Cingulotomy for psychiatric disease: microelectrode guidance, a callosal reference system for documenting lesion location, and clinical results

Brain Structures and Networks Underlying Treatment Response to Deep Brain Stimulation Targeting the Inferior Thalamic Peduncle in Obsessive-Compulsive Disorder

<b><i>Background:</i></b> Obsessive-compulsive disorder (OCD) is a debilitating disease with a lifetime prevalence of 2–3%. Neuromodulatory treatments have been successfully used in severe cases. Deep brain stimulation (DBS) targeting the inferior thalamic peduncle (ITP) has been shown to successfully alleviate symptoms in OCD patients; however, the brain circuits implicated remain unclear. Here, we investigate the efficacious neural substrates following ITP-DBS for OCD. <b><i>Methods:</i></b> High-quality normative structural and functional connectomics and voxel-wise probabilistic mapping techniques were applied to assess the neural substrates of OCD symptom alleviation in a cohort of 5 ITP-DBS patients. <b><i>Results:</i></b> The region of most efficacious stimulation was located in the regions of the ITP and bed nucleus of the stria terminalis. Both functional and structural connectomics analyses demonstrated that successful symptom alleviation involved a brain network encompassing the bilateral amygdala and prefrontal regions. <b><i>Limitations:</i></b> The main limitation is the small size of the ITP-DBS cohort. While the findings are highly consistent and significant, these should be validated in larger studies. <b><i>Conclusions:</i></b> These results identify a tripartite brain network – composed of the bilateral amygdala and prefrontal regions 24 and 46 – whose engagement is associated with greater symptom improvement. They also provide information for optimizing targeting and identifying network components critically involved in ITP-DBS treatment response. Amygdala engagement in particular seems to be a key component for clinical benefits and could constitute a biomarker for treatment optimization.

Event-based control of autonomic and emotional states by the anterior cingulate cortex

Despite being an intensive area of research, the function of the anterior cingulate cortex (ACC) remains somewhat of a mystery. Human imaging studies implicate the ACC in various cognitive functions, yet surgical ACC lesions used to treat emotional disorders have minimal lasting effects on cognition. An alternative view is that ACC regulates autonomic states, consistent with its interconnectivity with autonomic control regions and that stimulation evokes changes in autonomic/emotional states. At the cellular level, ACC neurons are highly multi-modal and promiscuous, and can represent a staggering array of task events. These neurons nevertheless combine to produce highly event-specific ensemble patterns that likely alter activity in downstream regions controlling emotional and autonomic tone. Since neuromodulators regulate the strength of the ensemble activity patterns, they would regulate the impact these patterns have on downstream targets. Through these mechanisms, the ACC may determine how strongly to react to the very events its ensembles represent. Pathologies arise when specific event-related representations gain excessive control over autonomic/emotional states.

Lesion location and outcome following cingulotomy for obsessive-compulsive disorder

OBJECTIVE

Obsessive-compulsive disorder (OCD) is among the most debilitating and medically refractory psychiatric disorders. While cingulotomy is an anatomically targeted neurosurgical treatment that has shown significant promise in treating OCD-related symptoms, the precise underlying neuroanatomical basis for its beneficial effects has remained poorly understood. Therefore, the authors sought to determine whether lesion location is related to responder status following cingulotomy.

METHODS

The authors reviewed the records of 18 patients who had undergone cingulotomy. Responders were defined as patients who had at least a 35% improvement in the Yale-Brown Obsessive Compulsive Scale (YBOCS) score. The authors traced the lesion sites on T1-weighted MRI scans and used an anatomical registration matrix generated by the imaging software FreeSurfer to superimpose these lesions onto a template brain. Lesion placement was compared between responders and nonresponders. The placement of lesions relative to various anatomical regions was also compared.

RESULTS

A decrease in postoperative YBOCS score was significantly correlated with more superiorly placed lesions (decrease -0.52, p = 0.0012). While all lesions were centered within 6 mm of the cingulate sulcus, responder lesions were placed more superiorly and posteriorly along the cingulate sulcus (1-way ANOVA, p = 0.003). The proportions of the cingulum bundle, cingulate gyrus, and paracingulate cortex affected by the lesions were the same between responders and nonresponders. However, all responders had lesions covering a larger subregion of Brodmann area (BA) 32. In particular, responder lesions covered a significantly greater proportion of the posterior BA32 (1-way ANOVA, p = 0.0064).

CONCLUSIONS

Lesions in patients responsive to cingulotomy tended to be located more superiorly and posteriorly and share greater coverage of a posterior subregion of BA32 than lesions in patients not responsive to this treatment.

Robotic Guided Bilateral Anterior Cingulate Radiofrequency Ablation for Obsessive-Compulsive Disorder

Background

Bilateral anterior cingulotomy (BAC) constitutes the most commonly performed procedure for treatment of refractory OCD. Evolution of stereotactic procedures has rekindled the interest in the effective management of refractory psychiatric disorders, especially OCD with utmost safety and excellent outcomes.

Objective

The aim of this study was to demonstrate the technique of performing BAC under robotic guidance using radiofrequency ablation with an operative video.

