Anterior Capsulotomy Research Articles

Image sharpening algorithms improve clarity of surgical field during 3D heads-up surgery

BackgroundImage-sharpening algorithms with color adjustments enable real-time processing of the surgical field with a delay of 4 msec for heads-up surgery using digital three-dimensional displays. The aim of this study was to investigate the usefulness of the algorithms with the Artevo 800® digital microscope.MethodsSeven vitreoretinal surgeons evaluated the effects of image-sharpening processing on the clarity of the surgical field with the Artevo 800® system that is used for cataract and vitreous surgeries. The scorings were made on a 10-point scale for anterior capsulotomy, phacoemulsification, cortex aspiration, core vitrectomy, and peeling of an epiretinal membrane or an internal limiting membrane. In addition, the images during the internal limiting membrane peeling were processed with or without color adjustments. We also evaluated the skewness (asymmetry in the distribution of the pixels) and kurtosis (sharpness in the distribution of the pixel) of the images to evaluate the contrast with each intensity of image-sharpening.ResultsOur results showed that the mean visibility score increased significantly from 4.9 ± 0.5 at 0% (original image) to 6.6 ± 0.5 at 25% intensity of the image-sharpening algorithm (P < 0.01). The visibility scores of the internal limiting membrane increased significantly from 0% (6.8 ± 0.3, no color adjustments) to 50% after the color adjustments (7.4 ± 0.4, P = 0.012). The mean skewness decreased significantly from 0.83 ± 2.02 at 0% (original source) to 0.55 ± 1.36 at 25% intensity of the image-sharpening algorithm (P = 0.01). The mean kurtosis decreased significantly from 0.93 ± 2.14 at 0% (original image) to 0.60 ± 1.44 at 25% intensity of the image-sharpening algorithm (P = 0.02).ConclusionsWe conclude that the image-sharpening algorithms can improve the clarity of the surgical field during 3D heads-up surgery by decreasing the skewness and kurtosis.Trial registrationThis was a prospective clinical study performed at a single academic institution, and the procedures used were approved by the Institutional Review Committee of the Kyorin University School of Medicine (reference number, 1904). The procedures also conformed to the tenets of the Declaration of Helsinki.

Repetitive Negative Thinking–Specific and –Nonspecific White Matter Tracts Engaged by Historical Psychosurgical Targets for Depression

BackgroundRepetitive negative thinking (RNT) is a frequent symptom of major depressive disorder (MDD) that is associated with poor outcomes and treatment resistance. While most studies on RNT have focused on structural and functional characteristics of gray matter, this study aimed to examine the association between white matter (WM) tracts and interindividual variability in RNT. MethodsA probabilistic tractography approach was used to characterize differences in the size and anatomical trajectory of WM fibers traversing psychosurgery targets historically useful in the treatment of MDD (anterior capsulotomy, anterior cingulotomy, and subcaudate tractotomy) in patients with MDD and low (n = 53) or high (n = 52) RNT, and healthy control subjects (n = 54). MDD samples were propensity matched on depression and anxiety severity and demographics. ResultsWM tracts traversing left hemisphere targets and reaching the ventral anterior body of the corpus callosum (thus extending to contralateral regions) were larger in the high-RNT MDD group compared with low-RNT (effect size D = 0.27, p = .042) and healthy control (D = 0.23, p = .02) groups. MDD was associated with greater size of tracts that converge onto the right medial orbitofrontal cortex regardless of RNT intensity. Other RNT-nonspecific findings in MDD involved tracts reaching the left primary motor and right primary somatosensory cortices. ConclusionsThis study provides the first evidence to our knowledge that WM connectivity patterns, which could become targets of intervention, differ between high- and low-RNT participants with MDD. These WM differences extend to circuits that are not specific to RNT, possibly subserving reward mechanisms and psychomotor activity.

