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Frontiers in Human Neuroscience 2022Self-injurious behavior (SIB) is associated with diverse psychiatric conditions. Sometimes (e.g., in patients with autism spectrum disorder or acquired brain injuries),...
Self-injurious behavior (SIB) is associated with diverse psychiatric conditions. Sometimes (e.g., in patients with autism spectrum disorder or acquired brain injuries), SIB is the most dominant symptom, severely restricting the psychosocial functioning and quality of life of the patients and inhibiting appropriate patient care. In severe cases, it can lead to permanent physical injuries or even death. Primary therapy consists of medical treatment and if implementable, behavioral therapy. For patients with severe SIB refractory to conventional therapy, neuromodulation can be considered as a last recourse. In scientific literature, several successful lesioning and deep brain stimulation targets have been described that can indicate a common underlying neuronal pathway. The objectives of this study were to evaluate the short- and long-term clinical outcome of patients with severe, therapy refractory SIB who underwent DBS with diverse underlying psychiatric disorders and to correlate these outcomes with the activated connectivity networks. We retrospectively analyzed 10 patients with SIB who underwent DBS surgery with diverse psychiatric conditions including autism spectrum disorder, organic personality disorder after hypoxic or traumatic brain injury or Tourette syndrome. DBS targets were chosen according to the underlying disorder, patients were either stimulated in the nucleus accumbens, amygdala, posterior hypothalamus, medial thalamus or ventrolateral thalamus. Clinical outcome was measured 6 months after surgery and at long-term follow-up after 10 or more years using the Early Rehabilitation Barthel index (ERBI) and time of restraint. Connectivity patterns were analyzed using normative connectome. Based on previous literature the orbitofrontal cortex, superior frontal gyrus, the anterior cingulate cortex, the amygdala and the hippocampus were chosen as regions of interest. This analysis showed a significant improvement in the functionality of the patients with DBS in the short- and long-term follow-up. Good clinical outcome correlated with higher connectivity to the amygdala and hippocampus. These findings may suggest a common pathway, which can be relevant when planning a surgical procedure in patients with SIB.
PubMed: 36092644
DOI: 10.3389/fnhum.2022.958247 -
Pediatric Neurosurgery 2023Resection of brain lesions associated with refractory epilepsy to achieve seizure control is well accepted. However, concurrent behavioral effects of these lesions such...
INTRODUCTION
Resection of brain lesions associated with refractory epilepsy to achieve seizure control is well accepted. However, concurrent behavioral effects of these lesions such as changes in mood, personality, and cognition and the effects of surgery on behavior have not been well characterized. We describe 5 such children with epileptogenic lesions and significant behavioral abnormalities which improved after surgery.
CASE DESCRIPTIONS
Five children (ages 3-14 years) with major behavioral abnormalities and lesional epilepsy were identified and treated at our center. Behavioral problems included academic impairment, impulsivity, self-injurious behavior, and decreased social interaction with diagnoses of ADHD, oppositional defiant disorder, and autism. Pre-operative neuropsychiatric testing was performed in 4/5 patients and revealed low-average cognitive and intellectual abilities for their age, attentional difficulties, and poor memory. Lesions were located in the temporal (2 gangliogliomas, 1 JPA, 1 cavernoma) and parietal (1 DNET) lobes. Gross total resection was achieved in all cases. At mean 1-year follow-up, seizure freedom (Engel 1a in 3 patients, Engel 1c in 2 patients) and significant behavioral improvements (academic performance, attention, socialization, and aggression) were achieved in all. Two patients manifested violence pre-operatively; one had extreme behavior with violence toward teachers and peers despite low seizure burden. Since surgery, his behavior has normalized.
CONCLUSION
We identified 5 patients with severe behavioral disorders in the setting of lesional epilepsy, all of whom demonstrated improvement after surgery. The degree of behavioral abnormality was disproportionate to epilepsy severity, suggesting a more complicated mechanism by which lesional epilepsy impacts behavior. We propose a novel paradigm in which lesionectomy may offer behavioral benefit even when seizures are not refractory. Thus, behavioral improvement may be an important novel goal for neurosurgical resection in children with epileptic brain lesions.
Topics: Child; Humans; Psychosurgery; Treatment Outcome; Retrospective Studies; Epilepsy; Seizures; Brain Neoplasms
PubMed: 36787706
DOI: 10.1159/000529683 -
Revista de Neurologia Aug 2020Aggressiveness is part of the behavioural manifestations associated with some mental disorders; it is a symptom that is difficult to manage and is often resistant to...
INTRODUCTION
Aggressiveness is part of the behavioural manifestations associated with some mental disorders; it is a symptom that is difficult to manage and is often resistant to pharmacological measures. Surgery for behavioural disorders emerges as a therapeutic alternative. This procedure consists in performing interventions on different structures of the limbic system in order to correct the alteration of the circuit involved in producing the symptoms.
AIM
To describe the clinical outcomes of a posterior hypothalamotomy with gamma knife to control aggressiveness in 20 patients resistant to treatment, who underwent surgery at the Imbanaco Medical Centre between 2013 and 2018.
