Limbic Leucotomy Research Articles

Magnetic Resonance Imaging-guided Stereotactic Limbic Leukotomy for Treatment of Intractable Psychiatric Disease

Magnetic Resonance Imaging-guided Stereotactic Limbic Leukotomy for Treatment of Intractable Psychiatric Disease

Review of long-term results of stereotactic psychosurgery.

Stereotactic psychosurgery is an effective method for treating some medically intractable psychiatric illnesses. However, it is unfamiliar and the long-term clinical results have not been reported in Asia. The long-term results of psychosurgery are evaluated and the neuroanatomical basis is discussed. Twenty-one patients underwent stereotactic psychosurgery for medically intractable psychiatric illnesses since 1993. All were referred from psychiatrists for these disorders. Two patients showed aggressive behavior, 12 had obsessive-compulsive disorder (OCD), and seven had depression with anxiety disorders. Bilateral amygdalotomy and subcaudate tractotomy were performed for aggressive behavior, limbic leucotomy was performed for OCD, and subcaudate tractotomy with or without cingulotomy was performed for depression with anxiety. OCD was evaluated with the Yale-Brown Obsessive Compulsive Scale (YBOCS), the visual analogue scale, the Clinical Global Impression Scale, and the Overt Aggression Scale (OAS). The Mini-Mental State Examination and the Wechsler Adult Intelligence Scale-Revised were used for the evaluation of aggressive behavior. The 17-item Hamilton Depression Rating Scale (HAMD) was used for evaluation of depression. Ventriculography was used in the first seven patients and magnetic resonance imaging-guided stereotaxy was used in the recent 14 cases for localization of the target. The lesions were made with a radiofrequency lesion generator. OAS scores in the two patients with aggressive behavior during follow up declined from 8 to 2 with clinical improvement. All 12 patients with OCD returned to their previous life and showed the mean YBOCS scores decreased from 34 to 3. Ten patients with OCD could be followed up (mean 45 months). All patients returned to their previous social life. In seven patients with depression with anxiety, HAMD scores declined from 28.5 to 16.5. There was no operative mortality and no significant morbidity except for one case of mild transient urinary incontinence. These long-term results indicate that stereotactic psychosurgery is a safe and effective method of treating some medically intractable psychiatric illnesses.

Improvement in Severe Self-Mutilation Following Limbic Leucotomy

The efficacy of neurosurgical intervention for self-mutilation behavior associated with severe, intractable psychiatric disorders remains undetermined. We report the effects of limbic leucotomy in 5 consecutive patients with severe self-mutilation behaviors. After unsolicited referrals from their psychiatrists and careful consideration by the Massachusetts General Hospital Cingulotomy Assessment Committee (MGH-CAC), 5 patients were treated with limbic leucotomy. Their primary DSM-IV psychiatric diagnoses were either obsessive-compulsive disorder or schizoaffective disorder. Comorbid severe, treatment-refractory self-mutilation was an additional target symptom. Outcome was measured by an independent observer using the Clinical Global Improvement. Current Global Psychiatric-Social Status Rating, and DSM-IV Global Assessment of Functioning scales in addition to telephone interviews with patients, families, their psychiatrists, and treatment teams. The mean postoperative follow-up period was 31.5 months. All measures indicated sustained improvement in 4 of 5 patients. In particular, there was a substantial decrease in self-mutilation behaviors. Postoperative complications were transient in nature. and postoperative compared with preoperative neuropsychological assessments revealed no clinically significant deficits. In carefully selected patients as described in this report, limbic leucotomy may be an appropriate therapeutic consideration for self-mutilation associated with severe, intractable psychiatric disorders.

Contemporary psychosurgery and a look to the future

Despite a long and controversial history, psychosurgery has persisted as a modern treatment option for some severe, medically intractable psychiatric disorders. The goal of this study was to review the current state of psychosurgery. In this review, the definition of psychosurgery, patient selection criteria, and anatomical and physiological rationales for cingulotomy, subcaudate tractotomy, anterior capsulotomy, and limbic leukotomy are discussed. The historical developments, modern procedures, and results of these four contemporary psychosurgical procedures are also reviewed. Examples of recent advances in neuroscience indicating a future role for neurosurgical intervention for psychiatric disease are also mentioned. A thorough understanding of contemporary psychosurgery will help neurosurgeons and other physicians face the ethical, social, and technical challenges that are sure to lie ahead as modern science continues to unlock the secrets of the mind and brain.

