Bilateral Anterior Capsulotomy for Treatment-Resistant Obsessive-Compulsive Disorder.

INTRODUCTION: Ablative surgery is an intervention of last resort for treatment-resistant obsessive-compulsive disorder (TROCD). Our center has been using bilateral anterior capsulotomy (BAC) for the past 20 years for patients eligible for limbic surgery. This report details our experience with BAC for TROCD. METHOD: Five patients with OCD met eligibility criteria for BAC. Entry protocols were complex and took around 6 months to complete. Stereotactic radiofrequency was used to produce the capsulotomies. Lesion length varied between 5.7 and 16.9 mm in the coronal plane. Patients were followed between 4 and 20 years. RESULTS: All 5 patients (100%) were responders as defined by the widely accepted criteria of a reduction of ≥35% in Yale-Brown Obsessive Compulsive Scale (YBOCS) score at 18-month follow-up. Four patients remained responders at the 48 months. One patient was lost to follow-up. Responder status when viewed from the perspective of the YBOCS was sustained over the 4- to 20-year follow-up with one relapse 19 years postsurgery when medications were discontinued. Real-world psychiatric outcomes were different as other vulnerabilities surfaced illustrating the multifactorial determinants of mental health. No patient had any significant long-term neurocognitive or physical side effects. CONCLUSION: BAC should remain an option of last resort for patients with severe OCD who remain unresponsive to all other interventions.

Exploring arterial anatomy of the internal capsule: an analysis of the deep vascular structures and related white matter pathways.

BACKGROUND AND OBJECTIVES: The internal capsule is supplied by perforators originating from the internal carotid artery, middle cerebral artery, anterior choroidal artery and anterior cerebral artery. The aim of this study is to examine the vascular anatomy of the internal capsule, along with its related white matter anatomy, in order to prevent potential risks and complications during surgical interventions. METHODS: Twenty injected hemispheres prepared according to the Klingler method were dissected. Dissections were photographed at each stage. The findings obtained from the dissections were illustrated to make them more understandable. Additionally, the origins of the arteries involved in the vascularization of the internal capsule, their distances to bifurcations, and variations in supplying territories have been thoroughly examined. RESULTS: The insular cortex and the branches of the middle cerebral artery on the insula and operculum were observed. Following decortication of the insular cortex, the extreme capsule, claustrum, external capsule, putamen and globus pallidus structures were exposed. The internal capsule is shown together with the lenticulostriate arteries running on the anterior, genu and posterior limbs. Perforators supplying the internal capsule originated from the middle cerebral artery, anterior cerebral artery, internal carotid artery and anterior choroidal artery. The internal capsule's vascular supply varied, with the medial lenticulostriate arteries (MLA) and lateral lenticulostriate arteries (LLA) being the primary arteries. The anterior limb was most often supplied by the MLA, while the LLA and anterior choroidal artery dominated the genu and posterior limb. The recurrent artery of Heubner originated mostly from the A2 segment. The distance from the ICA bifurcation to the origin of the first LLA on M1 is 9.55 ± 2.32 mm, and to the first MLA on A1 is 5.35 ± 1.84 mm. MLA branching from A1 and proximal A2 ranged from 5 to 9, while LLA originating from the MCA ranged from 7 to 12. CONCLUSION: This study provides comprehensive understanding of the arterial supply to the internal capsule by combining white matter dissection. The insights gained from this study can help surgeons plan and execute procedures including oncological, psychosurgical, and vascular more accurately and safely. The illustrations derived from the dissections serve as valuable educational material for young neurosurgeons and other medical professionals.

Structural connectivity modifications following deep brain stimulation of the subcallosal cingulate and nucleus accumbens in severe anorexia nervosa.

