Stereotactic MRI-guided laser interstitial thermal therapy for extratemporal lobe epilepsy.

OBJECTIVE: Magnetic resonance imaging (MRI)-guided laser interstitial thermal therapy (MRg-LITT) is an alternative to open epilepsy surgery. We assess safety and effectiveness of MRg-LITT for extratemporal lobe epilepsy (ETLE) in patients who are considered less favorable for open resection. METHODS: We retrospectively reviewed sequential cases of patients with focal ETLE who underwent MRg-LITT between 2012 and 2019. Epileptogenic zones were determined from standard clinical and imaging data ± stereoelectroencephalography (SEEG). Standard stereotactic techniques, MRI thermometry, and a commercial laser thermal therapy system were used for ablations. Anatomic MRI was used to calculate ablation volumes. Clinical outcomes were determined longitudinally. RESULTS: Thirty-five patients with mean epilepsy duration of 21.3 ± 12.2 years underwent MRg-LITT for focal ETLE at a mean age 36.4 ± 12.7 years. A mean 2.59 ± 1.45 trajectories per patient were used to obtain ablation volumes of 8.8 ± 7.5 cm3 . Mean follow-up was 27.3 ± 19.5 months. Of 32 patients with >12 months of follow-up, 17 (53%) achieved good outcomes (Engel class I + II) of whom 14 (44%) were Engel class I. Subgroup analysis revealed better outcomes for patients with lesional ETLE than for those who were nonlesional, multifocal, or who had failed prior interventions (P = .02). Of 13 patients showing favorable seizure-onset patterns (localized low voltage fast activity or rhythmic spiking on SEEG) prior to ablation, 9 (69%) achieved good outcomes, whereas only 3 of 11 (27%) who show other slower onset patterns achieved good outcomes. Minor adverse events included six patients with transient sensorimotor neurologic deficits and four patients with asymptomatic hemorrhages along the fiber tract. Major adverse events included one patient with a brain abscess that required stereotactic drainage and one patient with persistent hypothalamic obesity. Three deaths-two seizure-associated and one suicide-were unrelated to surgical procedures. SIGNIFICANCE: MRI-guided laser interstitial thermal therapy (or MRg-LITT) was well-tolerated and yielded good outcomes in a heterogeneous group of ETLE patients. Lesional epilepsy and favorable seizure-onset patterns on SEEG predicted higher likelihoods of success.

Tractography Study of Deep Brain Stimulation of the Anterior Cingulate Cortex in Chronic Pain: Key to Improve the Targeting.

BACKGROUND: Deep brain stimulation (DBS) of the anterior cingulate cortex (ACC) is a new treatment for alleviating intractable neuropathic pain. However, it fails to help some patients. The large size of the ACC and the intersubject variability make it difficult to determine the optimal site to position DBS electrodes. The aim of this work was therefore to compare the ACC connectivity of patients with successful versus unsuccessful DBS outcomes to help guide future electrode placement. METHODS: Diffusion magnetic resonance imaging (dMRI) and probabilistic tractography were performed preoperatively in 8 chronic pain patients (age 53.4 ± 6.1 years, 2 females) with ACC DBS, of whom 6 had successful (SO) and 2 unsuccessful outcomes (UOs) during a period of trialing. RESULTS: The number of patients was too small to demonstrate any statistically significant differences. Nevertheless, we observed differences between patients with successful and unsuccessful outcomes in the fiber tract projections emanating from the volume of activated tissue around the electrodes. A strong connectivity to the precuneus area seems to predict unsuccessful outcomes in our patients (UO: 160n/SO: 27n), with (n), the number of streamlines per nonzero voxel. On the other hand, connectivity to the thalamus and brainstem through the medial forebrain bundle (MFB) was only observed in SO patients. CONCLUSIONS: These findings could help improve presurgical planning by optimizing electrode placement, to selectively target the tracts that help to relieve patients' pain and to avoid those leading to unwanted effects.

Intracranial ablative procedures for the treatment of chronic pain.

