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Kochanski RB, Slavin KV. The future perspectives of psychiatric neurosurgery. PROGRESS IN BRAIN RESEARCH 2022; 270:211-228. [PMID: 35396029 DOI: 10.1016/bs.pbr.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The future of psychiatric neurosurgery can be viewed from two separate perspectives: the immediate future and the distant future. Both show promise, but the treatment strategy for mental diseases and the technology utilized during these separate periods will likely differ dramatically. It can be expected that the initial advancements will be built upon progress of neuroimaging and stereotactic targeting while surgical technology becomes adapted to patient-specific symptomatology and structural/functional imaging parameters. This individualized approach has already begun to show significant promise when applied to deep brain stimulation for treatment-resistant depression and obsessive-compulsive disorder. If effectiveness of these strategies is confirmed by well designed, double-blind, placebo-controlled clinical studies, further technological advances will continue into the distant future, and will likely involve precise neuromodulation at the cellular level, perhaps using wireless technology with or without closed-loop design. This approach, being theoretically less invasive and carrying less risk, may ultimately propel psychiatric neurosurgery to the forefront in the treatment algorithm of mental illness. Despite prominent development of non-invasive therapeutic options, such as stereotactic radiosurgery or transcranial magnetic resonance-guided focused ultrasound, chances are there will still be a need in surgical management of patients with most intractable psychiatric conditions.
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Affiliation(s)
- Ryan B Kochanski
- Neurosurgery, Methodist Healthcare System, San Antonio, TX, United States
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, United States; Neurology Service, Jesse Brown Veterans Administration Medical Center, Chicago, IL, United States.
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Barrios-Anderson A, McLaughlin NCR, Patrick MT, Marsland R, Noren G, Asaad WF, Greenberg BD, Rasmussen S. The Patient Lived-Experience of Ventral Capsulotomy for Obsessive-Compulsive Disorder: An Interpretive Phenomenological Analysis of Neuroablative Psychiatric Neurosurgery. Front Integr Neurosci 2022; 16:802617. [PMID: 35273481 PMCID: PMC8902594 DOI: 10.3389/fnint.2022.802617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
Ventral Capsulotomy (VC) is a surgical intervention for treatment-resistant Obsessive-Compulsive Disorder (OCD). Despite clinical studies, little is known about patient perception and lived experience after neurosurgery for severe OCD. To examine the lived experiences of patients who have undergone VC for severe, treatment-resistant OCD through qualitative analysis. We conducted semi-structured interviews with six participants treated with VC for OCD. Interviews were analyzed using Interpretive Phenomenological Analysis. The following themes emerged: (1) After years of conventional treatments, patients felt neurosurgery was their “last hope” and described themselves as “desperate,” (2) While some described the surgery as a “supernatural experience,” patients also demonstrated understanding of the scientific procedure, its risks and potential benefits, (3) The surgical experience itself was positive or neutral, which was linked to trust in the clinical team, (4) Post-surgery, participants described months of heightened fear as they awaited lesion formation and functional improvement. (5) Patients consistently contextualized outcome in the context of their own life goals. Patients undergoing VC have positive views of this neurosurgical intervention, but psychiatric neurosurgical teams should anticipate patient discomfort with the time needed to achieve behavioral improvement following surgery and emphasize the importance of post-operative psychiatric care.
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Affiliation(s)
- Adriel Barrios-Anderson
- Warren Alpert Medical School of Brown University, Providence, RI, United States
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, RI, United States
- Psychiatric Neurosurgery Program, Butler Hospital, Providence, RI, United States
- *Correspondence: Adriel Barrios-Anderson,
| | - Nicole C. R. McLaughlin
- Psychiatric Neurosurgery Program, Butler Hospital, Providence, RI, United States
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, United States
| | - Morgan T. Patrick
- Psychiatric Neurosurgery Program, Butler Hospital, Providence, RI, United States
| | - Richard Marsland
- Psychiatric Neurosurgery Program, Butler Hospital, Providence, RI, United States
| | - Georg Noren
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, RI, United States
- Psychiatric Neurosurgery Program, Butler Hospital, Providence, RI, United States
| | - Wael F. Asaad
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, RI, United States
- Department of Neuroscience, Brown University, Providence, RI, United States
- Carney Institute for Brain Science, Brown University, Providence, RI, United States
| | - Benjamin D. Greenberg
- Psychiatric Neurosurgery Program, Butler Hospital, Providence, RI, United States
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, United States
- Center for Neurorestoration and Neurotechnology (CfNN), Providence VA Medical Center, Providence, RI, United States
| | - Steven Rasmussen
- Psychiatric Neurosurgery Program, Butler Hospital, Providence, RI, United States
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, United States
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Lai Y, Wang T, Zhang C, Lin G, Voon V, Chang J, Sun B. Effectiveness and safety of neuroablation for severe and treatment-resistant obsessive-compulsive disorder: a systematic review and meta-analysis. J Psychiatry Neurosci 2020; 45:356-369. [PMID: 32549057 PMCID: PMC7850151 DOI: 10.1503/jpn.190079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 08/05/2019] [Accepted: 01/16/2020] [Indexed: 11/01/2022] Open
Abstract
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.
