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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 -
Tidsskrift For Den Norske Laegeforening... Dec 2022
Topics: Humans; History, 20th Century; Psychosurgery; Mental Disorders; Learning
PubMed: 36511739
DOI: 10.4045/tidsskr.22.0505 -
Brain Sciences Dec 2021Deep brain stimulation (DBS) requires a precise localization, which is especially difficult at the hypothalamus, because it is usually performed in anesthetized...
Deep brain stimulation (DBS) requires a precise localization, which is especially difficult at the hypothalamus, because it is usually performed in anesthetized patients. We aimed to characterize the neurophysiological properties posteromedial hypothalamus (PMH), identified by the best neurophysiological response to electrical stimulation. We obtained microelectrode recordings from four patients with intractable aggressivity operated under general anesthesia. We pooled data from 1.5 mm at PMH, 1.5 mm upper (uPMH) and 1.5 mm lower (lPMH). We analyzed 178 units, characterized by the mean action potential (mAP). Only 11% were negative. We identified the next types of units: P1N1 (30.9%), N1P1N2 (29.8%), P1P2N1 (16.3%), N1P1 and N1N2P1 (6.2%) and P1N1P2 (5.0%). Besides, atypical action potentials (amAP) were recorded in 11.8%. PMH was highly different in cell composition from uPMH and lPMH, exhibiting also a higher percentage of amAP. Different kinds of cells shared similar features for the three hypothalamic regions. Although features for discharge pattern did not show region specificity, the probability mass function of inter-spike interval were different for all the three regions. Comparison of the same kind of mAP with thalamic neurons previously published demonstrate that most of cells are different for derivatives, amplitude and/or duration of repolarization and depolarization phases and also for the first phase, demonstrating a highly specificity for both brain centers. Therefore, the different properties described for PMH can be used to positively refine targeting, even under general anesthesia. Besides, we describe by first time the presence of atypical extracellular action potentials.
PubMed: 35053786
DOI: 10.3390/brainsci12010043 -
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 -
CNS Neuroscience & Therapeutics Aug 2019Patients with epilepsy and refractory comorbid psychiatric disorders often experience functional impairments and a lower quality of life as well as showing a lack of...
OBJECTIVES
Patients 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.
METHODS
In 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.
RESULTS
After 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.
CONCLUSION
Anterior 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.
Topics: Adolescent; Adult; Aggression; Comorbidity; Epilepsy; Female; Humans; Internal Capsule; Male; Medication Adherence; Psychotic Disorders; Quality of Life; Retrospective Studies; Young Adult
PubMed: 30868752
DOI: 10.1111/cns.13118 -
European Psychiatry : the Journal of... Nov 2023The European Psychiatric Association (EPA) is an organization that speaks on behalf of its individual members and members of National Psychiatric Associations (NPAs)....
BACKGROUND
The European Psychiatric Association (EPA) is an organization that speaks on behalf of its individual members and members of National Psychiatric Associations (NPAs). The aim of this study to identify and investigate current contents of ethical codes and practices in the countries belonging to EPA.
METHODS
The study is an expert survey sent out to 44 representatives of 30 NPAs covering the following topics: the existence of national bodies dealing with ethical issues in psychiatry, the availability of documents relevant to ethical issues, the types of ethical issues addressed at the national level, and the current and envisaged ethical debates.
RESULTS
Out of 44 experts invited to participate in the study, 31 NPAs from 30 countries responded (response rate 70.45%). In the majority of countries, the general mission statement serves as the main document covering ethical issues in psychiatry. Most frequently, internal documents were reported to address medical malpractice, workplace bullying, plagiarism, academic fraud, sexual abuse, and discrimination/racism. Furthermore, internal documents cover the ethical assessment of potentially controversial procedures, including psychosurgery, euthanasia, and pregnancy termination. The most important topics for debate at the level of NPAs/EPA were associated with violations of clinical practice standards and human rights.
CONCLUSIONS
NPAs are active in the field of professional ethics, defining ethical standards related to interactions among professionals and services provided by mental health care professionals. Future collaboration of NPAs, under the umbrella of the EPA, could allow to develop a database of local ethical documents that would be translated into English and accessible to all EPA members.
Topics: Humans; Psychiatry; Europe; Surveys and Questionnaires
PubMed: 37909413
DOI: 10.1192/j.eurpsy.2023.2470 -
Surgical Neurology International 2021Delusions and hallucinations, hallmarks of the psychotic disorders, usually do not respond to surgical intervention. For many years, the surgical technique of choice for...
BACKGROUND
Delusions and hallucinations, hallmarks of the psychotic disorders, usually do not respond to surgical intervention. For many years, the surgical technique of choice for the treatment of refractory aggressiveness in psychotic patients in our Service was amygdalotomy in isolation or associated with anterior cingulotomy. No improvement of hallucinations and delusions was noticed in any of these patients. To improve the control of aggression, subcaudate tractotomy was added to the previous surgical protocol. The main goal of the present study was to investigate the impact of this modified surgical approach on delusions and hallucinations.
METHODS
Retrospective analysis of the medical records of psychotic patients presenting with treatment-resistant aggressiveness, delusions, and hallucinations submitted to bilateral subcaudate tractotomy + bilateral anterior cingulotomy + bilateral amygdalotomy in our institution.
RESULTS
Five patients, all males, with ages ranging from 25 to 65 years, followed up by a mean of 45.6 months (17-72 months), fulfilled the inclusion criteria. Delusions and hallucinations were abolished in four of them.
CONCLUSION
These results suggest that the key element for relieving these symptoms was the subcaudate tractotomy and that the orbitofrontal and ventromedial prefrontal cortices play an important role in the genesis of hallucinatory and delusional symptoms of schizophrenia and other psychoses.