Procedure

A 23-year-old gentleman diagnosed with symptoms of OCD for a duration of 8 years and was refractory to conventional therapy. The trajectories for BAC were planned on the robotic platform (ROSA, Zimmer-Biomet, Warsaw, Indiana, USA). The target point was selected on the anterior cingulate, approximately 2 cms posterior to the anterior most point of the frontal horn, 2-3 mm above the corpus callosum and 7 mm lateral to the midline. Pre coronal (1 cm anterior and 3 cms lateral to midline) holes of 2.5 mm diameter were made using pneumatic handheld drill. Radiofrequency (RF) thermocoagulation of the anterior cingulum was performed using an RF probe of 2.2 mm diameter and 4 mm uninsulated tip under robotic guidance after confirming the position with intraoperative O-arm imaging bilaterally.

Results

The surgery was uneventful and the patient had a significant improvement following surgery, with the Yale Brown Obsessive Compulsive Scale of 18 at 1 year follow-up compared to the preoperative score of 36.

Conclusion

Robotic-guided BAC is a safe and effective technique for the treatment of drug-refractory OCD. Intraoperative O arm CT augments the precision of the lesions created.

Potential optimization of focused ultrasound capsulotomy for obsessive compulsive disorder

Obsessive-compulsive disorder is a debilitating and often refractory psychiatric disorder. Magnetic resonance-guided focused ultrasound is a novel, minimally invasive neuromodulatory technique that has shown promise in treating this condition. We investigated the relationship between lesion location and long-term outcome in obsessive-compulsive disorder patients treated with focused ultrasound to discern the optimal lesion location and elucidate the efficacious network underlying symptom alleviation. Postoperative images of eleven patients who underwent focused ultrasound capsulotomy were used to correlate lesion characteristics with symptom improvement at one year follow-up. Normative resting-state functional MRI and normative diffusion MRI-based tractography analyses were used to determine the networks associated with successful lesions. Obsessive-compulsive disorder patients treated with inferior thalamic peduncle deep brain stimulation (n = 5) and lesions from the literature implicated in obsessive-compulsive disorder (n = 18) were used for external validation. Successful long-term relief of obsessive-compulsive disorder was associated with lesions that included a specific area in the dorsal anterior limb of the internal capsule. Normative resting-state functional MRI analysis showed that lesion engagement of areas 24 and 46 was significantly associated with clinical outcomes (R = 0.79, p = 0.004). The key role of areas 24 and 46 was confirmed by (1) normative diffusion MRI-based tractography analysis showing that streamlines associated with better outcome projected to these areas, (2) association of these areas with inferior thalamic peduncle deep brain stimulation patients' outcome (R = 0.83, p = 0.003); (3) the connectedness of these areas to obsessive-compulsive disorder-causing lesions, as identified using literature-based lesion network mapping. These results provide considerations for target improvement, outlining the specific area of the internal capsule critical for successful magnetic resonance-guided focused ultrasound outcome and demonstrating that discrete frontal areas are involved in symptom relief. This could help refine focused ultrasound treatment for obsessive-compulsive disorder and provide a network-based rationale for potential alternative targets.

The anterior cingulate cortex and event-based modulation of autonomic states

In spite of being an intensive area of research focus, the anterior cingulate cortex (ACC) remains somewhat of an enigma. Many theories have focused on its role in various aspects of cognition yet surgically precise lesions of the ACC, used to treat severe emotional disorders in human patients, typically have no lasting effects on cognition. An alternative view is that the ACC has a prominent role in regulating autonomic states. This view is consistent with anatomical data showing that a main target of the ACC are regions involved in autonomic control and with the observation that stimulation of the ACC evokes changes in autonomic states in both animals and humans. From an electrophysiological perspective, ACC neurons appear able to represent virtually any event or internal state, even though there is not always a strong link between these representations and behavior. Ensembles of neurons form robust contextual representations that strongly influence how specific events are encoded. The activity patterns associated with these contextually-based event representations presumably impact activity in downstream regions that control autonomic state. As a result, the ACC may regulate the autonomic and perhaps emotional reactions to events it is representing. This event-based control of autonomic tone by the ACC would likely arise during all types of cognitive and affective processes, without necessarily being critical for any of them.

Minimally Invasive Bilateral Anterior Cingulotomy via Open Minicraniotomy Using a Novel Multiport Cisternoscope: A Cadaveric Demonstration

BACKGROUND

Bilateral anterior cingulotomy has been used to treat chronic pain, obsessive compulsive disorder, and addictions. Lesioning of the target area is typically performed using bilateral stereotactic electrode placement and target ablation, which involves transparenchymal access through both hemispheres.

OBJECTIVE

To evaluate an endoscopic direct-vision lesioning using a unilateral parasagittal minicraniotomy for minimally invasive bilateral anterior cingulotomy using a novel multiport endoscope through the anterior interhemispheric fissure.

METHODS

A novel multiport magnetic resonance imaging (MRI)-compatible neuroendoscope prototype is used to demonstrate cadaveric cingulate lesioning through a lateral imaging port while simultaneously viewing the pericallosal arteries as landmarks through a tip imaging port. The lateral port enables extended lesioning of the gyrus while rotation of the endoscope about its axis provides access to homologous areas of both hemispheres.

RESULTS

Cadaver testing confirmed the capability to navigate the multiport neuroendoscope between the hemispheres using concurrent imaging from the tip and lateral ports. The lateral port enabled exploration of the gyrus, visualization of lesioning, and subsequent inspection of lesions. Tip-port imaging provided navigational cues and allowed the operator to ensure that the endoscope tip did not contact tissue. The multiport design required instrument rotation in the coronal plane of only 20° to lesion both gyri, while a standard endoscope necessitated a rotation of 54°.