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Affiliation(s)
- Yijie Lai
- From the Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lai, Wang, Zhang, Sun); the Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lin); the Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); and the Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea (Chang)
| | - Tao Wang
- From the Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lai, Wang, Zhang, Sun); the Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lin); the Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); and the Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea (Chang)
| | - Chencheng Zhang
- From the Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lai, Wang, Zhang, Sun); the Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lin); the Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); and the Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea (Chang)
| | - Guozhen Lin
- From the Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lai, Wang, Zhang, Sun); the Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lin); the Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); and the Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea (Chang)
| | - Valerie Voon
- From the Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lai, Wang, Zhang, Sun); the Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lin); the Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); and the Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea (Chang)
| | - Jinwoo Chang
- From the Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lai, Wang, Zhang, Sun); the Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lin); the Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); and the Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea (Chang)
| | - Bomin Sun
- From the Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lai, Wang, Zhang, Sun); the Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lin); the Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); and the Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea (Chang)
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Obsessive-Compulsive Disorder: Lesions. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Miguel EC, Lopes AC, McLaughlin NCR, Norén G, Gentil AF, Hamani C, Shavitt RG, Batistuzzo MC, Vattimo EFQ, Canteras M, De Salles A, Gorgulho A, Salvajoli JV, Fonoff ET, Paddick I, Hoexter MQ, Lindquist C, Haber SN, Greenberg BD, Sheth SA. Evolution of gamma knife capsulotomy for intractable obsessive-compulsive disorder. Mol Psychiatry 2019; 24:218-240. [PMID: 29743581 PMCID: PMC6698394 DOI: 10.1038/s41380-018-0054-0] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 02/26/2018] [Accepted: 03/06/2018] [Indexed: 11/08/2022]
Abstract
For more than half a century, stereotactic neurosurgical procedures have been available to treat patients with severe, debilitating symptoms of obsessive-compulsive disorder (OCD) that have proven refractory to extensive, appropriate pharmacological, and psychological treatment. Although reliable predictors of outcome remain elusive, the establishment of narrower selection criteria for neurosurgical candidacy, together with a better understanding of the functional neuroanatomy implicated in OCD, has resulted in improved clinical efficacy for an array of ablative and non-ablative intervention techniques targeting the cingulum, internal capsule, and other limbic regions. It was against this backdrop that gamma knife capsulotomy (GKC) for OCD was developed. In this paper, we review the history of this stereotactic radiosurgical procedure, from its inception to recent advances. We perform a systematic review of the existing literature and also provide a narrative account of the evolution of the procedure, detailing how the procedure has changed over time, and has been shaped by forces of evidence and innovation. As the procedure has evolved and adverse events have decreased considerably, favorable response rates have remained attainable for approximately one-half to two-thirds of individuals treated at experienced centers. A reduction in obsessive-compulsive symptom severity may result not only from direct modulation of OCD neural pathways but also from enhanced efficacy of pharmacological and psychological therapies working in a synergistic fashion with GKC. Possible complications include frontal lobe edema and even the rare formation of delayed radionecrotic cysts. These adverse events have become much less common with new radiation dose and targeting strategies. Detailed neuropsychological assessments from recent studies suggest that cognitive function is not impaired, and in some domains may even improve following treatment. We conclude this review with discussions covering topics essential for further progress of this therapy, including suggestions for future trial design given the unique features of GKC therapy, considerations for optimizing stereotactic targeting and dose planning using biophysical models, and the use of advanced imaging techniques to understand circuitry and predict response. GKC, and in particular its modern variant, gamma ventral capsulotomy, continues to be a reliable treatment option for selected cases of otherwise highly refractory OCD.