Mechanisms underlying capsulotomy for refractory obsessive-compulsive disorder: neural correlates of negative affect processing overlap with deep brain stimulation targets

Ablative procedures such as anterior capsulotomy are potentially effective in refractory obsessive-compulsive disorder (OCD). Converging evidence suggests the ventral internal capsule white matter tracts traversing the rostral cingulate and ventrolateral prefrontal cortex and thalamus is the optimal target for clinical efficacy across multiple deep brain stimulation targets for OCD. Here we ask which prefrontal regions and underlying cognitive processes might be implicated in the effects of capsulotomy by using both task fMRI and neuropsychological tests assessing OCD-relevant cognitive mechanisms known to map across prefrontal regions connected to the tracts targeted in capsulotomy. We tested OCD patients at least 6 months post-capsulotomy (n = 27), OCD controls (n = 33) and healthy controls (n = 34). We used a modified aversive monetary incentive delay paradigm with negative imagery and a within session extinction trial. Post-capsulotomy OCD subjects showed improved OCD symptoms, disability and quality of life with no differences in mood or anxiety or cognitive task performance on executive, inhibition, memory and learning tasks. Task fMRI revealed post-capsulotomy decreases in the nucleus accumbens during negative anticipation, and in the left rostral cingulate and left inferior frontal cortex during negative feedback. Post-capsulotomy patients showed attenuated accumbens-rostral cingulate functional connectivity. Rostral cingulate activity mediated capsulotomy improvement on obsessions. These regions overlap with optimal white matter tracts observed across multiple stimulation targets for OCD and might provide insights into further optimizing neuromodulation approaches. Our findings also suggest that aversive processing theoretical mechanisms may link ablative, stimulation and psychological interventions.

The Efficacy of Anterior Capsulotomy and Basal Capsulectomy Adherent to Expanded Scalp Flap During Alopecia Reconstruction in Pediatric Burned Patients.

Scalp expansion is an optimal treatment for alopecia resulting from burn injuries, especially in the pediatric population through providing highly vascularized adjacent local tissues with optimal hair density, color matching, texture, and hair-bearing characteristics. The aim of this study was to evaluate the efficacy of anterior capsulotomy and basal capsulectomy adherent to expanded scalp flap during alopecia reconstruction with scalp expansion in pediatric burned patients. The study was conducted on 127 patients with an age range of 5 to 19 years who presented with postburn alopecia accompanied by hairline loss. The patients were divided into 2 groups: group I consisted of 58 patients who were operated on using conventional technique, and group II consisted of 69 patients who were operated using modified technique including basal capsulectomy on the skull side and anterior capsulotomy on the expanded scalp flap. The Hairdex, a validated questionnaire of Hair-Specific Health-Related Quality of Life measures, showed that percentage of satisfaction concerning outcomes was 91.50%, psychological well-being was 95%, and self-confidence was 84.30% in group II, compared with 63%, 55.70%, and 66.20%, respectively, in group I. This significant values had a great positive effect on patient satisfaction, changing child's behavior and self-confidence. Although physiological background of tissue expansion is the same, proper flap design with anterior capsulotomy on flap undersurface and basal capsulectomy on the skull side improve results of the traditional method significantly and minimize the complication rate. These surgical modifications provide maximum benefits from expanded tissue, with restoration of the hairline and a uniform hair direction. Level III, case-control study.

Posterior Capsulotomy Size Affects the Formation of Significant Visual Axis Opacification in Congenital and Developmental Cataract.

To assess the relationship between posterior capsulotomy size and significant visual axis opacification (VAO) in congenital and developmental cataract. The charts of children aged 7 years and younger who underwent cataract surgery including primary posterior capsulotomy (PPC) and limited anterior vitrectomy between 2012 and 2022 were retrospectively reviewed. Eyes with PPC size smaller than the anterior capsulotomy size were considered as group 1. Eyes with PPC size larger than the anterior capsulotomy size were considered as group 2. Clinical characteristics, the need for Nd:YAG laser treatment or further surgery for significant VAO, and other postoperative complications were compared between the groups. Sixty eyes of 41 children were included in the study. The median age at the time of surgery was 5.5 and 3 years in groups 1 and 2, respectively (P = .076). Primary intraocular lens implantation was performed in 23 (85.2%) eyes in group 1 and 25 (75.8%) eyes in group 2 (P = .364). There was no difference between the groups in terms of postoperative visual acuity (P = .983) and refractive errors (P = .154). Eight (29.6%) pseudophakic eyes received Nd:YAG laser treatment in group 1, but none of the eyes in group 2 (P = .001). Four (14.8%) eyes in group 1 and 1 (3%) eye in group 2 underwent further surgery for VAO (P = .100). The need for further intervention for significant VAO was statistically higher in group 1 (44.4% vs 3%, P < .001). Larger PPC size in pediatric cataract may reduce the need for further intervention for significant VAO. [J Pediatr Ophthalmol Strabismus. 2023;60(6):441-447.].