Surgery for Psychiatric Disorders

The modern therapeutic approach to most psychiatric diseases involves a combination of well-supervised psychotherapy, pharmacotherapy, and electroconvulsive therapy. Patients who fail to adequately respond to these modern treatment methods and remain severely disabled may be considered for surgical intervention. Cingulotomy, capsulotomy, subcaudate tractotomy, and limbic leucotomy are the most common psychosurgical procedures performed today, with response rates in the 35% to 65% range. Modern stereotactic techniques have reduced complication rates, but controversy remains regarding the optimal surgical procedure. The major psychiatric diagnostic categories that might respond to surgery include treatment-refractory major affective disorders, obsessive-compulsive disorder, and chronic anxiety states. Surgery should be considered as one part of an entire treatment plan and must be followed by an appropriate psychiatric rehabilitation program. It should only be carried out by an expert multidisciplinary team consisting of a neurologist a neurosurgeon, and a psychiatrist with experience in these disorders. Surgical intervention remains a reasonable therapeutic option for select patients with a disabling psychiatric disease and may be underutilized.

Modern neurosurgery for psychiatric disorders.

The evolution, rationale, and results of modern functional neurosurgery to treat psychiatric disorders are documented. The potential benefits of neurosurgical treatment for selected, critically ill, psychiatric patients are considered. The history, anatomic features, and evolution of and contemporary indications for the four currently used procedures (cingulotomy, subcaudate tractotomy, limbic leukotomy, and capsulotomy) are reviewed. Available outcome, neuropsychological assessment, and functional imaging data are presented. Recently, there has been a renaissance of interest in the surgical treatment of psychiatric disease. Modern psychiatric neurosurgical procedures are quite safe, with extremely low surgical mortality rates and transient postoperative morbidity. In selected cases, patients with conditions that had previously been completely refractory to comprehensive medical and behavioral intervention demonstrated significant improvement. This improvement was usually observed in the absence of long-term adverse neuropsychological consequences. Recent outcome studies, together with advances in neurobiology, psychiatry, functional imaging, and stereotaxy, support the further investigation of modern functional neurosurgical procedures to treat psychiatric disorders and their application for a subset of psychiatric patients with conditions refractory to all other therapies.

Neurosurgical treatment of obsessive-compulsive disorder

Case reports suggest that neurosurgical operations can improve symptoms in patients with severe treatment-refractory obsessive-compulsive disorder (OCD). However, it is unclear which procedure is best and which may produce the most side-effects. I review the literature on the efficacy and complications of four frequently used neurosurgical procedures (cingulotomy, capsulotomy, limbic leucotomy and subcaudate tractotomy) that are used to treat refractory OCD. Since the vast majority of patients who underwent surgery were severely and chronically disabled, it is likely that these procedures were of assistance in alleviating some of their symptoms. It is currently impossible to determine which surgical procedure is the best for a particular patient. Despite a lack of controlled data and inconsistencies in the literature, it appears that when non-surgical treatments have failed to improve OCD symptoms significantly in severely ill patients, at least partial relief can be obtained by some people with OCD by neurosurgery. Results of cumulative studies strongly support the need for continued research in this area.

Neurosurgery for mental disorders (NMD) A clinical worldwide perspective: past, present and future

The use of neurosurgery for mental disorders (NMD) is a clinical issue that involves many ethical considerations. It is a treatment that offers hope for many patients with severe and debilitating affective and anxiety disorders and should be widely available. Its current use worldwide (UK, Sweden, US, Australasia, Europe) is reviewed and the types of procedures currently used are explained (stereotactic subcaudate tractotomy, anterior capsulotomy, cingulotomy, limbic leucotomy). In addition, clinical strategies for the evaluation and management of patients both prior to and following NMD are discussed.

S-75-4 - Contemporary indications and interventions for psychiatric neurosurgery: Anoverview

Psychosurgery, the neurosurgical treatment of psychiatric disease, has a history dating back to antiquity, and involves all of the clinical neurosciences. This review discusses the history of psychosurgery, its development in the 19th century, and the conditions of its use and abuse in the 20th century, with a particular focus on the frontal lobotomy. The transition to the modern era of psychosurgery is discussed, as well as the neurobiology underlying current psychosurgical procedures. The techniques of stereotactic cingulotomy, capsulotomy, subcaudate tractotomy, and limbic leukotomy are described, as well their indications and side effects. Due to the past abuse of psychosurgery, procedures are currently under strict control, and the example of the Cingulotomy Committee at the Massachusetts General Hospital is discussed. Finally, future directions of psychosurgery and somatic therapies are explored, including transcranial magnetic stimulation, vagal nerve stimulation, deep brain stimulation, gene therapy, and stem cell therapy. In summary, this review provides a concise yet comprehensive introduction to the history, current practice, and future trends of neurosurgery for psychiatric disorders.

