Application of Multichannel Electrical Stimulation of the Neck
Nervous Structures in Patients with Depressive Disorders:
An fMRI Case Study
Vladimir Kublanov
1
, Timur Petrenko
1
and Aleksandr Efimtcev
2
1
Ural Federal University, Mira 19, Yekaterinburg, Russian Federation
2
The Almazov National Medical Research Centre, St. Petersburg, Russian Federation
Keywords: Neuro-electrostimulation, Neuroimaging, functional MRI, Depression Disorder.
Abstract: The article presents the pilot functional neuroimaging study results of the treatment process by means
neuro-electrostimulator SYMPATHOCOR-01 in patients with depressive disorder. The study involved three
patients. The changes in the brain's default mode network (DMN) as a result of neuro-electrostimulation
course are demonstrated. Along with clinical improvement (HDRS-21 and BDI-II scales), changes in
DMN's performance from neuroimaging data are shown. An increase in the medial prefrontal cortex and
cingulate gyrus functional connection activity with various parts of the brain was noted. These changes
indicate the activation of neuroplasticity processes and restoring the work of DMN in patients with
depression.
1 INTRODUCTION
The rapid spread of depressive disorder among the
working-age population of developed countries
determines the relevance of the search for effective
treatment and rehabilitation approaches o this
disease. It is known that depressive disorder occurs
at any age, acutely limiting a person’s adaptation to
changing environment. In the European Union the
depression came in first place among causes of the
able-bodied life years loss. The direct and indirect
economic losses associated with this disorder exceed
300 billion euros per year. (Research Institute of
Scientific and Technological Information, 2014)
Modern neurophysiological studies have
discovered the most important role of impaired
neurotrophic regulation processes in the
pathogenesis of depressive disorder (Licznerski and
Duman, 2013). There was a marked decrease frontal
cortex activity - responsible for analytical functions
and decision making (Bremner et al., 2002; Cotter et
al., 2001); hippocampus and amygdala -
participating in the processes of learning and
memory, emotional response (Rajkowska et al.,
2001; Sheline, 2003); autonomic centers of the brain
stem - regulating the work of the internal organs,
circadian processes and neurogenesis
activity (Khalsa SBS et al., 2000).
Neuroplasticity is a combination of multi-level
processes of continuous morphofunctional
reorganization of the brain, thus providing
adaptation to changing external and internal
conditions. The most studied of the processes of
neuroplasticity are the processes of neurotrophic
regulation. The actions of neurotrophic factors are
explained through the activation of genetically
programmed regulation mechanisms impacting to
nervous tissue. In the case of depression, we are
talking about damage of the basic neuroplasticity
processes, as evidenced by numerous studies (Doan
et al., 2015; Kraus et al., 2017; Liu et al., 2017).
Today to get a new knowledge about brain
potential possibilities and search the effective
methods of stimulating neuroplasticity processes a
priority task of the basic sciences in all developed
countries.
A modern medical approach to the treatment of
depressive disorder is aimed at regulating synaptic
transmission processes due to indirect increase
activity of certain neurotransmitters (such as
serotonin, norepinephrine and dopamine). As
clinical practice shows, this approach has poor
effectiveness. Only one third of patients with
depressive disorder respond to antidepressant
therapy (Culpepper et al., 2015).
564
Kublanov, V., Petrenko, T. and Efimtcev, A.
Application of Multichannel Electrical Stimulation of the Neck Nervous Structures in Patients with Depressive Disorders: An fMRI Case Study.
DOI: 10.5220/0007681705640571
In Proceedings of the 12th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2019), pages 564-571
ISBN: 978-989-758-353-7
Copyright
c
2019 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved
Innovative approaches involved neuroplasticity
processes is more effective, because of affecting to
pathological mechanisms accompanying depression.
Modulation of neurotrophic regulation makes it
possible to influence to electrochemical transmission
of nerve impulses and activate the process of
neuroprotection (Malykhin and Coupland, 2015).
Emergence of the modern neurovisualization
methods opens the possibilities in the neuroplasticity
investigation. Functional magnetic resonance
imaging (fMRI), which is an intravital non- invasive
dynamic investigation of active brain structures
during their functioning.
The purpose of the study is to identify brain
functional changes in treatment depressive disorder
patients by the SYMPATHOCOR-01 device by
means of fMRI. Results, presented in the study are
an extended version of previously published case
study (Kublanov et al., 2018).