Selective laser capsulotomy complications: Management and prevention.

To report how to manage and prevent the incomplete laser cut and following uncut tags of anterior capsular lens, performed using the selective laser capsulotomy. We describe three possible approaches: peeling the anterior capsulotomy disc with forceps, breaking the tags using the cystotomy needle tip, or cutting them using a 23-G vitrectomy scissors. Using the 23-G vitrectomy scissors resulted in no complication. Peeling the anterior capsulotomy using the forceps instead caused zonular stress with subsequent risks of zonular dialysis, whereas using the cystotomy needle tip resulted in irregular capsulotomy rim and weakness all along the capsulotomy edge where micro tears caused a tear during the rest of cataract surgery. Incomplete laser cut and subsequent discontinuous capsulotomy results in the presence of multiple tags which create strong adherence between the central capsulotomy disc and the peripheral capsule. Key steps of the procedure to prevent an incomplete laser cut, which are the anterior lens capsule staining and laser beam focusing, and how to correctly manage them, which may shorten the learning curve and enhance the outcomes.

Femtosecond Laser Capsulotomy in Previous Radial Keratotomy.

The aim of this study was to describe clinical experience using femtosecond laser-assisted anterior capsulotomy in eyes with previous radial keratotomy. Eyes of patients with previous radial keratotomy and cataract-related vision impairment who underwent phacoemulsification and intraocular lens implantation were retrospectively reviewed. Eyes with any vision impairment cause other than cataract or previous radial keratotomy were excluded. Sixteen postradial keratotomy eyes were included. In 5 patients, manual anterior capsulectomy was successfully performed. Six eyes underwent femtosecond laser capsulotomy using routine parameters (incision depth 500 μm and 4 μJ power), of which in 3 eyes capsulotomies were complete, whereas in the other 3 eyes incomplete capsulotomy was evident. In 3 patients, both incision depth and power parameters were doubled (incision depth 1000 μm and 8 μJ power), whereas in 2 patients, only the pulse energy was doubled (8 μJ power) and in all 6 cases, the capsulotomy was successfully completed. At the last follow-up, all capsulotomies were intact without radial tears, and the intraocular lenses were stable and central. Radial corneal scars after previous radial keratotomy may interfere with femtosecond laser-assisted anterior capsulotomy using routine parameters. Surgeons should be alert and ready to convert to manual anterior capsulectomy. Modification of the laser parameters may overcome this potential complication.

A rare case of complete anterior capsular occlusion following phacoemulsification with acrylic intraocular lens and capsular tension ring implantation in pseudoexfoliation syndrome

A 72-year-old man presented with bilateral brunescent cataract with pseudoexfoliation syndrome and subtle phacodonesis. He underwent right eye phacoemulsification with a 5-mm continuous curvilinear capsulorrhexis and implantation of an acrylic hydrophilic intraocular lens (IOL) with a polymethyl methacrylate (PMMA) capsular tension ring (CTR). Six months postoperatively, anterior capsule fibrosis and complete closure of the capsulorhexis opening were noted. A neodymium: YAG (Nd: YAG) laser anterior capsulotomy was performed for visual recovery. The centripetal forces of capsular fibrosis after cataract surgery may exceed the centrifugal resistance of the standard CTR in patients with pseudoexfoliation. Such patients must be frequently monitored postoperatively. A Nd: YAG laser anterior capsulotomy is a safe and effective option to manage even thick membranous anterior capsular occlusion. This is a unique case report since anterior capsular fibrosis and complete occlusion despite CTR in situ are extremely rare (reported only once to the best of our knowledge).