CONCLUSION

Multiport MRI-compatible endoscopy can be effectively used in cisternal endoscopy, whereby a unilateral parasagittal minicraniotomy can be used for endoscopic interhemispheric bilateral anterior cingulotomy.

Connectivity-based identification of a potential neurosurgical target for mood disorders

OBJECTIVE

Stereotactic ablation (cingulotomy) and subcallosal cingulate deep brain stimulation (SCC DBS) of different regions of the cingulum bundle (CB) have been successfully used to treat psychiatric disorders, such as depression and bipolar disorder. They are hypothesized to work by disrupting white matter pathways involved in the clinical manifestation of these disorders. This study aims to compare the connectivity of different CB subregions using tractography to evaluate stereotactic targets for the treatment of mood disorders.

METHODS

Fourteen healthy volunteers underwent 3T-MR imaging followed by connectivity analysis using probabilistic tractography. Twenty-one anatomic regions of interest were defined for each subject: 10 CB subregions (including the classical cingulotomy and SCC DBS targets) and 11 cortical/subcortical structures implicated in mood disorders. Connectivity results were compared using Friedman and Bonferroni-corrected post-hoc Wilcoxon tests.

RESULTS

CB connectivity showed a high degree of regional specificity. Both of the traditional stereotactic targets had widespread connectivity with discrete topology. The cingulotomy target connected primarily to the dorsomedial frontal, dorsal anterior cingulate, and posterior cingulate cortices, whereas the SCC DBS target connected mostly to the subgenual anterior cingulate and medial/central orbitofrontal cortices. However, a region of the rostral dorsal CB, lying between these surgical targets, encompassed statistically equivalent connections to all five cortical regions.

CONCLUSIONS

The CB is associated with brain structures involved in affective disorders, and the rostral dorsal CB demonstrates connectivity that is comparable to the combined connectivity of cingulotomy and SCC DBS neurosurgical interventions. The rostral dorsal CB represents a surgical target worthy of clinical exploration for mood disorders.

The cingulum bundle: Anatomy, function, and dysfunction

The cingulum bundle is a prominent white matter tract that interconnects frontal, parietal, and medial temporal sites, while also linking subcortical nuclei to the cingulate gyrus. Despite its apparent continuity, the cingulum's composition continually changes as fibres join and leave the bundle. To help understand its complex structure, this review begins with detailed, comparative descriptions of the multiple connections comprising the cingulum bundle. Next, the impact of cingulum bundle damage in rats, monkeys, and humans is analysed. Despite causing extensive anatomical disconnections, cingulum bundle lesions typically produce only mild deficits, highlighting the importance of parallel pathways and the distributed nature of its various functions. Meanwhile, non-invasive imaging implicates the cingulum bundle in executive control, emotion, pain (dorsal cingulum), and episodic memory (parahippocampal cingulum), while clinical studies reveal cingulum abnormalities in numerous conditions, including schizophrenia, depression, post-traumatic stress disorder, obsessive compulsive disorder, autism spectrum disorder, Mild Cognitive Impairment, and Alzheimer's disease. Understanding the seemingly diverse contributions of the cingulum will require better ways of isolating pathways within this highly complex tract.

The Neural Code for Pain: From Single-Cell Electrophysiology to the Dynamic Pain Connectome

Pain occurs in time. In naturalistic settings, pain perception is sometimes stable but often varies in intensity and quality over the course of seconds, minutes, and days. A principal aim in classic electrophysiology studies of pain was to uncover a neural code based on the temporal patterns of single neuron firing. In contrast, modern neuroimaging studies have placed emphasis on uncovering the spatial pattern of brain activity (or “map”) that may reflect the pain experience. However, in the emerging field of connectomics, communication within and among brain networks is characterized as intrinsically dynamic on multiple time scales. In this review, we revisit the single-cell electrophysiological evidence for a nociceptive neural code and consider how those findings relate to recent advances in understanding systems-level dynamic processes that suggest the existence of a “dynamic pain connectome” as a spatiotemporal physiological signature of pain. We explore how spontaneous activity fluctuations in this dynamic system shape, and are shaped by, acute and chronic pain experiences and individual differences in those experiences. Highlighting the temporal dimension of pain, we aim to move pain theory beyond the concept of a static neurosignature and toward an ethologically relevant account of naturalistic dynamics.

Frameless stereotactic magnetic resonance imaging-guided laser interstitial thermal therapy to perform bilateral anterior cingulotomy for intractable pain: feasibility, technical aspects, and initial experience in 3 patients

BACKGROUND

Bilateral anterior cingulotomy is well described for certain pain and psychiatric disorders. Typically, stereotactic frame-based radiofrequency ablation is used. We report the feasibility of a frameless approach using magnetic resonance imaging-guided laser induced thermal therapy (MRgLITT).

OBJECTIVE

To report experience and outcomes for MRgLITT in bilateral anterior cingulotomy.

METHODS

Three patients with chronic refractory cancer-related pain underwent bilateral anterior cingulotomy. The Brief Pain Inventory (Short Form) was used for pain evaluation. Frameless stereotaxy using the Medtronic S7 Navigation system was used for laser catheter placement. Patients were followed for evaluation of pain control outcomes.