The SYMPATHOCOR-01 neuro-
electrostimulation device is essentially the
technology of multi-channel neuro-
electrostimulation by means of a spatially distributed
physical field (Kublanov et al., 2012).
The device is included in the register of medical
equipment products of the Russian Federation
(registration certificate FCR 2007/00757) and has
the Certificate of correspondence to the
requirements of the regulations GOST R 50444-92.
The spatially-distributed field of the current
pulses is formed between two multi-element
electrodes of the device. Each multi-element
electrode comprises a cluster of thirteen partial
current-conducting elements. The multi-element
electrodes are arranged on the neck into left and
right sides. In the working state, one element of one
multi-element electrode performs the role of the
anode. Elements on the other side become the
cathodes.
A feature of the extension in current work is the
implementation of the multifactorial nature of neuro-
electrostimulation due to the realization of the
possibility to change the field structure, the
stimulation target and to choose bio-tropic
parameters of current pulses, adequate to the
anatomical location of the stimulation targets.
Figure 1: Scheme of the partial current-conducting
elements of the multi-element electrodes location.
Placing the multi-element electrodes on the
subject neck, the central elements of multi-element
electrodes have to be located in projections of the
neck ganglia of the sympathetic nervous system
targets (Fig. 1).
Note the following basic bio-tropic
characteristics of the field: the current partial pulses
duration τ is from 15 to 60 usec. The frequency f of
pulses group is from 5 to 150 Hz. The cathode
elements are switched accordingly to each given rule
(for example, a pseudo-random with the clockwise
or counterclockwise direction of switching, and so
on). The used anode is set depending on the
stimulation target. In this work upper and middle
neck ganglia of the sympathetic nervous system are
used as the target. The duration of the anode
connection varies from 30 seconds to several
minutes and is controlled by the physician. The
current pulses amplitude can be up to 15 mA.
The treatment application of the neuro-
electrostimulation device is implemented as the
DCASNS technique (Dynamic Correction of the
Sympathetic Nervous System Activity) (Kublanov et
al., 2014). The DCASNS technique provides
correction of autonomic balance, which is
characterized by the ratio between the sympathetic
and parasympathetic departments of the autonomic
nervous system (ANS) (Kublanov et al., 2017).
2 MATERIAL AND METHODS
Depending on pathogenesis of the peripheral or
central dysfunctions of the ANS, the dynamic
correction of the activity sympathetic nervous
system (DCASNS) algorithm has two different
branches. Decision of which branch should be
executed is based on nature of the ANS dysfunction.
The bio-tropic parameters of the implemented
current pulse field (the field structure, pulses
amplitude, frequency, and duration) are calculated
from the analysis of the heart rhythm variability. In
particular, in the case of the abnormal hyperactivity
of sympathetic innervation, it is necessary to block
or suppress the activity of the sympathetic nervous
system. In contrast, sympathetic innervation should
be increased, if the hyperactivity of the
parasympathetic innervation is observed. In case of
central dysfunctions, the bio-tropic parameters of the
stimulation field are calculated, based on analysis of
the main activity rhythms of the cerebral cortex and
its deviation from the norm.
In clinic practice, the ‘SYMPATHOCOR-01’
device and DCASNS algorithm were efficiently
Application of Multichannel Electrical Stimulation of the Neck Nervous Structures in Patients with Depressive Disorders: An fMRI Case
Study
565
applied for treatment of various diseases including
organic and/or functional disorders of the CNS
and/or the ANS: consequences of brain trauma or
stroke, epilepsy, chronic headache, somatoform
disorders, anxiety and depressive spectrum
disorders, attention- deficit hyperactivity disorder,
disorders involving cognitive impairments
(Kublanov et al., 2017).
In the December of 2017, at the State Scientific-
Research Institute of Physiology & Basic Medicine
(SSRI PBM), the pilot study of the hemodynamic
reactions, caused by the neuronal activity of the
brain, by means of the rfMRI, was conducted.
The study was conducted with the approval of
the Research Institute of Biomedical Ethics SSRI
PBM. Protocol of the local ethical committee # 13
dated 16.11.2017.