PURPOSE: Anorexia nervosa (AN) is a mental health disorder characterized by significant weight loss and associated medical and psychological comorbidities. Conventional treatments for severe AN have shown limited effectiveness, leading to the exploration of novel interventional strategies, including deep brain stimulation (DBS). However, the neural mechanisms driving DBS interventions, particularly in psychiatric conditions, remain uncertain. This study aims to address this knowledge gap by examining changes in structural connectivity in patients with severe AN before and after DBS. METHODS: Sixteen participants, including eight patients with AN and eight controls, underwent baseline T1-weigthed and diffusion tensor imaging (DTI) acquisitions. Patients received DBS targeting either the subcallosal cingulate (DBS-SCC, N = 4) or the nucleus accumbens (DBS-NAcc, N = 4) based on psychiatric comorbidities and AN subtype. Post-DBS neuroimaging evaluation was conducted in four patients. Data analyses were performed to compare structural connectivity between patients and controls and to assess connectivity changes after DBS intervention. RESULTS: Baseline findings revealed that structural connectivity is significantly reduced in patients with AN compared to controls, mainly regarding callosal and subcallosal white matter (WM) tracts. Furthermore, pre- vs. post-DBS analyses in AN identified a specific increase after the intervention in two WM tracts: the anterior thalamic radiation and the superior longitudinal fasciculus-parietal bundle. CONCLUSIONS: This study supports that structural connectivity is highly compromised in severe AN. Moreover, this investigation preliminarily reveals that after DBS of the SCC and NAcc in severe AN, there are WM modifications. These microstructural plasticity adaptations may signify a mechanistic underpinning of DBS in this psychiatric disorder.

Neurosurgery for psychiatric disorders: reviewing the past and charting the future.

Surgical techniques targeting behavioral disorders date back thousands of years. In this review, the authors discuss the history of neurosurgery for psychiatric disorders, starting with trephination in the Stone Age, progressing through the fraught practice of prefrontal lobotomy, and ending with modern neurosurgical techniques for treating psychiatric conditions, including ablative procedures, conventional deep brain stimulation, and closed-loop neurostimulation. Despite a tumultuous past, psychiatric neurosurgery is on the cusp of becoming a transformative therapy for patients with psychiatric dysfunction, with an ever-increasing evidence base suggesting reproducible and ethical therapeutic benefit.

Microsurgical anatomy of the anterior cerebral artery and the arterial supply of the cingulate gyrus.

PURPOSE: The cingulate gyrus is a potential surgical area to treat tumours, psychiatric diseases, intractable pain and vascular malformations. The aim of the study was to define the topographic anatomy and arterial supply of the cingulate gyrus located on the medial surface of the cerebral hemisphere. METHODS: We studied thirty-six hemispheres, each hemisected in the midsagittal plane. The vertical thickness of the cingulate gyrus was measured at the anterior commissure (AC), posterior commissure (PC), and genu levels of the corpus callosum. The branches of the anterior and posterior cerebral arteries supplying each zone were noted separately. The arterial pathways were transformed to digital data in AutoCAD to identify the condensation and reduction areas. RESULTS: The mean AC-PC distance was 27.17 ± 1.63 mm. The thinnest region was the genu level of the corpus callosum (10.29 mm). The superior internal parietal artery (SIPA), inferior internal parietal artery (IIPA) and pericallosal artery (PrCA) supplied all zones of the cingulate gyrus. The anterior zone received the greatest supply. The arterial condensation and reduction areas on both sides of cingulate gyrus and its x, y, and z coordinates specified. CONCLUSIONS: The target cingulotomy (TC) area was determined for anterior cingulotomy. The properties of the TC area are that the thinnest region of the cingulate gyrus is supplied relatively less than other areas and is close to the anterior cingulotomy areas in the literature. The arterial reduction area (ARA) was found to be suitable for corpus callosotomy in terms of avoiding haemorrhage.

Commentary on the Continued Investigational Status of DBS for Psychiatric Indications.

Behavioral disorders exact a tragic toll on patients, families, and society. Consequently, the search for better treatments is a public health priority. Recent research promises to lead to advances in psychiatric treatment that may include implantation of deep brain stimulation (DBS) devices. In this commentary, the authors discuss how promising results from initial pilot studies of DBS in treatment-resistant depression (TRD) were not validated in 2 randomized, controlled, multicenter trials. Reliance on pilot data may have contributed to the selection of primary efficacy endpoints that were not achieved, and to the underestimation of adverse events and device-related complications. Published data on the population prevalence of affective disorders also may have led sponsors to overestimate the number of patients with TRD who were candidates for DBS therapy. Consequently, a more complete discussion of certain aspects of the depression trials may allow a realistic appraisal of the clinical and ethical situation of DBS therapy for TRD in a US regulatory context. A US regulatory perspective also may clarify the clinical research and reimbursement consequences of the Humanitarian Device Exemption (HDE) approval status of DBS for obsessive-compulsive disorder (OCD). Retrospective analyses akin to failure modes and effects analysis in engineering may clarify unexpected results in the DBS depression trials. Recent research suggests that subject selection in future trials may be augmented by advanced neuroimaging methods. For the present, the noncommercial research status of DBS to treat depression and the HDE status for OCD appear likely to remain in place.