RESULTS

Four MRgLITT bilateral cingulotomy procedures were performed in 3 patients. Two patients had a single MRgLITT procedure while the third had repeat ablation after pain recurrence. First time ablation coordinates were (medians): x = 7.9 mm (range, 6.9-8.6); y = 20.5 mm (range, 20-22); z = 6.9 mm (range, 2.9-7.0) above the lateral ventricle roof. Median trajectory length was 85.5 mm (range, 80-90). Median ablation volume was 1.5 cm3 (range, 0.6-1.2). Median ablation time was 257 seconds (range, 136-338) per cingulum and power was 10.0 Watts (range, 10-11). Median preoperative pain severity (PSS) and interference scores (PIS) were 7.7 (range, 7.5-9.3) and 9.9 (range, 9.7-10.0), respectively. Median postoperative PSS and PIS scores were 1.6 (range, 1.0-2.8) and 2.0 (range, 0.3-2.6), respectively.

CONCLUSION

MRgLITT cingulotomy is well tolerated for treatment of cancer pain and can be easily performed framelessly for appropriate candidates.

Early MRI Characteristics after MRI-Guided Laser-Assisted Cingulotomy for Intractable Pain Control

BACKGROUND AND PURPOSE

Cingulotomy is a well-accepted stereotactic procedure in the treatment of debilitating pain syndromes. At our institution, we used a 980-nm diode laser to perform MR imaging-guided laser-assisted cingulotomy. We report the early MR imaging changes associated with this technique.

MATERIALS AND METHODS

In this retrospective analysis, MR imaging-guided laser-assisted cingulotomy was performed in 4 patients with intractable pain secondary to metastatic disease. Patients were imaged at various time points postprocedure, with visual analysis of MR imaging changes in the cingulate gyri during that timeframe.

RESULTS

Twenty-four hours postablation, 4 distinct zones of concentric rings reminiscent of an "owl eye" shape were noted in the cingulate gyri. Extrapolating from the imaging characteristics of the rings, we defined each zone as follows: The central zone (zone 1) represents a laser probe void with fluid, zones 2 and 3 have signal characteristics that represent hemorrhage and leaked protein, and zone 4 has a peripheral ring of acute infarction, enhancement, and surrounding edema. One patient with 1-year follow-up showed persistent concentric rings with resolution of enhancement and edema.

CONCLUSIONS

Post-MR imaging-guided laser-assisted cingulotomy rings appear to represent a continuum of injury created by the laser probe and thermal injury. The imaging changes are similar to those described for laser ablation of tumor-infiltrated brain with a 1064-nm laser. This is the first study to characterize early MR imaging changes after MR imaging-guided laser-assisted cingulotomy by using a 980-nm laser. It is important for neuroradiologists and neurosurgeons to understand expected imaging findings as laser ablation cingulotomy re-emerges to treat intractable pain.

Opioid modulation of resting-state anterior cingulate cortex functional connectivity

Individuals misuse oxycodone, a widely prescribed opioid analgesic, in part to self-medicate physical and emotional pain. Physical and emotional pain is thought to be represented in the brain by a 'pain matrix,' consisting of the insula, thalamus, and somatosensory cortices, with processing of the affective dimension of pain in the dorsal and rostral anterior cingulate cortex (ACC). The current study examined oxycodone's effects on resting-state functional connectivity between the dorsal ACC, rostral ACC, and other regions of the pain matrix using functional magnetic resonance imaging (fMRI). In a within-subjects, randomized, double-blind, placebo-controlled, dose-response design, 14 healthy subjects completed a resting-state scan following ingestion of placebo, 10 mg, or 20 mg of oxycodone. Functional correlations between the dorsal and rostral ACC seed regions and the pain matrix were examined and compared across sessions. Both doses of oxycodone reduced functional coupling between the dorsal ACC and bilateral anterior insula/putamen and the rostral ACC and right insula relative to placebo (no differences between doses). The findings do not withstand correction for multiple comparisons, and thus should be considered preliminary. However, they are consistent with the idea that oxycodone may produce its physical and emotional 'analgesic' effects through disruption of ACC-insula and ACC-putamen connectivity.

Midcingulate Motor Map and Feedback Detection: Converging Data from Humans and Monkeys

The functional and anatomical organization of the cingulate cortex across primate species is the subject of considerable and often confusing debate. The functions attributed to the midcingulate cortex (MCC) embrace, among others, feedback processing, pain, salience, action-reward association, premotor functions, and conflict monitoring. This multiplicity of functional concepts suggests either unresolved separation of functional contributions or integration and convergence. We here provide evidence from recent experiments in humans and from a meta-analysis of monkey data that MCC feedback-related activity is generated in the rostral cingulate premotor area by specific body maps directly related to the modality of feedback. As such, we argue for an embodied mechanism for adaptation and exploration in MCC. We propose arguments and precise tools to resolve the origins of performance monitoring signals in the medial frontal cortex, and to progress on issues regarding homology between human and nonhuman primate cingulate cortex.

[Surgery for behavioral disorders: the state of the art]

BACKGROUND

Surgery for behavioral disorders (SBD) is becoming a more common treatment since the development of neuromodulation techniques.

METHODS

This article is a non-systematic review of the history, current indications, techniques and surgical targets of SBD. We divide its history into 3 eras: the first era starts in the beginning of psychosurgery and finishes with the development of stereotactic techniques, when the second one starts. It is characterized by the realization of stereotactic lesions. We are traveling through the third era, which begins when deep brain stimulation (DBS) starts to be used for SBD.

RESULTS

In spite of the serious mistakes committed in the past, nowadays, SBD is reawakening. The psychiatric disorders which are most frequently treated by surgery are: treatment-resistant depression, obsessive-compulsive disorder and Tourette syndrome. Furthermore, some patients with abnormal aggression were surgically treated. There are several stereotactic targets described for these disorders. Vagus nerve stimulation may be also used for depression.

