Beneficial effect of subsequent lesion procedures after nonresponse to initial cingulotomy for severe, treatment-refractory obsessive-compulsive disorder

Cingulotomy for Intractable Pain: A Systematic Review of an Underutilized Procedure

Pain management is a critical aspect of cancer treatment and palliative care, where pain can significantly impact quality of life. Chronic pain, which affects a significant number of people worldwide, remains a prevalent and challenging symptom for patients. While medications and psychosocial support systems play a role in pain management, surgical and radiological interventions, including cingulotomy, may be necessary for refractory cases. Cingulotomy, a neurosurgical procedure targeting the cingulate gyrus, aims to disrupt neural pathways associated with emotional processing and pain sensation, thereby reducing the affective component of pain. Although cingulotomy has shown promise in providing pain relief, particularly in patients refractory to traditional medical treatment, its use has declined in recent years due to advancements in non-destructive therapies and concerns about long-term efficacy and patient suitability. Modern stereotactic methods have enhanced the precision and safety of cingulotomy, reducing associated complications and mortality rates. Despite these advancements, questions remain regarding its long-term efficacy and suitability for patients with limited life expectancy, particularly those with cancer. A comprehensive systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, aimed at providing insights into the efficacy, potential benefits, and limitations of this neurosurgical procedure in managing intractable pain. An electronic search of PubMed, Embase, Scopus, and Web of Science was conducted with open database coverage dates. The review focused on outcomes such as pain intensity and quality of life. The inclusion criteria encompassed human studies of any age experiencing intractable cancer or non-cancer pain, with cingulotomy as the primary intervention. Various study designs were considered, including observational studies, clinical trials, and reviews focusing on pain and cingulotomy. Exclusion criteria included non-human studies, non-peer-reviewed articles, and studies unrelated to pain or cingulotomy. This review highlights the efficacy of stereotactic anterior cingulotomy in managing intractable pain, particularly when conventional treatments fail. Advanced MRI-guided techniques enhance precision, but challenges like cost and expertise persist. Studies included in this review showed significant pain relief with minimal adverse effects, although the optimal target remains debated. Neurocognitive risks exist, but outcomes are generally favorable. Expected adverse events include transient effects like urinary incontinence and confusion. Reoperation may be necessary for inadequate pain control, with a median pain relief duration of three months to a year. A double stereotactic cingulotomy appears to be safe and effective for refractory pain.

Intraoperative valence testing to adjudicate between ventral capsule/ventral striatum and bed nucleus of the stria terminalis target selection in deep brain stimulation for obsessive-compulsive disorder

OBJECTIVE

Deep brain stimulation (DBS) is an accepted therapy for severe, treatment-refractory obsessive-compulsive disorder (trOCD). The optimal DBS target location within the anterior limb of the internal capsule, particularly along the anterior-posterior axis, remains elusive. Empirical evidence from several studies in the past decade has suggested that the ideal target lies in the vicinity of the anterior commissure (AC), either just anterior to the AC, above the ventral striatum (VS), or just posterior to the AC, above the bed nucleus of the stria terminalis (BNST). Various methods have been utilized to optimize target selection for trOCD DBS. The authors describe their practice of planning trajectories to both the VS and BNST and adjudicating between them with awake intraoperative valence testing to individualize permanent target selection.

METHODS

Eight patients with trOCD underwent awake DBS with trajectories planned for both VS and BNST targets bilaterally. The authors intraoperatively assessed the acute effects of stimulation on mood, energy, and anxiety and implanted the trajectory with the most reliable positive valence responses and least stimulation-induced side effects. The method of intraoperative target adjudication is described, and the OCD outcome at last follow-up is reported.

RESULTS

The mean patient age at surgery was 41.25 ± 15.1 years, and the mean disease duration was 22.75 ± 10.2 years. The median preoperative Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score was 39 (range 34-40). Two patients had previously undergone capsulotomy, with insufficient response. Seven (44%) of 16 leads were moved to the second target based on intraoperative stimulation findings, 4 of them to avoid strong negative valence effects. Three patients had an asymmetric implant (1 lead in each target). All 8 patients (100%) met full response criteria, and the mean Y-BOCS score reduction across the full cohort was 51.2% ± 12.8%.

CONCLUSIONS

Planning and intraoperatively testing trajectories flanking the AC-superjacent to the VS anteriorly and to the BNST posteriorly-allowed identification of positive valence responses and acute adverse effects. Awake testing helped to select between possible trajectories and identify individually optimized targets in DBS for trOCD.