Cognitive and quality-of-life related factors of body mass index (BMI) improvement after deep brain stimulation in the subcallosal cingulate and nucleus accumbens in treatment-refractory chronic anorexia nervosa.

BACKGROUND: Up to 20% of the cases of anorexia nervosa (AN) are chronic and treatment-resistant. Recently, the efficacy of deep brain stimulation (DBS) for severe cases of AN has been explored, with studies showing an improvement in body mass index and other psychiatric outcomes. While the effects of DBS on cognitive domains have been studied in patients with other neurological and psychiatric conditions so far, no evidence has been gathered in AN. METHODS: Eight patients with severe, chronic, treatment-resistant AN received DBS either to the nucleus accumbens (NAcc) or subcallosal cingulate (SCC; four subjects on each target). A comprehensive battery of neuropsychological and clinical outcomes was used before and 6-month after surgery. FINDINGS: Although Body Mass Index (BMI) did not normalise, statistically significant improvements in BMI, quality of life, and performance on cognitive flexibility were observed after 6 months of DBS. Changes in BMI were related to a decrease in depressive symptoms and an improvement in memory functioning. INTERPRETATION: These findings, although preliminary, support the use of DBS in AN, pointing to its safety, even for cognitive functioning; improvements of cognitive flexibility are reported. DBS seems to exert changes on cognition and mood that accompany BMI increments. Further studies are needed better to determine the impact of DBS on cognitive functions.

Ethical examination of deep brain stimulation's 'last resort' status.

Deep brain stimulation (DBS) interventions are novel devices being investigated for the management of severe treatment-resistant psychiatric illnesses. These interventions require the invasive implantation of high-frequency neurostimulatory probes intracranially aiming to provide symptom relief in treatment-resistant disorders including obsessive-compulsive disorder and anorexia nervosa. In the scientific literature, these neurostimulatory interventions are commonly described as reversible and to be used as a last resort option for psychiatric patients. However, the 'last resort' status of these interventions is rarely expanded upon. Contrastingly, usages of DBS devices for neurological symptoms (eg, Parkinson's disease, epilepsy or dystonia) have paved the way for established safety and efficacy standards when used earlier in a disease's timeline. As DBS treatments for these neurological diseases progress to have earlier indications, there is a parallel ethical concern that early implementation may one day become prescribed for psychiatric illnesses. The purpose of this article is to build off contemporary understandings of reversible neurostimulatory interventions to examine and provide clarifications on the 'last resort' status of DBS to better address its ethically charged use in psychiatric neurosurgery. To do this, evaluative differences between DBS treatments will be discussed to demonstrate how patient autonomy would be a paramount guiding principle when one day implementing these devices at various points along a psychiatric disease's timeline. In presenting the clarification of 'last resort' status, the ethical tensions of early DBS interventions will be better understood to assist in providing psychiatric patients with more quality of life years in line with their values.

Outcomes of deep brain stimulation surgery for substance use disorder: a systematic review.

Long has the standard of care for substance use disorder (SUD) been pharmacotherapy, psychotherapy, or rehabilitation with varying success. Deep brain stimulation (DBS) may have a beneficial reduction in the addiction-reward pathway. Recent studies have found reduced relapse and improvements in quality of life following DBS stimulation of the nucleus accumbens. We aim to identify positive outcomes and adverse effects to assess the viability of DBS as a treatment of addiction. A PubMed search following PRISMA guidelines was conducted to identify the entirety of reports reporting DBS as a treatment for SUD. Outcomes were extracted from the literature to be summarized, and a review of the quality of publications was also performed. From 2305 publications, 14 studies were found to fit the inclusion criteria published between 2007 and 2019. All studies targeted the nucleus accumbens (NAc) and remission rates at 6 months, 1 year, 2 years, and more than 6 years were 61% (20/33), 53% (17/32), 43% (14/30), and 50% (3/6), respectively. Not all studies detailed the stimulation settings or coordinates. The most common adverse effect across studies was a weight change of at least 2 kg. DBS shows potential as a long-term treatment of SUD in refractory patients. Further studies with controlled double-blind paradigms are needed for evaluation of the efficacy and safety of this treatment. Future studies should also investigate other brain regions for stimulation and optimal device stimulation parameters.