Three patients diagnosed with ICD F33 have
participated in this pilot study. The patients have
signed the informative participation consent. The
study was carried out on the MR system GE
Discovery MR750W, 3.0 Tesla, in accordance with
the following protocols:
T1 SPGR 3D reconstruction, up to 256 cross-
sections, voxel size 1 mm3; mandatory capturing the
whole head surface, including nose and ears;
fMRI in the resting state mode (33 cross-
sections, thickness up to 4,5 mm)
T2-WI, FLAIR (weighted images for exclusion
of the chronic gliosis sources). The stimuli were
send by means of the Nordic NeuroLab BrainEx.
For registration to standard space a T1 high-
resolution 3D MPRAGE (magnetization prepared
rapid gradient echo) was performed. with the
following scan parameters: repetition time (TR)=2.5
s, echo time (TE)=3.52 ms, 190 sagittal slices with
no gap, field-of-view (FoV)=230 mm, flip angle
(FA)=8°, in-plane resolution=1.2×1.2 mm2, slice
thickness=1.2 mm. During RS-fMRI acquisition,
using gradient echo T2* weighted EPI, participant
was instructed to keep the eyes closed and not to
think about anything. The imaging parameters were:
100 volumes, TR=3000 ms, TE=52 ms, FA=90°,
33 interleaved slices, slice thickness=4,5 mm,
imaging matrix 64×64 and FoV=220 mm. The study
timeline is presented in the table 1.
Table 1: Study timeline.
I phase II phase
-T1-sag
-RS
-Visual Nordic
-DTI
-MRA
-T1-sag
-RS
-Visual Nordic
-DTI
-MRA
Here: T1-sag – weighted image in the sagittal
projection; RS - resting state functional MRI (BOLD
signal); MRA - MR-angiography, a medical test that
helps physicians diagnose and treat medical
conditions and diseases of the blood vessels.
The first phase was conducted before treatment
for the baseline state evaluation. The second phase
was conducted 5 days after 5 procedures of the
DCASNS, and in order to evaluate long term
reaction of the CNS.
The biotropic field features of the
SYMPATHOCOR-01 were set in accordance with
the DCASNS technique. There were one 15-minutes
procedure every day.
Our research team has experience in processing
and analyzing neuroimaging data in similar clinical
tasks (Efimtsev et al., 2014; Shelepin et al., 2018;
Sokolov et al., 2017; Trufanov et al., 2016).
Statistical analysis of data and evaluation of the
results of neuroimaging studies, as well as
individually or in group totally (resting state fMRI
data), were performed using CONN v.18 software
package (Functional connectivity Toolbox),
designed to determine the relationships between
different brain regions, including dynamic mode,
connectivity mapping, determining the structure of
various resting state networks and functional
networks of the brain.
This tool enables voxel correlation analysis
(communication between voxel groups) by plotting
the time dependencies between the BOLD signal
from a given voxel / group of voxels and each voxel
in the scan area. Many types of data are used for
processing. We used the analysis based on the
regions of interest measures (ROI-to-ROI), because
it corresponds to our main goal, is suitable for
performing individual analysis and provides a visual
graphical (and quantitative) representation in the
form of brain functional connectivity maps. For a
ROI-based analysis, Medial Prefrontal Cortex was
chosen as a seed ROI, as it is considered a part of
default mode network (DMN).
Evaluation of clinical status of patient was
performed twice - before and after the course of
neuroelectrostimulation. Clinical assessment was
supplemented by symptom scores on psychometric
scales: Beck Depression Inventory (BDI-II) (Beck et
al., 1996), Hamilton Depression Rating Scale
(HDRS-21) (Hamilton, 1960). During the study,
patients did not take any additional antidepressant
therapy.
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566
3 RESULTS
The data of clinical dynamics, assessment of
psychometric scales and fMRI analysis of research
are given. At the end of the section the group
analysis data is represented.
Abbreviations: PFC - positive functional
connectivity; NFC - negative functional
connectivity; MPFC — Medial Prefrontal Cortex;
PCC - posterior cingulum; BA – Brodmann area
Patient No. 794., Male, 28 years. Diagnosis:
recurrent depressive disorder of the current severe
episode (F33.2).
Table 2: Psychometric scales dynamics.
BDI-II HDRS-21
Before Afte
r
Before Afte
r
51 32 28 6
Before treatment, there were obvious signs of
depression, visible in appearance, even by a non-
expert. Noticeable inhibition and unproductive
thinking and motor activity. The content of thinking
is the experience of failures and mistakes of life,
excessive concern for health. Serious sleep
disorders.