Neurosurgical Approaches for Treatment-Resistant Obsessive-Compulsive Disorder

Treatment-resistant obsessive-compulsive disorder (trOCD) is a severely disabling, life-threatening psychiatric disorder affecting ∼0.5% of the US population. Following the failure of multiple medical and psychotherapeutic treatment lines, patients with trOCD, like others with functional disorders, may benefit from invasive neuromodulation. Cumulative evidence suggests that disrupting abnormal hyperdirect cortico-striato-thalamo-cortical (CSTC) pathway activity offers sustainable, robust symptomatic relief in most patients. Multiple surgical approaches allow for modulation of the CSTC pathway, including stereotactic lesions and electrical stimulation. This review aims to describe the modern neurosurgical approaches for trOCD, recent advances in our understanding of pathophysiology, and future therapeutic directions.

Correlations between single nucleotide polymorphisms in obsessive-compulsive disorder with the clinical features or response to therapy

Obsessive-compulsive disorder (OCD) is a debilitating neuropsychiatric disorder, in which the patient endures intrusive thoughts or is compelled to perform repetitive or ritualized actions. Many cases of OCD are considered to be familial or heritable in nature. It has been shown that a variety of internal and external risk factors are involved in the pathogenesis of OCD. Among the internal factors, genetic modifications play a critical role in the pathophysiological process. Despite many investigations performed to determine the candidate genes, the precise genetic factors involved in the disease remain largely undetermined. The present review summarizes the single nucleotide polymorphisms that have been proposed to be associated with OCD symptoms, early onset disease, neuroimaging results, and response to therapy. This information could help us to draw connections between genetics and OCD symptoms, better characterize OCD in individual patients, understand OCD prognosis, and design more targeted personalized treatment approaches.

The Evolution of Modern Ablative Surgery for the Treatment of Obsessive-Compulsive and Major Depression Disorders

In this review, we describe the evolution of modern ablative surgery for intractable psychiatric disease, from the original image-guided cingulotomy procedure described by Ballantine, to the current bilateral anterior cingulotomy using MRI-guided stereotactic techniques. Extension of the single lesion bilateral cingulotomy to the extended bilateral cingulotomy and subsequent staged limbic leucotomy (LL) is also discussed. Other ablative surgeries for psychiatric disease including subcaudate tractotomy (SCT) and anterior capsulotomy (AC) using modern MRI-guided ablative techniques, as well as radiosurgical capsulotomy, are described. Finally, the potential emerging role of MR-guided focused ultrasound (MRgFUS) for treating conditions such as major depressive disorder (MDD) and obsessive-compulsive disorder (OCD) is discussed.

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.

Magnetic Resonance-Guided Focused Ultrasound Surgery for Obsessive-Compulsive Disorders: Potential for use as a Novel Ablative Surgical Technique

Surgical treatment for psychiatric disorders, such as obsessive-compulsive disorder (OCD) and depression, using ablative techniques, such as cingulotomy and capsulotomy, have historically been controversial for a number of scientific, social, and ethical reasons. Recently, with the elucidation of anatomical and neurochemical substrates of brain function in healthy controls and patients with such disorders using various functional neuroimaging techniques, these criticisms are becoming less valid. Furthermore, by using new techniques, such as deep brain stimulation (DBS), and identifying more precise targets, beneficial effects and the lack of serious complications have been demonstrated in patients with psychiatric disorders. However, DBS also has many disadvantages. Currently, magnetic resonance-guided focused ultrasound surgery (MRgFUS) is used as a minimal-invasive surgical method for generating precisely placed focal thermal lesions in the brain. Here, we review surgical techniques and their potential complications, along with anterior limb of the internal capsule (ALIC) capsulotomy by radiofrequency lesioning and gamma knife radiosurgery, for the treatment of OCD and depression. We also discuss the limitations and technical issues related to ALIC capsulotomy with MRgFUS for medically refractory OCD and depression. Through this review we hope MRgFUS could be considered as a new treatment choice for refractory OCD.

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.