The Proud History of Psychosurgery in the USA.

To understand the development and growth of psychosurgery, the context of psychiatric care in the mid-twentieth-century USA must be considered-for example, overpopulation and understaffing of public institutions, and typical use of psychotherapy, which was generally useless in treating the symptomatology of severe mental illness. Therefore, the introduction of prefrontal lobotomy (and, later, transorbital lobotomy) by Drs. Walter Freeman and James Watts, who modified the technique of leukotomy developed by Nobel Prize laureate Dr. Egas Moniz, was considered revolutionary and quickly gained widespread acceptance by medical community. No other alternative treatment at the time demonstrated comparable efficacy. At its peak, psychosurgery was sometimes applied inappropriately, but records from multiple institutions across the USA demonstrate that these were exceptional cases, whereas, as a rule, selection of surgical candidates was based on very strict criteria, indicating the high professionalism and humanity of medical staff. Although psychosurgery has declined heavily since the 1950s, it is not obsolete and is currently considered a valuable treatment option, realized through various open, stereotactic, or radiosurgical procedures.

Gottlieb Burckhardt (1836-1907): 19th-Century Pioneer of Psychosurgery.

Gottlieb Burckhardt was a 19th-century Swiss psychiatrist who introduced the psychosurgical method known as topectomy as a means to relieve the symptoms of aggression and agitation in individuals diagnosed with mental disease. Specifically, he performed topical excision of part of the cerebral cortex on 6 patients with chronic schizophrenia. Most of these patients became more approachable and easier to manage, but they also showed signs of aphasia or seizures, and 2 died soon after the surgery. Burckhardt's presentation of the results of his surgical procedures to the Berlin Medical Congress in 1890 caused an enormous controversy within the European medical community and resulted in his ostracism from it. He continued practicing, however and dispensing advice in his role as a mental hospital director, though he soon gave up his surgical endeavours. His innovative theory of higher cerebral functions anticipated the lobotomy procedure that was developed nearly half a century later by the neurologist Egas Moniz (1874-1955).

[Rolf Hassler: from leucotomy to stereotaxy]. / Rolf Hassler: von der Leukotomie zur Stereotaxie.

Rolf Hassler is one of the most renowned German specialists in psychiatry, neurology and neuroanatomy. Hassler's career exemplifies medicine as scientific endeavor. Relaying on an expertise in neuroanatomy gained at Oscar and Cecile Vogt's Kaiser Wilhelm Institute, especially regarding the structure of the thalamus, Hassler enabled Freiburg University's neurosurgery clinic the invention of stereotactic "stepped leucotomy" and established thalamotomy internationally in a leading way. While directing the Neuroanatomical/Neurobiological department of the Max Planck Institute for Brain Research from 1959 until 1982, Hassler continued to study the effects of stimulation and targeted subcortical electrocoagulation in the cat brain. The Freiburg trained neurosurgeon Gert Dieckmann helped Hassler to apply the newly gained knowledge for the stereotactic therapy of torticollis, tics and obsessions and compulsions. The use however of thalamotomy also as a surgical therapy for aggressiveness in children, mainly during the late 1960s and early 1970s, is starting to provoke public criticism. Contrary however to the accusation of a medicine shaped by Nazi ideology into a "science without humanity", Hasslers career reveals a problematic intrinsic to medicine: the together of "art of healing and science".

Two Solitudes: Wilder Penfield, Ewen Cameron, and the Search for a Better Lobotomy.

