Treatment of chronic obsessive compulsive states with stereotactic anterior capsulotomy or cingulotomy

Summary A neuropsychological model on how to evaluate patients subjected to stereotactic psychosurgery is presented. Four patients with chronic obsessive compulsive neurosis were randomly assigned to either Stereotactic anterior capsulotomy or cingulotomy, and assessed pre-, peri-, and postoperatively according to this model. The best immediate and long-term follow-up results in reducing obsessional symptoms were obtained in the two capsulotomized patients.Psychosurgery should only be performed by a multidisciplinary team of specialists, with objective evaluation, adequate information on patients, and reliable test instruments.     

“Getting physical”: the management of neuropsychiatric disorders using novel physical treatments

Objective

To summarize and review the utility of physical interventions in the treatment of psychiatric disorders.

Methods

A systematic review of the literature pertaining to novel physical interventions, namely, transcranial magnetic stimulation, deep brain stimulation, vagus nerve stimulation, and neurosurgery, was conducted using MEDLINE, EMBASE, and PSYCHLIT. Bibliographies of papers were scrutinized for further relevant references along with literature known to the authors.

Results

Currently available physical interventions worldwide are reviewed with respect to efficacy, applications, and putative indications. Physical interventions have experienced a resurgence of interest for both the investigation of brain function and the treatment of neuropsychiatric disorders. The widespread availability of neuroimaging technology has advanced our understanding of brain function and allowed closer examination of the effects of physical treatments. Clinically, transcranial magnetic stimulation seems likely to have a role in the management of depression, and its use in other neuropsychiatric disorders appears promising. Following on from its success in the management of intractable epilepsy, vagus nerve stimulation is undergoing evaluation in the treatment of depression with some success in refractory cases. Deep brain stimulation has improved mood in patients with Parkinson’s disease and may also relieve symptoms of obsessive-compulsive disorder. Neurosurgery has re-invented itself by way of increased technical sophistication, and although further assessment of its efficacy and clinical utility is still needed, its widespread practice reflects its increasing acceptance as a viable treatment of last resort.

Conclusion

It is clear that physical treatments are here to stay and “getting physical” offers a useful addition to the neuropsychiatrist’s therapeutic armamentarium. However, like all new treatments these interventions need to remain under rigorous scientific scrutiny to determine accurately their immediate and long-term effects.     

A prospective, long-term study of personality traits in patients with intractable obsessional illness treated by capsulotomy

The crux when contemplating neurosurgery for otherwise intractable mental illness is whether there is a price which the patient may have to pay, in terms of adverse personality changes, for symptom relief. In the present study of 19 patients undergoing thermo-capsulotomy for intractable obsessional illness, personality characteristics were studied pre-operatively, and at 1-year and 8-year follow-up, using the Karolinska Scales of Personality (KSP). Small mean score changes toward normalization were apparent on all 15 KSP scales at the 1-year follow-up, and significant improvements in anxiety proneness were noted at the 8-year follow-up. One patient who sustained a surgical complication showed deviant postoperative scores on scales related to psychopathic traits. There were no such deviant scores for the remaining subjects. The incidence of adverse personality changes following capsulotomy is low and does not increase with time. This conclusion, based on groups of patients, does not of course preclude the possibility that adverse personality changes may occur in individual patients.     