After treatment – all indicators are in the normal
range, except the motivation to work.
In patient 794 in 2 phase, the following changes
were identified in comparison to 1 phase (before
stimulation):
- “normalization” of the DMN, which was
expressed in the presence of all arear of
activation, usually detected in healthy subjects.
- recovery of positive FCs of the medial prefrontal
cortex with the left lower temporal gyrus,
anterior cingulum, left angular gyrus, right
postcentral gyrus, precuneus, right middle frontal
gyrus, right upper frontal gyrus, the left caudate;
- the change in the localization of negative FC of
the medial prefrontal cortex: FC with the lateral
occipital cortex bilaterally, the left temporal lobe,
the left medial frontal gyrus appeared, FCs with
opercular cortex, thalamus, insula disappeared
(Fig. 2).
Before Treatment: symptoms of depression are
determined by appearance. Expresses ideas of guilt
and meaninglessness of his life. Severe insomnia.
Feelings of powerlessness and lethargy. Pronounced
fluctuations in mood throughout the day and
alarming concerns about the state of their health.
After Treatment: depressive symptoms are detected
only with the active questioning of the patient.
Sleeping has improved significantly, and anxiety has
almost disappeared. Activity and cheerfulness
appeared.
Figure 2: Patient 794. Resting state fMRI maps – before
treatment (a), after treatment (b) show the changes in the
default brain network (p <0.001).
Patient No. 889. Woman, 53 years. Diagnosis:
recurrent depressive disorder current episode
average (F33.1).
Table 3: Psychometric scales dynamics.
BDI-II HDRS-21
Before Afte
r
Before Afte
r
38 27 17 5
In patient 889, before stimulation, the functional
connectivity of the MPFC was distributed as
follows:
- expressed negative FCs predominantly in the left
hemisphere with temporal lobes (middle and
superior temporal gyri), right thalamus,
hippocampus and putamen, left pre- and
postcentral gyri, parietal region (BA5, BA7);
- positive FCs with anterior and orbital parts of the
frontal lobes, and with the precentral cortex
a
b
Application of Multichannel Electrical Stimulation of the Neck Nervous Structures in Patients with Depressive Disorders: An fMRI Case
Study
567
(BA4), and the visual cortex
After stimulation, the DMN was represented as
“normal”:
- negative FSs symmetrically with the frontal
cortex (BA6, BA8, BA9), with the parietal
region (BA5, BA7) became significantly weaker,
but the lateralization of the remaining FCs was
still present (in the left hemisphere)
- appeared (recovered) positive FCs with posterior
cingulum, angular gyri, right middle and superior
temporal gyrus, hippocampus. At the same time,
the positive FCs with basal ganglia, putamen,
caudate, right insula, paracingular was preserved.
In this way, this patient had a rather expressed
dynamics, both according to HDRS-21, and
according to rfMRI, which demonstrated almost
complete “stabilization” of DMN (Fig. 3).
Figure 3: Patient 889. Statistical maps of post-processing
of resting state fMRI: before treatment (a), after treatment
(b) show the changes of functional connectivity in default
mode network (p <0.001).
Patient No. 865., Female, 54 years. Diagnosis:
recurrent depressive disorder current episode
average (F33.1).
Table 4: Psychometric scales dynamics.
BDI-II HDRS-21
Before Afte
r
Before Afte
r
13 11 17 6
Before treatment: pronounced signs of
depression during patient questioning. Severe
insomnia in all stages of sleep. Loss of interest in the
environment. Inhibition of thought and speech.
Alarming concerns about your health.
After treatment: no depressive statements; no
insomnia; active talks about inner state; there was a
feeling of unreality and automaticity of what is
happening (depersonalization).
Figure 4: Patient 865. Statistical maps of resting state
fMRI - before treatment (a), after treatment (b) show the
changes of functional connectivity in default mode
network (p <0.001).
In patient 865, who had a less expressed degree
of depression (on the Hamilton scale) and,
accordingly, insignificant dynamics after treatment,
the appearance of positive FCs with bilateral angular
gyri, lateral occipital cortex, bilateral fusiform gyri.
Negative FCs remained unchanged at all time points.