Oral N-acetylcysteine in the treatment of obsessive-compulsive disorder: A systematic review of the clinical evidence

Obsessive-compulsive disorder (OCD) is characterized by the presence of obsessions and/or compulsions. It is a leading cause of morbidity worldwide, as it can interfere with all aspects of life. Despite the adequate treatment trials, half of patients preserve residual or impairing symptoms and selective serotonin reuptake inhibitors (SSRIs) are not free from adverse side effects. This work aims to systematically review the current evidence available concerning the efficacy of N-acetylcysteine (NAC) in the treatment of OCD. Five randomized placebo-controlled trials (RCTs), 3 case reports and 2 case series were included. The studies developed so far are somehow contradictory. However, our pooled result from the 4 observational studies (n = 13) showed a mean reduction in Y-BOCS score after NAC treatment of -11 points (p = .01). Pooled mean difference from 4 of the 5 RCTs included was 3.35, with a95% confidence interval of -0.21-6.91 and a p-value barely below statistical significance (p = .07). This result trends to favour the use of NAC over placebo in OCD patients. NAC has an optimal tolerability profile, even in higher doses, and the most frequently reported adverse events were gastrointestinal. Despite the degree of evidence being D, in our opinion the potential of NAC is underestimated. Considering its exceptional tolerability profile, the use as an add-on agent should be contemplated, on an ad hoc basis.

Reduced integrity of the uncinate fasciculus and cingulum in depression: A stem-by-stem analysis

INTRODUCTION

The subgenual cingulate gyrus (Brodmann's Area 25: BA25) is hypermetabolic in depression and has been targeted successfully with deep brain stimulation. Two of the white matter tracts that play a role in treatment response are the uncinate fasciculus (UF) and the cingulum bundle. The UF has three prefrontal stems, the most medial of which extends from BA25 (which deals with mood regulation) and the most lateral of which extends from the dorso-lateral prefrontal cortex (concerned with executive function). The cingulum bundle has numerous fibers connecting the lobes of the cerebrum, with the longest fibers extending from BA25 to the amygdala. We hypothesize that there is reduced integrity in the UF, specific to the medial prefrontal stems, as well as in the subgenual and amygdaloid fibers of the cingulum bundle. Our secondary hypothesis is that these changes are present from the early stages of depression.

OBJECTIVE

Compare the white matter integrity of stems of the UF and components of the cingulum bundle in first-onset depressed, recurrent/chronic depressed, and non-depressed control subjects.

METHODS

Depressed patients (n = 103, first-onset = 57, chronic = 46) and non-depressed control subjects (n = 74) underwent MRI with 32-directional DTI sequences. The uncinate fasciculi and cingulum bundles were seeded, and the fractional anisotropy (FA) measured in each of the three prefrontal stems and the body of the UF, as well as the subgenual, body, and amygdaloid fiber components of the cingulum bundle. FA measurements were compared between groups using ANOVA testing with post-hoc Tukey analysis.

RESULTS

There were significant reductions in FA in the subgenual and polar stems of the UF bilaterally, as well as the subgenual and amygdaloid fibers of the cingulum bundle, in depressed patients compared with controls (p < 0.001). There was no significant difference seen in the lateral UF stem or the main body of the cingulum. No significant difference was demonstrated in any of the tracts between first-onset and chronic depression patients.

CONCLUSION

Depressed patients have reduced white matter integrity in the subgenual and polar stems of the uncinate fasciculi but not the lateral stems, as well as in the subgenual and amygdaloid cingulum fibers. These changes are present from the first-onset of the disease.

Subcaudate Tractotomy White Matter Anatomy and Variability: A Diffusion Tensor Imaging Study

BACKGROUND

Subcaudate tractotomy is a functional ablative procedure performed for treatment-resistant psychiatric disease, targeting the white matter tracts ventral to the head of the caudate nucleus. The white matter anatomy of this region has extensive interindividual variability, and this is thought to impact upon the treatment response to ablative and deep brain stimulation procedures.

OBJECTIVE

We aim to assess in detail the white matter tract anatomy and topographic variability underlying subcaudate tractotomy.

METHODS

74 non-depressed adult volunteers underwent MRI including diffusion tensor imaging. Individualized regions of interest were formed in both hemispheres using native non-normalized data to simulate a subcaudate tractotomy. Tractography and analysis were performed and the exact tract locations measured including mean distances and standard deviations to assess variability.

RESULTS

The cingulum bundle, uncinate fasciculus, corticostriatal fibres, and corticothalamic fibres were consistently demonstrated. The location of the cingulum bundle was consistent across subjects, but there was extensive interindividual variability in the topographic location of the other tracts.

CONCLUSION

We have demonstrated a detailed analysis of the white matter tracts and their anatomical variability underlying subcaudate tractotomy. This has significant implications for neurosurgical targeting.

