Limbic Leucotomy Research Articles

Special Report: Autism Spectrum Disorder and Inflexible Thinking—Affecting Patients Across the Lifespan

Special Report: Autism Spectrum Disorder and Inflexible Thinking—Affecting Patients Across the Lifespan

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.

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.

Effectiveness and safety of neuroablation for severe and treatment-resistant obsessive-compulsive disorder: a systematic review and meta-analysis.

Several neuroablative procedures are available for severe and treatment-resistant obsessive-compulsive disorder (OCD), but limited knowledge about their relative clinical advantages and disadvantages poses obstacles for treatment decision-making. We searched PubMed, Embase, Scopus, Web of Knowledge and the Cochrane Library for reports up to February 2019. We reviewed the literature on the effectiveness (assessed using the Yale-Brown Obsessive Compulsive Scale [Y-BOCS]) and safety of various neuroablative interventions for severe and treatment-resistant OCD. We included 23 studies involving 487 patients in the systematic review; 21 studies with 459 patients entered meta-analysis. Overall, neuroablation achieved a response rate (proportion of patients with ≥ 35% reduction in Y-BOCS) of 55%. Most of the adverse events (88.4%) were mild and transient. The top 3 adverse events were headache (14.9%), cognitive deficits (9.1%) and behaviour problems (8.1%). Severe or permanent adverse events included personality changes (2.3%) and brain edema or brain cyst (1.5%). The response rates associated with capsulotomy, limbic leucotomy and cingulotomy were 59% (95% confidence interval [CI] 54-65), 47% (95% CI 23-72) and 36% (95% CI 23-50), respectively. Interventions with different coverages of the dorsal part of the internal capsule were associated with different adverse-event profiles but were unlikely to modify clinical effectiveness. The level of evidence of most included studies was relatively low. Ablative surgeries are safe and effective for a large proportion of patients with severe and treatment-resistant OCD. Among the available procedures, capsulotomy seemed to be the most effective. Further research is needed to improve clinical effectiveness and minimize risks.

The Potential Usefulness of Magnetic Resonance Guided Focused Ultrasound for Obsessive Compulsive Disorders

Obsessive compulsive disorder is a debilitating condition characterized by recurrent obsessive thoughts and compulsive reactions. A great portion of the obsessive compulsive disorder (OCD) patients are managed successfully with psychiatric treatment such as selective serotonin-reuptake inhibitor and cognitive behavioral psychotherapy, but more than 10% of patients are remained as non-responder who needs neurosurgical treatments. These patients are potential candidates for the neurosurgical management. There had been various kind of operation, lesioning such as leucotomy or cingulotomy or capsulotomy or limbic leucotomy, and with advent of stereotaxic approach and technical advances, deep brain stimulation was more chosen by neurosurgeon due to its characteristic of reversibility and adjustability. Gamma knife radiosurgery are also applied to make lesion targeting based on magnetic resonance (MR) imaging, but the complication of adverse radiation effect is not predictable. In the neurosurgical field, MR guided focused ultrasound has advantage of less invasiveness, real-time monitored procedure which is now growing to attempt to apply for various brain disorder. In this review, the neurosurgical treatment modalities for the treatment of OCD will be briefly reviewed and the current state of MR guided focused ultrasound for OCD will be suggested.

Ablative Limbic System Surgery: Review and Future Directions.

The limbic system is a network of interconnected brain regions regulating emotion, memory, and behavior. Pathology of the limbic system can manifest as psychiatric disease, including obsessive-compulsive disorder and major depressive disorder. For patients with these disorders who have not responded to standard pharmacological and cognitive behavioral therapy, ablative surgery is a neurosurgical treatment option. The major ablative limbic system procedures currently used are anterior capsulotomy, dorsal anterior cingulotomy, subcaudate tractotomy, and limbic leucotomy. In this review, we include a brief history of ablative limbic system surgery leading up to its current form. Mechanistic justification for these procedures is considered in a discussion of the pathophysiology of psychiatric disease. We then discuss therapeutic efficacy as demonstrated by recent trials. Finally, we consider future directions, including the search for predictors of treatment response, the development of more precise targeting methods, and the use of advances in neuroimaging to track treatment response.