PATIENTS AND METHODS
The severity of the aggressiveness was quantified using the Overt Aggression Scale (OAS) and the Clinical Global Impression Scale (CGI-SI), and its functional impact is evaluated using the Global Assessment of Functioning scale (GAF).
RESULTS
Control over aggressiveness was observed in all patients treated by posterior hypothalamotomy with gamma knife, evidenced by a decrease in the scores on the OAS and CGI-SI and an improvement in the GAF.
CONCLUSIONS
Posterior hypothalamotomy gives rise to few complications, is a safe procedure and offers good results, suggesting that it could be a good alternative treatment in cases of treatment-resistant aggressiveness where it seems that all the possible pharmacological and therapeutic measures have failed.
Topics: Adolescent; Adult; Aggression; Autistic Disorder; Child; Combined Modality Therapy; Drug Resistance; Female; Humans; Hyperphagia; Hypothalamus, Posterior; Intellectual Disability; Magnetic Resonance Imaging; Male; Neuroimaging; Patient Care Team; Psychosurgery; Psychotropic Drugs; Radiosurgery; Severity of Illness Index; Sleep Initiation and Maintenance Disorders; Treatment Outcome; Young Adult
PubMed: 32672347
DOI: 10.33588/rn.7103.2019509 -
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 -
Neurosurgery May 2020The cingulum bundle (CB) has long been a target for psychiatric neurosurgical procedures, but with limited understanding of the brain networks being impacted. Recent...
BACKGROUND
The cingulum bundle (CB) has long been a target for psychiatric neurosurgical procedures, but with limited understanding of the brain networks being impacted. Recent advances in human tractography could provide a foundation to better understand the effects of neurosurgical interventions on the CB; however, the reliability of tractography remains in question.
OBJECTIVE
To evaluate the ability of different tractography techniques, derived from typical, human diffusion-weighted imaging (DWI) data, to characterize CB connectivity described in animal models. This will help validate the clinical applicability of tractography, and generate insight on current and future neurosurgical targets for psychiatric disorders.
METHODS
Connectivity of the CB in 15 healthy human subjects was evaluated using DWI-based tractography, and compared to tract-tracing findings from nonhuman primates. Brain regions of interest were defined to coincide with the animal model. Tractography was performed using 3 techniques (FSL probabilistic, Camino probabilistic, and Camino deterministic). Differences in connectivity were assessed, and the CB segment with the greatest connectivity was determined.
RESULTS
Each tractography technique successfully reproduced the animal tracing model with a mean accuracy of 72% (68-75%, P < .05). Additionally, one region of the CB, the rostral dorsal segment, had significantly greater connectivity to associated brain structures than all other CB segments (P < .05).
CONCLUSION
Noninvasive, in vivo human analysis of the CB, using clinically available DWI for tractography, consistently reproduced the results of an animal tract-tracing model. This suggests that tractography of the CB can be used for clinical applications, which may aid in neurosurgical targeting for psychiatric disorders.
Topics: Animals; Brain; Diffusion Tensor Imaging; Female; Humans; Macaca; Male; Models, Animal; Neural Pathways; Neurosurgical Procedures; Registries; Reproducibility of Results; White Matter
PubMed: 31264700
DOI: 10.1093/neuros/nyz225 -
Adicciones Jul 2021
Topics: Cocaine; Cocaine-Related Disorders; Humans; Parkinson Disease; Psychosurgery
PubMed: 33768270
DOI: 10.20882/adicciones.1614 -
Personalized Medicine in Psychiatry 2023Major Depressive Disorder (MDD) and Obsessive-Compulsive Disorder (OCD) are common and potentially incapacitating conditions. Even when recognized and adequately...
Major Depressive Disorder (MDD) and Obsessive-Compulsive Disorder (OCD) are common and potentially incapacitating conditions. Even when recognized and adequately treated, in over a third of patients with these conditions the response to first-line pharmacological and psychotherapeutic measures is not satisfactory. After more assertive measures including pharmacological augmentation (and in the case of depression, transcranial magnetic stimulation, electroconvulsive therapy, or treatment with ketamine or esketamine), a significant number of individuals remain severely symptomatic. In these persons, different ablation and deep-brain stimulation (DBS) psychosurgical techniques have been employed. However, apart from the cost and potential morbidity associated with surgery, on average only about half of patients show adequate response, which limits the widespread application of these potentially life-saving interventions. Possible reasons are considered for the wide variation in outcomes across different series of patients with MDD or OCD exposed to ablative or DBS psychosurgery, including interindividual anatomical and etiological variability. Low-intensity focused ultrasound (LIFU) is an emerging technique that holds promise in its ability to achieve anatomically circumscribed, noninvasive, and reversible neuromodulation of deep brain structures. A possible role for LIFU in the personalized presurgical definition of neuromodulation targets in the individual patient is discussed, including a proposed roadmap for clinical trials addressed at testing whether this technique can help to improve psychosurgical outcomes.