手术中脑血管造影在治疗脑血管疾病中的应用

目的探讨在脑血管疾病手术中脑血管造影的应用价值。方法对38例脑血管病病人在手术中进行脑血管造影。38例中男21例,女17例,年龄3岁~53岁,平均(34±9)岁。38例中动静脉畸形(AVM)27例,畸形血管团大小为2~8cm,其中巨大AVMs(直径≥6cm)7例(25·9%);动脉瘤11例,其中巨大动脉瘤(直径≥2·5cm)3例。手术前Hunt-Hess分级情况:1级4例,2级4例,3级3例。病人经气管插管全麻后经右侧股动脉插管,到达手术涉及的颅内动脉。病灶处理完毕后进行血管造影。结果38例中9例急性颅内出血病人手术前未造影,手术中经过血管造影证实,其中7例为AVMs,另外2例证实为动脉瘤。36例(94·7%)经过造影证实病变处理满意,1例(9·0%)眼动脉瘤夹闭后有残留,重新调整动脉瘤夹;1例(3·7%)后颅窝AVM残存,病人无重要动脉被夹闭,无手术死亡病例,无造影相关并发症发生。术中血管造影需要时间为20~125min,平均(53±22)min。结论术中脑血管造影有助于医师及时发现残余动脉瘤或AVM,载瘤动脉闭塞,立即修正技术缺陷,避免再次手术,降低手术后合并症。     

Treatment of obsessive-compulsive disorder by psychosurgery

We report a longitudinal study of 26 patients with medically intractable obsessive-compulsive disorder (OCD) who were treated with psychosurgery and had a comprehensive follow-up for a mean 10 years. Seventeen patients had combined orbitomedial and cingulate lesions, 6 cingulate lesions only and 3 orbitomedial lesions only. Eighteen patients were interviewed personally and lesions verified on magnetic resonance imaging scans in fourteen. On a 6-point global rating scale, 10 (38%) patients had obvious improvement, another 6 (23%) showed mild improvement of doubtful clinical value, and the remaining 10 showed either no change (n= 6; 23%) or were judged to be worse (n= 4; 15%). Both obsessive and compulsive symptoms improved, and this change was independent of the changes in anxiety and depression scores. No significant predictors of improvement were identified. Patients with cingulate lesions only fared worse. Eight patients who had a second operation did not show much improvement. A comparison of a subgroup of patients with 10 matched nonsurgical OCD controls supported the contention that the improvement in OCD was attributable to the psychosurgery. Important adverse effects in the stereotactic surgery group (n= 20) were epilepsy (1 patient) and personality change (2 patients). The psychosurgery group performed relatively poorly on the Wisconsin Card Sort Test but did not show any deterioration in Wechsler Intelligence and Memory scores.     

Frameless stereotactic subcaudate tractotomy for intractable obsessive–compulsive disorder

Summary Obsessive–compulsive disorder (OCD) is a chronic, disabling disorder. Psychosurgery may be indicated for a subset of patients for whom no conventional treatment is satisfactory. This paper focuses on the stereotactic subcaudate tractotomy (SST). Thus far, these procedures have been carried out using frame-based stereotactic techniques. However, modern – highly accurate – frameless stereotactic procedures have successfully been introduced in neurosurgical practice. We developed a novel frameless stereotactic subcaudate tractotomy procedure with promising initial results in a patient suffering from intractable OCD. This is the first report on frameless SST. Future studies should examine whether other ablative stereotactic psychosurgery procedures can be done using frameless stereotactic methods.     

Applicants for stereotactic neurosurgery for psychiatric disorders: role of the Flemish advisory board

Objective: Research on stereotactic neurosurgery for psychiatric disorders (SNPD) is rapidly evolving. Knowledge on patients undergoing SNPD is of crucial importance. We describe applicants for SNPD and examine the necessity for a multidisciplinary advisory board. Method: Summary of the current practice of the Flemish advisory board (SNPD committee) and analysis of a questionnaire investigating the attitude of clinicians on SNPD. Results: In 7 years, 91 applications were submitted, nine patients did not fulfill diagnostic criteria for OCD, 65 patients received a positive recommendation, 50 SNPD procedures were performed. The prevalence of SNPD in the current year in Belgium is 0.6/million inhabitants. Ninety‐seven per cent of clinicians consider the expertise and advice of the SNPD committee essential for indication setting. Forty‐four percent of clinicians consider referral of a patient for capsulotomy, 82% for electrical brain stimulation. Conclusion: Neurosurgery is exclusively considered for severe, treatment‐refractory psychiatric disorders. Clinicians consider the SNPD committee essential in the decision‐making process prior to intervention.