CONCLUSION

The results of DBS in these disorders seem to be encouraging. However, more randomized trials are needed in order to establish the effectiveness of SBD. It must be taken in mind that a proper patient selection will help us to perform a safer procedure as well as to achieve better surgical results, leading SBD to be more accepted by psychiatrists, patients and their families. Further research is needed in several topics such as: physiopathology of behavioral disorders, indications of SBD and new surgical targets.

Hoarding symptoms and prediction of poor response to limbic system surgery for treatment-refractory obsessive-compulsive disorder

Object

Recent findings have suggested a correlation between obsessive-compulsive disorder (OCD) symptom dimensions and clinical outcome after limbic system surgery for treatment-refractory patients. Based on previous evidence that the hoarding dimension is associated with worse outcome in conventional treatments, and may have a neural substrate distinct from OCD, the authors examined a large sample of patients undergoing limbic surgery (40 with capsulotomy, 37 with cingulotomy) and investigated if symptom dimensions, in particular hoarding, could influence treatment outcome.

Methods

Data from 77 patients from 3 different research centers at São Paulo (n = 17), Boston (n = 37), and Stockholm (n = 23) were analyzed. Dimensional Yale-Brown Obsessive Compulsive Scale (Y-BOCS; São Paulo) or Y-BOCS Symptom Checklist scores (Boston and Stockholm) were used to code the presence of 4 well-established symptom dimensions: forbidden thoughts, contamination/cleaning, symmetry/order, and hoarding. Reductions in YBOCS scores determined clinical outcome.

Results

Mean Y-BOCS scores decreased 34.2% after surgery (95% CI 27.2%–41.3%), with a mean follow-up of 68.1 months. Patients with hoarding symptoms had a worse response to treatment (mean Y-BOCS decrease of 22.7% ± 25.9% vs 41.6% ± 32.2%, respectively; p = 0.006), with no significant effect of surgical modality (capsulotomy vs cingulotomy). Patients with forbidden thoughts apparently also had a worse response to treatment, but this effect was dependent upon the co-occurrence of the hoarding dimension. Only the negative influence of the hoarding dimension remained when an ANOVA model was performed, which also controlled for preoperative symptom severity.

Conclusions

The presence of hoarding symptoms prior to surgery was associated with worse clinical outcome after the interventions. Patients with OCD under consideration for ablative surgery should be carefully screened for hoarding symptoms or comorbid hoarding disorder. For these patients, the potentially reduced benefits of surgery need to be carefully considered against potential risks.

Lesion analysis for cingulotomy and limbic leucotomy: comparison and correlation with clinical outcomes

OBJECT

Cingulotomy and limbic leucotomy are lesioning surgeries with demonstrated benefit for medically intractable psychiatric illnesses. They represent significant refinements of the prefrontal lobotomy used from the 1930s through the 1950s. However, the associations between anatomical characterization of these lesions and outcome data are not well understood. To elucidate these procedures and associations, the authors sought to define and compare the neuroanatomy of cingulotomy and limbic leucotomy and to test a method that uses neuroanatomical data and voxel-based lesion-symptom mapping (VLSM) to reveal potential refinements to modern psychiatric neurosurgical procedures.

METHODS

T1-weighted MR images of patients who had undergone cingulotomy and limbic leucotomy were segmented and registered onto the Montreal Neurological Institute T1-weighted template brain MNI152. Using an atlas-based approach, the authors calculated, by case, the percentage of each anatomical structure affected by the lesion. Because of the infrequency of modern lesion procedures and the requirement for higher-resolution clinical imaging, the sample size was small. The pilot study correlated cingulotomy and limbic leucotomy lesion characteristics with clinical outcomes for patients with obsessive-compulsive disorder. For this study, preoperative and postoperative Yale-Brown Obsessive Compulsive Scale scores for 11 cingulotomy patients and 8 limbic leucotomy patients were obtained, and lesion masks were defined and compared anatomically by using an atlas-based method. Statistically significant voxels were additionally calculated by using VLSM techniques that correlated lesion characteristics with postoperative scores.

RESULTS

Mean lesion volumes were 13.3 ml for cingulotomy and 11.8 ml for limbic leucotomy. As expected, cingulotomy was isolated to the anterior cingulum. The subcaudate tractotomy portion of limbic leucotomy additionally affected Brodmann area 25, the medial orbitofrontal cortex, and the nucleus accumbens. Initial results indicated that the dorsolateral regions of the cingulotomy lesion and the posteroventral regions of the subcaudate tractotomy lesion were associated with improved postoperative Yale-Brown Obsessive Compulsive Scale scores.

CONCLUSIONS

Cingulotomy and limbic leucotomy are lesioning surgeries that target pathological circuits implicated in psychiatric disease. Lesion analysis and VLSM contextualize outcome data and have the potential to be useful for improving lesioning neurosurgical procedures.

The will to persevere induced by electrical stimulation of the human cingulate gyrus

Anterior cingulate cortex (ACC) is known to be involved in functions such as emotion, pain, and cognitive control. While studies in humans and nonhuman mammals have advanced our understanding of ACC function, the subjective correlates of ACC activity have remained largely unexplored. In the current study, we show that electrical charge delivery in the anterior midcingulate cortex (aMCC) elicits autonomic changes and the expectation of an imminent challenge coupled with a determined attitude to overcome it. Seed-based, resting-state connectivity analysis revealed that the site of stimulation in both patients was at the core of a large-scale distributed network linking aMCC to the frontoinsular and frontopolar as well as some subcortical regions. This report provides compelling, first-person accounts of electrical stimulation of this brain network and suggests its possible involvement in psychopathological conditions that are characterized by a reduced capacity to endure psychological or physical distress.

