Bilateral Anterior Capsulotomy Research Articles

Ventral targeted anterior capsulotomy for treatment-resistant depression and obsessive-compulsive disorder: A treatment method with cases

BackgroundAblative surgery using bilateral anterior capsulotomy (BAC) is an option for treatment resistant depression (TRD) and obsessive-compulsive disorder (TROCD). The location and extent of the lesion within anterior limb of the internal capsule (ALIC) remains uncertain. Accumulating evidence has suggested that the lesion should be located ventrally while limiting the dorsal extent. Our center is now targeting specific fiber tracts within the lower half of the ALIC. MethodPresurgical diffusion tensor Magnetic Resonance Imaging (MRI) was used to identify individual fibre tracts within the ventral aspect of the ALIC in the last two patients who underwent BAC at our center. One patient had TRD and the other had both TROCD and TRD. Radiofrequency-induced thermal lesions were created in the identified targets with lesion volumes between 20 and 229 mm3 (average 95 mm3). FindingsBoth patients were responders with neither experiencing significant side effects including compromised executive functions. LimitationsThe generalizability of our findings is limited because the outcome is based on two subjects. ConclusionThis work suggests that BAC can be individually tailored and more limited to the ventral aspect of the ALIC and is effective and safe for TRD and TROCD. Accumulating data also suggests that to be clinically effective the length of the capsulotomy should be about 10mm. BAC’s use may increase with the growing utilization and mastery of magnetic resonance guided focused ultrasound.

Anterior Capsulotomy for Refractory Obsessive-Compulsive Disorder: A Tractography and Lesion Geometry study

Introduction: A bilateral anterior capsulotomy effectively treats refractory obsessive-compulsive disorder (OCD). We investigated the geometry of lesions and disruption of white matter pathways within the anterior limb of the internal capsule (ALIC) in patients with different outcomes. Methods: In this retrospective study, we analyzed data from 18 patients with refractory OCD who underwent capsulotomies. Patients were grouped into “responders” and “nonresponders” based on the percentage of decrease in the Yale-Brown Obsessive-Compulsive Scale (YBOCS) after surgery. We investigated neurobehavioral adverse effects and analyzed the overlap between lesions and the ventromedial prefrontal (vmPFC) and dorsolateral prefrontal (dlPFC) pathways. Probabilistic maps were constructed to investigate the relationship between lesion location and clinical outcomes. Results: Of the 18 patients who underwent capsulotomies, 12 were responders (>35% improvement in YBOCS), and six were nonresponders. The vmPFC pathway was more involved than the dlPFC pathway in responders (p = 0.01), but no significant difference was observed in nonresponders (p = 0.10). The probabilistic voxel-wise efficacy map showed a relationship between ventral voxels within the ALIC with symptom improvement. Weight gains occurred in 11/18 (61%) patients and could be associated with medial voxels within the ALIC. Conclusion: The optimal outcome after capsulotomy in refractory OCD is linked to vmPFC disruption in the ALIC. Medial voxels within the ALIC could be associated with weight gains following capsulotomy.

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.

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.

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 < 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.

Interstitial laser anterior capsulotomy for obsessive–compulsive disorder: lesion size and tractography correlate with outcome

BackgroundAnterior capsulotomy is a well-established treatment for refractory obsessive–compulsive disorder (OCD). MRI-guided laser interstitial thermal therapy (LITT) allows creation of large, sharply demarcated lesions with the safeguard of real-time imaging.ObjectiveTo...

Magnetic Resonance Imaging-Guided Laser Thermal Ventral Capsulotomy for Intractable Obsessive-Compulsive Disorder.

Obsessive-compulsive disorder (OCD) is a disabling condition characterized by intrusive thoughts and repetitive behaviors. A subset of individuals have severe, treatment-resistant illness and are nonresponsive to medication or behavioral therapies. Without response to conventional therapeutic options, surgical intervention becomes an appropriate consideration. To report clinical outcomes and the safety profile of bilateral ventral anterior capsulotomy for OCD using magnetic resonance (MR)-guided laser interstitial thermal therapy (LITT) in 10 patients followed for 6 to 24 mo. A total of 10 patients underwent LITT for severe OCD; 1 patient withdrew prior to follow-up. LITT is a minimally invasive ablative technique performed with precise targeting and use of thermography under MR guidance. Lesions of the ventral anterior limb of the internal capsule by other techniques have been shown to be efficacious in prior studies. A total of 7 of the 9 patients were considered full responders (77.8%; Yale-Brown Obsessive-Compulsive Scale change≥35%). Adverse effects included transient apathy/amotivation postsurgery (2 patients). One patient had a small tract hemorrhage where the laser fiber traversed the cerebral cortex as well as persistent insomnia postsurgery. One individual died after a drug overdose 7 mo postsurgery, which was judged unrelated to the surgery. LITT ventral capsulotomy was generally well tolerated, with promising evidence of effectiveness in the largest such series to date. Results were comparable to those after gamma knife ventral capsulotomy, as well as ventral anterior limb deep brain stimulation.