Gamma-knife subcaudate tractotomy for treatment-resistant depression and target characteristics: a case report and review

Stereotactic subcaudate tractotomy has previously been suggested to be an effective treatment for depression. This is the first study to report the use of gamma-knife subcaudate tractotomy for treatment-resistant depression. A 49-year-old woman with major depressive disorder had been treated for 30 years, with nine suicide attempts during that time. The right and left target maximum diameter was 11 mm within 50 % isodose lines. The target was located more posteriorly and inferiorly than the subgenual cingulate target typically used for deep-brain stimulation. The maximum radiation dose was 130 Gy. During the 4 months after surgery, the patient improved gradually from 23 to 4 according to the Hamilton Rating Scale for Depression and antidepressant medication was discontinued. Target-sized focal lesions were identified and no edema was seen postoperatively. No aggravation or neurologic deficit occurred during the 2.5 years of follow-up. Gamma-knife subcaudate tractotomy for depression is a minimally invasive technique. Investigations of the effectiveness and safety profile in a larger group are warranted.

The Co-evolution of Neuroimaging and Psychiatric Neurosurgery

The role of neuroimaging in psychiatric neurosurgery has evolved significantly throughout the field's history. Psychiatric neurosurgery initially developed without the benefit of information provided by modern imaging modalities, and thus lesion targets were selected based on contemporary theories of frontal lobe dysfunction in psychiatric disease. However, by the end of the 20th century, the availability of structural and functional magnetic resonance imaging (fMRI) allowed for the development of mechanistic theories attempting to explain the anatamofunctional basis of these disorders, as well as the efficacy of stereotactic neuromodulatory treatments. Neuroimaging now plays a central and ever-expanding role in the neurosurgical management of psychiatric disorders, by influencing the determination of surgical candidates, allowing individualized surgical targeting and planning, and identifying network-level changes in the brain following surgery. In this review, we aim to describe the coevolution of psychiatric neurosurgery and neuroimaging, including ways in which neuroimaging has proved useful in elucidating the therapeutic mechanisms of neuromodulatory procedures. We focus on ablative over stimulation-based procedures given their historical precedence and the greater opportunity they afford for post-operative re-imaging, but also discuss important contributions from the deep brain stimulation (DBS) literature. We conclude with a discussion of how neuroimaging will transition the field of psychiatric neurosurgery into the era of precision medicine.

Multi-tensor investigation of orbitofrontal cortex tracts affected in subcaudate tractotomy

Subcaudate tractotomy (SCT) is a neurosurgical lesioning procedure that can reduce symptoms in medically intractable obsessive compulsive disorder (OCD). Due to the putative importance of the orbitofrontal cortex (OFC) in symptomatology, fibers that connect the OFC, SCT lesion, and either the thalamus or brainstem were investigated with two-tensor tractography using an unscented Kalman filter approach. From this dataset, fibers were warped to Montreal Neurological Institute space, and probability maps with center-of-mass analysis were subsequently generated. In comparing fibers from the same OFC region, including medial OFC (mOFC), central OFC (cOFC), and lateral OFC (lOFC), the area of divergence for fibers connected with the thalamus versus the brainstem is posterior to the anterior commissure. At the anterior commissure, fibers connected with the thalamus run dorsal to those connected with the brainstem. As OFC fibers travel through the ventral aspect of the internal capsule, lOFC fibers are dorsal to cOFC and mOFC fibers. Using neuroanatomical comparison, tracts coursing between the OFC and thalamus are likely part of the anterior thalamic radiations, while those between the OFC and brainstem likely belong to the medial forebrain bundle. These data support the involvement of the OFC in OCD and may be relevant to creating differential lesional procedures of specific tracts or to developing deep brain stimulation programming paradigms.

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.

Ablative Limbic System Surgery: Review and Future Directions

The limbic system is a network of interconnected brain regions regulating emotion, memory, and behavior. Pathology of the limbic system can manifest as psychiatric disease, including obsessive-compulsive disorder and major depressive disorder. For patients with these disorders who have not responded to standard pharmacological and cognitive behavioral therapy, ablative surgery is a neurosurgical treatment option. The major ablative limbic system procedures currently used are anterior capsulotomy, dorsal anterior cingulotomy, subcaudate tractotomy, and limbic leucotomy. In this review, we include a brief history of ablative limbic system surgery leading up to its current form. Mechanistic justification for these procedures is considered in a discussion of the pathophysiology of psychiatric disease. We then discuss therapeutic efficacy as demonstrated by recent trials. Finally, we consider future directions, including the search for predictors of treatment response, the development of more precise targeting methods, and the use of advances in neuroimaging to track treatment response.

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.