Three main techniques delineate a possible role for intracranial ablative procedures in patients with chronic pain. Recent studies demonstrate a continued need for clinical investigation into central mechanisms of neuroablation to best define its role in the care of patients with otherwise intractable and severe pain syndromes. Cingulotomy can result in long-term pain relief. Although it can be associated with subtle impairments of attention, there is little risk to other cognitive domains.

Cingulate epileptogenesis in hypothalamic hamartoma.

Hypothalamic hamartoma (HH) is a relatively rare cause of epilepsy, mainly affecting children. Nearly all patients develop gelastic seizures, often followed by other focal seizure types. Our case illustrates the mechanisms of epileptogenesis in HH. The patient developed gelastic attacks as a baby, and secondarily generalized seizures and drop attacks at 9 years of age. Magnetic resonance imaging (MRI) confirmed the presence of a HH. Presurgical assessment with intracranial electroencephalography (EEG) monitoring recorded gelastic seizures with generalized epileptiform activity. Functional stimulation of the hamartoma provoked gelastic attacks. Single pulse electrical stimulation (SPES) was used to identify epileptogenic cortex. SPES of the left cingular cortex provoked generalized responses similar to the spontaneous generalized discharges. Our results suggest that long-standing history of epilepsy in patients with HH may be related to additional sources of epileptogenic activity. Electrical stimulation performed in this patient provided additional data to favor the hypothesis of secondarily epileptogenesis in the cingulate gyrus independently from the primary origin in the HH.

Cingulate gyrus epilepsy: clinical and behavioral aspects, with surgical outcomes.

BACKGROUND: Cingulate gyrus epilepsy is controversial because it may overlap with other frontal lobe epilepsy syndromes. Reported cases are rare in the pre-magnetic resonance imaging literature but are more common thereafter. Information about peri-ictal and ictal behaviors is scarce. OBJECTIVES: To characterize epilepsy originating from the cingulate gyrus and to report surgical outcomes. DESIGN: Case studies. SETTING: Academic research. PATIENTS: We report 3 surgically treated cases of cingulate gyrus epilepsy, with seizure-free or almost seizure-free outcomes. The cases were identified from a database of 4201 consecutive epilepsy monitoring unit admissions since October 1998 through September 2008. All 3 cases involved cingulate lesions. MAIN OUTCOME MEASURES: Neuroimaging, video electroencephalographic, pathologic, and surgical outcome data were reviewed. RESULTS: All 3 patients had lesional left anterocingulate seizures confirmed by magnetic resonance imaging and experienced cessation of seizures after lesionectomy. Two patients had auras (fear and laughter) previously associated with cingulate gyrus epilepsy. All patients had clinical features consistent with frontal lobe epilepsy, including hyperkinetic behavior and ictal vocalization. Two patients had behavioral changes with aggression, personality disorder, and poor judgment; some behavioral episodes lasted for days and were socially devastating. One patient, a commercial pilot, showed behavior as a passenger that resulted in a diversionary landing. The other patient demonstrated behavior that led to his arrest, and he was almost arrested again in the hospital for threatening security officers. Aberrant behaviors in all 3 patients completely resolved after lesionectomy. CONCLUSIONS: Lesional cingulate gyrus epilepsy is uncommon. Our 3 confirmed cases included 2 patients with unique and severe behavioral changes that resolved with lesionectomy.

Ablative procedures for chronic pain.

The advent of neuroaugmentative techniques has reduced the application of neuroablative procedures, especially as regards pain of functional origin. Although intracranial ablative procedures are now rarely performed, spinal ablative procedures, such as anterolateral cordotomies or midline myelotomies, remain important in the management of cancer pain. These procedures produce immediate and satisfactory pain relief with acceptable complication rates. An important future trend will be the application of radiosurgery guided by functional imaging (eg,fMRI, PET) to place such intracranial lesions as cingulotomies or medial thalamotomies.

Psychosurgery for self-injurious behavior in Tourette's disorder.