Histopathological findings of anterior lens capsule in paediatric cataract patients

AbstractPurpose: To investigate the histopathological findings of the anterior lens capsule in patients with paediatric cataracts.Methods: This study is a prospective interventional study. Anterior capsule tissue samples which were obtained by anterior capsulotomy method during phaco surgery were fixed in 0.1 M phosphate buffered 2.5% glutaraldehyde at +4°C for 2–4 h and after passing through other stages, thin sections were taken and stained. It was then examined and visualized under HITACHI HT7800 transmission electron microscope.Results: Twenty‐three eyes of 19 patients were included. Three patients had unilateral cataract and remaining 16 had bilateral cataract. Four patients had concomitant systemic disease including hydrocephalus, cerebral palsy, juvenile myelomonocytic leukaemia and Down syndrome. Except for one patient, common findings were single‐layered epithelium under the capsule, degenerated organelles with round‐oval and prismatic‐oval nuclei in some regions, enlarged mitochondria and heterochromatin cells. In the case with cerebral palsy, unlike the normal lens structure, collagen fibrils of the connective tissue and fibroblast‐like cells were observed in the epithelial area that should be located under the capsule, in both eyes. Disorganized distribution of collagen fibrils and vacuole structures in the cytoplasm of fibroblast‐like cells were observed.Conclusions: Similar histopathological findings were found in paediatric cataracts with or without systemic disease. Due to the presence of increased inflammation and gliosis in cerebral palsy, the absence of lens epithelium may have developed as a result of degeneration in this patient. The absence of lens epithelium and inflammation are thought to play a role in the development of dense subcapsular fibrosis.

Stereotactic Radiofrequency Ablation for Treatment-Refractory Depression: A Systematic Review and Meta-Analysis.

(1) Background: Major depressive disorder (MDD) generates a large proportion of global disease burden. Stereotactic radiofrequency ablation (SRA) may be beneficial for selected patients with its most debilitating and refractory forms, but effect size is uncertain. (2) Methods: A systematic literature review and meta-analysis on SRA for MDD was carried out. Patient-level data were extracted from articles reporting validated depression measures (Beck Depression Inventory (BDI), Montgomery–Åsberg Depression Rating Scale (MADRS)), pre- and at least six months post surgery. To accommodate different outcome measures, the standardised mean difference (SMD) between both scores was used as the principal effect size. Data were synthesised using a random-effects model. (3) Results: Five distinct studies were identified, comprising 116 patients (64 included in meta-analysis). Effect size comparing post- vs. pre-operative scores was 1.66 (CI 1.25–2.07). Anterior cingulotomy (two studies, n = 22) and anterior capsulotomy (three studies, n = 42) showed similar effect sizes: 1.51 (CI 0.82–2.20) vs. 1.74 (CI 1.23–2.26). Multiple procedures were performed in 30 of 116 (25.9%) patients. Based on patient-level data, 53% (n = 47) were responders (≥50% improvement), of which 34% reached remission (MADRS ≤ 10 or BDI ≤ 11). BDI mean improvement was 16.7 (44.0%) after a second procedure (n = 19). (4) Conclusions: The results are supportive of the benefit of SRA in selected patients with refractory MDD.

Impact of Capsulotomy on Hip Biomechanics during Arthroscopy.

