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Deep Brain Stimulation of the Lateral Habenular Complex in Treatment-Resistant Depression: Traps and Pitfalls of Trajectory Choice

Schneider, Till M. MD*; Beynon, Christopher MD*; Sartorius, Alexander MD, PhD; Unterberg, Andreas W. MD, PhD*; Kiening, Karl L. MD, PhD*

doi: 10.1227/NEU.0b013e318277a5aa
Surgical Anatomy and Technique

BACKGROUND: Deep brain stimulation (DBS) has recently been discussed as a promising treatment option for severe cases of major depression. Experimental data have suggested that the lateral habenular complex (LHb-c) is a central region of depression-related neuronal circuits. Because of its location close to the midline, stereotactic targeting of the LHb-c presents surgeons with distinct challenges.

OBJECTIVE: To define the obstacles of DBS surgery for stimulation of the LHb-c and thus to establish safe trajectories.

METHODS: Stereotactic magnetic resonance imaging data sets of 54 hemispheres originating from 27 DBS patients were taken for analysis on a stereotactic planning workstation. After alignment of images according to the anterior commissure--posterior commissure definition, analyses focused on vessels and enlarged ventricles interfering with trajectories.

RESULTS: As major trajectory obstacles, enlarged ventricles and an interfering superior thalamic vein were found. A standard frontal trajectory (angle > 40° relative to the anterior commissure--posterior commissure in sagittal images) for bilateral stimulation was safely applicable in 48% of patients, whereas a steeper frontal trajectory (angle <40 relative to the anterior commissure--posterior commissure in sagittal images) for bilateral stimulation was possible in 96%. Taken together, safe bilateral targeting of the LHb-c was possible in 98% of all patients.

CONCLUSION: Targeting LHb-c is a feasible and safe technique in the majority of patients undergoing surgery for DBS. However, meticulous individual planning to avoid interference with ventricles and thalamus-related veins is mandatory because an alternative steep frontal entry point has to be considered in about half of the patients.

ABBREVIATIONS: AC-PC, anterior commissure--posterior commissure

DBS, deep brain stimulation

LHb-c, lateral habenular complex

MHb, medial habenula

RM, Riechert-Mundinger

STV, superior thalamic vein

ZD, Zamorano-Duchovny

Author Information

*Division of Stereotactic Neurosurgery, Department of Neurosurgery, Universitätsklinikum Heidelberg, Heidelberg, Germany;

Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Mannheim, Germany

Correspondence: Karl Kiening, MD, PhD, Head, Division of Stereotactic Neurosurgery, Department of Neurosurgery, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany. E-mail:

Received June 28, 2012

Accepted September 20, 2012

Copyright © by the Congress of Neurological Surgeons