Case report
Acute severe depression induced by intraoperative stimulation of the substantia nigra: A case report

https://doi.org/10.1016/j.parkreldis.2007.04.005Get rights and content

Abstract

We present a 62 years old man with Parkinson's disease (PD) who underwent bilateral stimulation in the subthalamic nucleus (STN). During the intraoperative evaluation, stimulation through the lowest contact in the right STN area, induced an acute depressive state, during which the patient was crying and expressing that he did not want to live. The patient returned to his normal state of mood within seconds after the cessation of stimulation. Repeated blinded stimulations resulted in the same response. Immediate postoperative magnetic resonance imaging (MRI) revealed that the lowest contact of the right electrode was located in the substantia nigra.

Introduction

The subthalamic nucleus (STN) is an established therapeutical target for deep brain stimulation (DBS) in Parkinson's disease (PD). It is well known that depression may occur after STN DBS, which has often been attributed to the marked reduction of l-dopa postoperatively [1], and not to a direct the effect of STN stimulation. Bejjani et al. [2] reported in one patient that stimulation of the left-sided substantia nigra reticulata (SNR) just ventral to the STN gave rise to acute stimulation-induced depression. We present here a patient in whom right-sided intra-operative macrostimulation ventral to the STN led to an acute reversible depression.

Section snippets

Case presentation

A right-handed 62-year-old gentleman with a 14 year history of PD presented initially with dragging of the left leg, stiffness and decreased left arm swing. The symptoms responded well to l-dopa, but after 10 years sustained therapy, he developed progressively disabling motor fluctuations with peak dose chorea. Ropinirole was tried and 1 year later, apomorphine was also administered. The patient developed, however, an allergic reaction to apomorphine. The ropinirole was also eventually

Discussion

Depression during off periods and mild hypomania during on periods is well recognised in some patients with PD on long-term l-dopa therapy raising the possibility that dopaminergic mechanisms may be involved.

This case report shows that the acute electrical high frequency stimulation of a restricted area in the SN, which is one of the main output systems of the basal ganglia, can give rise to a major reversible affective disorder, independent of stimulation of other contacts within the STN

Acknowledgements

The authors have nothing to disclose. No grants are pertinent to this paper.

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