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Hurwitz TA, Avecillas-Chasin JM, Bogod NM, Honey CR. Ventral targeted anterior capsulotomy for treatment-resistant depression and obsessive-compulsive disorder: A treatment method with cases. J Affect Disord 2024; 350:887-894. [PMID: 38272366 DOI: 10.1016/j.jad.2024.01.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Ablative surgery using bilateral anterior capsulotomy (BAC) is an option for treatment resistant depression (TRD) and obsessive-compulsive disorder (TROCD). The location and extent of the lesion within anterior limb of the internal capsule (ALIC) remains uncertain. Accumulating evidence has suggested that the lesion should be located ventrally while limiting the dorsal extent. Our center is now targeting specific fiber tracts within the lower half of the ALIC. METHOD Presurgical diffusion tensor Magnetic Resonance Imaging (MRI) was used to identify individual fibre tracts within the ventral aspect of the ALIC in the last two patients who underwent BAC at our center. One patient had TRD and the other had both TROCD and TRD. Radiofrequency-induced thermal lesions were created in the identified targets with lesion volumes between 20 and 229 mm3 (average 95 mm3). FINDINGS Both patients were responders with neither experiencing significant side effects including compromised executive functions. LIMITATIONS The generalizability of our findings is limited because the outcome is based on two subjects. CONCLUSION This work suggests that BAC can be individually tailored and more limited to the ventral aspect of the ALIC and is effective and safe for TRD and TROCD. Accumulating data also suggests that to be clinically effective the length of the capsulotomy should be about 10mm. BAC's use may increase with the growing utilization and mastery of magnetic resonance guided focused ultrasound.
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Affiliation(s)
- Trevor A Hurwitz
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.
| | | | - Nicholas M Bogod
- Department of Medicine, Division of Neurology, University of British Columbia, Vancouver, BC, Canada.
| | - Christopher R Honey
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada.
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Poologaindran A, Profyris C, Young IM, Dadario NB, Ahsan SA, Chendeb K, Briggs RG, Teo C, Romero-Garcia R, Suckling J, Sughrue ME. Interventional neurorehabilitation for promoting functional recovery post-craniotomy: a proof-of-concept. Sci Rep 2022; 12:3039. [PMID: 35197490 PMCID: PMC8866464 DOI: 10.1038/s41598-022-06766-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 02/02/2022] [Indexed: 02/06/2023] Open
Abstract
The human brain is a highly plastic ‘complex’ network—it is highly resilient to damage and capable of self-reorganisation after a large perturbation. Clinically, neurological deficits secondary to iatrogenic injury have very few active treatments. New imaging and stimulation technologies, though, offer promising therapeutic avenues to accelerate post-operative recovery trajectories. In this study, we sought to establish the safety profile for ‘interventional neurorehabilitation’: connectome-based therapeutic brain stimulation to drive cortical reorganisation and promote functional recovery post-craniotomy. In n = 34 glioma patients who experienced post-operative motor or language deficits, we used connectomics to construct single-subject cortical networks. Based on their clinical and connectivity deficit, patients underwent network-specific transcranial magnetic stimulation (TMS) sessions daily over five consecutive days. Patients were then assessed for TMS-related side effects and improvements. 31/34 (91%) patients were successfully recruited and enrolled for TMS treatment within two weeks of glioma surgery. No seizures or serious complications occurred during TMS rehabilitation and 1-week post-stimulation. Transient headaches were reported in 4/31 patients but improved after a single session. No neurological worsening was observed while a clinically and statistically significant benefit was noted in 28/31 patients post-TMS. We present two clinical vignettes and a video demonstration of interventional neurorehabilitation. For the first time, we demonstrate the safety profile and ability to recruit, enroll, and complete TMS acutely post-craniotomy in a high seizure risk population. Given the lack of randomisation and controls in this study, prospective randomised sham-controlled stimulation trials are now warranted to establish the efficacy of interventional neurorehabilitation following craniotomy.
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Affiliation(s)
- Anujan Poologaindran
- Brain Mapping Unit, Department of Psychiatry, University of Cambridge, Cambridge, UK.,The Alan Turing Institute, British Library, London, UK
| | - Christos Profyris
- Netcare Linksfield Hospital, Johannesburg, South Africa.,Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Isabella M Young
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Nicholas B Dadario
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia.,Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Syed A Ahsan
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Kassem Chendeb
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Robert G Briggs
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - Charles Teo
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Rafael Romero-Garcia
- Brain Mapping Unit, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - John Suckling
- Brain Mapping Unit, Department of Psychiatry, University of Cambridge, Cambridge, UK.,The Alan Turing Institute, British Library, London, UK
| | - Michael E Sughrue
- Brain Mapping Unit, Department of Psychiatry, University of Cambridge, Cambridge, UK. .,Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia.