PubMed: 36969502
DOI: 10.1016/j.pmip.2023.100100 -
Neurology India Mar 2024With advances in technology, neurosurgical procedures are being examined for potential use in psychiatric conditions. However, the use of neurosurgical procedures in...
With advances in technology, neurosurgical procedures are being examined for potential use in psychiatric conditions. However, the use of neurosurgical procedures in psychiatry carries the baggage of memories of psychosurgery. Different neurosurgical techniques carry their characteristic safety, efficacy, and complication profile. The introduction of deep brain stimulation has generated a new interest in surgical treatment with a distinct advantage over lesioning procedures used in the past. In such a scenario, it is essential that an informed discussion takes place regarding the use of these neurosurgical procedures in psychiatric disorders such that patient safety, informed consent, regulatory requirements, and research are taken care of.
Topics: Humans; Psychosurgery; India; Deep Brain Stimulation; Mental Disorders; Neurosurgical Procedures
PubMed: 38817176
DOI: 10.4103/neuroindia.NI_1160_20 -
BMC Anesthesiology May 2023To investigate the effects of ultrasound-guided erector spinae plane block (ESPB) on acute and chronic post-surgical pain in patients underwent video-assisted... (Randomized Controlled Trial)
Randomized Controlled Trial
Effects of ultrasound-guided erector spinae plane block on postoperative acute pain and chronic post-surgical pain in patients underwent video-assisted thoracoscopic lobectomy: a prospective randomized, controlled trial.
OBJECTIVE
To investigate the effects of ultrasound-guided erector spinae plane block (ESPB) on acute and chronic post-surgical pain in patients underwent video-assisted thoracoscopic lobectomy.
METHODS
A total of 94 patients, who underwent elective unilateral video-assisted thoracoscopic lobotomy from August 2021 to December 2021 were randomly divided into general anesthesia group (group A, n = 46) and ESPB combined with general anesthesia group (group B, n = 48) by computer. Patient controlled intravenous analgesia(PCIA) was performed in both groups after operation. The numerical rating scale(NRS) of rest and cough pain at post anesthesia care unit(PACU), 2 h, 6 h, 12 h, 24 and 48 h after operation, frequency of PCIA in 24 h after operation, frequency of rescue analgesia, patient satisfaction, adverse reactions and complications were recorded in the two groups. Incidence of chronic pain at 3 months and 6 months after operation, the effect of daily life and rating of chronic pain management measures were recorded in the two groups.
RESULTS
Compared with group A, rest and cough NRS score at 2 h, 6 h, 12 h, 24 and 48 h after surgery, frequency of PCIA use at 24 h after surgery, frequency of rescue analgesia were significantly decreased in group B (P < 0.05). There was no significant difference in NRS scores of rest and cough at PACU after operation between 2 groups after surgery at post anesthesia care unit (P > 0.05). There were no significant differences in the incidence of postoperative chronic pain between the 2 groups(P > 0.05);The effect of postoperative chronic pain on daily life and pain management measures in group B were significantly lower than those in group A(P < 0.05). Compared with group A, patients in group B had higher satisfaction degree, lower incidence of postoperative nausea and vomiting(PONV), and lower incidence of agitation during anesthesia recovery (P < 0.05). There were no pneumothorax, hematoma and toxicity of local anesthetic in the 2 groups.
CONCLUSION
Ultrasound-guided erector spinae plane block can significantly reduce acute post-surgical pain, can not reduce the incidence of chronic post-surgical pain, but can significantly reduce the severity of chronic pain in patients underwent video-assisted thoracoscopic lobectomy.
TRIAL REGISTRATION
ChiCTR2100050313,date of registration:26/08/2021.
Topics: Humans; Acute Pain; Chronic Pain; Cough; Prospective Studies; Psychosurgery; Thoracic Surgery, Video-Assisted; Anesthesia, Conduction; Pain, Postoperative; Analgesia, Patient-Controlled; Nerve Block; Ultrasonography, Interventional
PubMed: 37161305
DOI: 10.1186/s12871-023-02100-5 -
National Science Review Mar 2020Addiction is a major public-health crisis associated with significant disability and mortality. Although various pharmacological and behavioral treatments are currently...
Addiction is a major public-health crisis associated with significant disability and mortality. Although various pharmacological and behavioral treatments are currently available, the clinical efficacy of these treatments is limited. Given this situation, there is a growing interest in finding an effective neurosurgical treatment for addiction. First, we discuss the use of ablative surgery in treating addiction. We focus on the rise and fall of nucleus accumbens ablation for addiction in China. Subsequently, we review recent studies that have explored the efficacy and safety of deep-brain-stimulation treatment for addiction. We conclude that neurosurgical procedures, particularly deep-brain stimulation, have a potentially valuable role in the management of otherwise intractable addictive disorders. Larger well-controlled clinical trials, however, are needed to assess clinical efficacy and safety. We end by discussing several key issues involved in this clinical field and identifying some areas of progress.
PubMed: 34692088
DOI: 10.1093/nsr/nwz207