Variability and Anatomical Specificity of the Orbitofrontothalamic
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Brain Imaging and Behavior DOI 10.1007/s11682-015-9462-9 ORIGINAL RESEARCH Variability and anatomical specificity of the orbitofrontothalamic fibers of passage in the ventral capsule/ventral striatum (VC/VS): precision care for patient-specific tractography-guided targeting of deep brain stimulation (DBS) in obsessive compulsive disorder (OCD) Nikolaos Makris1,2,3,4 & Yogesh Rathi1,2 & Palig Mouradian1 & Giorgio Bonmassar1 & George Papadimitriou1 & Wingkwai I. Ing1 & Edward H. Yeterian5 & Marek Kubicki1,2 & Emad N. Eskandar1 & Lawrence L. Wald1 & Qiuyun Fan1 & Aapo Nummenmaa1 & Alik S. Widge1,6 & Darin D. Dougherty1 # Springer Science+Business Media New York 2015 Abstract Deep Brain Stimulation (DBS) is a neurosurgical orbitofrontothalamic connections and estimated their topo- procedure that can reduce symptoms in medically intractable graphic variability within the VC/VS region. Our obsessive-compulsive disorder (OCD). Conceptually, DBS of results showed that the morphology of the individual the ventral capsule/ventral striatum (VC/VS) region targets orbitofrontothalamic fibers of passage in the VC/VS region reciprocal excitatory connections between the orbitofrontal is complex and inter-individual variability in their topography cortex (OFC) and thalamus, decreasing abnormal reverberant is high. We applied this method to an example OCD patient activity within the OFC-caudate-pallidal-thalamic circuit. In case who underwent DBS surgery, formulating an initial proof this study, we investigated these connections using diffusion of concept for a tractography-guided patient-specific approach magnetic resonance imaging (dMRI) on human connectome in DBS for medically intractable OCD. This may improve on datasets of twenty-nine healthy young-adult volunteers with current surgical practice, which involves implanting all pa- two-tensor unscented Kalman filter based tractography. tients at identical stereotactic coordinates within the VC/VS We studied the morphology of the lateral and medial region. Keywords Diffusion tensor imaging . Diffusion * Nikolaos Makris tractography . Connectome . Obsessive-compulsive disorder [email protected] (OCD) . Deep brain stimulation (DBS) . Tractography-guided DBS 1 Departments of Psychiatry, Neurology, Neurosurgery and Radiology, Center for Morphometric Analysis, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Building 149, 13th Street, Charlestown, MA 02129, USA Introduction 2 Department of Psychiatry, Psychiatry Neuroimaging Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Obsessive-compulsive disorder (OCD) is a chronic mental Boston, MA, USA illness affecting 4–7 million people in the U.S. Patients are 3 McLean Imaging Center, McLean Hospital, Harvard Medical impaired in multiple Research Domain constructs (Cuthbert School, Boston, MA, USA and Insel 2010, 2013) including Habit (perseverative compul- 4 Department of Anatomy and Neurobiology, Boston University sive behaviors), Sustained Threat (anxiety in response to ob- School of Medicine, Boston, MA, USA sessional thoughts that they know are untrue), and Reward 5 Department of Psychology, Colby College, Waterville, ME, USA Learning (inability to learn to resist obsessions/compulsions 6 Picower Institute for Learning & Memory, Massachusetts Institute of despite negative consequences). Medication and behavioral Technology, Cambridge, MA, USA therapies yield inadequate symptom relief in 50–70 % Brain Imaging and Behavior (Greist et al. 1995; Koran et al. 2007; Pallanti et al. 2002; reveals pathway specificity, there will be little clarity regard- Pittenger and Bloch 2014) of patients. As a result, OCD re- ing target engagement or the correlation of any specific cir- mains a leading worldwide cause of disability, equivalent in cuitry to therapeutic effect. We identified this problem and impact to more visible disorders such as schizophrenia addressed it to a certain extent in two recent papers examining (Ayuso-Mateos 2002). Roughly one-third of patients are un- which gray and white matter structures were lesioned by able to work due to their symptoms (Mancebo et al. 2008)and subcaudate tractotomy in a cohort identified from a their caregivers report profound, life-impairing stress Massachusetts General Hospital database of patients main- (Laidlaw et al. 1999). The clinical syndrome and the underly- tained since 1992 (Yang et al. 2014) and mapping the anatomy ing constructs have been linked to a set of cortico-striato- of fibers of passage in the VC/VS region in normal subjects thalamo-cortical (CSTC) loops, circuits that subserve goal- using DTI probabilistic tractography (Yang et al. 2015). directed action, learning, and motivation (Ahmari