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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 -
Neurology India 2019Radiation-induced brain edema (RIBE) is a serious complication of radiation therapy. It may result in dramatic clinico-radiological deterioration. At present, there are...
BACKGROUND
Radiation-induced brain edema (RIBE) is a serious complication of radiation therapy. It may result in dramatic clinico-radiological deterioration. At present, there are no definite guidelines for management of the complication. Corticosteroids are the usual first line of treatment, which frequently fails to provide long-term efficacy in view of its adverse complication profile. Bevacizumab has been reported to show improvement in cases of steroid-resistant radiation injury. The objective of this study is to evaluate the role of Bevacizumab in post-radiosurgery RIBE.
MATERIAL AND METHODS
Since 2012, 189 out of 1241 patients who underwent radiosurgery at our institution developed post-radiosurgery RIBE, 17 of which did not respond to high-dose corticosteroids. We systematically reviewed these 17 patients of various intracranial pathologies with clinic-radiological evidence of RIBE following gamma knife radiosurgery (GKRS). All patients received protocol-based Bevacizumab therapy. The peer-reviewed literature was evaluated.
RESULTS
82 percent of the patients showed improvement after starting Bevacizumab. The majority began to improve after the third cycle started improvement after the third cycle of Bevacizumab. Clinical improvement preceded radiological improvement by an average of eight weeks. The first dose was 5 mg/kg followed by 7.5-10 mg/kg at with two-week intervals. Bevacizumab needs to be administered for an average of seven cycles (range 5-27, median 7) for best response. Steroid therapy could be tapered in most patients by the first follow-up. One patient did not respond to Bevacizumab and needed surgical decompression for palliative care. One noncompliant patient died due to radiation injury.
CONCLUSION
Bevacizumab is a effective and safe for treatment of RIBE after GKRS. A protocol-based dose schedule in addition to frequent clinical and radiological evaluations are required. Bevacizumab should be considered as an early treatment option for RIBE.
Topics: Adult; Angiogenesis Inhibitors; Bevacizumab; Brain Edema; Female; Humans; Male; Middle Aged; Radiation Injuries; Radiosurgery; Retrospective Studies; Young Adult
PubMed: 31744962
DOI: 10.4103/0028-3886.271242 -
Stereotactic and Functional Neurosurgery 2019Selective laser amygdalohippocampotomy (SLAH) is a minimally invasive surgical treatment for medial temporal lobe epilepsy. Visual field deficits (VFDs) are a...
Selective laser amygdalohippocampotomy (SLAH) is a minimally invasive surgical treatment for medial temporal lobe epilepsy. Visual field deficits (VFDs) are a significant potential complication. The objective of this study was to determine the relationship between VFDs and potential mechanisms of injury to the optic radiations and lateral geniculate nucleus. We performed a retrospective cross-sectional analysis of 3 patients (5.2%) who developed persistent VFDs after SLAH within our larger series (n = 58), 15 healthy individuals and 10 SLAH patients without visual complications. Diffusion tractography was used to evaluate laser catheter penetration of the optic radiations. Using a complementary approach, we evaluated evidence for focal microstructural tissue damage within the optic radiations and lateral geniculate nucleus. Overablation and potential heat radiation were assessed by quantifying ablation and choroidal fissure CSF volumes as well as energy deposited during SLAH.SLAH treatment parameters did not distinguish VFD patients. Atypically high overlap between the laser catheter and optic radiations was found in 1/3 VFD patients and was accompanied by focal reductions in fractional anisotropy where the catheter entered the lateral occipital white matter. Surprisingly, lateral geniculate tissue diffusivity was abnormal following, but also preceding, SLAH in patients who subsequently developed a VFD (all p = 0.005).In our series, vision-related complications following SLAH, which appear to occur less frequently than following open temporal lobe -surgery, were not directly explained by SLAH treatment parameters. Instead, our data suggest that variations in lateral geniculate structure may influence susceptibility to indirect heat injury from transoccipital SLAH.