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Affiliation(s)
- Euripedes C Miguel
- Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil.
| | - Antonio C Lopes
- Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Nicole C R McLaughlin
- Departments of Psychiatry and Human Behavior and Neurosurgery, Warren Alpert Medical School of Brown University and Veterans Affairs Medical Center of Providence, Providence, RI, USA
| | - Georg Norén
- Departments of Psychiatry and Human Behavior and Neurosurgery, Warren Alpert Medical School of Brown University and Veterans Affairs Medical Center of Providence, Providence, RI, USA
| | - André F Gentil
- Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Clement Hamani
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Harquail Centre for Neuromodulation, University of Toronto, Toronto, Ontario, Canada
| | - Roseli G Shavitt
- Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Marcelo C Batistuzzo
- Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Edoardo F Q Vattimo
- Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Miguel Canteras
- Discipline of Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | | | | | - Erich Talamoni Fonoff
- Department of Neurology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Ian Paddick
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Marcelo Q Hoexter
- Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | | | - Suzanne N Haber
- University of Rochester School of Medicine, Rochester, New York, USA
- McLean Hospital, Harvard University, Boston, USA
| | - Benjamin D Greenberg
- Departments of Psychiatry and Human Behavior and Neurosurgery, Warren Alpert Medical School of Brown University and Veterans Affairs Medical Center of Providence, Providence, RI, USA
| | - Sameer A Sheth
- Discipline of Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Balachander S, Arumugham SS, Srinivas D. Ablative neurosurgery and deep brain stimulation for obsessive-compulsive disorder. Indian J Psychiatry 2019; 61:S77-S84. [PMID: 30745680 PMCID: PMC6343416 DOI: 10.4103/psychiatry.indianjpsychiatry_523_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Despite advancements in pharmacotherapeutic and behavioral interventions, a substantial proportion of patients with obsessive-compulsive disorder (OCD) continue to have disabling and treatment-refractory illness. Neurosurgical interventions, including ablative procedures and deep brain stimulation (DBS), have emerged as potential treatment options in this population. We review the recent literature on contemporary surgical options for OCD, focusing on clinical aspects such as patient selection, presurgical assessment, and safety and effectiveness of these procedures. Given the invasiveness and limited evidence, these procedures have been performed in carefully selected patients with severe, chronic, and treatment-refractory illness. Along with informed consent, an independent review by a multidisciplinary team is mandated in many centers. Both ablative procedures and DBS have been found to be helpful in around half the patients, with improvement observed months after the procedure. Various targets have been proposed for either procedure, based on the dominant corticostriatal model of OCD. There is no strong evidence to recommend one procedure over the other. Hence, the choice of procedure is often based on the factors such as affordability, expertise, and reversibility of adverse effects. Surgery is not recommended as a standalone treatment but should be provided as part of a comprehensive package including medications and psychotherapeutic interventions. Available evidence suggest that the benefits of the procedure outweigh the risks in a treatment-refractory population. Advances in neurosurgical techniques and increasing knowledge of neurobiology are likely to bring about further progress in the efficacy, safety, and acceptability of the procedures.
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Affiliation(s)
- Srinivas Balachander
- Department of Psychiatry, OCD Clinic, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Shyam Sundar Arumugham
- Department of Psychiatry, OCD Clinic, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Dwarakanath Srinivas
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Rasmussen SA, Noren G, Greenberg BD, Marsland R, McLaughlin NC, Malloy PJ, Salloway SP, Strong DR, Eisen JL, Jenike MA, Rauch SL, Baer L, Lindquist C. Gamma Ventral Capsulotomy in Intractable Obsessive-Compulsive Disorder. Biol Psychiatry 2018; 84:355-364. [PMID: 29361268 DOI: 10.1016/j.biopsych.2017.11.034] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 09/26/2017] [Accepted: 11/17/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Despite the development of effective pharmacologic and cognitive behavioral treatments for obsessive-compulsive disorder (OCD), some patients continue to be treatment-refractory and severely impaired. Fiber tracts connecting orbitofrontal and dorsal anterior cingulate cortex with subcortical nuclei have been the target of neurosurgical lesions as well as deep brain stimulation in these patients. We report on the safety and efficacy of ventral gamma capsulotomy for patients with intractable OCD. METHODS Fifty-five patients with severely disabling, treatment-refractory OCD received bilateral lesions in the ventral portion of the anterior limb of the internal capsule over a 20-year period using the Leksell Gamma Knife. The patients were prospectively followed over 3 years with psychiatric, neurologic, and neuropsychological assessments of safety and efficacy, as well as structural neuroimaging. RESULTS Thirty-one of 55 patients (56%) had an improvement in the primary efficacy measure, the Yale-Brown Obsessive Compulsive Scale, of ≥35% over the 3-year follow-up period. Patients had significant improvements in depression, anxiety, quality of life, and global functioning. Patients tolerated the procedure well without significant acute adverse events. Five patients (9%) developed transient edema that required short courses of dexamethasone. Three patients (5%) developed cysts at long-term follow-up, 1 of whom developed radionecrosis resulting in an ongoing minimally conscious state. CONCLUSIONS Gamma Knife ventral capsulotomy is an effective radiosurgical procedure for many treatment-refractory OCD patients. A minority of patients developed cysts at long-term follow-up, 1 of whom had permanent neurological sequelae.