In the 1940s, Wilder Penfield carried out a series of experimental psychosurgeries with the psychiatrist D. Ewen Cameron. This article explores Penfield's brief foray into psychosurgery and uses this episode to re-examine the emergence of his surgical enterprise. Penfield's greatest achievement - the surgical treatment of epilepsy - grew from the same roots as psychosurgery, and the histories of these treatments overlap in surprising ways. Within the contexts of Rockefeller-funded neuropsychiatry and Adolf Meyer's psychobiology, Penfield's frontal lobe operations (including a key operation on his sister) played a crucial role in the development of lobotomy in the 1930s. The combination of ambiguous data and the desire to collaborate with a psychiatrist encouraged Penfield to try to develop a superior operation. However, unlike his collaboration with psychiatrists, Penfield's productive working relationship with psychologists encouraged him to abandon the experimental "gyrectomy" procedure. The story of Penfield's attempt to find a better lobotomy can help us to examine different forms of interdisciplinarity within biomedicine.

Psychosurgery in the History of Stereotactic Functional Neurosurgery.

The paper invites to reappraise the role of psychosurgery for and within the development of functional stereotactic neurosurgery. It highlights the significant and long-lived role of stereotactic neurosurgery in the treatment of severe and chronic mental disorders. Stereotactic neurosurgery developed out of psychosurgery. It was leucotomy for psychiatric disorders and chronic pain that paved the way for stereotactic dorsomedial thalamotomy in these indications and subsequently for stereotactic surgery in epilepsy and movement disorders. Through the 1960s stereotactic psychosurgery continued to progress in silence. Due to the increased applications of stereotactic surgery in psychiatric indications, psychosurgery's renaissance was proclaimed in the early 1970s. At the same time, however, a public fearing mind control started to discredit all functional neurosurgery for mental disorders, including stereotactic procedures. In writing its own history, stereotactic neurosurgery's identity as a neuropsychiatric discipline became subsequently increasingly redefined as principally a sort of "surgical neurology," cut off from its psychiatric origin.

Johann Bernhard Aloys von Gudden: The Unrecognized Role of the Psychiatrist and Neuroanatomist in Modern Stereotactic Neurosurgery.

Bernhard von Gudden was the founder of the famous school of psychiatry and neuroanatomy in Munich, Germany. Beyond his association with the mysterious death of King Ludwig II of Bavaria, not much is known about Bernhard von Gudden's work in neuroanatomy. He pioneered fiber tract mapping by studying the effects of neurodegeneration following brain lesions. His ideas and work lay the foundation for subsequent fiber tract mapping strategies including the latest method using diffusion tensor magnetic resonance. This paper describes and acknowledges his contribution to the field, now collectively known as connectomics, and describes how it has become an essential tool in modern stereotactic neurosurgery.

Against the Current: Wilder Penfield, the Frontal Lobes and Psychosurgery.

Psychosurgery refers to the surgical interruption of the white matter fibres joining the frontal cortex to the remainder of the cortical mantle and to the thalamus, in an attempt to mitigate the manifestations of psychosis. It reached its heyday following World War Two and was abandoned with the introduction of major tranquilisers such as chlorpromazine. Wilder Penfield, unlike most of his contemporaries, had a jaundiced view of psychosurgery. This paper addresses Penfield's early experience with experimental, penetrating brain trauma and with the surgical resection of frontal, epileptogenic lesions, which explain his antagonism towards psychosurgery.

À contre-courant : Wilder Penfield, les lobes frontaux et la psychochirurgie. La psychochirurgie consiste notamment en l'interruption chirurgicale des fibres de la substance blanche reliant le cortex frontal au reste du manteau cortical et au thalamus, et ce, pour tenter d'atténuer les manifestations de la psychose. Cette technique a atteint son apogée à la suite de la Deuxième Guerre mondiale pour être ensuite délaissée avec l'introduction des principaux tranquillisants, par exemple la chlorpromazine. À la différence de la plupart de ses contemporains, Wilder Penfield ne voyait pas d'un très bon œil la psychochirurgie. Cet article entend aborder les premiers travaux expérimentaux de Penfield portant sur les traumatismes cérébraux par pénétration et sur la résection chirurgicale de lésions frontales épileptogènes, ce qui expliquerait son opposition à l'égard de la psychochirurgie.

No going back? Reversibility and why it matters for deep brain stimulation.