Tractography-Guided Anterior Capsulotomy for Major Depression and Obsessive-Compulsive Disorder: Targeting the Emotion Network.

Bilateral anterior capsulotomy (BAC) is an effective surgical option for patients with treatment-resistant major depression (TRMD) and treatment-resistant obsessive-compulsive disorder (TROCD). The size of the lesion and its precise dorsal-ventral location within the anterior limb of the internal capsule (ALIC) remain undefined. To present a method to identify the trajectories of the associative and limbic white matter pathways within the ALIC for targeting in BAC surgery. Using high-definition tractography, we prospectively tested the feasibility of this method in 2 patients with TRMD and TROCD to tailor the capsulotomy lesion to their limbic pathway. The trajectories of the associative and limbic pathways were identified in the ALIC of both patients and we targeted the limbic pathways by defining the dorsal limit of the lesion in a way to minimize the damage to the associative pathways. The final lesions were smaller than those that have been previously published. This individualized procedure was associated with long-term benefit in both patients. Tractography-guided capsulotomy is feasible and was associated with long-term benefit in patients with TRMD and TROCD.

Magnetic resonance-guided focused ultrasound capsulotomy for refractory obsessive compulsive disorder and major depressive disorder: clinical and imaging results from two phase I trials.

Obsessive compulsive disorder (OCD) and major depressive disorder (MDD) are common, often refractory, neuropsychiatric conditions for which new treatment approaches are urgently needed. Magnetic resonance-guided focused ultrasound (MRgFUS) is a novel surgical technique permitting incisionless ablative neurosurgery. We examined the safety profile, clinical response, and imaging correlates of MRgFUS bilateral anterior capsulotomy in patients with refractory obsessive compulsive disorder (OCD, N = 6) and major depressive disorder (MDD, n = 6). There were no serious adverse events. Nonserious adverse events included headaches and pin-site swelling in 7/12 patients. The response rate was 4/6 and 2/6 in the OCD and MDD cohorts respectively. To delineate the white-matter tracts impacted by capsulotomy, a normative diffusion MRI-based structural connectome was used, revealing tracts terminating primarily in the frontal pole, medial thalamus, striatum, and medial-temporal lobe. Positron emission tomography (PET) analysis (nine subjects) revealed widespread decreases in metabolism bilaterally in the cerebral hemispheres at 6 months post treatment, as well as in the right hippocampus, amygdala, and putamen. A pretreatment seed-to-voxel resting-state functional magnetic resonance imaging (rs-fMRI) analysis (12 subjects) revealed three voxel clusters significantly associated with eventual clinical response. MRgFUS capsulotomy appears to be safe, well tolerated, and according to these initial results, may be an important treatment option for patients with refractory OCD and MDD. MRgFUS capsulotomy results in both targeted and widespread changes in neural activity, and neuroimaging may hold potential for the prediction of outcome.

An Analysis of Clinical Outcome and Tractography following Bilateral Anterior Capsulotomy for Depression

Introduction: Bilateral anterior capsulotomy (BAC) is an effective surgical procedure for patients with treatment-resistant major depression (TRMD). In this work, we analyze the connectivity of the BAC lesions to identify connectivity “fingerprints” associated with clinical outcomes in patients with TRMD. Methods: We performed a retrospective study of ten patients following BAC surgery. These patients were divided into “responders” and “non-responders” based on the relative change in the Beck depression inventory (BDI) score after surgery. We generated the dorsolateral prefrontal associative (DLPFC) pathways and the ventromedial prefrontal limbic (vmPFC) pathways going through the anterior limb of the internal capsule and analyzed if the overlap of the BAC lesions with these pathways was associated with either outcome. Finally, we used the BAC lesions of our patients to generate group-averaged connectivity “fingerprints” associated with either outcome. Results: Six patients were responders (≥50% improvement in BDI), four patients were non-responders (<50% improvement). No significant impairments were found in most neuropsychological tests after surgery. The overlap analysis showed that in the responder group, there was less involvement of the DLPFC pathways than the vmPFC pathways (p = 0.001). Conversely, in the non-responder group, there was no significant difference between the involvement of both pathways (p = 0.157). The responder and non-responder connectivity fingerprint showed significant connections with the vmPFC limbic areas. However, the non-responder connectivity fingerprint also showed stronger connectivity to associative areas including the DLPFC and lateral orbitofrontal cortices. Conclusions: The optimum outcome following BAC surgery in this cohort was associated with interruption of vmPFC pathways and the relative preservation of DLPFC pathways.

