emphasizes the unique multi-disciplinary talents of our Center for neuromodulation bringing together uh neurosurgeons neuropsychiatrists and biomedical Engineers to create a unique patient-specific treatment plan around around deep brain stimulation therapy for obsessive-compulsive disorder