Cervical spinal cord stimulation for prevention and treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage: clinical and radiographic outcomes of a prospective single-center clinical pilot study.

BACKGROUND: Cerebral vasospasm induced by aneurysmal subarachnoid hemorrhage (aSAH) is a major cause of high morbidity and mortality, for which there is no consistently effective treatment. Cervical spinal cord stimulation (cSCS) has been shown to induce vasodilatation and improve peripheral and cerebral blood flow in both animal and human studies. This pilot study was performed to assess the clinical effect and long-term results of cSCS treatment in aSAH patients. METHODS: This was the first IRB- and US FDA-approved prospective non-randomized non-controlled study comprising of 12 aSAH patients (8 women, 4 men, age range 34-62 years) treated between May and November 2008. All patients underwent up to 2 weeks of cSCS with a single percutaneously implanted 8-contact electrode. Neurological outcomes at discharge and follow-up of up to 13 years and mortality/complications rates were analyzed. RESULTS: All 12 aSAH patients underwent cSCS electrode implantation immediately after securing the aneurysm. Patients were stimulated for 10-14 consecutive days starting within 3 days of aneurysm rupture. Angiographic vasospasm occurred in six patients; two patients developed new vasospasm-related neurological symptoms; both recovered completely by discharge time. One patient died from unrelated multi-system failure; the rest were followed up clinically (average, 7.5 years; range, 12-151 months) and angiographically (average, 6.5 years; range, 36-125 months). No delayed ischemic neurological deficits/strokes and no cSCS-related adverse effects were observed. CONCLUSIONS: Our short- and long-term data suggest that cSCS is feasible and safe for patients in the acute aSAH settings. Small size of the patient cohort and lack of control do not allow us to conclude whether cSCS is able to prevent cerebral vasospasm, decrease its severity, and improve clinical outcomes in aSAH patients. However, our findings support further clinical trials and development of cSCS as a new concept to prevent and treat cerebral vasospasm. CLINICALTRIALS: gov NCT00766844, posted on 10/06/2008.

Sanger Brown and Edward Schäfer before Heinrich Klüver and Paul Bucy: their observations on bilateral temporal lobe ablations.

Fifty years before a report on the complete bitemporal lobectomy syndrome in primates, known as the Klüver-Bucy syndrome, was published, 2 talented investigators working at the University College in London, England-neurologist Sanger Brown and physiologist Edward Schäfer-also made this discovery. The title of their work was "An investigation into the functions of the occipital and temporal lobes of the monkey's brain," and it involved excisional brain surgery in 12 monkeys. They were particularly interested in the then-disputed primary cortical locations relating to vision and hearing. However, following extensive bilateral temporal lobe excisions in 2 monkeys, they noted peculiar behavior including apparent loss of memory and intelligence resembling "idiocy." These investigators recognized most of the behavioral findings that later came to be known as the Klüver-Bucy syndrome. However, they were working within the late-19th-century framework of cerebral cortical localizations of basic motor and sensory functions. Details of the Brown and Schäfer study and a glimpse of the neurological thinking of that period is presented. In the decades following the pivotal work of Klüver and Bucy in the late 1930s, in which they used a more advanced neurosurgical technique, tools of behavioral observations, and analysis of brain sections after euthanasia, investigators have elaborated the full components of the clinical syndrome and the extent of their resections. Other neuroscientists sought to isolate and determine the specific temporal neocortical, medial temporal, and deep limbic structures responsible for various visual and complex behavioral deficits. No doubt, Klüver and Bucy's contribution led to a great expansion in attention given to the limbic system's role in action, perception, emotion, and affect-a tide that continues to the present time.

Quantifying sulcal and gyral topography in relation to deep seated and ventricular lesions: cadaveric study for basing surgical approaches and review of literature.

OBJECTIVE: Numerical implication of sulcal and gyral topography for surgical approaches has not been studied. METHODS: Percentage gain of distance using sulci as compared to that of gyri was calculated by measuring distances toward the ventricles in 15 hemispheres. RESULTS: Superior frontal sulcus was closest proving greater than 50% gain in distance compared to superior frontal gyrus; inferior temporal sulcus provided greater gain in the temporal lobe. CONCLUSION: Sulci provide upto 58% distance gain. For trans-gyral approaches, MFG and ITG were found closer to the respective ventricular area.

Chronic epilepsy due to low grade temporal lobe tumors and due to hippocampal sclerosis: do they differ in post-surgical outcome?