Pallidal deep brain stimulation combined with capsulotomy for Tourette's syndrome with psychiatric comorbidity.

A current challenge is finding an effective and safe treatment for severely disabled patients with Tourette's syndrome (TS) and comorbid psychiatric disorders, in whom conventional treatments have failed. The authors aimed to evaluate the utility of globus pallidus internus deep brain stimulation (GPi-DBS) combined with bilateral anterior capsulotomy in treating these clinically challenging patients. The authors conducted a retrospective review of the clinical history and outcomes of 10 severely disabled patients with treatment-refractory TS and a psychiatric comorbidity, who had undergone GPi-DBS combined with bilateral anterior capsulotomy in their hospital. At the time of surgery, patients presented mainly with obsessive-compulsive disorder and affective disorders. Clinical outcome assessments of tic and psychiatric symptoms, as well as of general adaptive functioning and quality of life, were performed at the time of surgery and at 6, 12, and between 24 and 96 months postsurgery. After surgery, all patients showed significant progressive improvements in tic and psychiatric symptoms, along with improvements in general adaptive functioning and quality of life. Tic alleviation reached 64% at 12 months and 77% at the last follow-up on the Yale Global Tic Severity Scale. At the final follow-up, patients had functionally recovered and displayed no or only mild tic and psychiatric symptoms. All patients tolerated treatment reasonably well, with no serious side effects. GPi-DBS combined with bilateral anterior capsulotomy seems to offer major clinical benefits to severely disabled patients with otherwise treatment-refractory TS and psychiatric comorbidities.

Hypoactivity in the Paraterminal Gyrus Following Bilateral Anterior Capsulotomy.

Objective:Bilateral anterior capsulotomy (BAC) is one of the ablative neurosurgical procedures used to treat major depressive disorder or obsessive-compulsive disorder when all other therapies fail. Tristolysis, a reduction in sadness, is the most striking clinical effect of BAC and is seen in the first 1 to 2 weeks after surgery. This retrospective study measured regional cerebral blood flow (rCBF) following surgery to identify which cortical regions were impacted and could account for this clinical effect.Methods:All patients had their capsulotomies done in Vancouver by the same team. Pre- and postoperative single-photon emission computed tomography perfusion scans were analyzed for 10 patients with major depressive disorder and 3 with obsessive-compulsive disorder. rCBF was measured semiquantitatively by calculating the ratio between an identified region of interest and a whole brain reference area.Results:Decreased rCBF was found in the paraterminal gyri. Increased rCBF was found in the dorsolateral prefrontal cortices and in the left lateral temporal lobe.Conclusions:BAC causes hypoactivity in the paraterminal gyri and is the most likely explanation for its tristolytic effect, suggesting that the paraterminal gyrus is the limbic cortical locus for the emotion of sadness. Increased activity in the dorsolateral prefrontal cortices may be occurring via connectional diaschisis, and suppression by overactive paraterminal gyri during depression may account for some of the neurocognitive deficits observed during depressive episodes.

Jean Talairach: a cerebral cartographer.

Although French psychiatrist-turned-neurosurgeon Jean Talairach (1911-2007) is perhaps best known for the stereotaxic atlas he produced with Pierre Tournoux and Gábor Szikla, he has left his mark on most aspects of modern stereotactic and functional neurosurgery. In the field of psychosurgery, he expressed critique of the practice of prefrontal lobotomy and subsequently was the first to describe the more selective approach using stereotactic bilateral anterior capsulotomy. Turning his attention to stereotaxy, Talairach spearheaded the team at Hôpital Sainte-Anne in the construction of novel stereotaxic apparatus. Cadaveric investigation using these tools and methods resulted in the first human stereotaxic atlas where the use of the anterior and posterior commissures as intracranial reference points was established. This work revolutionized the approach to cerebral localization as well as leading to the development of numerous novel stereotactic interventions by the Sainte-Anne team, including tumor biopsy, interstitial irradiation, thermal ablation, and endonasal procedures. Together with epileptologist Jean Bancaud, Talairach invented the field of stereo-electroencephalography and developed a robust scientific methodology for the assessment and treatment of epilepsy. In this article the authors review Talairach's career trajectory in its historical context and in view of its impact on modern stereotactic and functional neurosurgery.