Estimulación cerebral para el trastorno obsesivo-compulsivo resistente a tratamiento médico

Approximately 10% of patients with obsessive-compulsive disorder have very disabling chronic forms of the disease, which are resistant to all current conservative therapies. These patients experience a significant deterioration in their quality of life and high rates of suicide. The development of new effective neurosurgical treatments has led to an improvement in a significant percentage of patients that would otherwise have remained severely disabled.We comprehensively review remission rates, adverse effects and fundamental methodological aspects of the current neurosurgical techniques for medication resistant obsessive-compulsive disorder. The making of small lesions in specific targets of the limbic circuit, such as cingulotomy, capsulotomy, limbic leucotomy and subcaudate tractotomy, is being replaced by deep brain stimulation through electrodes located in these targets, which is reversible and adaptable to every patient's need. Furthermore, the development of neuroimaging techniques and a better understanding of brain circuits in the last decades, have allowed the identification of new targets for neurostimulation in this disorder, with good results.Research must continue in order to help in the treatment of medication-resistant obsessive-compulsive disorder.

Lesion analysis for cingulotomy and limbic leucotomy: comparison and correlation with clinical outcomes.

Cingulotomy and limbic leucotomy are lesioning surgeries with demonstrated benefit for medically intractable psychiatric illnesses. They represent significant refinements of the prefrontal lobotomy used from the 1930s through the 1950s. However, the associations between anatomical characterization of these lesions and outcome data are not well understood. To elucidate these procedures and associations, the authors sought to define and compare the neuroanatomy of cingulotomy and limbic leucotomy and to test a method that uses neuroanatomical data and voxel-based lesion-symptom mapping (VLSM) to reveal potential refinements to modern psychiatric neurosurgical procedures. T1-weighted MR images of patients who had undergone cingulotomy and limbic leucotomy were segmented and registered onto the Montreal Neurological Institute T1-weighted template brain MNI152. Using an atlas-based approach, the authors calculated, by case, the percentage of each anatomical structure affected by the lesion. Because of the infrequency of modern lesion procedures and the requirement for higher-resolution clinical imaging, the sample size was small. The pilot study correlated cingulotomy and limbic leucotomy lesion characteristics with clinical outcomes for patients with obsessive-compulsive disorder. For this study, preoperative and postoperative Yale-Brown Obsessive Compulsive Scale scores for 11 cingulotomy patients and 8 limbic leucotomy patients were obtained, and lesion masks were defined and compared anatomically by using an atlas-based method. Statistically significant voxels were additionally calculated by using VLSM techniques that correlated lesion characteristics with postoperative scores. Mean lesion volumes were 13.3 ml for cingulotomy and 11.8 ml for limbic leucotomy. As expected, cingulotomy was isolated to the anterior cingulum. The subcaudate tractotomy portion of limbic leucotomy additionally affected Brodmann area 25, the medial orbitofrontal cortex, and the nucleus accumbens. Initial results indicated that the dorsolateral regions of the cingulotomy lesion and the posteroventral regions of the subcaudate tractotomy lesion were associated with improved postoperative Yale-Brown Obsessive Compulsive Scale scores. Cingulotomy and limbic leucotomy are lesioning surgeries that target pathological circuits implicated in psychiatric disease. Lesion analysis and VLSM contextualize outcome data and have the potential to be useful for improving lesioning neurosurgical procedures.

Marked Response to VNS in a Post-Cingulotomy Patient: Implications for the Mechanism of Action of VNS in TRD.