Double-blind optimization of subcallosal cingulate deep brain stimulation for treatment-resistant depression: a pilot study

BACKGROUND

Deep brain stimulation (DBS) of the subcallosal cingulate (SCC) is reported to be a safe and effective new treatment for treatment-resistant depression (TRD). However, the optimal electrical stimulation parameters are unknown and generally selected by trial and error. This pilot study investigated the relationship between stimulus parameters and clinical effects in SCC-DBS treatment for TRD.

METHODS

Four patients with TRD underwent SCC-DBS surgery. In a double-blind stimulus optimization phase, frequency and pulse widths were randomly altered weekly, and corresponding changes in mood and depression were evaluated using a visual analogue scale (VAS) and the 17-item Hamilton Rating Scale for Depression (HAM-D-17). In the open-label postoptimization phase, depressive symptoms were evaluated biweekly for 6 months to determine long-term clinical outcomes.

RESULTS

Longer pulse widths (270-450 μs) were associated with reductions in HAM-D-17 scores in 3 patients and maximal happy mood VAS responses in all 4 patients. Only 1 patient showed acute clinical or mood effects from changing the stimulation frequency. After 6 months of open-label therapy, 2 patients responded and 1 patient partially responded.

LIMITATIONS

Limitations include small sample size, weekly changes in stimulus parameters, and fixed-order and carry-forward effects.

CONCLUSION

Longer pulse width stimulation may have a role in stimulus optimization for SCC-DBS in TRD. Longer pulse durations produce larger apparent current spread, suggesting that we do not yet know the optimal target or stimulus parameters for this therapy. Investigations using different stimulus parameters are required before embarking on large-scale randomized sham-controlled trials.

The neural bases of social pain: evidence for shared representations with physical pain

Experiences of social rejection or loss have been described as some of the most "painful" experiences that we, as humans, face and perhaps for good reason. Because of our prolonged period of immaturity, the social attachment system may have co-opted the pain system, borrowing the pain signal to prevent the detrimental consequences of social separation. This review summarizes a program of research that has explored the idea that experiences of physical pain and social pain rely on shared neural substrates. First, evidence showing that social pain activates pain-related neural regions is reviewed. Then, studies exploring some of the expected consequences of such a physical pain-social pain overlap are summarized. These studies demonstrate that a) individuals who are more sensitive to one kind of pain are also more sensitive to the other and b) factors that increase or decrease one kind of pain alter the other in a similar manner. Finally, what these shared neural substrates mean for our understanding of socially painful experience is discussed.

MR imaging of psychosurgery: rostral atrophy following stereotacic subcaudate tractotomy

There are few reports of MR imaging findings following psychosurgery. Here, we report the findings of 3T MR imaging of the sequelae of stereotactic subcaudate tractotomy (SST). Rostral atrophy is noted on conventional imaging. Diffusion tensor (DT) tractography demonstrated no communicating white matter tracts between the inferior frontal lobes, which appeared normally as thick fibre bundles in age-matched controls. DT tractography provides a unique tool for the evaluation of sequelae of ablative psychosurgical procedures.

Neurostimulatory and ablative treatment options in major depressive disorder: a systematic review

INTRODUCTION

Major depressive disorder is one of the most disabling and common diagnoses amongst psychiatric disorders, with a current worldwide prevalence of 5-10% of the general population and up to 20-25% for the lifetime period.

HISTORICAL PERSPECTIVE

Nowadays, conventional treatment includes psychotherapy and pharmacotherapy; however, more than 60% of the treated patients respond unsatisfactorily, and almost one fifth becomes refractory to these therapies at long-term follow-up.

NONPHARMACOLOGICAL TECHNIQUES

Growing social incapacity and economic burdens make the medical community strive for better therapies, with fewer complications. Various nonpharmacological techniques like electroconvulsive therapy, vagus nerve stimulation, transcranial magnetic stimulation, lesion surgery, and deep brain stimulation have been developed for this purpose.

DISCUSSION

We reviewed the literature from the beginning of the twentieth century until July 2009 and described the early clinical effects and main reported complications of these methods.

Gliomas of the cingulate gyrus: surgical management and functional outcome

Object

In this paper, the authors' goal was to summarize their experience with the surgical treatment of gliomas arising from the cingulate gyrus.

Methods

The authors analyzed preoperative data, surgical strategies, complications, and functional outcome in a series of 34 patients (mean age 42 years, range 12–69 years; 14 females) who underwent 38 operations between May 2001 and November 2008.

Results

In 7 cases (18%) the tumor was located in the posterior (parietal) part of the cingulate gyrus, and in 31 (82%) the tumor was in the anterior (frontal) part. In 10 cases (26%) the glioma was solely located in the cingulate gyrus, and in 28 cases (74%) the tumor extended to the supracingular frontal/parietal cortex. Most cases (23 [61%]) had seizures as the presenting symptom, 8 patients (24%) suffered from a hemiparesis/hemihypesthesia, and 4 patients (12%) had aphasic symptoms.

