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Abdulrazeq H, Philips AP, Sastry R, Lauro PM, McLaughlin NCR, Asaad WF. The persistent value of lesions in psychiatric neurosurgery. Lancet Psychiatry 2024:S2215-0366(24)00115-9. [PMID: 38906167 DOI: 10.1016/s2215-0366(24)00115-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/23/2024] [Accepted: 04/03/2024] [Indexed: 06/23/2024]
Abstract
Neurosurgery for intractable psychiatric conditions has seen a resurgence with the increasing use of deep brain stimulation (DBS). Although DBS promises reversible neuromodulation and has become more popular than older lesioning methods, lesioning might still be preferred in specific cases. Here, we review the evidence for DBS and lesions in the treatment of intractable neuropsychiatric conditions and consider the factors that favour the continued use of lesioning procedures in appropriately selected cases. Broadly, systemic factors including comparative effectiveness, cost, and ethical arguments support an ongoing role for lesioning. Such a role is also supported by practical considerations including patient experiences of this type of therapy, the relative intensity of follow-up care, access to sparse or specialised follow-up care, and relative infection risk. Overall, we argue that neurosurgical lesion procedures remain an important alternative to DBS and their continued availability is necessary to fulfil the imperatives of mental health parity and enhance access to effective mental health treatments. Nonetheless, the efficacy of DBS and recent advances in closed-loop stimulation and remote programming might provide solutions to some of the challenges associated with wider use of electrical neuromodulation. Concerns about the scarcity of high-level evidence for the efficacy of lesioning procedures as well as the potential irreversible adverse effects of lesioning remain to be addressed.
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Affiliation(s)
- Hael Abdulrazeq
- Department of Neurosurgery, The Warren Alpert Medical School, Brown University, Providence, RI, USA.
| | - Alexander P Philips
- Department of Neurosurgery, The Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Rahul Sastry
- Department of Neurosurgery, The Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Peter M Lauro
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nicole C R McLaughlin
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School, Brown University, Providence, RI, USA; Carney Institute for Brain Science, Brown University, Providence, RI, USA
| | - Wael F Asaad
- Department of Neurosurgery, The Warren Alpert Medical School, Brown University, Providence, RI, USA; Department of Neuroscience, Brown University, Providence, RI, USA; Carney Institute for Brain Science, Brown University, Providence, RI, USA
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2
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Riordan CP, Owusu-Adjei B, Daci R, Phelan A, Mietus CJ, Kosarchuk J, Lambert W, Qureshi HM, Lim JC, Mihalek O, Li D, Sorour O, Homsy C, Kryzanski J, Aulet R, Johnson MD. Self-Trephination in Cranial Excoriation Disorder. Neurosurgery 2024:00006123-990000000-01204. [PMID: 38856202 DOI: 10.1227/neu.0000000000003004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/29/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND AND IMPORTANCE Trephination is a procedure in which a small hole is made in the skull. Rare cases of self-trephination by individuals seeking medical benefit have been reported. Excoriation disorder is a compulsive skin-picking condition in which an individual self-inflicts cutaneous lesions. Left untreated, severe excoriation disorder can pose significant health risks. CLINICAL PRESENTATION Here, we describe 5 patients who presented with self-trephination due to a severe form of compulsive cranial excoriation at 2 neighboring academic medical centers over a 4-year period. We review the clinical presentation of self-trephination in cranial excoriation disorder and associated risk factors, surgical and nonsurgical interventions, complications of the disease, treatments, and mortality. Defining clinical characteristics include repetitive self-induced destruction of the scalp and skull with entry into the intracranial compartment, frequent psychiatric comorbidities, infection or injury of the brain with consequent neurological morbidity or mortality, and frequent treatment failures because of poor adherence. CONCLUSION Self-trephination in cranial excoriation disorder is a severe neuropsychological disorder and neurosurgical emergency that exposes the brain and is often life-threatening. Appropriate therapy requires antibiotics, surgical debridement and repair of the wound, and concomitant effective psychiatric management of the underlying compulsion, including the use of antidepressants and behavioral therapy.