Chronic seizures as a presenting feature of low grade temporal lobe gliomas and hippocampal sclerosis (HS) are reported to have similar outcomes although the prognostic indicators may not be the same. This study seeks to identify the variables that are associated with poor surgical outcome in both conditions. A retrospective analysis from our epilepsy data base was performed. All low-grade temporal lobe gliomas were selected and relevant variables were compared to the same variables in HS patients. There were 34 tumors (out of 233 cases of chronic temporal lobe epilepsy = 14.6 %) with a mean age of onset of 19 years, and the preoperative duration was 12.3 years. When compared to 120 HS patients both of these factors were significantly different (p < 0.001). Age at the time of surgery for tumors was 31.08 (p = 0.5). Tumors were left sided in 20 patients. In tumor cases amygdala resection was complete in 75 %, for hippocampus 24 % were complete and 39 % partial. Astrocytoma, ganglioglioma and oligodendroglioma constituted 80 % of tumor cases. Good outcome (Engel's Class I) was achieved in 88.2 % of tumor cases and 71 % of HS cases while poor outcome (Class III + IV) was seen in 5.9 and 16.7 % respectively. The follow up period for the two groups was not significantly different. In multivariate logistic regression analysis, the groups differed significantly in preoperative delay (between diagnosis and surgery) and in epilepsy outcome. Chronic temporal lobe epilepsy due to low-grade tumors had significantly better surgical outcome with considerably less preoperative delay. The age of onset of seizures was younger in HS patients but a delay in surgical treatment was significantly longer. Given that the diagnosis of treatment-resistant TLE secondary to HS can be established after two failed AED trials at optimal doses, shortening the interval between diagnosis and surgery may improve epilepsy outcome.

Modified brainstem auditory evoked responses in patients with non-brainstem compressive cerebral lesions.

The brainstem auditory evoked response (BAER) is sensitive to pontomesencephalic integrity, transtentorial brain herniation, and at times increased intracranial pressure (ICP). The authors report their experience utilizing a recently described rapid rate, binaural, click and 1,000-Hz tone-burst modification of the BAER (MBAER) in 22 symptomatic non-trauma patients with non-brainstem compressive space-taking cerebral lesions. The majority presented with mild to moderate clinical signs suggestive of increased ICP, and focal neurological deficits. The cerebral lesions, mostly tumors (17), averaged 4-5 cm in diameter, with radiological signs of mass effect such as flattening of the sulci, midline shift, and narrowing of the basal cisterns. A number of significant changes in Wave V and V (n) latency and less so amplitude were found in patients compared with age-matched normal volunteers, as well as those again studied after surgical decompression. Similar MBAER changes had been noted in normal volunteers placed in a dependent head position. Possible mechanisms to explain these findings are discussed. The methodology shows promise and if combined with automated peak recognition could make Neuro ICU monitoring practical.

Repositioning of supraorbital nerve stimulation electrode using retrograde needle insertion: a technical note.

INTRODUCTION: With growing interest and acceptance of peripheral nerve stimulation (PNS) approach, there is now an increasing need in developing clear procedural details to resolve frequent complications and minimize associated tissue injury. Migration and suboptimal positioning of PNS electrodes are one of the most commonly observed complications of PNS approach. MATERIALS AND METHODS: We present a simple technique for repositioning a supraorbital electrode using retrograde insertion of introducer needle that allows one to place percutaneous (cylindrical) PNS electrode into appropriate anatomical location with minimal additional injury to surrounding tissues. RESULTS: This approach has been successfully used in multiple cases. An illustrative case of electrode revision with proposed technique is described in detail. CONCLUSION: This technically simple approach to repositioning of cylindrical supraorbital electrodes using retrograde needle insertion eliminates the need for a more elaborate and invasive procedure. The technique can be used for electrode repositioning in most PNS applications.

Cardiac troponin I levels are a marker of myocardial dysfunction in subarachnoid hemorrhage and predicts poor neurologic outcome.

