J Neurosurg 144:293–304, 2026
This clinical study describes the development and prospective application of patient-specific tractography to refine anterior limb of the internal capsule (ALIC) deep brain stimulation (DBS) targeting for treatment-refractory obsessive-compulsive disorder (OCD). The authors generated a common responder connectivity map highlighting ALIC pathways to vmPFC/OFC, vlPFC, thalamus, STN, and midbrain, then used that map to guide implantation in a new cohort, achieving consistent and rapid Y-BOCS improvements.
The team also built a tractography-based stimulation model linking activation of specific unilateral ALIC pathways to symptom reduction, demonstrating selective prediction of obsessive–compulsive symptom improvement (but not mood or anxiety). Results suggest that tractography-guided “sweet spot” targeting at the ventral ALIC near the GPe can reduce trial-and-error programming and support precision ALIC DBS implementation.
Patient-specific tractography targeting: Using individualized diffusion MRI tractography to guide deep brain stimulation (DBS) lead placement in the anterior limb of the internal capsule (ALIC) for obsessive-compulsive disorder (OCD) enables more precise and consistent targeting of therapeutic white matter pathways.
Common responder map: A map of white matter connections shared by DBS responders was generated, highlighting key pathways to the ventromedial/orbitofrontal cortex (vmPFC/OFC), ventrolateral prefrontal cortex (vlPFC), and midbrain; targeting this “sweet spot” led to improved and predictable clinical outcomes.
Improved clinical efficacy: Tractography-based ALIC DBS resulted in an 80% response rate (≥35% Y-BOCS reduction) among prospective patients, with faster and more consistent OCD symptom improvement compared to prior methods.
Reduced trial-and-error programming: Targeting based on the common responder map minimized the need for multiple adjustments in stimulation parameters, streamlining clinical implementation.
Symptom specificity: Stimulation of the tractography-defined target selectively improved OCD symptoms (obsessions and compulsions) with less impact on mood or anxiety and minimal side effects such as hypomania.
Tractography-based predictive model: A quantitative model using patient-specific pathway activation predicted OCD symptom improvement (Y-BOCS reduction), with strongest predictive value for connections to vlPFC, vmPFC/OFC, thalamus, and midbrain, but not for depression or anxiety scores.
Updated common responder map validation: High-resolution 7T MRI data from additional responders confirmed the importance of connections to vlPFC, vmPFC/OFC, thalamus, and midbrain in therapeutic response.
Potential for clinical scalability: This precision targeting approach, if validated in larger cohorts, could enhance the predictability, effectiveness, and broader adoption of DBS for treatment-resistant OCD.
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