Functional Neurosurgery for Psychiatric Disorders: A Historical Perspective

Functional neurosurgery for psychiatric disorders ('psychosurgery') has a colorful, and sometimes dubious, history. From the time of the first operations in 1935 to today, its usefulness has been overshadowed by doubts and ethical questions. Psychosurgery became popular in the 1940s and early 1950s, especially in the United States. Its main indications were for intractable mental illness, in particular, depression, anxiety, and obsessive-compulsive disorders. However, its side effects, especially the 'frontal lobe syndrome', led to the need for more refined surgical approaches; the most important of these was the use of stereotaxis. Cingulotomy, subcaudate tractotomy, limbic leucotomy, and anterior capsulotomy are generally the stereotactic treatments of choice today. Indications and postoperative sequelae vary slightly across treatments. The indications remain as affective, anxiety, and obsessive-compulsive disorders. Despite approval by the United States Department of Health, Education, and Welfare in 1978, psychosurgery is still not a common treatment. This low acceptance is perhaps due to continued concern over ethical problems and inadequate reporting of outcomes.

The treatment of Gilles de la Tourette syndrome by limbic leucotomy.

A patient with Gilles de la Tourette syndrome and severe self-injurious compulsions who had failed to respond to drug treatment and behavioural therapy obtained a complete and sustained resolution of his destructive behaviour and improvement in his tics following bilateral limbic leucotomy.

Evidence for a biological hypothesis of obsessive-compulsive disorder.

There is scant but provocative evidence to support the concept of a biological etiology in obsessive-compulsive disorder (OCD). This evidence includes the phenomenologic similarities and associations with other major psychiatric disorders for which there is evidence of biologic etiologies; the genetic studies that show an increased familial occurrence of psychiatric illness including OCD and concordance for this disorder in monozygotic twins; biologic evidence and the historical association of OCD and CNS damage; the treatment response of OCD to antidepressant medication and possibly those medications that selectively modify serotonin neuronal activity and to selective anterior limbic leukotomy. This evidence and the evidence linking OCD to depressive illness are specifically reviewed and discussed.

Treatment Resistant or Untreatable?

Abstract Variety and magnitude of therapy-resistant depressive disorders continue to be of urgent interest to clinicians and researchers. In 1973, the section on pharmacopsychiatry of the World Psychiatric Association (WPA) held a symposium on Therapy-Resistant Depression, in Basel, Switzerland. 1 Clinical typology, biochemistry, genetics, therapeutic differential criteria, and theoretic considerations were explored to determine their role in resistance to treatment. 2 There were convincing indications that the rate of therapeutic failures in terms of ultimate outcome is considerable. Methodologic problems still prevail in distinguishing between poor results due to inadequate treatment and therapeutic failures after systematic administration of appropriate treatment modalities. In the Basel symposium, Kelly advocated limbic leucotomy as a promising step after every other method of treatment has failed. 3 Similarly, in a recent paper on the treatment of affective disorders, Shaw included stereotactic tractotomy as a treatment of choice when other treatment had failed. 4 It is nevertheless not generally accepted that a full battery of therapeutic methods must include brain surgical procedures. At any rate, the rationale for pharmacotherapy and electroconvulsive therapy (ECT) rests on the assumption that biochemical deficiencies are responsible for depressive syndromes and can be corrected by these treatments. I want to base my brief presentation on three patient profiles that demonstrate some principal aspects of resistance to treatment. I have treated each patient for several years, as had other psychiatrists before me, and, in one case, after me. These patients are by no means atypical, but on the contrary represent a rank and file of patients with affective illness. Yet for reasons that have to do with research design, they are most unlikely to be covered in reported clinical investigations.

Treatment-resistant or untreatable?

Variety and magnitude of therapy-resistant depressive disorders continue to be of urgent interest to clinicians and researchers. In 1973, the section on pharmacopsychiatry of the World Psychiatric Association (WPA) held a symposium on Therapy-Resistant Depression, in Basel, Switzerland. 1 Clinical typology, biochemistry, genetics, therapeutic differential criteria, and theoretic considerations were explored to determine their role in resistance to treatment. 2 There were convincing indications that the rate of therapeutic failures in terms of ultimate outcome is considerable. Methodologic problems still prevail in distinguishing between poor results due to inadequate treatment and therapeutic failures after systematic administration of appropriate treatment modalities. In the Basel symposium, Kelly advocated limbic leucotomy as a promising step after every other method of treatment has failed. 3 Similarly, in a recent paper on the treatment of affective disorders, Shaw included stereotactic tractotomy as a treatment of choice when other treatment had failed. 4 It is nevertheless not generally accepted that a full battery of therapeutic methods must include brain surgical procedures. At any rate, the rationale for pharmacotherapy and electroconvulsive therapy (ECT) rests on the assumption that biochemical deficiencies are responsible for depressive syndromes and can be corrected by these treatments. I want to base my brief presentation on three patient profiles that demonstrate some principal aspects of resistance to treatment. I have treated each patient for several years, as had other psychiatrists before me, and, in one case, after me. These patients are by no means atypical, but on the contrary represent a rank and file of patients with affective illness. Yet for reasons that have to do with research design, they are most unlikely to be covered in reported clinical investigations.

