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Neurosurgical Focus Feb 2023Despite its relatively low prevalence, schizophrenia has a high burden of illness due to its lifelong effects and the fact that it is often refractory to psychotropic...
OBJECTIVE
Despite its relatively low prevalence, schizophrenia has a high burden of illness due to its lifelong effects and the fact that it is often refractory to psychotropic treatment. This review investigated how neurosurgical interventions, primarily neuromodulation through deep brain stimulation (DBS), can mitigate treatment-refractory schizophrenia. Pathophysiological data and ongoing clinical trials were reviewed to suggest which targets hold promise for neurosurgical efficacy.
METHODS
A systematic review of the literature was conducted via an electronic search of the PubMed, Scopus, and Web of Science databases. Included papers were human or animal studies of neurosurgical interventions for schizophrenia conducted between 2012 and 2022. An electronic search of ClinicalTrials.gov and the International Clinical Trials Registry Platform was conducted to find ongoing clinical trials. The ROBINS-I (Risk of Bias in Nonrandomized Studies of Interventions) assessment tool was used to evaluate risk of bias in the study.
RESULTS
Eight human and 2 rat studies were included in the review. Of the human studies, 5 used DBS targeting the nucleus accumbens, subgenual anterior cingulate cortex, habenula, and substantial nigra pars reticulata. The remaining 3 human studies reported the results of subcaudate tractotomies and anterior capsulotomies. The rat studies investigated DBS of the nucleus accumbens and medial prefrontal cortex. Overall, human studies demonstrated long-term reduction in Positive and Negative Syndrome Scale scores in many participants, with a low incidence of surgical and psychological side effects. The rat studies demonstrated improved prepulse and latent inhibition in the targeted areas after DBS.
CONCLUSIONS
As identified in this review, recent studies have investigated the potential effects of therapeutic DBS for schizophrenia, with varying results. DBS targets that have been explored include the hippocampus, subgenual anterior cingulate cortex, habenula, substantia nigra pars reticulata, and medial prefrontal cortex. In addition to DBS, other neuromodulatory techniques such as neuroablation have been studied. Current evidence suggests that neuroablation in the subcaudate tract and anterior capsulotomy may be beneficial for some patients. The authors recommend further exploration of neuromodulation for treatment-refractory schizophrenia, under the condition that rigorous standards be upheld when considering surgical candidacy for these treatments, given that their safety and efficacy remain to be determined.
Topics: Humans; Rats; Animals; Schizophrenia; Neurosurgery; Neurosurgical Procedures; Psychosurgery; Nucleus Accumbens; Deep Brain Stimulation
PubMed: 36724524
DOI: 10.3171/2022.11.FOCUS22620 -
Journal of Clinical Neuroscience :... Sep 2023Overall survival (OS)for glioblastoma multiforme (GBM) has a known association with the extent of tumor resection with gross total resection (GTR) typically considered... (Meta-Analysis)
Meta-Analysis Review
Overall survival (OS)for glioblastoma multiforme (GBM) has a known association with the extent of tumor resection with gross total resection (GTR) typically considered as the upper limit. In certain regions such as the anterior temporal lobe, more extensive resection by means of a lobectomy may be feasible. In our systematic review and meta-analysis, we aimed to compare the outcomes of lobectomy and GTR for GBM. PubMed and Embase were queriedfor studies that compared the outcomes after lobectomy or GTR for GBM. The primary outcomes were OS, progression-free survival (PFS), and Karnofksy Performance Status (KPS) score at the latest follow-up. The secondary outcomes were seizure control at the latest follow-up and complication rates. Meta-analysis for OS and PFS was performed using individual-participant data reconstructed from published Kaplan-Meier curves. Random-effect meta-analysis was performed for KPS. The secondary outcomes were pooled using descriptive statistics. Of the 795 records screened, 6 were included in our study. Meta-analysis revealed that anterior temporal, frontal, or occipital lobectomy was associated with significantly better OS (p < 0.001) and PFS (p < 0.001) than GTR, but not KPS (MD = 6.37; 95% CI=(-13.80, 26.54); p = 0.536). Anterior temporal lobectomy was associated with significantly better seizure control rates than GTR for temporal GBM (OR = 27; 95% CI=(1.4, 515.9); p = 0.002). There was no statistically significant difference in complication rates between anterior temporal, frontal, or occipital lobectomy and GTR. In conclusion, lobectomy was associated with significantly better OS, PFS, and seizure control than GTR for GBM.