Bilateral anterior capsulotomy enhances medication compliance in patients with epilepsy and psychiatric comorbidities.

SummaryObjectivesPatients with epilepsy and refractory comorbid psychiatric disorders often experience functional impairments and a lower quality of life as well as showing a lack of compliance with anti‐epileptic medication regimens. We reasoned that widespread clinical benefits could be gained if the psychiatric comorbidities among these patients were reduced. In this study, we assessed the utility of anterior capsulotomy in managing medication‐refractory comorbid psychotic symptoms and aggression in patients with epilepsy.MethodsIn this retrospective case series, we evaluated the clinical outcomes of 13 epilepsy patients with severe psychiatric comorbidities who had received bilateral anterior capsulotomy. Clinical outcome assessments were performed at 1 week, 6 months, 1 year, and several years after surgery focusing on: (a) severity of psychotic symptoms, as assessed by the 18‐item Brief Psychiatric Rating Scale and the Positive and Negative Syndrome Scale; (b) severity of impulsivity and aggression, measured by the Barratt Impulsiveness Scale‐11 and the Buss‐Perry Aggression Scale; and (c) social function and quality of life, assessed by the Social Disability Screening Scale and the Quality of Life in Epilepsy.ResultsAfter anterior capsulotomy, patients displayed significant improvements of psychotic symptoms, as well as of impulsivity and aggression, along with improvements of social function and quality of life. The clinical benefits to patients were evident within 6 months after surgery and remained stable or continued to improve at a much slower rate thereafter. Furthermore, after anterior capsulotomy all patients complied with epilepsy interventions that they did not comply with prior to surgery. No significant side effects or complications occurred during the study.ConclusionAnterior capsulotomy seems to be a safe and effective treatment for epilepsy patients with otherwise intractable comorbid psychotic symptoms and aggression. Moreover, this neurosurgical treatment may improve the patients' social function, quality of life, and compliance with anti‐epilepsy medication regimens.

Radiosurgery for Behavioral Disorders.

Psychiatric illnesses create great suffering for patients and the medical solution is sometimes limited. The experience observed after treating patients with obsessive-compulsive disorder (OCD), depression, and anorexia nervosa by Gamma Knife radiosurgery (GKRS) is presented. Ten patients with medically refractory OCD, 3 patients with depression resistant to medical treatment and electroconvulsive therapy, and 5 patients with refractory anorexia nervosa have been treated. Bilateral anterior capsulotomy has been performed to treat OCD and bilateral cingulotomy has been applied to treat severe depression and anorexia nervosa. The accumulated experience about treatment of OCD by GKRS is reviewed. In our experience, 70% of OCD patients achieved a full response. We observed a significant improvement in patients with depression and anorexia nervosa evidenced by the scales of assessment (mean reduction of 40% in the Beck Depression Inventory at 1-year follow-up and 40% average increase of body mass index at 6-month follow-up). No side effects have been observed. These procedures are effective in reducing obsession, compulsion, depression, and anxiety, improving the quality of life of the patients without side effects.

Long-Term Follow-up Study of MRI-Guided Bilateral Anterior Capsulotomy in Patients With Refractory Anorexia Nervosa.

Anorexia nervosa (AN) is one of the most challenging psychiatric disorders to treat. The poor clinical outcomes warrant novel treatments for AN, especially in severe and persistent cases. To explore the feasibility of magnetic resonance imaging-guided bilateral anterior capsulotomy in the treatment of refractory AN. Seventy-four patients diagnosed with refractory AN who underwent capsulotomy completed this 3-yr follow-up study. Outcomes included body mass index (BMI) and results from a series of psychiatric scales (for obsessive, depressive, and anxious symptoms) that were implemented at baseline (presurgery), and 1 mo, 1 yr, and 3 yr after surgery. Compared to presurgical levels, BMI increased significantly at 1-yr and 3-yr follow-ups. Compared to presurgery scores, psychiatric scale scores were significantly improved at 1-mo postsurgery, and continued to remain low at the 1-yr and 3-yr follow-ups. In addition, Mini-Mental State Examination (MMSE) scores were in the normal range during the long-term follow-up. The most common short-term side effects included urinary incontinence (n=7), sleep disorders (n=8), and fatigue (n=6). Long-term complications included disinhibition (n=6), memory loss (n=3), and lethargy (n=4). No patient in this study experienced death or disability. Capsulotomy enabled patients with refractory AN to normalize their weight, especially those in life-threatening conditions. While it appears to be an acceptable life-saving treatment, it is indicated only when fulfilling strict criteria given its complications and irreversibility.