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Affiliation(s)
- Steven A Rasmussen
- Department of Psychiatry and Human Behavior, Butler Hospital, Brown University School of Medicine, Providence, Rhode Island.
| | - Georg Noren
- Department of Neurosurgery, Rhode Island Hospital, Brown University School of Medicine, Providence, Rhode Island
| | - Benjamin D Greenberg
- Department of Psychiatry and Human Behavior, Butler Hospital, Brown University School of Medicine, Providence, Rhode Island
| | - Richard Marsland
- Department of Psychiatry and Human Behavior, Butler Hospital, Brown University School of Medicine, Providence, Rhode Island
| | - Nicole C McLaughlin
- Department of Psychiatry and Human Behavior, Butler Hospital, Brown University School of Medicine, Providence, Rhode Island
| | - Paul J Malloy
- Department of Psychiatry and Human Behavior, Butler Hospital, Brown University School of Medicine, Providence, Rhode Island
| | - Stephen P Salloway
- Department of Psychiatry and Human Behavior, Butler Hospital, Brown University School of Medicine, Providence, Rhode Island
| | - David R Strong
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jane L Eisen
- Department of Psychiatry and Human Behavior, Butler Hospital, Brown University School of Medicine, Providence, Rhode Island
| | - Michael A Jenike
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Scott L Rauch
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lee Baer
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Christer Lindquist
- Department of Stereotactic Neurosurgery, Cromwell Hospital, London, United Kingdom
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Pepper J, Hariz M, Zrinzo L. Deep brain stimulation versus anterior capsulotomy for obsessive-compulsive disorder: a review of the literature. J Neurosurg 2015; 122:1028-37. [DOI: 10.3171/2014.11.jns132618] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Obsessive-compulsive disorder (OCD) is a chronic and debilitating psychiatric condition. Traditionally, anterior capsulotomy (AC) was an established procedure for treatment of patients with refractory OCD. Over recent decades, deep brain stimulation (DBS) has gained popularity. In this paper the authors review the published literature and compare the outcome of AC and DBS targeting of the area of the ventral capsule/ventral striatum (VC/VS) and nucleus accumbens (NAcc).
Patients in published cases were grouped according to whether they received AC or DBS and according to their preoperative scores on the Yale-Brown Obsessive-Compulsive Scale (YBOCS), and then separated according to outcome measures: remission (YBOCS score < 8); response (≥ 35% improvement in YBOCS score); nonresponse (< 35% improvement in YBOCS score); and unfavorable (i.e., worsening of the baseline YBOCS score).
Twenty studies were identified reporting on 170 patients; 62 patients underwent DBS of the VC/VS or the NAcc (mean age 38 years, follow-up 19 months, baseline YBOCS score of 33), and 108 patients underwent AC (mean age 36 years, follow-up 61 months, baseline YBOCS score of 30). In patients treated with DBS there was a 40% decrease in YBOCS score, compared with a 51% decrease for those who underwent AC (p = 0.004). Patients who underwent AC were 9% more likely to go into remission than patients treated with DBS (p = 0.02). No difference in complication rates was noted.
Anterior capsulotomy is an efficient procedure for refractory OCD. Deep brain stimulation in the VC/VS and NAcc area is an emerging and promising therapy. The current popularity of DBS over ablative surgery for OCD is not due to nonefficacy of AC, but possibly because DBS is perceived as more acceptable by clinicians and patients.
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Affiliation(s)
- Joshua Pepper
- 1Unit of Functional Neurosurgery, University College London Institute of Neurology, Queen Square
| | - Marwan Hariz
- 1Unit of Functional Neurosurgery, University College London Institute of Neurology, Queen Square
- 2Department of Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Ludvic Zrinzo
- 1Unit of Functional Neurosurgery, University College London Institute of Neurology, Queen Square
- 3Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom; and
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