Deep Brain Stimulation of Subgenual Cingulate Region for Treatment of an Early-Onset Conversion Disorder with Psychogenic Non-Epileptic Seizures and Prolonged Catatonia: Preliminary Results in One Patient

Conversion disorder (CD) with psychogenic non-epileptic seizures (PNES) and catatonia are considered “network pathologies” of cortico-striato-thalamo-cortical loops, in which subgenual cingulate region (SGC) plays a hub role in the modulation of motivational and cognitive functions involved in motor control [1, 2]. SGC, previously selected as Deep Brain Stimulation target for depression disorders [3], shows a PET/CT scan hypermetabolism also in patients with CD. We report a case of an 18-year-old female patient with severe, early-onset (12 years old) CD with PNES and prolonged catatonia. Because of daily episodes of PNES, prolonged catatonia (1 episode continued over 4 months with nasogastric feeding necessity) and consequent hospitalizations, development acquisitions were hindered, and intellectual deterioration was observed. A brain PET/CT scan analysis revealed a significant increase (p value <0.01 evaluated with a Statistical Parametric Software) of the regional cerebral metabolic rate on glucose consumption in bilateral putamen and caudate nuclei, bilateral prefrontal and orbitofrontal cortex, and subgenual cingulate gyrus, similar to patients with depression submitted to SGC DBS [3]. Due to the severe clinical impact of related symptoms on her life quality and therapeutic failures, the Paediatric Ethical Committee and legal guardian informed consent approved the SGC DBS application and the publication of this case. At 18 years old (July 2018), a bilateral DBS of the SGC was performed under general anesthesia using a frame-based (Leksell, Elekta Instruments®, Sweden) technique coupled with a robotic system for stereotactic neurosurgery (Neuromate®; Renishaw-Mayfield SA, Nyon, Switzerland). Two bilateral avascular trajectories were assigned to the anatomical targets located in a white matter