The authors chose an interhemispheric approach for tumor resection in 11 (29%) and a transcortical approach in 27 (71%) cases; intraoperative electrophysiological monitoring was applied in 23 (61%) and neuronavigation in 15 (39%) cases. A > 90% resection was achieved in 32 (84%) and > 70% in another 5 (13%) cases. Tumors were classified as low-grade gliomas in 11 cases (29%). A glioblastoma multiforme (WHO Grade IV, 10 cases [26%]) and oligoastrocytoma (WHO Grade III, 9 cases [24%]) were the most frequent histopathological results.

Postoperatively, patients in 13 cases suffered from a transient supplementary motor area syndrome (34%), all of whom had tumors in the anterior cingulate gyrus. In the early postoperative period (30 days) a new deficit occurred in 5 cases (13%, mild motor deficits or aphasic symptoms). One patient had a major bleeding episode 2 days after surgery and was in a persistent vegetative state.

Conclusions

Gliomas arising from the cingulate gyrus are rare. A gross-total resection is often possible and acceptably safe; intraoperative monitoring and neuronavigation are helpful adjuncts. In case of resection of gliomas arising from the anterior cingulate gyrus a supplementary motor area syndrome has to be considered, particularly when the tumor extends to the supracingular cortex

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders - first revision

In this report, which is an update of a guideline published in 2002 (Bandelow et al. 2002, World J Biol Psychiatry 3:171), recommendations for the pharmacological treatment of anxiety disorder, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are presented. Since the publication of the first version of this guideline, a substantial number of new randomized controlled studies of anxiolytics have been published. In particular, more relapse prevention studies are now available that show sustained efficacy of anxiolytic drugs. The recommendations, developed by the World Federation of Societies of Biological Psychiatry (WFSBP) Task Force for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-traumatic Stress Disorders, a consensus panel of 30 international experts, are now based on 510 published randomized, placebo- or comparator-controlled clinical studies (RCTs) and 130 open studies and case reports. First-line treatments for these disorders are selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs) and the calcium channel modulator pregabalin. Tricyclic antidepressants (TCAs) are equally effective for some disorders, but many are less well tolerated than the SSRIs/SNRIs. In treatment-resistant cases, benzodiazepines may be used when the patient does not have a history of substance abuse disorders. Potential treatment options for patients unresponsive to standard treatments are described in this overview. Although these guidelines focus on medications, non-pharmacological were also considered. Cognitive behavioural therapy (CBT) and other variants of behaviour therapy have been sufficiently investigated in controlled studies in patients with anxiety disorders, OCD, and PTSD to support them being recommended either alone or in combination with the above medicines.

Anterior cingulotomy for major depression: clinical outcome and relationship to lesion characteristics

BACKGROUND

Anterior cingulotomy (ACING) is a neurosurgical treatment for chronic refractory depression, pain, and obsessive-compulsive disorder. Anterior cingulotomy involves the placement of bilateral lesions in the anterior cingulate under stereotactic guidance. Although a long-established therapeutic intervention, the optimal location and volume of lesions are not known, but it is generally believed that efficacious lesions interrupt the fibers of the cingulum bundle.

METHODS

Using T2-weighted magnetic resonance imaging, we tested the hypothesis that lesions placed more anteriorly would be associated with a better clinical response. We also tested a secondary hypothesis that a superior clinical response would be associated with larger lesion volumes.

RESULTS

When assessed 12 months following surgery, a superior clinical response was associated with more anterior lesions but, unexpectedly, with smaller lesion volumes. Specifically, the best clinical response was associated with total (right plus left hemisphere) lesion volumes of 1000 to 2000 mm(3) centered at Montreal Neurological Institute (MNI) coordinates (+/- 9,19,30).

CONCLUSIONS

There is considerable evidence from neuroimaging studies that more rostral areas within the anterior cingulate cortex are functionally and structurally abnormal in patients with major depressive disorder. Anteriorly placed ACING lesions would target and modify function within such regions. It should not be assumed that larger lesions are associated with a better response. These findings of relationships between lesion characteristics and clinical response argue against the suggestion that ACING represents a placebo treatment.

Understanding genetic risk for aggression: clues from the brain's response to social exclusion

BACKGROUND

Although research indicates a relationship between the monoamine oxidase-A (MAOA) gene and aggression, the intervening neural and psychological mechanisms are unknown. Individuals with the low expression allele (MAOA-L) of a functional polymorphism in the MAOA gene might be prone to aggression because they are socially or emotionally hyposensitive and thus care less about harming others or because they are socially or emotionally hypersensitive and thus respond to negative social experiences with defensively aggressive behavior.

METHODS

We investigated the relationships between the MAOA polymorphism, trait aggression, trait interpersonal hypersensitivity, and neural responses to social exclusion in 32 healthy men and women.

RESULTS

The MAOA-L individuals (men and women) reported higher trait aggression than individuals with the high expression allele (MAOA-H). The MAOA-L individuals reported higher trait interpersonal hypersensitivity and showed greater dorsal anterior cingulate cortex (dACC) activity (associated with rejection-related distress) to social exclusion compared with MAOA-H individuals, consistent with a social hypersensitivity hypothesis. Moreover, the MAOA-aggression relationship was mediated by greater dACC reactivity to social exclusion, suggesting that MAOA might relate to aggression through socioemotional hypersensitivity.

CONCLUSIONS

These data suggest that the relationship between MAOA and aggression might be due to a heightened rather than a reduced sensitivity to negative socioemotional experiences like social rejection.