It should be noted that in this subject the cerebral
a
b
a
b
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568
papillary at one time point was characterized by
functional connections that are close to “normal”,
although they were less expressed (Fig. 4).
The results of the comparative analysis (phase 2
> phase 1) in Fig. 5 and tab. 5.
Figure 5: Comparative group analysis of the functional
connectivity of the brain in subjects before the beginning
of rehabilitation and after completing the full course of
rehabilitation: 2D statistical map (a), 3D statistical map
reconstruction (b) (p <0.005).
Table 5: Resting-State fMRI in the group of patients with
depressive disorder in comparison with the data after the
course of rehabilitation.
Brain region T Voxels Volume MNI coordinats
Cerebelum 3
(left hemisphere)
-3.62 59 472 (-9; -37; -19)
Cerebelum 3
(right hemisphere)
-2.95 95 760 (12; -35; -19)
Occipital Fusiform
Gyrus Lef
t
2.53 210 1680 (-27; -77; -14)
(Precuneous)
Precuneous Cortex
2.38 202 1616 (1; -59; 38)
Lateral Occipital
Cortex, inferior
division Righ
t
2.27 358 2864 (46; -74; -02)
Vermis 3 -2.17 99 792 (1; -40; -11)
4 DISCUSSION
Summarizing the results obtained, it can be said that
the dynamics of changes using rfMRI confirms the
clinical dynamics, which is even more expressed
than more serious initial condition of the patient. In
many publications, the authors talk about changes in
the stability and variability of the functioning of the
DMN, especially its main parts - the MPFC and
PCC, which are involved in realization of deep
cognitive functions, a complex analysis of both the
surrounding and inner human world.
The correlation of the functional connections of
these areas among themselves, as well as with other
parts of the brain and the severity of depression, was
determined. Considering the brain DMN, in all the
patients in the Stimulation group it was
“normalized” - due to the restoration of the main
positive FCs between MPFC, PCC and angular gyri.
In all patients in the “Stimulation” group, before
treatment, the fMRI-pattern was characterized by
complete “instability” of DMN, with a
predominance of negative FCs. Some scientists talk
about changes in local connectivity in the frontal
lobes. Such a phenomenon may occur, for example,
in patient 889, in whom positive FCs were strongly
expressed in these areas. These activation patterns
can be considered as a mechanism of hyper-
compensation in response to an episode of
depressive disorder, as well as FCs with the parietal
region - as a predictor of episode relapse.
Some patients showed changes in the FCs of the
hippocampus and insular cortex with MPFC.
According to many authors, the function of these
areas, incl. as part of the limbic system, changes in
depressive disorders, demonstrating reduced
connectivity. It is known that these brain structures
contribute in the formation of the emotional
background, which can thus explain their main role
in the mechanisms of development of a deep
depressive disorder, including the early stages.
Patient 865 had a feeling of unreality and
automaticity of what is happening
(depersonalization) probably reflected by more
expressed negative FCs between MPFC and insula
on the right, as well as increased local positive FCs
between MPFC and ventrolateral prefrontal cortex
(right and left). The involvement of these brain areas
a
b
Application of Multichannel Electrical Stimulation of the Neck Nervous Structures in Patients with Depressive Disorders: An fMRI Case
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569
in the depressive process is reflected in some
research.
5 CONCLUSIONS
In the course of 5 procedures of neuro-
electrostimulation using SIMPATHOCOR, the
restoration of MPFC and PCC connectivity was
noted in these three patients, which brought their
DMN to the “normal state”. However, the
conclusion must be coordinated with the initial state
of the DMN, which has variable individual
characteristics. This fact must be considered in
further similar studies in large groups.
The important point noted in the course of the
study is the fact that the “normalization” of the
DMN appeared the stronger, the more severe the
symptoms were observed in the patient. This
indicates the use of the most powerful mechanisms
of neuroplasticity, which are being "turned on" after
neuro-electrostimulation.
ACKNOWLEDGEMENTS
This data acquisition within the study (Chapter 3)
was supported by the Act 211 of the Government of
the Russian Federation (contract no.
02.A03.21.0006). Data processing (Chapter 4) was
funded by RFBR (project no, 18-29-02052).
Authors are grateful to all staff of SIRBPM who
participated in the organization of research. Special
thanks to Maria Rezakova for her help in obtaining
fMRI signals.
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