Background and Objectives: Anterior capsulotomy is routinely performed in hip arthroscopy to improve joint visualization; however, this can partly or completely disrupt the stabilizing ligaments of the hip. This study aimed to report the effects of conventional and extensive arthroscopic capsulotomies on hip stability. Materials and Methods: Eight freshly frozen cadaveric pelvises were used in this study. The range of motion and translation were measured and compared among different capsular conditions utilized in hip arthroscopy, with a special interest in the iliofemoral ligament (IFL) and zona orbicularis (ZO). The conditions included intact capsule, interportal capsulotomy, T-capsulotomy, complete IFL disruption, and complete IFL and ZO disruption. Internal rotation at three flexion planes (−10°, 0°, and 30°) and external rotation at six flexion planes (−10°, 0°, 30°, 60°, 90°, and 110°) were measured with corresponding femoral head translation distance at the application of 2.5 Nm torque. Results: As compared to an intact capsule, a significant increase in external rotation was observed after interportal capsulotomy from −10° to 60° and after T-capsulotomy from −10° to 110° flexion. A significant translation was observed only with a T-capsulotomy, which ranged from 1.9 to 2.3 mm across the flexion angles. Compared with conventional interportal capsulotomy, disruption of the entire IFL resulted in a significant increase in external rotation in all flexion planes, and significant translation was accompanied by disruption of the ZO. Conclusions: Interportal capsulotomy can result in an increase in range of motion, and T-capsulotomy can lead to significant translation. Partial or complete tears of the IFL and ZO can result in further external rotation and translation.

Efficacy of haptic sutured in-the-bag intraocular lens for intraocular lens-capsule complex stability: a comparison of three insertion methods.

To evaluate the efficacy and stability of haptic sutured in-the-bag intraocular lens (IOL) in eyes with zonular instability. A total 60 eyes of 60 patients were included in this retrospective cohort study. Postoperative stability in three groups [haptic sutured IOL in the bag, IOL in the bag insertion with haptics oriented toward areas of zonulysis, IOL with capsular tension ring (CTR) in the bag insertion] were compared according to the IOL insertion methods. To evaluate the IOL stability, the changes of anterior chamber depth (ACD), refraction, contraction of anterior continuous curvilinear capsulotomy (CCC) area, and tilt of IOL were compared. There was no significant difference in change of ACD (-0.04±0.01 mm in group of haptic sutured IOL, -0.07±0.01 mm in group of CTR insertion) and refraction (0.05±0.05 D in group of haptic sutured IOL, 0.37±015 D in group of CTR insertion) between the group of haptic sutured IOL in the bag and CTR insertion group. But in comparison of CCC contraction and IOL tilt, CTR insertion group showed less contraction (1.00%±0.52%) and less IOL tilt (2.66°±0.11°) than the group of haptic sutured IOL in the bag (6.32%±1.36%, 3.47°±0.11°, respectively). The CTR insertion group showed the least CCC contraction and the least tilt. In eyes with zonular instability, the method of haptic sutured IOL in-the-bag shows comparable stability in ACD and refraction in comparison with IOL with CTR in the bag insertion. The method of IOL only in-the-bag insertion shows the largest contraction of CCC and the largest tilt of IOL.

Inside-out and outside-in: Tips and tricks in posterior lenticonus.

Posterior lenticonus is a congenital condition characterized by the thinning and bowing of posterior lenticular capsule. Cataract develops when normal intra-lenticular pressure bulges the posterior capsule at the circumscribed portion of inherent thin posterior lens capsule, leading to derangement of lamellar lens fibers. This condition poses a surgical challenge as the presentation varies from thin, bulging posterior capsule to large, pre-existing posterior capsular dehiscence. This video highlights the tips for the surgical management of various scenarios of posterior lenticonus. In this video, tips for surgical management of various scenarios of posterior lenticonus are illustrated. Intraoperatively, ruptured posterior capsule is suspected by the presence of a fish-tail sign. The anterior capsulotomy is relatively easier in a flatter anterior lens capsule, owing to reduced intra-lenticular pressure. Hydro-dissection is avoided to prevent extension of pre-existing posterior capsular dehiscence or creation of rupture in a thinned-out capsule. The peripheral lens cortex aspiration is initiated first, followed by in each quadrant. In a presence of ruptured posterior capsule by vigilant inspection at this stage, the surgeon should change the direction of lens matter aspiration by aspirating the central lenticular matter first, followed by peripheral cortex like "inside-out". In absence of posterior capsule dehiscence, peripheral cortex is aspirated first, followed by central lens matter aspiration like "outside-in". Adequate anterior vitrectomy is performed until there are no vitreous tags. In the presence of pre-existing posterior capsular defect, the lens matter is aspirated from the center (inside-out), whereas in the absence of capsular defect, the lens matter is aspirated from the periphery (outside-in). https://youtu.be/8G6BCbFwr8Q.