Treatment-resistant major depression (TRMD, major depressive disorder that fails to respond to numerous therapies) is a relatively common and clinically challenging disorder. In many cases, the most severely affected TRMD patients have received surgical intervention (subcaudate tractotomy, limbic leucotomy, anterior capsulotomy, and anterior cingulotomy). New treatments, including vagus nerve stimulation (VNS) and deep brain stimulation, have emerged to treat individuals with TRMD. We describe the case of a woman, 53 years of age, with a long and sustained history of TRMD (33 years), which was unresponsive to numerous treatments (multiple pharmacotherapies, psychotherapy, electroconvulsive therapy [ECT]). Additionally, her TRMD failed to respond to a bilateral anterior cingulotomy. She underwent placement of a cervical vagus nerve stimulator and a brief course of ECT (3 unilateral treatments). Her depression improved markedly, and it has remained in sustained remission for 3.5 years. This case suggests a potential synergistic effect of VNS and ECT, as well as provides possible clues to the neural circuitry of VNS in TRMD.

Tractographic analysis of historical lesion surgery for depression.

Various surgical brain ablation procedures for the treatment of refractory depression were developed in the twentieth century. Most notably, key target sites were (i) the anterior cingulum, (ii) the anterior limb of the internal capsule, and (iii) the subcaudate white matter, which were regarded as effective targets. Long-term symptom remissions were better following lesions of the anterior internal capsule and subcaudate white matter than of the cingulum. It is possible that the observed clinical improvements of these various surgical procedures may reflect shared influences on presently unspecified brain affect-regulating networks. Such possibilities can now be analyzed using modern brain connectivity procedures such as diffusion tensor imaging (DTI) tractography. We determined whether the shared connectivities of the above lesion sites in healthy volunteers might explain the therapeutic effects of the various surgical approaches. Accordingly, modestly sized historical lesions, especially of the anatomical overlap areas, were 'implanted' in brain-MRI scans of 53 healthy subjects. These were entered as seed regions for probabilistic DTI connectivity reconstructions. We analyzed for the shared connectivities of bilateral anterior capsulotomy, anterior cingulotomy, subcaudate tractotomy, and stereotactic limbic leucotomy (a combination of the last two lesion sites). Shared connectivities between the four surgical approaches mapped onto the most mediobasal aspects of bilateral frontal lobe fibers, including the forceps minor and the anterior thalamic radiations that contacted subgenual cingulate regions. Anatomically, convergence of these shared connectivities may derive from the superolateral branch of the medial forebrain bundle (MFB), a structure that connects these frontal areas to the origin of the mesolimbic dopaminergic 'reward' system in the midbrain ventral tegmental area. Thus, all four surgical anti-depressant approaches may be promoting positive affect by converging influences onto the MFB.

Lesioning and Stimulation as Surgical Treatments for Psychiatric Disorders

This review outlines and compares current attempts at the treatment of psychiatric disorders through neurosurgical techniques. In particular, we have undertaken to compare the results of lesioning techniques with those of stimulation of the brain. The original lesioning techniques, and in particular the use of frontal lobotomy as used and developed at the end of the 19th century and early 20th century represent an interesting period of strong interplay between the neurosurgery and psychiatry and are described in the first section. With the advent of modern stereotaxy, more selective procedures were developed that were also guided by concurrent advances in the neurosciences and the early interpretations of the limbic circuitry. These selective procedures included the anterior cingulotomy, the anterior capsulotomy, the subcaudate tractotomy, and the general limbic leucotomy. A discussion of implementation of these procedures and their neurobiologic justification has also been included in the second section. Besides being the targets of procedures, which cause gross mechanical disruption, several of these brain regions have been used as radiosurgical targets, and are also being considered for electrical stimulation as a treatment modality. The next 3 sections of the review focus on the newer uses of deep brain stimulation for treating specifically major depressive disorder, obsessive-compulsive disorder, and Tourette syndrome. Several choices of targets are described for these diseases along with their proposed physiologic rationale. The sixth section subsequently compares the lesioning and stimulation techniques with a particular focus on their relative merits and complications.