Topics: Humans; Glioblastoma; Brain Neoplasms; Psychosurgery; Progression-Free Survival; Seizures; Retrospective Studies; Neurosurgical Procedures
PubMed: 37487449
DOI: 10.1016/j.jocn.2023.07.016 -
Stereotactic and Functional Neurosurgery 2022Ablative lesion procedures remain as the last option in treatment of refractory depression. Contemporary ablative psychosurgeries involve producing lesions in the... (Meta-Analysis)
Meta-Analysis
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.
Topics: Humans; Depression; Depressive Disorder, Treatment-Resistant; Psychosurgery; Neurosurgical Procedures; Gyrus Cinguli
PubMed: 35973404
DOI: 10.1159/000526000 -
Journal of Psychiatry & Neuroscience :... Sep 2020Several neuroablative procedures are available for severe and treatment-resistant obsessive-compulsive disorder (OCD), but limited knowledge about their relative... (Meta-Analysis)
Meta-Analysis
BACKGROUND
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.
METHODS
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.
RESULTS
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.
LIMITATIONS
The level of evidence of most included studies was relatively low.
CONCLUSION
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.
Topics: Humans; Obsessive-Compulsive Disorder; Outcome Assessment, Health Care; Psychosurgery; Radiofrequency Ablation
PubMed: 32549057
DOI: 10.1503/jpn.190079 -
Neurosurgical Review Aug 2021Long has the standard of care for substance use disorder (SUD) been pharmacotherapy, psychotherapy, or rehabilitation with varying success. Deep brain stimulation (DBS)... (Review)
Review
Long has the standard of care for substance use disorder (SUD) been pharmacotherapy, psychotherapy, or rehabilitation with varying success. Deep brain stimulation (DBS) may have a beneficial reduction in the addiction-reward pathway. Recent studies have found reduced relapse and improvements in quality of life following DBS stimulation of the nucleus accumbens. We aim to identify positive outcomes and adverse effects to assess the viability of DBS as a treatment of addiction. A PubMed search following PRISMA guidelines was conducted to identify the entirety of reports reporting DBS as a treatment for SUD. Outcomes were extracted from the literature to be summarized, and a review of the quality of publications was also performed. From 2305 publications, 14 studies were found to fit the inclusion criteria published between 2007 and 2019. All studies targeted the nucleus accumbens (NAc) and remission rates at 6 months, 1 year, 2 years, and more than 6 years were 61% (20/33), 53% (17/32), 43% (14/30), and 50% (3/6), respectively. Not all studies detailed the stimulation settings or coordinates. The most common adverse effect across studies was a weight change of at least 2 kg. DBS shows potential as a long-term treatment of SUD in refractory patients. Further studies with controlled double-blind paradigms are needed for evaluation of the efficacy and safety of this treatment. Future studies should also investigate other brain regions for stimulation and optimal device stimulation parameters.
Topics: Brain; Deep Brain Stimulation; Humans; Nucleus Accumbens; Quality of Life; Randomized Controlled Trials as Topic; Substance-Related Disorders
PubMed: 33037538
DOI: 10.1007/s10143-020-01415-y -
Child's Nervous System : ChNS :... Aug 2021Both corpus callosotomy (CC) and the ketogenic diet (KD) are commonly used in patients with Lennox Gastaut syndrome (LGS), as a significant proportion of these patients... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Both corpus callosotomy (CC) and the ketogenic diet (KD) are commonly used in patients with Lennox Gastaut syndrome (LGS), as a significant proportion of these patients develop pharmacoresistant epilepsy. But no systematic review has yet compared the efficacy and safety of these two measures.
METHODS
We conducted a systematic search on various databases to collating all available literature until 30th November 2020 with a primary objective to compare the efficacy of KD and CC in terms of the proportion of patients with complete seizure freedom, at least 75% and 50% reduction in seizure frequency at various time points after the institution of these modalities. We also attempted to compare the proportion and nature of adverse effects, impact on EEG, cognition, and behavior with these modalities. We only included original articles enrolling at least 10 patients with CC or KD for quantitative synthesis to determine a pooled estimate. We used a fixed or random effects model, depending on the degree of heterogeneity.