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Affiliation(s)
- Coleman P Riordan
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Brittany Owusu-Adjei
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
- UMass Memorial Health, Worcester, Massachusetts, USA
| | - Rrita Daci
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
- UMass Memorial Health, Worcester, Massachusetts, USA
| | - Alannah Phelan
- Division of Plastic Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Constance J Mietus
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
- UMass Memorial Health, Worcester, Massachusetts, USA
| | - Jacob Kosarchuk
- Department of Neurosurgery, Tufts University Medical Center, Boston, Massachusetts, USA
| | - William Lambert
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
- UMass Memorial Health, Worcester, Massachusetts, USA
| | - Hanya M Qureshi
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
- UMass Memorial Health, Worcester, Massachusetts, USA
| | - Jeewoo Chelsea Lim
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Olivia Mihalek
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Danielle Li
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Omar Sorour
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Christopher Homsy
- Department of Plastic Surgery, Tufts University Medical Center, Boston, Massachusetts, USA
| | - James Kryzanski
- Department of Neurosurgery, Tufts University Medical Center, Boston, Massachusetts, USA
| | - Ricardo Aulet
- UMass Memorial Health, Worcester, Massachusetts, USA
- Department of Otolaryngology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Mark D Johnson
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
- UMass Memorial Health, Worcester, Massachusetts, USA
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Elsouri KN, Heiser SE, Cabrera D, Alqurneh S, Hawat J, Demory ML. Management and Treatment of Obsessive-Compulsive Disorder (OCD): A Literature Review. Cureus 2024; 16:e60496. [PMID: 38883111 PMCID: PMC11180522 DOI: 10.7759/cureus.60496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 05/16/2024] [Indexed: 06/18/2024] Open
Abstract
Obsessive-compulsive disorder (OCD) is a prevalent and debilitating mental health condition. This literature review examines the latest strategies in managing and treating OCD, with an emphasis on psychotherapy, pharmacological interventions, and neurosurgical options. A comprehensive literature search utilizing PubMed, Google Scholar, ClinicalKey, and Embase databases was conducted. Utilizing chosen keywords, the resulting articles were filtered based on inclusion and exclusion criteria. Included articles were used to discuss current research regarding OCD treatment and management. Findings reveal the efficacy and obstacles of treatments such as cognitive-behavioral therapy, selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and evidence-based neurosurgical methods, offering a broad perspective on OCD management. We discuss the limitations of these established treatments and examine the innovative response of neurosurgery in treating patients with OCD. This review highlights the importance of individualized treatment plans and areas for future research.
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Affiliation(s)
- Kawther N Elsouri
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Samantha E Heiser
- Osteopathic Medicine, William Carey University College of Osteopathic Medicine, Hattiesburg, USA
- Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, USA
| | - Dominick Cabrera
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Sami Alqurneh
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Jaime Hawat
- Allopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, USA
| | - Michelle L Demory
- Immunology, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, USA
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Chang JG, Kim SJ, Kim CH. Neuroablative Intervention for Refractory Obsessive-Compulsive Disorder. Psychiatry Investig 2023; 20:997-1006. [PMID: 37997327 PMCID: PMC10678146 DOI: 10.30773/pi.2023.0214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/19/2023] [Accepted: 08/29/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVE This review aims to investigate the progression of neuroablation, along with documented clinical efficacy and safety, in the management of treatment-resistant obsessive-compulsive disorder (OCD). METHODS We searched and compiled clinical research results of neuroablation therapy reported to date. We extracted outcomes related to clinical efficacy, side effects, and surgical complications. Additionally, we summarized key claims and findings. RESULTS Neuroablative intervention is a potential treatment approach for refractory OCD. Recent advancements, such as real-time magnetic resonance monitoring and minimally invasive techniques employing ultrasound and laser, offer distinct advantages in terms of safety and comparative efficacy when compared to conventional methods. However, the absence of randomized controlled trials and long-term outcome data underscores the need for cautious consideration when selecting neuroablation. CONCLUSION Neuroablative intervention shows promise for refractory OCD, but vigilant consideration is essential in both patient selection and surgical method choices due to the potential for rare yet serious complications.