Topics: Adolescent; Adult; Aged; Amygdala; Cross-Sectional Studies; Epilepsy, Temporal Lobe; Female; Follow-Up Studies; Hippocampus; Humans; Laser Therapy; Male; Middle Aged; Postoperative Complications; Psychosurgery; Retrospective Studies; Risk Factors; Stereotaxic Techniques; Vision Disorders; Visual Fields; Young Adult
PubMed: 31618749
DOI: 10.1159/000502701 -
Stereotactic and Functional Neurosurgery 2019The last two decades have seen a re-emergence of surgery for intractable psychiatric disease, in large part due to increased use of deep brain stimulation. The... (Review)
Review
The last two decades have seen a re-emergence of surgery for intractable psychiatric disease, in large part due to increased use of deep brain stimulation. The development of more precise, image-guided, less invasive interventions has improved the safety of these procedures, even though the relative merits of modulation at various targets remain under investigation. With an increase in the number and type of interventions for modulating mood/anxiety circuits, the need for biomarkers to guide surgeries and predict treatment response is as critical as ever. Electroencephalography (EEG) has a long history in clinical neurology, cognitive neuroscience, and functional neurosurgery, but has limited prior usage in psychiatric surgery. MEDLINE, Embase, and Psyc-INFO searches on the use of EEG in guiding psychiatric surgery yielded 611 articles, which were screened for relevance and quality. We synthesized three important themes. First, considerable evidence supports EEG as a biomarker for response to various surgical and non-surgical therapies, but large-scale investigations are lacking. Second, intraoperative EEG is likely more valuable than surface EEG for guiding target selection, but comes at the cost of greater invasiveness. Finally, EEG may be a promising tool for objective functional feedback in developing "closed-loop" psychosurgeries, but more systematic investigations are required.
Topics: Deep Brain Stimulation; Electroencephalography; Forecasting; Humans; Intraoperative Neurophysiological Monitoring; Mental Disorders; Neurosurgical Procedures; Psychosurgery
PubMed: 31412334
DOI: 10.1159/000500994 -
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 -
Gaceta Medica de Mexico 2019Neurosurgical treatment, although controversial, is considered a useful resource in the treatment of chronic psychiatric diseases such as refractory aggressiveness. (Clinical Trial)
Clinical Trial
BACKGROUND
Neurosurgical treatment, although controversial, is considered a useful resource in the treatment of chronic psychiatric diseases such as refractory aggressiveness.
OBJECTIVE
To evaluate the clinical results and side effects of posteromedial hypothalamotomy associated with amygdalotomy in patients with refractory aggressiveness.
METHOD
A clinical trial was conducted in patients with chronic aggressiveness and refractory to pharmacological treatment. A central amygdalotomy associated with posteromedial hypothalamotomy was performed using thermo-coagulation by radiofrequency. The degree of aggressiveness was quantified by the Yudofsky's global scale of aggression. Postoperative changes in aggressive behavior continued to be evaluated every 6 months for at least 36 months.
RESULTS
A statistically significant change in aggressive behavior was observed during 36 months of follow-up. The collateral effects of the association of both procedures are described, the most frequent being drowsiness and some cases of reduction in sexual behavior.
CONCLUSION
Symmetric and simultaneous unilateral lesions of the central nucleus of the amygdala and the posteromedial hypothalamus contralateral to motor dominance give the same clinical effect in the reduction of the pathological aggression that the bilateral lesions.
Topics: Adult; Aggression; Amygdala; Female; Humans; Hypothalamus; Male; Mental Disorders; Middle Aged; Psychosurgery; Young Adult
PubMed: 31182879
DOI: 10.24875/GMM.19005128 -
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 -
CMAJ : Canadian Medical Association... May 2018
Topics: Female; History, 20th Century; Humans; Mental Disorders; Psychiatry; Psychosurgery; Sexism; Tranquilizing Agents
PubMed: 30991349
DOI: 10.1503/cmaj.171277 -
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 -
Frontiers in Neuroscience 2019The treatment of psychiatric patients presents significant challenges to the clinical community, and a multidisciplinary approach to diagnosis and management is... (Review)
Review
The treatment of psychiatric patients presents significant challenges to the clinical community, and a multidisciplinary approach to diagnosis and management is essential to facilitate optimal care. In particular, the neurosurgical treatment of psychiatric disorders, or "psychosurgery," has held fascination throughout human history as a potential method of influencing behavior and consciousness. Early evidence of such procedures can be traced to prehistory, and interest flourished in the nineteenth and early twentieth century with greater insight into cerebral functional and anatomic localization. However, any discussion of psychosurgery invariably invokes controversy, as the widespread and indiscriminate use of the transorbital lobotomy in the mid-twentieth century resulted in profound ethical ramifications that persist to this day. The concurrent development of effective psychopharmacological treatments virtually eliminated the need and desire for psychosurgical procedures, and accordingly the research and practice of psychosurgery was dormant, but not forgotten. There has been a recent resurgence of interest for non-ablative therapies, due in part to modern advances in functional and structural neuroimaging and neuromodulation technology. In particular, deep brain stimulation is a promising treatment paradigm with the potential to modulate abnormal pathways and networks implicated in psychiatric disease states. Although there is enthusiasm regarding these recent advancements, it is important to reflect on the scientific, social, and ethical considerations of this controversial field.
PubMed: 30828289
DOI: 10.3389/fnins.2019.00108