We evaluated the prognostic significance of myocardial dysfunction and associated cardiac troponin I elevation in patients with subarachnoid hemorrhage (SAH). Forty-one patients with no prior cardiac history and who presented with spontaneous SAH were prospectively studied. The LV ejection fraction (LVEF) and regional wall motion by echocardiogram were studied upon admission (Day 0), Day 1 and Day 3 following SAH. Serial troponin I levels, admission Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) were compared in patients with and without LV wall motion abnormality (WMA). Eight patients (20%) had evidence of WMA, of which five (63%) had global hypokinesis and the rest had regional WMA. Patients with WMA had significantly lower LVEF (30% vs 62%, p<0.001) at Day 0, significantly higher troponin I (0.938 vs 0.077, p<0.001) and significantly lower admission GCS (8.2 vs 14.1, p<0.001) compared to those without WMA. LV systolic function improved in 25% of patients by Day 3. Neurologic outcome (GOS) was adversely related to increase in troponin I levels (p=0.04), whereas WMA predicted poor neurologic status (GCS) (P<0.01) and increased hospital stay (P<0.01). Cardiac troponin I levels appear to be a sensitive marker of myocardial dysfunction, which occurred in 20% of patients with SAH, and helps predict poor neurologic outcome.

Myocardial dysfunction in subarachnoid hemorrhage: prognostication by echo cardiography and cardiac enzymes. A prospective study.

BACKGROUND: The myocardial dysfunction in nontraumatic sub-arachnoid hemorrhage (SAH) is not well understood. Borderline elevations of cardiac biomarkers, electrocardiographic repolarization abnormalities and systolic dysfunction have been reported but the clinical significance of these abnormalities is uncertain. METHODS: Patients without history of cardiac disease were prospectively evaluated for cardiac dysfunction. Myocardial regional wall motion and left ventricular ejection fraction (LVEF) were serially studied by transthoracic echocardiogram along with cardiac enzymes. RESULTS: The mean age of the study population was 53 years. Majority of the patients had aneurysms (N = 38). The mean LVEF was 55 +/- 15%. Eight patients had evidence of WMA, mostly global hypokinesia (63%). The mean LVEF of patients with WMA was significantly lower compared to those without WMA (p < 0.001) at day 0. Systolic function recovered in 25% of these patients. The mean value of troponin was significantly higher in those with WMA (p < 0.001) and mean GCS upon admission was significantly lower (p < 0.001). On multivariate analysis, WMA were associated with poor GCS (p < 0.01) and increased hospitalization (P < 0.01). CONCLUSIONS: WMA with systolic dysfunction occurred in 20% of patients and recovered within 3 days in 25%. Patients with evidence of WMA had a significant myocardial dysfunction, higher troponin levels and poor GCS.

Is an endothelial nitric oxide synthase gene mutation a risk factor in the origin of intraventricular hemorrhage?

OBJECT: Studies have shown decreased levels of nitric oxide (NO), the product of endothelial NO synthase (eNOS) gene activity, in infants with respiratory conditions and intraventricular hemorrhage (IVH). The authors evaluated the association of the eNOS gene promoter polymorphism T-786C with the cause of these conditions (respiratory conditions and IVH) in premature infants. METHODS: Blood samples from 124 African American premature infants were studied. The DNA was isolated and microplate polymerase chain reaction-restriction fragment length polymorphism assay was performed. Genotypes were scored as: TT homozygotes with 140 bp and 40 bp; CC homozygotes with 90 bp, 50 bp, and 40 bp; and TC heterozygotes with 140 bp, 90 bp, 50 bp, and 40 bp. Genotypes were stratified according to ethnicity, preterm status, and prematurity conditions. RESULTS: The mutant allele -786C was present in 15.3% of premature infants with respiratory distress syndrome, bronchopulmonary dysplasia, and IVH, compared with 7.25% in those premature infants without these conditions. A significant 2-fold increase of the mutant allele in patients compared with controls (p = 0.04, OR 2.3) reveals that the eNOS -786C allele could be a significant risk factor in the origin of respiratory conditions and IVH in premature infants. CONCLUSIONS: These results suggest that the mutant eNOS -786C allele is a significant risk factor in the origin of respiratory and IVH diseases, probably mediating an insufficient supply of endogenous NO in premature infants.

Congenital Chiari malformations.

Chiari malformation is the commonest anomaly of the craniovertebral junction involving both the skeletal as well as the neural structures. This entity has rapidly evolved over the past decade with newer visualization techniques, thus posing new challenges to diagnosis and management. This review includes the developmental theories, the latest nomenclature and existing treatment modalities of this interesting anomaly. Five theories tried to explain the malformation of the hindbrain and the neuraxis but no single theory completes the development of embryonic defects. Several atypical presentations have been reported with either incidental/asymptomatic features resulting in further classifications. The new magnetic resonance imaging flow techniques attempt to substantiate the clinical presentations and correlate with the abnormality which can be subtle in correlation. Surgical correction to improve the cranial volume, decrease the hydrocephalus and improve flow across the foramen magnum is the mainstay but needs to be tailored to a given type of malformation. Further clinical and imageological studies, especially longitudinal natural history, might improve our understanding of the atypical/asymptomatic presentations and the management that is currently available.