One of the most serious and difficult-to-treat conditions in child and adolescent psychiatry is self-injurious behavior (SIB). SIB can be associated with a number of psychiatric disorders, including mental retardation, schizophrenia, borderline personality disorder, pervasive developmental disorders, stereotypic movement disorder, and Tourette's Disorder. A variety of neurosurgical procedures have been used to treat both intractable SIB and severe Tourette's Disorder. Understandably, there are few reports concerning psychosurgery in children and adolescents for any condition or disorder. This report describes the use of cingulotomy and subsequent limbic leucotomy in an adolescent boy with Tourette's Disorder for SIB. His repetitive and medically serious SIB and failure of all other treatments prompted this intervention after careful, comprehensive review and discussion. Following the second surgery, the severity and frequency of his SIB were reduced.

[Modern day psychosurgery: a new approach to neurosurgery in psychiatric disease]. / La moderna psicocirugía: un nuevo enfoque de la neurocirugía en la enfermedad psiquiátrica.

AIMS: To obtain an up to date review of the different possible surgical approaches in the management of certain psychiatric disorders that are refractory to conservative treatment (pharmacotherapy, psychotherapy, electroconvulsive therapy). METHOD: In order to conduct this research we reviewed the work published by centres with the most experience in this type of surgery, mainly in North America and Europe, since its beginnings in the 1930s, with the controversy concerning prefrontal leucotomy, until the appearance of modern stereotactic techniques. We analyse the anatomophysiological bases, their main clinical indications, the surgical techniques used and their results, as well as perspectives for the future of this neurosurgical treatment. CONCLUSIONS: The most noteworthy progress in psychosurgery in recent years has been the combination of a more rigorous selection of patients and the higher degree of specificity with which treatment is performed on the brain structures involved in psychiatric disease. The most widely employed psychosurgical procedures at present are cingulotomy, anterior capsulotomy, subcaudate tractotomy, limbic leucotomy and postero medial hypothalamotomy, with favourable responses in about 35 70% of cases. The psychiatric diagnoses where the best results are to be found are obsessive compulsive disorder, chronic anxiety states and major depression. Current progress in neuroimaging techniques, increased neurophysiological knowledge and the revolutionary neuromodulation techniques, especially deep brain stimulation, offer an even more promising future for psychiatric neurosurgery.

Deficits in visual cognition and attention following bilateral anterior cingulotomy.

A series of eight tests of visual cognitive abilities was used to examine pre- to post-operative performance changes in a patient receiving bilateral anterior cingulotomy. Compared with a set of eight matched control participants, post-operatively, the patient exhibited deficits in (a) the ability to sequence novel cognitive operations required to generate multipart images or rotate perceptual stimuli; (b) the ability to search for, select, and compare images of objects when the instructions did not specify precisely which objects should be visualized; and, (c) the ability to select a controlled and unpracticed response over an automatic one. Other imagery and cognitive tasks were not affected. Results are consistent with the hypothesis that anterior cingulate cortex is a component of an executive control system. One of the anterior cingulate's roles may be to monitor on-line processing and signal the motivational significance of current actions or cognitions.

Psychosurgery.

The author describes the three commonly practiced surgical methods in the treatment of mental illness, i.e., cingulotomy, anterior capsulotomy, and posteromedial hypothalamotomy.

Volume reduction in the caudate nucleus following stereotactic placement of lesions in the anterior cingulate cortex in humans: a morphometric magnetic resonance imaging study.

OBJECT: The goal of this study was to test hypotheses regarding changes in volume in subcortical structures following anterior cingulotomy. METHODS: Morphometric magnetic resonance (MR) imaging methods were used to assess volume reductions in subcortical regions following anterior cingulate lesioning in nine patients. Magnetic resonance imaging data obtained before and 9 +/- 6 months following anterior cingulotomy were subjected to segmentation and subcortical parcellation. Significant volume reductions were predicted and found bilaterally within the caudate nucleus, but not in the amygdala, thalamus, lenticular nuclei, or hippocampus. Subcortical parcellation revealed that the volume reduction in the caudate nucleus was principally referrable to the body, rather than the head. Furthermore, the magnitude of volume reduction in the caudate body was significantly correlated with total lesion volume. CONCLUSIONS: Taken together, these findings implicate significant connectivity between a region of anterior cingulate cortex (ACC) lesioned during cingulotomy and the caudate body. This unique data set complements published findings in nonhuman primates, and advances our knowledge regarding patterns of cortical-subcortical connectivity involving the ACC in humans. Moreover, these findings indicate changes distant from the site of anterior cingulotomy lesions that may play a role in the clinical response to this neurosurgical procedure.