Ablation Surgeries for Treatment-Resistant Depression: A Meta-Analysis and Systematic Review of Reported Case Series

Background and Objectives: Ablative lesion procedures remain as the last option in treatment of refractory depression. Contemporary ablative psychosurgeries involve producing lesions in the anterior limb of the internal capsule (bilateral anterior capsulotomy – BAC), the supragenual anterior cingulate gyrus and cingulum (bilateral anterior cingulotomy – BACING), and subgenual anterior cingulate gyrus and subcortical orbitofrontal white matter (bilateral subcaudate tractotomy – BST). A combination of BACING and BST is known as limbic leukotomy (bilateral limbic leukotomy – BLL). All procedures claim some success, but cohorts are small, depression assessment instruments differ, and inclusion and outcome criteria and follow-up duration vary. In some cohorts, more than one type of surgery was performed in several patients, further confounding interpreting the available data. Current evidence is equivocal on which surgical target works best. Method and Aim: This systematic review and meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) standard on published cohorts was conducted to review and identify which is the best standalone ablative procedure for treatment-resistant depression (TRD) based on response rate (event rate) and adverse-effect profile using the Comprehensive Meta-Analysis software. Results and Conclusion: As a standalone neurosurgical procedure, we found that BAC appears to be the most effective and safest of all the ablative targets for TRD. A major limitation of this conclusion is the paucity of published case series where sample sizes are small and all are open label.

Thermocoagulation for the Treatment of Anorexia Nervosa Associated with Obsessive-Compulsive Disorder: Case Report

AbstractAnorexia nervosa (AN) and obsessive-compulsive disorder (OCD) are two psychiatric disorders that often overlap or are diagnosed as distinct disorders in the same individual. Although neurosurgical treatment is currently reserved for patients with refractory chronic OCD, it has been evidenced that it is also effective for the treatment of AN, since these two disorders share some pathophysiological neurocircuits. The present study aimed to report the case of a patient with AN, OCD, schizophrenia, and comorbid depression who underwent thermocoagulation of the nucleus accumbens associated with anterior cingulotomy and anterior capsulotomy, all of them bilaterally. Follow-up, performed 16 months after the procedure, showed substantial improvement in AN, OCD, and schizophrenia symptoms, demonstrating the effectiveness of this type of intervention in patients refractory to conservative treatment.

A narrative review of ablative neurosurgery in refractory mental disorders

SUMMARYNeurosurgery for mental disorder (NMD) is currently performed in the UK for cases of severe depressive disorder and obsessive–compulsive disorder refractory to treatment, under stringent regulations as set out under the Mental Health Act 1983. These surgical procedures appear to be effective for a proportion of individuals in this particularly treatment-resistant cohort. The two ablative procedures currently in use in the UK are anterior cingulotomy (ACING) and anterior capsulotomy (ACAPS). After briefly outlining these procedures, their evidence base and how they compare with other neurosurgical procedures, we suggest two ways in which they could be enhanced in terms of precision, namely the use of stereotactic (Gamma Knife®) radiosurgery guided by magnetic resonance imaging as well as a detailed and expanded standardised psychopathological and neuropsychological assessment both before and after surgery. The latter should involve extended long-term follow-up. We then reflect on how such psychopathological and neuropsychological assessments could help to understand why and how these procedures relieve patients’ suffering and distress.