Subependymoma at the foramen of Monro presenting with intermittent hydrocephalus: case report and review of the literature.

Subependymomas are benign neoplasms, accounting for 0.5 % of all central nervous system tumors. These tumors are frequently asymptomatic, often discovered incidentally at autopsy. However, patients may be symptomatic with the symptoms depending on location of the tumor. Since subependymomas typically arise from the ventricular wall, obstruction of cerebrospinal fluid is a major cause of onset symptoms. We present a rare case report of a subependymoma at the foramen of Monro presenting with intermittent hydrocephalus. The patient's tumor was asymptomatic for many years. Imaging findings included asymmetry of the lateral ventricles. The patient developed sudden onset of headache and altered mental status followed by complete resolution, likely due to intermittent hydrocephalus. She developed two more such episodes necessitating an emergent external ventricular drain placement followed by surgical resection. Our report illustrates a case of intermittent hydrocephalus due to a sessile subependymoma. Even though our patient presented with a histologically benign ventricular tumor, she demonstrated rapidly worsening symptoms that culminated in herniation. By presenting our case report, we hope to draw attention to this rare but potentially life-threatening presentation of subependymoma. Once diagnosed, we recommend early tumor removal and restoration of normal cerebrospinal fluid (CSF) pathways for these intraventricular tumors.

Management of acute ischemic stroke: current status of pharmacological and mechanical endovascular methods.

OBJECTIVE: To provide the current strategies of acute stroke management using pharmacological and interventional endovascular modalities. METHODS: Review of the literature for publications in English language literature on endovascular pharmacological and mechanical thrombolysis and clot retrieval. RESULTS: Aggressive management protocols have yielded therapeutic windows for effective reperfusion of ischemic brain in acute cerebral hypoperfusion/stroke. Starting with intravenous infusion of thrombolytics, which still remains to be the best feasible treatment for acute stroke management, recent advances in neuron imaging made it possible to utilize emergency cerebral angiographic evaluation of intracranial vessels followed by therapeutic measure that could be pharmacological or mechanical intervention. Intra-arterial clot lysis under image guidance combined with intravenous administration of thrombolytic is rapidly evolving with encouraging results. Microcatheters and endovascular appliances tested very positively, yielding better outcomes in acute stroke. MERCI trial, Multi MERCI trial and Stroke trials [emergency management of stroke (EMS) and interventional management of stroke (IMS)] have shown that early recanalization and reperfusion constitute good prognostic indicators by reducing mortality and improving neurological outcomes. Further trials are expected to yield better evidence to form guidelines for aggressive management of acute cerebral ischemia. DISCUSSION: Intravenous fibrinolysis is, to date, the best possible intervention in acute stroke and has been shown to be a better alternative to aspirin, the only known effective, pharmacological treatment. Endovascular interventions have shown very promising results with intra-arterial administration of thrombolytics as well as mechanical clot retrieving methods.

Gamma Knife stereotactic radiosurgery for intracranial metastases from conventionally radioresistant primary cancers: outcome analysis of survival and control of brain disease.

OBJECTIVE: The aim of this study was to analyze our experience with stereotactic radiosurgery in the management of patients with brain metastases from radioresistant primary cancers. METHODS: We retrospectively reviewed the clinical record of those patients for the outcome measures. All data were coded and entered into multivariate regression analysis for studying the relationship between survival and other variables. RESULTS: Over a 48-month period, 31 patients received radiosurgery for brain metastases from renal cell carcinoma (n = 7), malignant melanoma (n = 14), or colon carcinoma (n = 10) at our institution. The followup ranged from 1-48 months (mean = 17 months). At the time of last followup, 11 patients (35.5%) were alive and 20 had died. Six deaths (30%) resulted from progressive brain disease while 14 patients died from progressive primary and/or extracranial metastatic disease. Mean survival from radiosurgery was 12 months (95% CI, 7-17) and the median survival was 7 months. The 1 and 2 year actuarial survival rates were 32.5 +/- 1% and 12.2 +/- 1% respectively. The overall survival was directly related to tumor control time (P <0.001) and inversely to the number of metastases (P = 0.031). CONCLUSION: Gamma Knife stereotactic radiosurgery for intracranial metastases from conventionally radioresistant primary cancers is a safe and effective method to provide better local control of the brain disease and improve survival time.