Association, commissural, and projection pathways and their functional deficit reported in literature

This study demonstrates normal white matter structures of the supratentorial system revealed by diffusion tensor imaging. Their anatomic connections and functional significance are discussed in the context of the lesion-induced deficits reported in the literature, which may not fully represent the lesion-induced effects on the white matter function and may not be entirely specific to the tract discussed. Nevertheless, understanding the most common effects of lesions on the functional connectivity provides a framework that we can use in advanced neuroimaging studies, like diffusion tensor imaging, functional magnetic resonance imaging, and positron emission tomography, and in our daily clinical practice.

Tract identification by novel MRI signal changes following stereotactic anterior capsulotomy

BACKGROUND

Five patients underwent magnetic resonance imaging (MRI) following MRI-guided stereotactic bilateral anterior capsulotomy to detect lesion-related anatomic changes.

METHODS

Five disabled and treatment-resistant patients with major depression (n = 4) and obsessive-compulsive disorder (n = 1) underwent stereotactic bilateral anterior capsulotomy. All patients had postoperative MRI at 2 months and at 1-4 years after surgery. An additional patient who had a pure motor deficit following a spontaneous basal ganglia hemorrhagic stroke was imaged as a comparator.

RESULTS

The 2-month postcapsulotomy MRI showed a previously undescribed increase in T1-weighted signal within similar neural pathways for each patient. These pathways showed no changes in T2-weighted or fluid-attenuated inversion recovery sequences. The signal changes are different from the expected changes associated with anterograde Wallerian degeneration and identify retrograde changes in the proximal segment of the interrupted axon.

CONCLUSION

Previously undescribed T1-weighted signal alterations following stereotactic surgery identify retrograde non-Wallerian changes in interrupted axons and provide a new method in identifying and tracing lesioned pathways.

Human anterior cingulate cortex neurons encode cognitive and emotional demands

The cortical mechanisms and substrates of cognitive and emotional demands are poorly understood. Lesion studies and functional imaging implicate the anterior cingulate cortex (ACC). The caudal ACC (cACC) has been implicated in cognitive processes such as attention, salience, interference, and response competition, mostly on the basis of neuroimaging results. To test the hypothesis that individual cACC neurons subserve these functions, we monitored neuronal activity from single cells in the cACC while subjects were engaged in a mental arithmetic task, the cognitively demanding counting Stroop task, and/or the emotional Stroop interference task. We now report the first direct measures of single neurons in humans identifying a population of cACC neurons that respond differentially or in a graded manner to cognitively demanding high- and low-conflict Stroop tasks, including those with emotional valence. These data indicate that cACC neurons may be acting as salience detectors when faced with conflict and difficult or emotional stimuli, consistent with neuroimaging results of cACC responses to abrupt sensory, novel, task-relevant, or painful stimuli.

Rostral cingulate gyrus: A putative target for deep brain stimulation in treatment-refractory depression

Surgery for intractable affective illnesses has generated considerable controversy over the last century. Deep brain stimulation (DBS) has revolutionized neurosurgical practice, especially in the field of advanced Parkinson's disease and, more recently, in selected medical-refractory cases of obsessive-compulsive disorder. In this paper, we propose a discrete area of the rostral cingulate gyrus as a potential target for DBS in medical-resistant depressive patients. Brodmann's area 24a has proved to be a vital link in the integration of neural circuits underlying depression, both through proposed neurobiological models and accurate neuroimaging studies. The full reversibility and adjustability of DBS offer the best chance to treat the multidimensional and life-span profile of depression, so giving hope to a great number of desperate human beings.

Brain stimulation techniques in the treatment of obsessive-compulsive disorder: current and future directions

Recent studies on the epidemiology of obsessive-compulsive disorder (OCD) estimate 50 million patients suffer from OCD worldwide, thus making it a global problem. The treatment of OCD has changed substantially over the last 2 decades following the introduction of selective serotonin reuptake inhibitors, which provide symptom improvement in approximately 60% of patients. However, some patients remain resistant to the standard pharmacologic and behavioral treatments. Although some treatment-resistant patients respond to pharmacologic augmentations, others do not, and there is evidence that some of the most severe cases benefit from treatment with neurosurgical interventions. Besides pharmacologic, behavioral, and neurosurgical approaches, different brain stimulation methods-transcranial magnetic stimulation, deep brain stimulation, and electroconvulsive therapy-have been investigated in treatment-resistant patients with OCD. However, available data about the use of these techniques in OCD treatment are quite limited in terms of sample size and study design, given the difficulty in conducting standard blinded trials for these procedures. In addition, none of the mentioned treatments have received Food and Drug Administration approval for the treatment of OCD. Nevertheless, promising findings regarding efficacy, tolerability, and non-invasiveness and/or reversibility of these techniques have increased interest in investigating their use in treatment-resistant OCD.

Neurosurgical interventions for neuropsychiatric syndromes

Psychosurgical procedures have been used for the treatment of intractable mental illness for more than 50 years. With improvements in surgical techniques, including new implantable stimulators, advances in functional neuroimaging, and progress in our fundamental understanding of the pathophysiology of mental illness there is a renewed interest in neurosurgical treatment of refractory psychiatric illness. This article will review the history of psychosurgery and recent developments in surgical techniques and implantable devices used in this context. The results of psychosurgery for the treatment of several psychiatric conditions and neuropsychiatric symptoms will be presented, including obsessive-compulsive disorder, Tourette's syndrome, depression, anxiety, aggression, self-injurious behavior, and schizophrenia. Lastly, a perspective on the current and future role of psychosurgery for the treatment of mental illnesses will be discussed.