[Memory disorders and deep structures of the brain]. / Narusheniia pamiati i glubinnye struktury golovnogo mozga.

Clinical and neuropsychologic examination of 141 patients with arteriovenous malformations (AVM) was examined according to A.R.Lurye method. AVM of caudate nucleus were found in 27 patients, of thalamus in 34 ones, of hippocampal formation in 39 individuals, of gyrus cinguli in 41 cases. 102 patients were operated. Both total impairment of the memory and its peculiarities in damages of different structures were found in patients with AVM. A common peculiarity was the development of the amnestic symptom complex similar to Korsakov's syndrome. Such disorders occur only in combined damages of the deep structures (before the operation in patients with ventricular hemorrhages), excluding patients with AVM of caudate nucleus. The memory impairments were modal-nonspecific; in all the patients an audio-speech delayed memory was altered and reproduction in visual memory. Peculiarities of memory impairments in damage of separate structures were functional asymmetry of the defects of memory in AVM of caudate nucleus and thalamus (if present) as well as permanent inclusions and contaminations in AVM of gyrus cinguli. During process of evolution separate sides of memory function might be doubled in different structures, and each of them might have its own contribution to memory function.

Brain targets for pain control.

A variety of brain sites have been targeted for surgical treatment of intractable pain. Both ablative and chronic stimulation procedures have been reported to attenuate such pain. These targets include the thalamus and its projections, the periventricular gray, the cingulate cortex and the motor cortex. An overview of these procedures and their efficacy is provided.

The effect of anterior thalamic and cingulate cortex lesions on object-in-place memory in monkeys.

Six Macaque monkeys (Macaca mulatta) were trained in an object-in-place memory task, designed to capture the 'whole scene' nature of episodic memory. In this task the correct, rewarded, response in each scene was to a particular object of a pair, which always occupied a particular position in a unique background which had been generated using randomly chosen colours and shapes. In each session, the monkey learned a new list of these unique scenes. The animals then underwent surgical ablation of either the anterior thalamic nuclei or the cingulate cortex. It was found that the animals with anterior thalamic lesions showed a substantial impairment, whereas the monkeys with cingulate cortex ablations were not significantly impaired at the task. These results confirm the importance of the anterior thalamic nuclei in episodic memory, and suggest that the cingulate gyrus is not a region which is crucial in the type of episodic memory task used in the present experiment.

Novel strategies for treatment-resistant depression.

This article describes a highly selective constellation of the more unique strategies for managing the treatment-resistant patient. In light of the often-devastating toll that treatment-resistant depression takes on an individual's life, it behooves us to continue the search for more effective strategies for those patients that fail more traditional interventions. As each successive move down the treatment algorithm flowchart becomes necessary, the risk/benefit ratio may shift toward less well-substantiated, but still biologically informed, strategies. Although some of the more unusual treatments described in this article represent minimally charted territories, the more promising techniques are deserving of further careful exploration.

Neurosurgical treatment of Tourette's syndrome: a critical review.

Some patients with Tourette's syndrome (TS) remain disabled despite conventional treatment. Recently, neurosurgical procedures have been reported to be potentially effective interventions for such intractable cases. Clinicians are now being asked to make recommendations to patients about these candidate operations. This review explores the reported experience with neurosurgical treatment of TS to assess critically the evidence regarding risks and benefits. Toward that end, the rationale for the various procedures and the relevant neuroanatomy are outlined and recommendations for patient selection and management of future cases are discussed. We reviewed all available published reports on this subject and two unpublished cases, totaling 36 patients. Although a variety of operations have been used to treat TS, there is limited evidence pertaining to the risks or benefits of any surgical procedure. Neurosurgical treatment of TS remains experimental, since there is only anecdotal experience with these operations. Furthermore, there is no compelling evidence that any neurosurgical procedure is superior to all others. If these experimental neurosurgeries are to continue, guidelines should be developed regarding patient and operation selection, and interdisciplinary assessment committees should implement such guidelines at institutions where these operations are performed. Moreover, future cases should be prospectively studied using contemporary technologies to assess lesion placement and size and validated clinical instruments to characterize patients and assess outcome, including adverse effects.