Far-lateral approach for lower basilar artery aneurysms.

OBJECTIVES: Aneurysms of the lower basilar artery are surgically difficult to expose and clip. Various cranial base approaches, which are associated with significant morbidity, have been used to access this region. We have used the far-lateral approach without occipital condyle drilling for clipping of lower basilar junction aneurysms to assess the exposure for adequate visualization and clipping, and to study the complications and outcome. DESIGN: Retrospective review of data. SETTING: Between 1997 and 2001, four patients with lower basilar artery aneurysms were operated on at Louisiana State University Health Sciences Center in Shreveport. The far-lateral approach without drilling of the occipital condyle was used in each procedure. PARTICIPANTS: Cases of basilar artery aneurysms. MAIN OUTCOME MEASURES: Glasgow Outcome Scale (GOS) score. RESULTS: All four aneurysms were clipped successfully. All patients had good outcome (GOS scores of 5 and 4). There were no instances of cerebrospinal fluid leakage or pseudomeningocele. Two patients experienced transient morbidity in the form of voice hoarseness and swallowing difficulty. CONCLUSION: The far-lateral approach without drilling of the occipital condyle adequately exposed the lower basilar artery for successful clipping of aneurysms and was associated with minimal morbidity.

Anterior subaxial cervical spine fixation using a plate with single screw per vertebral body: a simple and efficient construct - clinical series and a cadaver study.

OBJECTIVE: To report our experience with a novel construct for traumatic and nontraumatic cervical spine lesions that was validated by biomechanical studies of cadaver cervical spine. STUDY DESIGN: Consecutive cases of anterior cervical spine fixation performed over six years reviewed for stability offered by a construct comprising of a plate fixed by a single screw to each vertebral body. SETTING: A university hospital and a biomechanical lab. MATERIALS AND METHODS: Data were coded and entered into a statistical worksheet for multivariate analysis. Cadaver spine models applied for biomechanical study of stability. RESULTS: Total of 103 cases reviewed; 86 with single-level disease; traumatic in 66 (64%) cases and degenerative in 33 (32%) cases, including hard disks, OPLL, and spondylitis (4% with other causes). Fixation was with diskectomy in 59 and with corpectomy in 40. A bone graft was utilized for fusion in 87 and a bone-filled titanium spacer in 13. A single screw was placed in each vertebral body with a locking plate (having linear arrangement of holes). This construct remained strong in 95% of cases at the end of 6-24 months. Five cases failed requiring reoperation. Five patients with cervical spinal cord injury (SCI) died. On statistical analysis, construct was stronger with diskectomy compared with corpectomy. Construct used on cadavers confirmed the biomechanical stability in short segment fixation (C5-6). CONCLUSION: A conservative construct utilizing a single screw per vertebral body and a one-holed plate system appears to be strong enough to afford stability in both traumatic and nontraumatic lesions of subaxial cervical spine, comparable to others.

Association of meningioma and intracranial aneurysm: report of five cases and review of literature.

Meningiomas associated with intracranial aneurysms are very rare. The co-existence of both lesions is not only a diagnostic challenge but also has important therapeutic implications. We analyzed our experience of five such patients, the second largest group in the literature. All the lesions were successfully managed surgically. All the patients were female. The location of the meningioma was clinoidal (2), planum sphenoidale (1), petroclival (1) and pterional (1). Three patients had posterior communicating (PCOM) artery aneurysm associated with meningioma. The other aneurysms were internal carotid artery (ICA) and anterior communicating artery (ACOM). One patient with pterional meningioma had an anomalous meningeal artery arising from the right ophthalmic artery. In three patients both lesions underwent treatment at the same sitting. In two patients meningioma underwent excision first followed by aneurysm clipping. From our experience the incidence of meningiomas associated with aneurysms was 1.1%, which is not higher than the incidence of aneurysms in the general population.

A noncontiguous 2-level spinal injury in a young female driver due to a 3-point seat belt restraint.

