Changes in artistic expression after deep brain stimulation of the anterior thalamic nucleus

We performed deep-brain stimulation of the anterior thalamic nucleus (ANT-DBS) in a patient with drug-resistant focal epilepsy, resulting in seizure freedom. His drawing ability was evaluated before surgery, on postoperative day (POD) 5, and at one month using the Landscape Montage Technique (LMT). Although artistic ability was preserved, the one-month drawings used calmer colors and lacked overlapping structures. Self-Rating Depression Scale (SDS) scores remained normal. These changes may reflect improved emotional stability and enhanced visuospatial processing following seizure freedom. Seizure suppression has traditionally been the primary therapeutic goal in epilepsy; however, recent approaches increasingly emphasize quality of life (QOL).1 Here, we report a patient whose primary source of fulfillment was drawing and who achieved seizure control with ANT-DBS, resulting in notable changes in his artwork. A 45-year-old Japanese man, originally left-handed but later shifted to right-hand dominance, had a febrile seizure at 8 months and pertussis encephalitis with status epilepticus at 13 months. From age six, he developed focal impaired awareness seizures (FIAS) with mild intellectual disability and autism spectrum disorder (ASD). Although unemployed, he enjoyed drawing and won municipal art awards. At referral, he experienced several monthly FIAS, along with falls and occasional generalized convulsions. He was treated with carbamazepine 400 mg, topiramate 500 mg, and valproate 1200 mg. Lacosamide was discontinued due to somnolence and irritability. Magnetic resonance imaging (MRI) revealed right occipital focal cortical dysplasia (FCD) with marked right-hemispheric atrophy. Interictal scalp electroencephalogram showed sharp waves over O2 and T1. Wada test suggested early reorganization of language from right to left hemisphere. Neuropsychological assessment revealed global cognitive impairment. Preoperative evaluation suggested FCD as the primary epileptogenic zone (EZ), although the long clinical course indicated possible left-hemispheric involvement. Stereoelectroencephalography demonstrated seizure onset zone in the right premotor cortex, preceding ictal involvement of FCD, with semiology resembling right mesial temporal lobe epilepsy. Because the presumed EZ extended into widespread atrophic regions, extensive resection was considered to carry a high risk of language and visuospatial dysfunction. Thus, ANT-DBS was selected. The patient achieved seizure freedom for 3 months without complications. Coregistration of preoperative MRI and postoperative computed tomography using BrainLab demonstrated bilateral electrode placement in ANT. Stimulation parameters were −1/+C, 2.5 mA, 90 μs, 145 Hz for continuous stimulation. Drawing ability was evaluated using LMT (Figure 1). Preoperatively, he depicted all required items, using vivid colors such as red and yellow. A notable feature was yellow flowers extending beyond the river boundary. On POD 5, he showed reduced motivation and omitted some elements, including flowers, stones, and butterflies. At one month, all elements reappeared, and the drawings were dominated by calm colors such as green and light green, with no objects extending beyond the river boundary. The SDS scores were 35 preoperatively, 32 on POD 5, and 29 at one month. We compared preoperative drawings with those created during a three-month seizure-free period. Although depression has been reported as an adverse effect of ANT-DBS, SDS scores did not indicate depressive symptoms. The transient loss of motivation observed on POD 5 was considered to reflect perioperative stress, including wound pain, social loneliness, and restricted mobility during hospitalization. After discharge, these stress-related effects subsided, but persistent changes in color expression and drawing style remained. For patients unaware during seizures, the postictal state may have a greater impact on QOL than the seizure itself.1 Psychological stabilization following seizure control may have contributed to the increased use of calm colors in the postoperative drawings. Some features of Savant syndrome (SS) were also noted. SS is characterized by exceptional abilities coexisting with congenital or acquired neurological disorders and is frequently associated with ASD.2, 3 Individuals with ASD-associated SS often show a right-hemispheric bias and superior visuospatial abilities.4 Enhanced artistic abilities have been reported following left frontal and temporal brain contusions,5 in frontotemporal dementia,6-8 and after left frontal hemorrhagic infarction.9 The artistic talent often involves nonverbal abilities, with highly detailed and realistic works that typically lack abstract or symbolic components.10 Because this patient was congenitally left handed, dysfunction of the dominant right hemisphere may explain findings similar to those reported after left frontal dysfunction. Postoperative changes may additionally reflect seizure-related alterations in visuospatial processing. These findings highlight broader therapeutic goals and improve understanding of brain functions underlying artistic expression. The authors declare that they have no conflicts of interest. Written informed consent was obtained from the patient. The data that support the findings of this study are available upon request to the corresponding author. The data are not publicly available because they contain information that could compromise the privacy of research participants. Figure S1. Anatomical relationship between ANT and DBS electrodes. This figure shows the coregistration of preoperative MRI and postoperative CT performed using BrainLab. The light blue outline represents the entire thalamus, and the pink region indicates the anterior nucleus of the thalamus. Both electrodes were implanted bilaterally in the anterior thalamic nucleus; the left electrode was positioned slightly anteriorly, whereas the right electrode was positioned slightly posteriorly. Data S1. Data S2. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article. Why was deep brain stimulation selected instead of resective surgery? What postoperative changes were observed in the patient's drawings? Why were the observed changes in the drawings not considered to be manifestations of depression after ATN-DBS? Answers may be found in the supporting information.