RESULTS
We selected 23 and 7 articles describing the efficacy of CC and KD in 436 and 185 LGS patients out of 217 search items, but none of the studies compared directly these two entities. The indirect comparison between the pooled estimate of all patients with individual modalities revealed more patients with CC had seizure freedom, at least 75% and 50% reduction in seizure frequency (p=0.0001, 0.01, and 0.04 respectively). The proportion of patients with adverse effects was also higher for CC patients (p=0.01), although the proportion with serious adverse effects was not significantly different between the two modalities. Patients selected for CC were older, had higher seizure burden, more lag time after the onset of seizures, and received more number of antiseizure medications previously. Due to the availability of limited data, a firm conclusion could not be determined regarding the effect on EEG, cognition, and behavior with CC and KD.
CONCLUSION
CC is more efficacious than KD in reducing seizure frequency in patients with LGS, although it has relatively more adverse effects during the immediate perioperative period.
Topics: Child; Cognition; Diet, Ketogenic; Humans; Lennox Gastaut Syndrome; Psychosurgery; Seizures; Treatment Outcome
PubMed: 33871716
DOI: 10.1007/s00381-021-05174-z -
Child's Nervous System : ChNS :... Jan 2021Atonic seizures are associated with a particularly poor response to medical treatment. We performed a systematic review and meta-analysis to compare the efficacy of... (Meta-Analysis)
Meta-Analysis
PURPOSE
Atonic seizures are associated with a particularly poor response to medical treatment. We performed a systematic review and meta-analysis to compare the efficacy of corpus callosotomy (CC) and vagus nerve stimulation (VNS) in the management of atonic seizures in the pediatric population.
METHODS
A literature search was performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and recommendations, focusing on atonic seizures, CC, and VNS in pediatric populations. Pertinent clinical data were extracted and analyzed. Pooled effects between groups were calculated as standardized error (SE) with 95% confidence intervals (CIs). To assess for statistical significance, the Z-test was performed, using the pooled effect size (ES) and 95% CI for each intervention.
RESULTS
A total of 31 studies met the inclusion criteria, with 24 studies encompassing 425 children treated with CC and 7 studies encompassing 108 children treated with VNS. Twenty-four studies were included in a meta-analysis. There was a statistically significant difference in the primary outcome of atonic seizure control in favor of CC (overall effect size (ES) 0.73, 95% CI 0.69-0.77 for CC, ES 0.4, 95% CI 0.28-0.51 for VNS, p = 0.003). There was a higher rate of complications requiring reoperation in the CC cohort (6.6% vs. 3.8%) and a 14% rate of symptomatic disconnection syndrome.
CONCLUSIONS
While both techniques are safe, CC provides a much higher chance of effectively managing this morbid seizure type albeit with a higher risk of re-operation and disconnection syndrome.
Topics: Child; Cohort Studies; Corpus Callosum; Humans; Psychosurgery; Seizures; Treatment Outcome; Vagus Nerve Stimulation
PubMed: 32529546
DOI: 10.1007/s00381-020-04698-0 -
Neurosurgical Review Jun 2023Neurosurgery is a therapeutic option for patients with refractory obsessive-compulsive disorder who do not respond to previous treatments. Although its efficacy in... (Review)
Review
Neurosurgery is a therapeutic option for patients with refractory obsessive-compulsive disorder who do not respond to previous treatments. Although its efficacy in reducing clinical symptomatology has been proven, few studies have analyzed its effects at the cognitive level. The aim of this systematic review was to describe the cognitive outcomes of functional neurosurgery in patients that went through capsulotomies or cingulotomies. PubMed, Medline, Scopus, PsycInfo, PsyArticles, and Web of Knowledge were searched for studies reporting cognitive outcomes in refractory obsessive-compulsive patients after capsulotomies and cingulotomies. The risk of bias was assessed with the Assessment Tool for Before-After (Pre-Post) Studies With No Control Group tool; 13 studies met inclusion criteria, including 205 refractory obsessive-compulsive disorder patients for both surgical procedures. Results showed a substantial number of studies that did report significant cognitive improvement after surgery, being this improvement specially related to memory and executive functions. The second-most frequent finding is the maintenance of cognitive performance (nor improvement or worsening). From a neuropsychological point of view, this outcome might be considered a success, given that it is accompanied by amelioration of obsessive-compulsive symptoms. Subtle cognitive adverse effects have also been reported. Neurosurgery procedures appear to be safe from a cognitive point of view. Methodological issues must be improved to draw clearer conclusions, but capsulotomies and cingulotomies constitute an effective alternative treatment for refractory obsessive-compulsive disorder patients.