Deep brain stimulation (DBS) is frequently described as a 'reversible' medical treatment, and the reversibility of DBS is often cited as an important reason for preferring it to brain lesioning procedures as a last resort treatment modality for patients suffering from treatment-refractory conditions. Despite its widespread acceptance, the claim that DBS is reversible has recently come under attack. Critics have pointed out that data are beginning to suggest that there can be non-stimulation-dependent effects of DBS. Furthermore, we lack long-term data about other potential irreversible effects of neuromodulation. This has considerable normative implications for comparisons of DBS and brain lesioning procedures. Indeed, Devan Stahl and colleagues have recently argued that psychiatric DBS should be subject to the same legal safeguards as other forms of psychosurgery, supporting their position by forcibly criticising the claim that DBS is reversible. In this paper, I respond to these criticisms by first clarifying the descriptive and evaluative elements of the reversibility claim that supporters of DBS might invoke, and the different senses of 'reversibility' that we might employ in discussing the effects of medical procedures. I go on to suggest that it is possible to defend a nuanced version of the reversibility claim. To do so, I explain how DBS has some effects that are stimulation dependent in the short term, and argue that these effects can have significant normative implications for patient well-being and autonomy. I conclude that we should not abandon a nuanced version of the reversibility claim in the DBS debate.

The Origins of Human Functional Stereotaxis: A Reappraisal.

In order to shed light on the first application of human functional stereotactic neurosurgery, whether it was in the realm of movement disorders, as has been claimed repeatedly, or in the realm of psychiatry, a review of the original scholarly literature was conducted. Tracking and scrutinising original publications by Spiegel and Wycis, the pioneers of human stereotactic neurosurgery, it was found that its origin and the very incentive for its development and first clinical use were to avoid the side effects of frontal leucotomy. The first applications of functional stereotactic neurosurgery were in performing dorsomedial thalamotomies in psychiatric patients; it was only later that the stereotactic technique was applied in patients with chronic pain, movement disorders and epilepsy. Spiegel and Wycis' first functional stereotactic operations were for obsessive-compulsive disorder, schizophrenia, and other psychiatric conditions.

Jean Talairach: a cerebral cartographer.

Although French psychiatrist-turned-neurosurgeon Jean Talairach (1911-2007) is perhaps best known for the stereotaxic atlas he produced with Pierre Tournoux and Gábor Szikla, he has left his mark on most aspects of modern stereotactic and functional neurosurgery. In the field of psychosurgery, he expressed critique of the practice of prefrontal lobotomy and subsequently was the first to describe the more selective approach using stereotactic bilateral anterior capsulotomy. Turning his attention to stereotaxy, Talairach spearheaded the team at Hôpital Sainte-Anne in the construction of novel stereotaxic apparatus. Cadaveric investigation using these tools and methods resulted in the first human stereotaxic atlas where the use of the anterior and posterior commissures as intracranial reference points was established. This work revolutionized the approach to cerebral localization as well as leading to the development of numerous novel stereotactic interventions by the Sainte-Anne team, including tumor biopsy, interstitial irradiation, thermal ablation, and endonasal procedures. Together with epileptologist Jean Bancaud, Talairach invented the field of stereo-electroencephalography and developed a robust scientific methodology for the assessment and treatment of epilepsy. In this article the authors review Talairach's career trajectory in its historical context and in view of its impact on modern stereotactic and functional neurosurgery.

Effect of unilateral amygdalotomy and hypothalamotomy in patients with refractory aggressiveness.

BACKGROUND: Neurosurgical treatment, although controversial, is considered a useful resource in the treatment of chronic psychiatric diseases such as refractory aggressiveness. OBJECTIVE: To evaluate the clinical results and side effects of posteromedial hypothalamotomy associated with amygdalotomy in patients with refractory aggressiveness. METHOD: A clinical trial was conducted in patients with chronic aggressiveness and refractory to pharmacological treatment. A central amygdalotomy associated with posteromedial hypothalamotomy was performed using thermo-coagulation by radiofrequency. The degree of aggressiveness was quantified by the Yudofsky's global scale of aggression. Postoperative changes in aggressive behavior continued to be evaluated every 6 months for at least 36 months. RESULTS: A statistically significant change in aggressive behavior was observed during 36 months of follow-up. The collateral effects of the association of both procedures are described, the most frequent being drowsiness and some cases of reduction in sexual behavior. CONCLUSION: Symmetric and simultaneous unilateral lesions of the central nucleus of the amygdala and the posteromedial hypothalamus contralateral to motor dominance give the same clinical effect in the reduction of the pathological aggression that the bilateral lesions.