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Affiliation(s)
- Jhin Goo Chang
- Department of Psychiatry, Myongji Hospital, Hanyang University College of Medicine, Goyang, Republic of Korea
| | - Se Joo Kim
- Department of Psychiatry, Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chan-Hyung Kim
- Department of Psychiatry, Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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Fanty L, Yu J, Chen N, Fletcher D, Hey G, Okun M, Wong J. The current state, challenges, and future directions of deep brain stimulation for obsessive compulsive disorder. Expert Rev Med Devices 2023; 20:829-842. [PMID: 37642374 DOI: 10.1080/17434440.2023.2252732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/27/2023] [Accepted: 08/24/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Obsessive-compulsive disorder (OCD) is clinically and pathologically heterogenous, with symptoms often refractory to first-line treatments. Deep brain stimulation (DBS) for the treatment of refractory OCD provides an opportunity to adjust and individualize neuromodulation targeting aberrant circuitry underlying OCD. The tailoring of DBS therapy may allow precision in symptom control based on patient-specific pathology. Progress has been made in understanding the potential targets for DBS intervention; however, a consensus on an optimal target has not been agreed upon. AREAS COVERED A literature review of DBS for OCD was performed by querying the PubMed database. The following topics were covered: the evolution of DBS targeting in OCD, the concept of an underlying unified connectomic network, current DBS targets, challenges facing the field, and future directions which could advance personalized DBS in this challenging population. EXPERT OPINION To continue the increasing efficacy of DBS for OCD, we must further explore the optimal DBS response across clinical profiles and neuropsychiatric domains of OCD as well as how interventions targeting multiple points in an aberrant circuit, multiple aberrant circuits, or a connectivity hub impact clinical response. Additionally, biomarkers would be invaluable in programming adjustments and creating a closed-loop paradigm to address symptom fluctuation in daily life.
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Affiliation(s)
- Lauren Fanty
- Norman Fixel Institute for Neurological Diseases, University of Florida Health, Gainesville, FL, USA
| | - Jun Yu
- Norman Fixel Institute for Neurological Diseases, University of Florida Health, Gainesville, FL, USA
| | - Nita Chen
- Norman Fixel Institute for Neurological Diseases, University of Florida Health, Gainesville, FL, USA
| | - Drew Fletcher
- College of Medicine, University of Florida Health Science Center, Gainesville, FL, USA
| | - Grace Hey
- Norman Fixel Institute for Neurological Diseases, University of Florida Health, Gainesville, FL, USA
- College of Medicine, University of Florida Health Science Center, Gainesville, FL, USA
| | - Michael Okun
- Norman Fixel Institute for Neurological Diseases, University of Florida Health, Gainesville, FL, USA
| | - Josh Wong
- Norman Fixel Institute for Neurological Diseases, University of Florida Health, Gainesville, FL, USA
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Asher R, Hyun I, Head M, Cosgrove GR, Silbersweig D. Neuroethical implications of focused ultrasound for neuropsychiatric illness. Brain Stimul 2023; 16:806-814. [PMID: 37150289 DOI: 10.1016/j.brs.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 04/17/2023] [Accepted: 04/23/2023] [Indexed: 05/09/2023] Open
Abstract
BACKGROUND MR-guided focused ultrasound is a promising intervention for treatment-resistant mental illness, and merits contextualized ethical exploration in relation to more extensive ethical literature regarding other psychosurgical and neuromodulation treatment options for this patient population. To our knowledge, this topic has not yet been explored in the published literature. OBJECTIVE The purpose of this paper is to review and discuss in detail the neuroethical implications of MR-guided focused ultrasound for neuropsychiatric illness as an emerging treatment modality. METHODS Due to the lack of published literature on the topic, the approach involved a detailed survey and review of technical and medical literature relevant to focused ultrasound and established ethical issues related to alternative treatment options for patients with treatment-resistant, severe and persistent mental illness. The manuscript is structured according to thematic and topical findings. RESULTS This technology has potential benefits for patients suffering with severe mental illness, compared with established alternatives. The balance of technical, neuroscientific and clinical considerations should inform ethical deliberations. The nascent literature base, nuances in legal classification and permissibility depending upon jurisdiction, influences of past ethical issues associated with alternative treatments, tone and framing in media articles, and complexity of clinical trials all influence ethical assessment and evaluations of multiple stakeholders. Recommendations for future research are provided based on these factors. CONCLUSION Salient ethical inquiry should be further explored by researchers, clinicians, and ethicists in a nuanced manner methodologically, one which is informed by past and present ethical issues related to alternative treatment options, broader psychiatric treatment frameworks, pragmatic implementation challenges, intercultural considerations, and patients' ethical concerns.