Topics: Humans; Neurosurgery; Neurosurgical Procedures; Obsessive-Compulsive Disorder; Psychosurgery; Treatment Outcome; Cognition
PubMed: 37351641
DOI: 10.1007/s10143-023-02037-w -
World Neurosurgery Nov 2021Stereoelectroencephalography (sEEG) is an increasingly popular surgical technique used clinically to study neural circuits involved in medication-refractory epilepsy,...
BACKGROUND
Stereoelectroencephalography (sEEG) is an increasingly popular surgical technique used clinically to study neural circuits involved in medication-refractory epilepsy, and it is concomitantly used in the scientific investigation of neural circuitry underlying behavior.
METHODS
Using PRISMA guidelines, the U.S. National Library of Medicine at the National Institutes of Health PubMed database was queried for investigational or therapeutic applications of sEEG in human subjects. Abstracts were analyzed independently by 2 authors for inclusion or exclusion.
RESULTS
The study search identified 752 articles, and after exclusion criteria were applied, 8 studies were selected for in-depth review. Among those 8 studies, 122 patients were included, with indications ranging from schizophrenia to Parkinson disease. All the included studies were single-institution case series representing level IV scientific evidence.
CONCLUSIONS
sEEG is an important method in epilepsy surgery that could be applied to other neurologic and psychiatric diseases. Information from these studies could provide additional pathophysiologic information and lead to further development and refinement of neuromodulation therapies for such conditions.
Topics: Brain; Brain Mapping; Electroencephalography; Epilepsy; Humans; Parkinson Disease; Psychosurgery; Schizophrenia; Stereotaxic Techniques
PubMed: 34217862
DOI: 10.1016/j.wneu.2021.06.105 -
Journal of Psychiatry & Neuroscience :... Nov 2020Psychiatric surgery, including deep brain stimulation and stereotactic ablation, is an important treatment option in severe refractory psychiatric illness. Several large...
BACKGROUND
Psychiatric surgery, including deep brain stimulation and stereotactic ablation, is an important treatment option in severe refractory psychiatric illness. Several large trials have demonstrated response rates of approximately 50%, underscoring the need to identify and select responders preoperatively. Recent advances in neuroimaging have brought this possibility into focus. We systematically reviewed the psychiatric surgery neuroimaging literature to assess the current state of evidence for preoperative imaging predictors of response.
METHODS
We performed this study in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) frameworks, and preregistered it using PROSPERO. We systematically searched the Medline, Embase and Cochrane databases for studies reporting preoperative neuroimaging analyses correlated with clinical outcomes in patients who underwent psychiatric surgery. We recorded and synthesized the methodological details, imaging results and clinical correlations from these studies.
RESULTS
After removing duplicates, the search yielded 8388 unique articles, of which 7 met the inclusion criteria. The included articles were published between 2001 and 2018 and reported on the outcomes of 101 unique patients. Of the 6 studies that reported significant findings, all identified clusters of hypermetabolism, hyperconnectivity or increased size in the frontostriatal limbic circuitry.
LIMITATIONS
The included studies were few and highly varied, spanning 2 decades.
CONCLUSION
Although few studies have analyzed preoperative imaging for predictors of response to psychiatric surgery, we found consistency among the reported results: most studies implicated overactivity in the frontostriatal limbic network as being correlated with clinical response. Larger prospective studies are needed.
REGISTRATION
www.crd.york.ac.uk/prospero/display_record.php?RecordID=131151.
Topics: Deep Brain Stimulation; Humans; Mental Disorders; Neuroimaging; Outcome Assessment, Health Care; Preoperative Care; Psychosurgery; Radiofrequency Ablation; Stereotaxic Techniques
PubMed: 32293838
DOI: 10.1503/jpn.190208