OBJECTIVES: The purpose of this case is to describe noncontiguous fracture and dislocations of the thoracolumbosacral spine in a 23-year-old female driver with a 3-point seat belt restraint. CLINICAL FEATURES: A 23-year-old woman presented to us after a motor vehicle accident while driving with a 3-point seat belt restraint. She was neurologically intact except for loss of motor function in the distribution of the L5 nerve root in the right lower limb. Computed tomography and magnetic resonance imaging showed fracture and dislocation of T3 with considerable retrolisthesis and complete anterolisthesis of L5 over the sacrum. INTERVENTION AND OUTCOME: Both fractures were reduced and fixed with bone graft and instrumentation. She was discharged a month later without any further neurologic deterioration. CONCLUSIONS: To our knowledge, this case is the first report in the literature of a seat belt safety restraint causing 2 noncontiguous fracture dislocations of the spine. Although the consensus is that seat belts can prevent most spine injuries, this case shows that the seat belt can be a contributor to spine injury. It shows that the shoulder-lap restraint can act as 2 fulcrums at the upper and lower bands causing 2 separate fracture dislocations. A thorough radiologic evaluation of the spine with respect to the clinical findings is mandatory in seat belt-restrained road traffic accidents cases.

Gamma knife radiosurgery for arteriovenous malformations located in eloquent regions of the brain.

BACKGROUND: Stereotactic radiosurgery is an effective treatment strategy for selected group of patients with cerebral arteriovenous malformations (AVMs). AIM: The aim of this study was to evaluate the obliteration rates, complications, and patient outcomes after Gamma knife radiosurgery for cerebral arteriovenous malformations (AVMs) located in eloquent regions of the brain with an emphasis on neurological morbidity. MATERIALS AND METHODS: Between 2000 and December 2005, 37 patients with AVMs in eloquent locations (sensory, motor, speech, visual cortex, basal ganglia, and brain stem) underwent stereotactic radiosurgery. We retrospectively reviewed the clinical data of these patients to asses the outcomes. Of the 37 patients, only two patients had prior embolization. Three underwent prospective staged volume radiosurgery. Two patients needed redo-radiosurgery for residual AVM. Mean target volume was 9.1 cc. Three lesions had nidus volume more than 20 cc. Average marginal dose was 18.75 Gy. The median duration of follow-up was 23 months (range, 6-60 months). 15 patients had follow-up of more than 36 months. RESULTS: A total of 15 patients had follow-up of more than 36 months, thus available for evaluation of angiographic obliteration rates. Complete angiographic obliteration was documented in seven patients (46.7%). Four patients experienced hemorrhage during the latency period. One patient who had subsequent hemorrhage on follow-up developed worsening of neurological deficit. One patient developed significant sensory symptoms which resolved after steroids. No additional clinical deterioration related to treatment was noted in rest of the patients. CONCLUSIONS: AVMs located in eloquent and in deep locations can be treated safely with stereotactic radiosurgery with acceptable obliteration rates and minimal morbidity.

Nucleus Accumbens as a Novel Target for Deep Brain Stimulation in the Treatment of Addiction: A Hypothesis on the Neurochemical and Morphological Basis.

Addiction is a major cause of mortality and morbidity. Apart from psychotropic substances, alcohol and nicotine remain the common addictive materials responsible for the majority of deaths. Conventional conservative therapies are beneficial to certain populations, but the majority may require interventional treatments such as deep brain stimulation (DBS) in view of increasing mortality from drug abuse in recent years. We present a brief review on a novel neuromodulation target of the nucleus accumbens (NA) and its promising role in the management of addiction. The three stages of the addiction cycle are known to be mediated by dopaminergic pathways located in the mesolimbic dopamine system with connections to dorsal striatum, extended amygdala, cingulate gyrus, orbitofrontal cortex, prefrontal cortex, and ventral tegmental area. Recent advanced neuroimaging in humans and several animal studies demonstrated NA to be a vital anatomical area modulating this network. DBS of NA in animals reduced addictive behavior to alcohol, cocaine, and other narcotics significantly. The accidental observation that DBS of NA for psychiatric illnesses induced relief from addiction to alcohol and smoking has encouraged further research of late. Bilateral NA ablative surgery had shown nonrelapse in more than 50% of cases. Small series of patients have benefited so far from DBS of NA, but larger numbers are required to provide evidence-based treatment. The modulation of dopaminergic pathways through DBS of NA as a valid treatment for addiction is substantiated extensively by animal studies and also in a few clinical studies. However, this needs to be validated by a well-structured, multicenter controlled study in a large group of patients suffering from substance abuse.