Limbic leukotomy for intractable major affective disorders: A 7-year follow-up study using nine comprehensive psychiatric test evaluations

Surgical treatment of psychiatric disease can be effective for some patients with severe, intractable disorders. However, few long-term studies using comprehensive psychiatric test evaluation of patients who have undergone surgery have been carried out. Stereotactic limbic leukotomy (subcaudate tractotomy and cingulotomy) was performed via radiofrequency thermocoagulation on 16 patients with intractable major affective disorders (bipolar). Patients were followed for 7 years, and nine complete psychiatric test evaluations were conducted before and after the procedure. Clinical outcomes were evaluated using the Current Global Psychiatric–Social Status Scale (CGPSS). In the 7-year follow-up, mean scores on the Hamilton Depression Rating Scale and the Beck Depression Inventory declined significantly from 42 ± 5.76 to 20 ± 11.98 ( p < 0.01) and from 32 ± 9.13 to 19 ± 14.29 ( p < 0.05), respectively. Also, mean scores on the Hamilton Anxiety Rating Scale and Negative Symptom Scale declined significantly from 104 ± 53.62 to 57 ± 36.41 ( p < 0.01) and from 57 ± 15.38 to 33 ± 18.8 ( p < 0.05), respectively. There were no statistical differences before and after surgery for Young’s Mania Rating Scale, p > 0.1. Using the CGPSS, 68.8% of patients had a marked response (CGPSS of ⩾ 3), 18.9% of patients had a possible response (CGPSS of 2), and 12.6% did not improve or became worse (CGPSS of 0 or 1). There was no surgical mortality and only three patients experienced temporary minor complications. Based on these nine comprehensive psychiatric test evaluations, limbic leukotomy is an effective procedure for long-term treatment of severe, intractable major affective disorders, with no significant side effects. The results of the psychiatric tests carried out during the 7 years of follow-up were constant and stable. The current findings demonstrate that depression, anxiety, and negative symptoms are significantly reduced by limbic leukotomy, but mania and active symptoms are not. Surgical intervention remains an important therapeutic option for the treatment of major affective disorders, and is probably underused.

Neurosurgical Treatment of Intractable Tourette’s Syndrome: A Scientific Clinical Review of Literatures

Background Tourette’s syndrome (TS) is an inherited neuropsychiatric disorder characterized by fluctuating motor and vocal tics that starts in childhood. Diagnostic criteria for TS include the presence of multiple motor tics and one or more vocal tics, both of which must exceed a year’s duration. Pharmacotherapy has been the mainstay of the treatment. However, some TS patients will not respond to conventional medications. They might develop residual debilitating symptoms. The current article examines the reported experience with neurosurgical treatment of intractable Tourette’s syndrome. Design/Method All articles and textbooks containing descriptions of Tourette’s syndrome and its surgical treatment were reviewed. All related articles in PubMed were searched using these words: Tourette’s syndrome, TS, Tourette, Gilles de la Tourette, tic, tics, surgical treatment of tic disorders, surgical intervention of Tourrete’s syndrome, ablative surgery in Tourette’s syndrome, stereotactic surgery of Tourette’s syndrome. Only articles published in English were reviewed. In total, 11 articles and 2 textbooks were found describing the experimental surgery of refractory Tourette’s syndrome. All data about patient’s history, surgical treatment, outcome and side effects were collected and reviewed. Results Intractable Tourette’s syndrome may represent a special subgroup of the tic range. A variety of experimental procedures have been performed in an attempt to treat intractable Tourette’s syndrome, including: 1) frontal lobe operation (i.e., frontal lobotomy and bimedial frontal leucotomy), 2) limbic system operation (i.e., anterior cingulotomy, limbic leucotomy), 3) a novel multisite operation (i.e., anterior cingulotomy combined with infrathalamic lesions), 4) thalamic operation (i.e., bilateral coagulation of rostral infrathalamic and medial thalamic nuclei), and 5) a cerebellar operation (i.e., bilateral cerebellar dentatomy). There are serious uncertainties regarding any experimental neurosurgical procedures. However, in the case of severe, intractable Tourette’s syndrome, these appropriate concerns must be weighed against the risks of conventional therapies, including tardive dyskinesia. Patients who suffer from severe Tourette’s syndrome, and are debilitated by their symptoms, and have failed an exhaustive range of conventional pharmacologic therapies could be candidates for an experimental treatment. Conclusion Case reports in the literature provide only anecdotal evidence supporting the efficacy and safety of neurosurgical treatment of Tourette’s syndrome. There is no convincing evidence showing that any particular neurosurgical procedure is best for Tourette’s syndrome. If experimental neurosurgery for Tourette’s syndrome is to continue, then guidelines should be developed regarding patient and operation selection. Also, accurate clinical measurement should be applied preoperatively and postoperatively to monitor long-term outcome.

