-
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 -
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 -
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 -
Epilepsy Research Aug 2019RCTs are the gold standard in determining intervention efficacy with journal impact factor assumed to index research quality. Flint et al's (2017) systematic review...
PURPOSE
RCTs are the gold standard in determining intervention efficacy with journal impact factor assumed to index research quality. Flint et al's (2017) systematic review examined neurocognitive outcomes following paediatric temporal lobe epilepsy surgery. Retrieved evidence was restricted to non-RCTs, which pose greater risk of bias and thus diminish research quality. The current study evaluated risk of bias in sources retrieved by Flint et al. and explored whether impact factor related to research quality within this selected field.
METHODS
Methodological and reporting bias was evaluated using categories of bias specified by Cochrane. The relationship between the identified number of biases and journal impact factors of retrieved sources was examined.
RESULTS
All studies carried substantial risk for bias. Methodology bias included low sample size (76.71%; 56/73), risk of confounding cognitive outcomes due to failure to report pre-surgery neurocognitive data (21.92%; 16/73) and to determine whether patients were prescribed antiepileptic drugs at follow-up (53.42%; 39/73). Reporting bias included overstating claims based on findings (53.42%; 39/73), failure to report individual patient characteristics (66%; 33/50) and omitting the nature of surgical interventions (15.07%; 11/73). The number of sources of common bias within studies was not associated significantly with journal impact factor (p = .878).
CONCLUSION
This evaluation highlights risk of bias when sources are predominantly uncontrolled non-RCTs and provides evidence that journal impact factor is not a reliable indicator of quality within this field. Authors should limit bias in their methods and reporting of results, to ensure the highest quality evidence possible is used to inform treatment decisions and prognosis.
Topics: Child; Cross-Sectional Studies; Epilepsy, Temporal Lobe; Humans; Mental Status and Dementia Tests; Neurocognitive Disorders; Psychosurgery; Qualitative Research; Retrospective Studies; Temporal Lobe; Treatment Outcome
PubMed: 31125839
DOI: 10.1016/j.eplepsyres.2019.03.013 -
Epilepsy & Behavior : E&B Oct 2015Atonic seizures are debilitating and poorly controlled with antiepileptic medications. Two surgical options are primarily used to treat medically refractory atonic... (Review)
Review
Atonic seizures are debilitating and poorly controlled with antiepileptic medications. Two surgical options are primarily used to treat medically refractory atonic seizures: corpus callosotomy (CC) and vagus nerve stimulation (VNS). However, given the uncertainty regarding relative efficacy and surgical complications, the best approach for affected patients is unclear. The PubMed database was queried for all articles describing the treatment of atonic seizures and drop attacks with either corpus callosotomy or VNS. Rates of seizure freedom, >50% reduction in seizure frequency, and complications were compared across the two patient groups. Patients were significantly more likely to achieve a >50% reduction in seizure frequency with CC versus VNS (85.6% versus 57.6%; RR: 1.5; 95% CI: 1.1-2.1). Adverse events were more common with VNS, though typically mild (e.g., 22% hoarseness and voice changes), compared with CC, where the most common complication was the disconnection syndrome (13.2%). Both CC and VNS are well tolerated for the treatment of refractory atonic seizures. Existing studies suggest that CC is potentially more effective than VNS in reducing seizure frequency, though a direct study comparing these techniques is required before a definitive conclusion can be reached.
Topics: Corpus Callosum; Epilepsy, Generalized; Humans; Psychosurgery; Syncope; Vagus Nerve Stimulation
PubMed: 26247311
DOI: 10.1016/j.yebeh.2015.06.001