et al. Probabilistic tractography is useful for a general understand- 2013; Anticevic et al. 2014; Burguiere et al. 2013; ing of the topographic arrangement of the fibers of passage. Dougherty et al. 2010; Pauls et al. 2014; Posner et al. 2014). Current surgical practice involves implanting all pa- It is not known which loops are most important in OCD, but tients at identical stereotactic coordinates within the VC/ the orbitofrontal cortex (OFC) in particular is repeatedly im- VS region. Thus, DBS for OCD as currently practiced plicated by neuroimaging studies as a hub, as are ventromedial lacks specificity with respect to targeted engagement of prefrontal (vmPFC) and anterior cingulate (ACC) cortex individual fiber tracts. From a purely anatomical perspec- (Dougherty et al. 2010;MiladandRauch2012). tive, another important factor that adds complexity to the In cases of medically intractable OCD, neurosurgical treat- specificity of fiber tract target engagement is the morphol- ment is an option for reducing symptom burden and increas- ogy of individual fiber tracts. Along their trajectories, as ing quality of life. Although, given its limited application to fiber tracts course from origin toward their termination, date it is still too early to know with clarity how beneficial this they deploy their fibers in the form of a “cloud.” procedure is, our clinical experience and of others (Greenberg Although these clouds of fibers run side-by-side, they et al. 2010a) have shown that approximately one-third of the partially intertwine and share the same space, making it patients had meaningful clinical improvement, another third highly difficult to discern a specific fiber tract with clarity. showed partial clinical response while the remainder did not Another highly relevant problem in DBS target engage- show any meaningful response. Deep brain stimulation (DBS) ment is inter-subject variability, which increases the prob- of the ventral capsule/ventral striatum (VC/VS) region may ability of misplacement of the implant within the VC/VS target reciprocal excitatory connections between OFC and region. For DBS to enable optimal target engagement and thalamus, decreasing reverberant feedback activity within therapeutic efficacy, this surgical procedure should be- the OFC-caudate-pallidal-thalamic circuit, leading to thera- come patient-specific. Varying the specific implant coor- peutic gains (Greenberg et al. 2010b). More specifically, it is dinates based on tractography in individual patients would thought that the OFC connections with the thalamus are the be one way to achieve that specificity. most relevant in OCD pathophysiology (Fineberg et al. 2010; In this study, given the relevance of the orbitofrontothalamic Graybiel and Rauch 2000). The VC/VS target is not a single circuitry in OCD pathophysiology, we adressed issues of the identifiable anatomical structure, but includes both white mat- anatomical connectivity between the OFC and the thalamus. ter of the caudoventral part of the anterior limb of the internal We mapped the lateral orbitofrontothalamic (lOFC-thal) and capsule (ALIC) and the shell of the nucleus accumbens. Fibers the medial orbitofrontothalamic (mOFC-thal) connections and of passage in this region connect dorsal prefrontal cortex elucidated the topographic relationships of these two fiber con- (DPFC), dorsal anterior cingulate cortex (dACC), nections within the VC/VS region in humans. We measured the orbitofrontal cortex (OFC) and ventromedial prefrontal cortex inter-individual anatomical variabillity of lOFC-thal and (vmPFC) with the thalamus (principally mediodorsal, anterior mOFC-thal connections in a sample of twenty-nine individuals medial, medial pulvinar, and midline-intralaminar nuclei), using two-tensor diffusion tractography of Connectome data amygdala, hypothalamus and brainstem (substantia nigra, and data from an OCD DBS patient. Our results represent an ventral tegmental area, raphe nuclei and peduncolopontine initial proof of concept indicating the relevance of a tegmental nucleus). The trajectories of these fibers of passage tractography-guided patient-specific approach in DBS neuro- show a characteristic general pattern of topographic organiza- surgery for OCD. tion in VC/VS, but the individual projections and bundles overlap considerably (Jbabdi et al. 2013;Lehmanetal. 2011;Yangetal.2015). In DBS practice, anatomical inhomo- Methods geneity in VC/VS results in the stimulation of multiple differ- ent structures by implanted electrodes. Unless visualization of We used magnetic DTI-based tractography in 29 human sub- the various fiber tracts in this region is done in a manner that jects to study the fibers of passage at the VC/VS area in the Brain Imaging and Behavior caudoventral region of the anterior limb of internal