Psychosurgery for Self-Injurious Behavior in Tourette's Disorder

One of the most serious and difficult-to-treat conditions in child and adolescent psychiatry is self-injurious behavior (SIB). SIB can be associated with a number of psychiatric disorders, including mental retardation, schizophrenia, borderline personality disorder, pervasive developmental disorders, stereotypic movement disorder, and Tourette's Disorder. A variety of neurosurgical procedures have been used to treat both intractable SIB and severe Tourette's Disorder. Understandably, there are few reports concerning psychosurgery in children and adolescents for any condition or disorder. This report describes the use of cingulotomy and subsequent limbic leucotomy in an adolescent boy with Tourette's Disorder for SIB. His repetitive and medically serious SIB and failure of all other treatments prompted this intervention after careful, comprehensive review and discussion. Following the second surgery, the severity and frequency of his SIB were reduced.

Update on neurosurgical treatment for obsessive compulsive disorder

Responses to pharmacotherapy and psychotherapy in obsessive-compulsive disorder (OCD) range from 60 to 80% of cases. However, a subset of OCD patients do not respond to adequately conducted treatment trials, leading to severe psychosocial impairment. Stereotactic surgery can be indicated then as the last resource. Five surgical techniques are available, with the following rates of global post-operative improvement: anterior capsulotomy (38-100%); anterior cingulotomy (27-57%); subcaudate tractotomy (33-67%); limbic leucotomy (61-69%), and central lateral thalamotomy/anterior medial pallidotomy (62.5%). The first technique can be conducted as a standard neurosurgery, as radiosurgery or as deep brain stimulation. In the standard neurosurgery neural circuits are interrupted by radiofrequency. In radiosurgery, an actinic lesion is provoked without opening the brain. Deep brain stimulation consists on implanting electrodes which are activated by stimulators. Literature reports a relatively low prevalence of adverse events and complications. Neuropsychological and personality changes are rarely reported. However, there is a lack of randomized controlled trials to prove efficacy and adverse events/complication issues among these surgical procedures. Concluding, there is a recent development in the neurosurgeries for severe psychiatric disorders in the direction of making them more efficacious and safer. These surgeries, when correctly indicated, can profoundly alleviate the suffering of severe OCD patients.

Surgery in Tourette syndrome.

Tourette syndrome (TS) is a neuropsychiatric disorder with onset in early childhood. It is characterized by tics and often accompanied by disturbances in behavior, such as obsessive-compulsive disorder (OCD). In most cases, the disorder is self-limited or can be treated by medication or behavioral therapy. In a small percentage, however, symptoms are intractable to any conservative treatment. Since 1955, various attempts have been made to treat these patients through neurosurgical procedures. The target sites have been diverse and include the frontal lobe (prefrontal lobotomy and bimedial frontal leucotomy), the limbic system (limbic leucotomy and anterior cingulotomy), the thalamus, and the cerebellum. Combined approaches have also been tried such as anterior cingulotomies plus infrathalamic lesions. The results have often been unsatisfactory or major side effects have occurred, such as hemiplegia or dystonia. Our review of the literature from 1960 until 2003 revealed 21 reports and 3 descriptions in textbooks covering about 65 patients in total who had undergone ablative procedures for intractable TS, the first being reported in 1962. In 1999, deep brain stimulation (DBS) was introduced as a new approach for intractable TS. To date, 3 patients have been reported who underwent bilateral thalamic stimulation, with promising results on tics and obsessive-compulsive symptoms.

