Cingulotomy for intractable obsessive-compulsive disorder. Prospective long-term follow-up of 18 patients.

BACKGROUND: The purpose of this study was to assess prospectively long-term change in obsessive-compulsive disorder (OCD) symptoms in patients with an OCD diagnosis that was confirmed by structured interview and with documented unsuccessful trials of multiple medications and attempts at behavior therapy. METHODS: We conducted an unblinded preoperative and follow-up assessment of comorbid diagnosis; OCD, depressive, and anxiety symptoms; and functional status in 18 patients who underwent cingulotomy. RESULTS: At a mean follow-up of 26.8 months, five patients (28%) met conservative criteria for treatment responders, and three others (17%) were partial responders. The group improved significantly in mean functional status, and few serious adverse events were found. Improvement in OCD symptoms was strongly correlated with improvement in depressive and anxiety symptoms. CONCLUSIONS: The rate of clinical improvement was consistent with a previous retrospective study in the same setting, indicating that 25% to 30% of the patients who previously were unresponsive to medication and behavioral treatments are significantly improved after cingulotomy. Cingulotomy remains a last resort treatment for severely incapacitated patients who have not responded to all other state-of-the-art pharmacological and behavioral treatments for OCD and is not to be taken lightly.

Treatment of psychiatric illness by stereotactic cingulotomy.

The treatment of 198 psychiatrically disabled patients with stereotactic cingulotomy was evaluated prospectively for a mean follow-up of 8.6 years. Patients with major affective disorders and anxiety disorders fared the best, with a return to normal functioning in the majority. Patients with obsessive-compulsive disorders, schizophrenia, and personality disorders improved less predictably, with an uneven improvement in functioning that required active ongoing psychiatric treatment. Low mortality and morbidity, a reduction of violent behavior, a possible reduction of suicidal risk, and a lessening of the intractable suffering of chronic psychiatric illness all indicate that cingulotomy can be an effective, safe treatment for patients with affective disorders that are unresponsive to all other forms of therapy.

Magnetic resonance image-guided stereotactic cingulotomy for intractable psychiatric disease.

We describe the modern operative technique of magnetic resonance (MR) image-guided stereotactic cingulotomy and discuss the indications, results, and complications of this procedure. A retrospective analysis of psychiatric outcome was performed for 34 patients with intractable major affective disorder and/or obsessive-compulsive disorder who underwent MR image-guided stereotactic cingulotomy since 1991. Fourteen patients underwent multiple cingulotomies (50 total procedures). Overall, 38% of the patients were classified as responders, 23% as possible responders, and 38% as nonresponders. Of the patients who did not respond to initial cingulotomies and who underwent multiple cingulotomies, 36% became responders, 36% possible responders, and 28% nonresponders. There were no deaths or long-term side effects related to the procedure. The therapeutic results of MR image-guided stereotactic cingulotomy are similar to the results of earlier methods of cingulotomy, and the use of MR imaging offers substantial technical advantages. This procedure also compares favorably with other neurosurgical procedures performed for intractable psychiatric disease with a low rate of undesired side effects. Cingulotomy is safe and well tolerated, with over one-third of the patients demonstrating significant improvement; however, prospective long-term follow-up studies are needed to further define the role of surgery in treating intractable psychiatric disease.

Historical overview of psychosurgery and its problematic.

In 1936, Egas Moniz published his first paper on frontal leucotomy for psychiatric illness. The initial enthusiasm for this innovative treatment of intractable psychiatric disorders and chronic pain was soon tempered by reports of undesirable side-effects, and neurosurgeons began a search for modifications of leucotomy which would increase safety without reducing efficacy. As a result of these clinical investigations, the original imprecise, radical frontal leucotomy has been superseded by precise, small stereotactically placed lesions in the limbic system and the descriptive phase "limbic system surgery" is replacing the out-moded word "psychosurgery". This presentation will document some of the more important contributions to a currently under-utilized, often criticized approach to the treatment of suffering individuals chronically disabled by psychiatric illness and pain.

Computed tomographic analysis of bilateral cingulotomy for intractable mood disturbance and chronic pain.

Forty-two patients out of 300 who had undergone bilateral stereotactic cingulotomies were studied by means of computerized tomography (CT). The appearance showed bilateral encephalomalacia, measuring on the average 5 X 7 mm2, located in the cingulate gyrus. These induced lesions had attenuation values similar to cerebrospinal fluid and did not enhance with contrast. CT is a useful technique for initial evaluation, management, and follow up of these patients.

Potentiometric determination of ionized and total calcium in blood plasma of Holstein and Jersey cows.

The effects of stage of lactation and breed on total and ionized calcium in blood plasma were determined for eight Holstein and eight Jersey cows fed a diet containing .25% Ca during the dry period and fed a diet with .50% Ca after calving. Blood samples were obtained by jugular venipuncture at 2-wk intervals from 4 wk before calving through wk 10 of lactation. Total and ionized Ca contents of fresh plasma were determined potentiometrically with an ion-specific electrode. Total Ca in plasma also was determined by atomic absorption spectrophotometry. Average concentrations determined by atomic absorption were approximately .7 mg/dl higher than those for the ion-specific electrode. Plasma total and ionized Ca were lower in both breeds at calving than any other time during the sampling period. Jersey cows had lower total Ca (7.47 mg/dl) and ionized Ca (4.25 mg/dl) than Holsteins (8.10 and 4.66 mg/dl) on day of calving. Ionized Ca as a percentage of total calcium increased from 55 to 57% at parturition and then decreased slowly to 53% at peak lactation. Changes in percentage of ionized Ca may indicate the contribution of bone resorption relative to dietary Ca in meeting the Ca requirement for lactation.

Computed tomography in cerebral abscess.

Computed tomography (CT) scans of 9 surgically proved cases of cerebral abscess were reviewed. The CT characteristics were studied, as were the postoperative scans. Also assessed were the contributions to the diagnosis of the clinical features, plain radiographic examinations, radionuclide imaging, and angiography. The accuracy and information content of CT scans of cerebral abscesses should lead to a significant reduction in morbidity and mortality.

Neurosurgical treatment of severe obsessive-compulsive disorder associated with Tourette's syndrome.

We describe two patients with Gilles de la Tourette's syndrome (TS) and disabling obsessive-compulsive and ritualistic behaviors who underwent bilateral radiofrequency anterior cingulotomy. Both achieved a limited but sustained improvement in behavioral symptoms and overall functional abilities. Our observations indicate involvement of limbic structures in this disorder. The procedure should be considered for patients with TS complicated by resistant obsessive-compulsive disorder.

Can the psro's be cost effective? A study of the effect of the Commonwealth Health Agencies monitoring program on the length of stay of Medicaid patients in Massachusetts.

To analyze the effect of the Commonwealth Health Agencies Monitoring Program on the length of stay of a sample of Massachusetts Medicaid patients, we compared their experience with that of non-Medicaid patients. We found a consistently decreasing trend in the length of stay of Medicaid patients during the 2 1/2-year period studied. The average length of stay of Medicaid patients decreased by 11.9 per cent relative to the norm, whereas the non-Medicaid length of stay decreased by only 6.6 per cent. We infer that the Program may be credited within the 5.3 per cent differential decrease. The consistency and reliability of the data suggest that similar results may be extrapolated to the hospitals not sampled. We conclude that Professional Standards Review Organizations, of which this program was a precursor, can be cost effective, given an expanded review mandate and the application of suibable evaluative processes.