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Bijanki KR, Pathak YJ, Najera RA, Storch EA, Goodman WK, Simpson HB, Sheth SA. Defining functional brain networks underlying obsessive-compulsive disorder (OCD) using treatment-induced neuroimaging changes: a systematic review of the literature. J Neurol Neurosurg Psychiatry 2021; 92:776-786. [PMID: 33906936 PMCID: PMC8223624 DOI: 10.1136/jnnp-2020-324478] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 02/24/2021] [Accepted: 03/24/2021] [Indexed: 01/09/2023]
Abstract
Approximately 2%-3% of the population suffers from obsessive-compulsive disorder (OCD). Several brain regions have been implicated in the pathophysiology of OCD, but their various contributions remain unclear. We examined changes in structural and functional neuroimaging before and after a variety of therapeutic interventions as an index into identifying the underlying networks involved. We identified 64 studies from 1990 to 2020 comparing pretreatment and post-treatment imaging of patients with OCD, including metabolic and perfusion, neurochemical, structural, functional and connectivity-based modalities. Treatment class included pharmacotherapy, cognitive-behavioural therapy/exposure and response prevention, stereotactic lesions, deep brain stimulation and transcranial magnetic stimulation. Changes in several brain regions are consistent and correspond with treatment response despite the heterogeneity in treatments and neuroimaging modalities. Most notable are decreases in metabolism and perfusion of the caudate, anterior cingulate cortex, thalamus and regions of prefrontal cortex (PFC) including the orbitofrontal cortex (OFC), dorsolateral PFC (DLPFC), ventromedial PFC (VMPFC) and ventrolateral PFC (VLPFC). Modulating activity within regions of the cortico-striato-thalamo-cortical system may be a common therapeutic mechanism across treatments. We identify future needs and current knowledge gaps that can be mitigated by implementing integrative methods. Future studies should incorporate a systematic, analytical approach to testing objective correlates of treatment response to better understand neurophysiological mechanisms of dysfunction.
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Affiliation(s)
- Kelly R Bijanki
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Yagna J Pathak
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
| | - Ricardo A Najera
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Eric A Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Wayne K Goodman
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - H Blair Simpson
- Department of Psychiatry, Columbia University Medical Center, New York, New York, USA
| | - Sameer A Sheth
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
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Avecillas-Chasin JM, Hurwitz TA, Bogod NM, Honey CR. Tractography-Guided Anterior Capsulotomy for Major Depression and Obsessive-Compulsive Disorder: Targeting the Emotion Network. Oper Neurosurg (Hagerstown) 2021; 20:406-412. [PMID: 33475697 DOI: 10.1093/ons/opaa420] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/07/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Bilateral anterior capsulotomy (BAC) is an effective surgical option for patients with treatment-resistant major depression (TRMD) and treatment-resistant obsessive-compulsive disorder (TROCD). The size of the lesion and its precise dorsal-ventral location within the anterior limb of the internal capsule (ALIC) remain undefined. OBJECTIVE To present a method to identify the trajectories of the associative and limbic white matter pathways within the ALIC for targeting in BAC surgery. METHODS Using high-definition tractography, we prospectively tested the feasibility of this method in 2 patients with TRMD and TROCD to tailor the capsulotomy lesion to their limbic pathway. RESULTS The trajectories of the associative and limbic pathways were identified in the ALIC of both patients and we targeted the limbic pathways by defining the dorsal limit of the lesion in a way to minimize the damage to the associative pathways. The final lesions were smaller than those that have been previously published. This individualized procedure was associated with long-term benefit in both patients. CONCLUSION Tractography-guided capsulotomy is feasible and was associated with long-term benefit in patients with TRMD and TROCD.
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Affiliation(s)
| | - Trevor A Hurwitz
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicholas M Bogod
- Neurosciences Program, Vancouver General Hospital, Division of Neurology, UBC Department of Medicine, Vancouver, British Columbia, Canada
| | - Christopher R Honey
- Department of Surgery, Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
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