PubMed: 34621590
DOI: 10.25259/SNI_599_2021 -
Journal of Psychiatric Research Jun 2020Stereotactic ablation (cingulotomy) and subcallosal cingulate deep brain stimulation (SCC DBS) of different regions of the cingulum bundle (CB) have been successfully...
OBJECTIVE
Stereotactic ablation (cingulotomy) and subcallosal cingulate deep brain stimulation (SCC DBS) of different regions of the cingulum bundle (CB) have been successfully used to treat psychiatric disorders, such as depression and bipolar disorder. They are hypothesized to work by disrupting white matter pathways involved in the clinical manifestation of these disorders. This study aims to compare the connectivity of different CB subregions using tractography to evaluate stereotactic targets for the treatment of mood disorders.
METHODS
Fourteen healthy volunteers underwent 3T-MR imaging followed by connectivity analysis using probabilistic tractography. Twenty-one anatomic regions of interest were defined for each subject: 10 CB subregions (including the classical cingulotomy and SCC DBS targets) and 11 cortical/subcortical structures implicated in mood disorders. Connectivity results were compared using Friedman and Bonferroni-corrected post-hoc Wilcoxon tests.
RESULTS
CB connectivity showed a high degree of regional specificity. Both of the traditional stereotactic targets had widespread connectivity with discrete topology. The cingulotomy target connected primarily to the dorsomedial frontal, dorsal anterior cingulate, and posterior cingulate cortices, whereas the SCC DBS target connected mostly to the subgenual anterior cingulate and medial/central orbitofrontal cortices. However, a region of the rostral dorsal CB, lying between these surgical targets, encompassed statistically equivalent connections to all five cortical regions.
CONCLUSIONS
The CB is associated with brain structures involved in affective disorders, and the rostral dorsal CB demonstrates connectivity that is comparable to the combined connectivity of cingulotomy and SCC DBS neurosurgical interventions. The rostral dorsal CB represents a surgical target worthy of clinical exploration for mood disorders.
Topics: Brain; Deep Brain Stimulation; Gyrus Cinguli; Humans; Mood Disorders; White Matter
PubMed: 32272241
DOI: 10.1016/j.jpsychires.2020.03.011 -
Stereotactic and Functional Neurosurgery 2020Thalamotomy is an endorsed treatment for medication-refractory tremor. It used to be the standard, but nowadays deep brain stimulation (DBS) has become the treatment...
BACKGROUND
Thalamotomy is an endorsed treatment for medication-refractory tremor. It used to be the standard, but nowadays deep brain stimulation (DBS) has become the treatment option of choice. Nevertheless, DBS has the disadvantage of hardware failure, battery replacement, and frequent setting adjustment. Radiofrequency (RF) thalamotomy lacks these issues, is relatively inexpensive, and has a broad applicability in patients with significant comorbidity. Therefore, we analyzed the long-term patient-reported outcome of RF thalamotomy in a cohort of patients with an otherwise intractable tremor.
METHODS
A single-center cohort of 27 consecutive patients with intractable tremor was assessed after unilateral RF thalamotomy. Over time, 4 patients had died because of non-related causes. In total, 21 patients responded to a telephone survey to assess their personal judgment on postoperative tremor severity, using a validated tremor scale, adverse events, recurrence, and patient satisfaction. The median time between surgery and telephone survey was 39 months (range 12-126). Seven patients had an additional analysis with postoperative imaging, video-assisted electromyography tremor registration, and a self-reported treatment effect (SRTE) assessment.
RESULTS
Nineteen out of 21 patients (90.5%) reported absence or significant improvement of their tremor. The rating score (WHIGET/UPDRS-III) dropped significantly from a mean of 3.57 preoperatively to 1.05 postoperatively (p < 0.001). Eleven patients (52.4%) reported adverse events, but the majority (76.2%) did not consider the adverse events to be severe. SRTE assessment showed a direct postoperative effect of 89.6 of 100 points (SD 10.8), with a gradual decrease to 75.3 (SD 23.5) during follow-up.
CONCLUSIONS
RF thalamotomy is a very effective long-term treatment for medication-refractory tremor and should therefore be considered in patients with a refractory unilateral tremor.
Topics: Adult; Aged; Aged, 80 and over; Cohort Studies; Electromyography; Female; Follow-Up Studies; Humans; Male; Middle Aged; Patient Reported Outcome Measures; Patient Satisfaction; Psychosurgery; Radiofrequency Ablation; Thalamus; Treatment Outcome; Tremor
PubMed: 32316017
DOI: 10.1159/000506999 -
Indian Journal of Psychological Medicine Nov 2023In the early 20 century, psychosurgery had gained worldwide popularity for treating mentally ill persons, especially in western countries. We attempt to chronicle its...
BACKGROUND
In the early 20 century, psychosurgery had gained worldwide popularity for treating mentally ill persons, especially in western countries. We attempt to chronicle its journey in the Mysore Government Mental Hospital (MGMH), now the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru.
METHODS
Archived case records and registers of patients admitted from 1939 to 1947 were reviewed to identify those who had undergone psychosurgery. Case records of the identified patients were assessed for clinical information, including the details of psychosurgery.
RESULTS
Among the patients, 107 had undergone psychosurgery, primarily leucotomy. Schizophrenia (51.5%) was the most common diagnosis in them, and 33.7% of all patients were reported to have improved. Yet, inconsistencies were found about the presence and degree of improvement. Possible side effects were not consistently documented.
CONCLUSION
Psychosurgery was adopted at the MGMH very soon following its introduction in the western world. However, ambiguity about its benefits and risks was noted in the current study.
PubMed: 38545541
DOI: 10.1177/02537176231154811