La moderna psicocirugía: un nuevo enfoque de la neurocirugía en la enfermedad psiquiátrica

To obtain an up to date review of the different possible surgical approaches in the management of certain psychiatric disorders that are refractory to conservative treatment (pharmacotherapy, psychotherapy, electroconvulsive therapy). In order to conduct this research we reviewed the work published by centres with the most experience in this type of surgery, mainly in North America and Europe, since its beginnings in the 1930s, with the controversy concerning prefrontal leucotomy, until the appearance of modern stereotactic techniques. We analyse the anatomophysiological bases, their main clinical indications, the surgical techniques used and their results, as well as perspectives for the future of this neurosurgical treatment. The most noteworthy progress in psychosurgery in recent years has been the combination of a more rigorous selection of patients and the higher degree of specificity with which treatment is performed on the brain structures involved in psychiatric disease. The most widely employed psychosurgical procedures at present are cingulotomy, anterior capsulotomy, subcaudate tractotomy, limbic leucotomy and postero medial hypothalamotomy, with favourable responses in about 35 70% of cases. The psychiatric diagnoses where the best results are to be found are obsessive compulsive disorder, chronic anxiety states and major depression. Current progress in neuroimaging techniques, increased neurophysiological knowledge and the revolutionary neuromodulation techniques, especially deep brain stimulation, offer an even more promising future for psychiatric neurosurgery.

Reply to Limbic Leucotomy in Self-Mutilation

Article AbstractLetter to the EditorSir: We appreciate Dr. Dean's careful review and thoughtful comments about our article.1 Regarding the cost of the neurosurgical procedure we described, we do not believe that economic arguments should enter into our clinical decision making. Our primary concern is the patient's well-being.

Regional Cerebral Blood Flow Changes in Patients with Intractable Obsessive Compulsive Disorders Treated by Limbic Leukotomy

The object of this study is to assess the changes in regional cerebral blood flow (rCBF) following stereotactic limbic leukotomy in patients with medically intractable Obsessive-Compulsive Disorder (OCD). Technetium-99-Hexa Methyl Propylene Amine Oxime (^99mTc-HMPAO) Single Photon Emission Computed Tomography (SPECT) data obtained before and after limbic leukotomy were subjected to image fusion with MRI images. Eight samples were obtained from healthy voluteers. After localization of the ROI (Region Of Interest) in anatomical area, rCBF measurements were obtained by METLAB. The results of this study show a change of rCBF following limbic leukotomy in intractable OCD. Postoperative ^99mTc-HMPAO SPECT findings implicate the medial frontal cortex, cingulate and striatum, which culd be linked to limbic leukotomy that blocks the functional connection of corticolimbic loop.

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

To assess the efficacy and complication rates of magnetic resonance imaging-guided stereotactic limbic leukotomy for the treatment of intractable major depressive disorder (MDD) and obsessive-compulsive disorder (OCD). We conducted preoperative evaluations and postoperative follow-up assessments of efficacy and complications for 21 patients who underwent limbic leukotomy. Efficacy was based on physician- and patient-rated global assessments of functioning, as well as evaluations using disease-specific rating scales commonly used in studies of MDD and OCD. The mean time from limbic leukotomy to follow-up assessment was 26 months. On the basis of standard outcome measures, 36 to 50% of patients were considered to be treatment responders. Although permanent surgical morbidity was rare, there were reports of postoperative sequelae, including apathy, urinary incontinence, and memory complaints, which occurred in a substantial minority of cases. For this cohort of 21 patients with chronic severe MDD or OCD, who had experienced failure with an exhaustive array of previous treatments, limbic leukotomy was associated with substantial benefit for 36 to 50%. This rate is comparable to those of previous studies of limbic system surgery and indicates that limbic leukotomy is a feasible treatment option for severe, treatment-refractory MDD or OCD. Adverse consequences associated with the procedure included affective, cognitive, and visceromotor sequelae, which were generally transient.