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Affiliation(s)
- Rachel Asher
- Brigham and Women's Hospital/Harvard Medical School, 60 Fenwood Rd, Boston, MA, 02115, USA.
| | - Insoo Hyun
- Center for Bioethics at Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA.
| | - Mitchell Head
- Te Kotahi Research Institute/University of Waikato, Gate 4C, 194H Hillcrest Rd, Hillcrest, Hamilton, 3216, Aotearoa, New Zealand.
| | - G Rees Cosgrove
- Brigham and Women's Hospital/Harvard Medical School, 60 Fenwood Rd, Boston, MA, 02115, USA.
| | - David Silbersweig
- Brigham and Women's Hospital/Harvard Medical School, 60 Fenwood Rd, Boston, MA, 02115, USA.
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Shofty B, Gadot R, Provenza N, Storch EA, Goodman WK, Sheth SA. Neurosurgical Approaches for Treatment-Resistant Obsessive-Compulsive Disorder. Psychiatr Clin North Am 2023; 46:121-132. [PMID: 36740348 DOI: 10.1016/j.psc.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Ben Shofty
- Department of Neurosurgery, University of Utah, 175 North Medical Drive East, 5th Floor, Salt Lake City, UT 84132, USA
| | - Ron Gadot
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge Street Suite 9A, Houston, TX 77030, USA
| | - Nicole Provenza
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge Street Suite 9A, Houston, TX 77030, USA
| | - Eric A Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA
| | - Wayne K Goodman
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA
| | - Sameer A Sheth
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge Street Suite 9A, Houston, TX 77030, USA; Department of Psychiatry, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA.
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Kammen A, Cavaleri J, Lam J, Frank AC, Mason X, Choi W, Penn M, Brasfield K, Van Noppen B, Murray SB, Lee DJ. Neuromodulation of OCD: A review of invasive and non-invasive methods. Front Neurol 2022; 13:909264. [PMID: 36016538 PMCID: PMC9397524 DOI: 10.3389/fneur.2022.909264] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/19/2022] [Indexed: 12/27/2022] Open
Abstract
Early research into neural correlates of obsessive compulsive disorder (OCD) has focused on individual components, several network-based models have emerged from more recent data on dysfunction within brain networks, including the the lateral orbitofrontal cortex (lOFC)-ventromedial caudate, limbic, salience, and default mode networks. Moreover, the interplay between multiple brain networks has been increasingly recognized. As the understanding of the neural circuitry underlying the pathophysiology of OCD continues to evolve, so will too our ability to specifically target these networks using invasive and noninvasive methods. This review discusses the rationale for and theory behind neuromodulation in the treatment of OCD.
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Affiliation(s)
- Alexandra Kammen
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Jonathon Cavaleri
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Jordan Lam
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Adam C. Frank
- Department of Psychiatry, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Xenos Mason
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Wooseong Choi
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Marisa Penn
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Kaevon Brasfield
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Barbara Van Noppen
- Department of Psychiatry, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Stuart B. Murray
- Department of Psychiatry, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Darrin Jason Lee
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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Hosseini M, Pierre K, Felisma P, Mampre D, Stein A, Fusco A, Reddy R, Chandra V, Lucke-Wold B. Focused ultrasound: Innovation in use for neurologic conditions. TRAUMA AND EMERGENCY MEDICINE 2022; 1:1-12. [PMID: 36745142 PMCID: PMC9897206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Focused ultrasound has emerged as a key tool for neurologic disorders. In this focused review, we discuss the utility in disrupting the blood brain barrier to maximize treatment. This can facilitate creating direct coagulative lesions and aid in the administration of chemotherapy. Furthermore, it can facilitate neuromodulation when used in pulse sequencing. The current literature regarding brain tumors, essential tremor, and obsessive-compulsive disorder is reviewed. Additionally, concepts and experimental outcomes for neurodegenerative disease such as Alzheimer's is presented. Focused ultrasound as a tool is still in its infancy but the potential for adjuvant and direct therapy is promising. More clinical uses will become apparent in coming decades.
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Affiliation(s)
- Mohammad Hosseini
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Kevin Pierre
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Patrick Felisma
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - David Mampre
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Allison Stein
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Anna Fusco
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Ramya Reddy
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Vyshak Chandra
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
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