6 Neurosurgical interventions in psychiatry

<i>Retired from clinical practice Jan 2014.</i> <i>Brian qualified from Cambridge University (with Part 2 in Experimental Psychology) and The London Hospital Medical College, 1973. FRCS (England) 1978. Wellcome Trust Research Fellowship – studies on functions of the dopamine systems led to MD (Cantab). Neurosurgical training at the (Royal) London Hospital, with additional special interest in functional neurosurgery. Appointed consultant neurosurgeon at University Hospital of Wales, Cardiff, 1988. Service development: surgical management of intractable pain. Service development: neurosurgery for mental disorder. President, International Neuromodulation Society, 2000–2003. Published widely on therapeutic neurostimulation.</i> <i>2016 – Senior editor, series of evidence-based guidelines on therapeutic neurostimulation and on intrathecal drug delivery.</i> The evolution of “psychosurgery”, now better referred to as Neurosurgery for Mental Disorders (NMD), will be reviewed and discussed in relation to historical context and attitudes. Key considerations for the future will be highlighted. The early history is often regarded now with embarrassment and even horror. The eminent physiologist John Fulton, whose 1935 London lecture triggered the notorious epidemic of radical and relatively indiscriminate frontal lobe surgery, had serious reservations. He knew that intellectual and affective functions could be separated anatomically and was probably the first to advocate more selective procedures, to avoid the sometimes devastating side effects. However, “lobotomy” was given impetus by the eminence of its pioneers, Moniz and Freeman, and by respected neurosurgeons elsewhere, including the UK. The socio-economic benefit of the liberation from asylums of large numbers of indefinite-stay patients for whom, it should be remembered, no drug treatment was available until 1954 (chlorpromazine; antidepressants in 1958), clearly provided great encouragement. However, Walter Freeman’s cavalier approach in the USA helped to close this first chapter. A technically much more specific approach (“Chapter 2”) became available in 1947 when stereotactic neurosurgery for humans (it had long been used in animal experiments) was introduced. Case-selection also gradually improved, moving away from treating schizophrenia and from “correcting” behaviour, towards relieving affective disorders. Anterior capsulotomy was introduced in 1951 and (stereotactic) cingulotomy in 1962. Developments continued, for example subcaudate tractotomy using yttrium⁹⁰ seeds, of which more than 1300 were performed in London from 1961 until the 1990s. There was still much opposition but when a US Congress Commission was convened in 1974, expecting to ban “psychosurgery”, the evidence of benefit and relative absence of harm was now so compelling that it won official approval. The more refined procedures have continued with demonstrable success but in relatively small numbers. Between 1993 and 2008, 55 patients underwent bilateral anterior capsulotomy in Cardiff, 45 for depression. The 24 for whom full datasets were available showed an overall improvement of 52%, with a 75% -or-more improvement in 10. There were no significant changes in executive function, attention and concentration, or immediate and delayed memory, and the adverse-effect profile showed it to be safe. However, antagonism continued to be encountered. Deep brain stimulation (DBS) for psychiatric disorders is not new but it re-emerged in 1999 as a more flexible and superficially more acceptable alternative to traditional lesioning (“Chapter 3 ”). The relative advantages and disadvantages will be discussed. The future for NMD (“Chapter 4”) for otherwise intractable cases should be exciting, with developments in imaging and other technologies and with increasing understanding of targeted conditions. However, the need to exercise great caution, along with issues of consent and regulation, are paramount. NMD is only one tool and its successful and continuing use depends heavily upon cultural attitudes.

A study of cognitive function in treatment-refractory obsessive-compulsive disorder treated with capsulotomy.

