Potential Surgical Targets For Deep Brain Stimulation In Treatment-Resistant Depression

Jason S. Hauptman, MD; Antonio A. F. DeSalles, MD, PhD; Randall Espinoza, MD, MPH; Mark Sedrak, MD; Warren Ishida, MD

Disclosures

Neurosurg Focus. 2008;25(1):E3 

In This Article

Rostral Cingulate Cortex: Area 24a

Drs. Sakas and Panourias[57] proposed the rostral cingulate gyrus (Brodmann area 24a) as an appropriate therapeutic target for TRD (Fig. 5). The rostral cingulate cortex is thought to mediate between the dorsal (dorsolateral pre-frontal cortex, dorsal anterior cingulate cortex, inferior parietal cortex, and striatum) and ventral (paralimbic cortex, subcortical hypothalamus, insula, subgenual cingulate cortex, and brainstem) areas of limbic-cortical dysregulation in depression.[37,57] Smaller volumes of the rostral cingu-late cortex have been found in boys with subclinical depression.[3]

Figure 5.

Diffusion tensor and stereotactic images showing localization of the rostral cingulate. Note the projections to and from the cingulate cortex, dorsal frontal cortices, and across corpus callosum. Fractional anisotropy = 0.2; minimum fiber length 36 mm.

Metabolic studies have confirmed that the rostral cingu-late cortex shows increased glucose utilization in patients who respond to antidepressants (as opposed to nonresponders), with metabolic activity predicting the magnitude of the response to pharmacotherapy.[37,53,57] Rostral cingulate cortex involvement in depression has also been corroborated by functional MR imaging data.[14] This area's central role in mediating the dysfunction between the ventral (neurocognitive) and dorsal (somatic) compartments makes it an attractive candidate for neuromodulation. No electrode has yet been implanted in the rostral cingulate cortex in humans; however, stereotactic lesioning of this area has shown beneficial effects.[64]

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