Stereotactic Limbic Leucotomy—A Follow-up at 16 Months

Sixty-six patients were assessed clinically, psychologically and physiologically before operation, at six weeks and at a mean of 16 months following stereotactic limbic leucotomy. Seventy-three per cent were clinically improved at six weeks and 76 per cent at 16 months. In obsessional neurosis, 89 per cent of patients showed definite clinical improvement at 16 months; in chronic anxiety, 66 per cent were improved; in depression, 78 per cent; and in the small number of schizophrenics treated the improvement rate was over 80 per cent. Self-assessment and observer-assessment questionaires and scales measuring Depression, Anxiety, Neuroticism, Hysterical symptoms and Obsessional symptoms and traits all showed highly significant reductions of mean scores at 16 months. There was no fall-off in intelligence, and adverse effects were minimal. Limbic leucotomy, with its enhanced accuracy and safety, compares very favourably with similarly assessed, more extensive 'free-hand' procedures, and in obsessional neurosis and chronic anxiety the results are superior.

Pituitary hormone response to brain stimulation in man.

Plasma cortisol, GH and LH responses to electrical stimulation of the orbital part of the frontal lobe and the cingulate area of the brain were studied in patients undergoing limbic leucotomy. In six out of 15 patients the plasma cortisol levels increased by 5-7--18-0 mug/100 ml after orbito-frontal stimulation whereas plasma GH values did not rise during this period. Plasma LH levels remained unchanged. No definite hormone responses could be attributed to stimulation of the cingulate area. It appears that the orbito-frontal area of the brain is concerned with augmenting the release of ACTH but not that of GH or LH.

Stereotactic limbic leucotomy--a follow-up study of thirty patients.

SummaryThis prospective study reports the results of stereotactic limbic leucotomy at a mean of 17 months following surgery. Clinical improvement had occurred in twenty-four (80%) of the patients, fifteen (50%) of them being symptom free or much improved. Fourteen of sixteen patients suffering from obsessional neurosis were improved, as were five of seven with chronic anxiety and the degree of improvement at 17 months was superior to that at 6 weeks. Psychometric scores of anxiety, obsessions and neuroticism were all significantly reduced at 17 months. The mean depression scores were also significantly reduced and this result was superior to that reported in a previous study of ‘free-hand’ operations.Adverse effects were not a problem following limbic leucotomy. Emotional blunting, disinhibition, post-operative epilepsy and excessive weight gain were not encountered, and intelligence was unaffected by the operation. Limbic leucotomy is a much more limited and precise procedure than older ‘free-hand’ operations which we have studied, but its therapeutic effects are comparable and in obsessional neurosis, superior.

Stereotactic limbic leucotomy: a preliminary report on forty patients.

The neurophysiological aspects and operative technique of stereotactic limbic leucotomy have been described in a previous paper (Kelly, Richardson and Mitchell-Heggs, 1973). The present investigation is a prospective study designed to assess the results of such surgery in a group of 40 severely ill psychiatric patients, who had failed to respond satisfactorily to every other type of treatment. The results have been assessed clinically, psychologically and physiologically, in a very detailed way, at six weeks; a similar follow-up at one year is in progress. A comparison is made between the results of the present series and those of a previous: study (Kellyet al., 1972), in which more extensive leucotomy operations were carried out, and similar means of assessment were employed.

Physiological changes during operations on the limbic system in man.

The limbic system is a phylogenetically old part of the brain which is concerned with a variety of emotional and viscerosomatic functions. It has been found that small discrete lesions, placed by stereotaxis in this system during limbic leukotomy, may result in marked clinical improvement in severely incapacitated psychiatric patients who have failed to respond to any other type of treatment. In one patient, electrical stimulation of the anterior cingulate gyrus was carried out under local anesthesia to locate a suitable site for a limbic lesion. Physiological arousal was produced, as evidenced by changes in heart rate, forearm blood flow, sweat gland activity and respiration. Bilateral lesions, 8 mm in diameter, produced by freezing this site, resulted in marked clinical improvement. Peripheral physiological changes are now being used to aid in the selection of target sites in various parts of the limbic system. Under general anesthesia marked respiratory changes have been found on stimulation of the lower medial quadrant of the frontal lobe, anterior cingulate gyrus, above the roof of the lateral ventricle, and in the amygdala nucleus of the temporal lobe. Lesions are made with a cryogenic probe at sites of maximum physiological response. It is postulated that physiological monitoring during electrical stimulation of target areas will improve the accuracy of lesion placement. Some of the results of this procedure are described.

THE CINGULAR GYRUS: AREA 24

THE CINGULAR GYRUS: AREA 24