OBJECTIVE Anterior capsulotomy (AC) is sometimes used as a last resort for treatment-refractory obsessive-compulsive disorder (OCD). Previous studies assessing neuropsychological outcomes in patients with OCD have identified several forms of cognitive dysfunction that are associated with the disease, but few have focused on changes in cognitive function in OCD patients who have undergone surgery. In the present study, the authors investigated the effects of AC on the cognitive function of patients with treatment-refractory OCD. METHODS The authors selected 14 patients with treatment-refractory OCD who had undergone bilateral AC between 2007 and 2013, 14 nonsurgically treated OCD patients, and 14 healthy control subjects for this study. The 3 groups were matched for sex, age, and education. Several neuropsychological tests, including Similarities and Block Design, which are subsets of the Wechsler Abbreviated Scale of Intelligence; Immediate and Delayed Logical Memory and Immediate and Delayed Visual Reproduction, which are subsets of the Wechsler Memory Scale-Revised; and Corrects, Categories, Perseverative Errors, Nonperseverative Errors, and Errors, subtests of the Wisconsin Card Sorting Test, were conducted in all 42 subjects at baseline and after AC, after nonsurgical treatment, or at 6-month intervals, as appropriate. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) was used to measure OCD symptoms in all 28 OCD patients. RESULTS The Y-BOCS scores decreased significantly in both OCD groups during the 12-month follow-up period. Surgical patients showed higher levels of improvement in verbal memory, visual memory, visuospatial skills, and executive function than the nonsurgically treated OCD patients. CONCLUSIONS The findings of this study suggest that AC not only reduces OCD symptoms but also attenuates moderate cognitive deficits.

Bilateral anterior capsulotomy for patients with refractory obsessive-compulsive disorder: A multicenter, long-term, follow-up study.

The objectives of this retrospective study were to analyze the short-term and long-term effects and complications of stereotactic anterior capsulotomy for patients with refractory obsessive-compulsive disorder (OCD). The advantages and disadvantages of stereotactic anterior capsulotomy have been discussed. Between October 2007 and June 2010, 37 patients with OCD underwent anterior capsulotomy in West China Hospital of Sichuan University or Mian Yang Central Hospital. The clinical effects were evaluated by an independent psychiatrist preoperatively and after 1 week, and after 1, 3, 6, 12, 36, and 60 months postoperatively. The main parameters were evaluated by scores on the Yale-Brown obsessive compulsive scale (Y-BOCS), Hamilton depression scale (HAMD), and Hamilton anxiety scale (HAMA). 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) and diffusion tensor imaging (DTI) were performed preoperatively and at 3 and 6 months postoperatively. On comparing the scores obtained at various time points, the effects of anterior capsulotomy were as follows: The Y-BOCS score of the 37 patients decreased in the fifth year postoperatively (P < 0.05); 27 (73.0%) patients exhibited significant improvement (>50% decrease in the Y-BOCS score); 6 (16.2%) patients exhibited partial improvement (20-50% decrease in the Y-BOCS score); and, 4 (10.8%) patients exhibited no evident improvement (<20% decrease in the Y-BOCS score). Moreover, depression and anxiety improved among all the patients (P < 0.05). FDG-PET showed that the glucose metabolic rate had decreased in bilateral frontal cerebral lobe and basal ganglia. DTI showed that the transverse fibers in bilateral anterior limb of the internal capsule were disconnected. Using MRI guidance, stereotactic treatment of refractory OCD via bilateral anterior internal capsulotomy significantly improved several OCD symptoms such as compulsive behavior, depression, and anxiety. In addition, the assessment of the effects and complications of this treatment was most accurate at 6 months postoperatively.

Clinical improvements following bilateral anterior capsulotomy in treatment-resistant depression.

The purpose of this study was to evaluate a programme of lesion surgery carried out on patients with treatment-resistant depression (TRD). This was a retrospective study looking at clinical and psychometric data from 45 patients with TRD who had undergone bilateral stereotactic anterior capsulotomy surgery over a period of 15 years, with the approval of the Mental Health Act Commission (37 with unipolar depression and eight with bipolar disorder). The Beck Depression Inventory (BDI) before and after surgery was used as the primary outcome measure. The Montgomery-Asberg Depression Rating Scale was administered and cognitive aspects of executive and memory functions were also examined. We carried out a paired-samples t test on the outcome measures to determine any statistically significant change in the group as a consequence of surgery. Patients improved on the clinical measure of depression after surgery by -21.20 points on the BDI with a 52% change. There were no significant cognitive changes post-surgery. Six patients were followed up in 2013 by phone interview and reported a generally positive experience. No major surgical complications occurred. With the limitations of an uncontrolled, observational study, our data suggest that capsulotomy can be an effective treatment for otherwise TRD. Performance on neuropsychological tests did not deteriorate.