Primum non nocere: psychosurgery in a case of severe anorexia nervosa. A case report

IntroductionBilateral cingulotomy and anterior capsulotomy are two neurosurgical procedures which are reserved as a last resort for cases of severe OCD in Spain; these procedures are not approved in cases of AN.ObjectivesWe present the case of a 29-year-old female patient who was diagnosed with anorexia nervosa (AN) when she was 15 (2006). Due to the severity of the case the patient needed to be hospitalized for many months due to excessive weight loss. She was also treated in an out-patient department and started several intensive psychotherapeutic procedures. In 2015 the patient’s family took her to a private clinic where she was diagnosed with Obsessive-compulsive disorder (OCD) and had a bilateral cingulotomy and anterior capsulotomy.MethodsA case report where the ethical implications of the case are weighed alongside a review of the relevant literature regarding neurosurgical treatments of AN.ResultsThere were no significant short or long term improvements in terms of Body Mass Index or reduction of symptoms, the patient’s cognitive functions showed a decline in neuropsychological tests. Contrary to that the patient has needed hospitalizations for at least 9 months per year since the surgery and has needed admission in the Intensive Care Unit at least 3 times because of extreme malnutrition. Due to her need for chronic hospitalization was institutionalized in a long-stay psychiatric hospital.ConclusionsPsychosurgery is a controversial therapy which has limited evidence in cases of AN. Our case shows the way in which neurosurgical procedures can do more harm than good and worsen the prognosis of patients.DisclosureNo significant relationships.

Femtosecond laser-assisted anterior capsulotomy in children undergoing cataract surgery: a large case series

ObjectiveTo evaluate safety and postoperative visual outcomes of low-energy femtosecond laser-assisted (FLA) anterior capsulotomy in paediatric cataract surgery.Methods and analysisWe report a retrospective single-centre consecutive case series of 51 eyes...

The Evolution of Modern Ablative Surgery for the Treatment of Obsessive-Compulsive and Major Depression Disorders.

In this review, we describe the evolution of modern ablative surgery for intractable psychiatric disease, from the original image-guided cingulotomy procedure described by Ballantine, to the current bilateral anterior cingulotomy using MRI-guided stereotactic techniques. Extension of the single lesion bilateral cingulotomy to the extended bilateral cingulotomy and subsequent staged limbic leucotomy (LL) is also discussed. Other ablative surgeries for psychiatric disease including subcaudate tractotomy (SCT) and anterior capsulotomy (AC) using modern MRI-guided ablative techniques, as well as radiosurgical capsulotomy, are described. Finally, the potential emerging role of MR-guided focused ultrasound (MRgFUS) for treating conditions such as major depressive disorder (MDD) and obsessive-compulsive disorder (OCD) is discussed.

144 Interstitial Laser Anterior Capsulotomy for Obsessive-compulsive Disorder: Lesion Size and Tractography Correlate with Outcome

INTRODUCTION: Anterior capsulotomy is a well-established treatment for refractory obsessive-compulsive disorder (OCD) and has been performed with radiofrequency ablation, stereotactic radiosurgery, and focused ultrasound. MRI-guided laser interstitial thermal therapy (LITT) allows creation of larger, more demarcated lesions with the safety conferred by real-time imaging of the ablation volume. METHODS: Patients with severe OCD refractory to pharmacotherapy and cognitive-behavioral therapy underwent bilateral anterior capsulotomy via LITT. The primary outcome was percent reduction in Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score over time. Lesion size was measured on post-ablation MRI. Disconnection of the anterior limb of the internal capsule (ALIC) was assessed via individual and normative tractography. RESULTS: Eighteen patients underwent laser anterior capsulotomy. Median follow-up was 6 months (range 3-51 months). Time occupied by obsessions improved immediately (median Y-BOCS item 1 score 4 to 1, P = 0.0002). Mean (± standard deviation) decrease in Y-BOCS score at last follow-up was 46 ± 32% (16 ± 11 points; P = 0.0002). Sixty-one percent of patients were responders. One patient had an asymptomatic intracerebral hemorrhage. Reduction in Y-BOCS score was positively associated with ablation volume (P = 0.006). Individual tractography demonstrated durable ALIC disconnection. Normative tractography revealed a dorsal-ventral gradient, with disconnection of orbitofrontal streamlines most strongly associated with a positive response to surgery (P &lt; 0.0001). CONCLUSION: Laser anterior capsulotomy resulted in immediate, marked improvement in OCD symptom severity. Larger lesions can be created safely and permit greater disconnection of the prefrontal-subcortical pathways involved in OCD. The importance of greater disconnection is presumably related to variation in ALIC structure and the complex role of the PFC in OCD.