Habituation and sensitization of the orienting response following bilateral anterior cingulotomy.

Skin conductance response (SCR) was measured in an orienting response (OR) and habituation paradigm in 10 post-cingulotomy and age-matched control subjects. While both groups habituated, the cingulotomy patients exhibited a slower habituation rate, and greater variability across trials compared to controls. Habituation abnormalities were not associated with increased sensitization, as neither extended habituation training or dishabituation differentiated the groups. An increased frequency of spontaneous SCR activations occurred post-cingulotomy. The results suggest that the cingulate cortex influences the temporal stability of habituation. These findings are consistent with the subtle attentional dysfunction noted following cingulate damage.

[Stereotaxic cingulotomy in the complex treatment of a schizophrenic patient with obsessive-compulsive disorder, resistant to treatment]. / Stereotaksicheskaia tsingulotomiia v kompleksnom lechenii bol'nogo shizofreniei s terapevticheski rezistentnymi obsessivno-kompul'- sivnymi narusheniiami.

The authors describe a case of continuous conservative treatment of a patient suffering from severe obsessions. At the definite stage of the disease, the patient underwent psychosurgical operation--bilateral anterior stereotaxic cingulotomy . The surgical intervention was necessitated by dramatic and steady deterioration of the patient's condition, loss of work fitness, suggesting official registration of disability; appearance of suicidal intentions. After the operation the patient started his work again in accordance with his specialty; the question about disability registration did not arise any more.

Ethics of psychosurgery.

The ethics of psychosurgery involve questions of moral philosophy and pragmatism in alleviating human suffering. The weighing of scientific data along with philosophical oughts and shoulds is required. The medical literature indicates definite efficacy for some kinds of limbic surgery, mainly cingulotomy and capsulotomy, in some kinds of conditions, namely major depression, pain and anxiety. The relative utility of these procedures given the severity of the illnesses and the safety of the procedures described is significant. Ethical and moral conflicts over altruism, autonomy and suffering require recognition before their due considerations (Kleinig 1985). The following recommendations emerge from these considerations: 1. No consideration of ethics in psychosurgery is complete without consideration of both the scientific data and moral conflicts. 2. The considerable efficacy and safety of cingulotomy and capsulotomy must be acknowledged. 3. Indications and contraindications do exist for selecting patients. Major psychiatric Axis I diagnoses of depression and anxiety are the indications. Personality disorders are not indications. 4. Peer review, unfettered consent and knowledge of the psychodynamics of severe illness are three ingredients necessary for wise decisions about performing limbic surgery. 5. The liberal advocation of autonomy without responsibility is an amoral, not liberating, point of view. 6. Politics should be denounced as the most serious ethical problem in medical decision making. Political intrusion into the scientific matters and the doctor-patient relationship has created ethical problems with psychosurgery and continues to do so today.

Psychosurgery today.

A review on indications, target points and results of stereotactic operations for treatment of psychiatric diseases is given, based on personal experiences and reports in the literature. As a conclusion the author suggests that the anatomical target should be chosen selectively. There is strong evidence that different approaches lead to different results. Cingulotomy is effective for chronic pain with addiction and depression, anterior capsulotomy for obsessive-compulsive and anxiety neurosis, innominotomy for chronic and recurrent depression, and postero-medial hypothalamotomy for restless, aggressive and destructive behaviour. Therefore, the target should be selected according to the individual symptoms of the patient. The results of operation are usually good and most patients can return to a normal life. The side-effects are infrequent and seldom serious. Modern psychosurgery does not modify the personality of the patient. On the contrary it often relieves it from disturbing symptoms of illness.