Brain Lobotomy: A Historical and Moral Dilemma with No Alternative?

BACKGROUND: Pioneered in 1936 by Portuguese neurologist and politician Egas Moniz, lobotomy was a definitive lesional surgery on the brain, which consisted of splitting the white fibers in the frontal lobes. Sixteen years later, the first antipsychotic medication appeared at Sainte-Anne Mental Hospital in Paris, drastically reducing the number of surgical lobotomies in France and worldwide. Lobotomy has been one of the most criticized medical procedures in history, with thousands of patients lobotomized around the world and causing serious consequences to their personalities and intellectual function. METHODS: In the 1940s, the French language was widely used as an alternative language in medical studies, the reason we decided to focus a francophone review on this subject. We conducted the first francophone review of the reported data for the period from 1935 to 1985. Moreover, for a clearer understanding of the background of the time, we also studied the social historical environment. RESULTS: A total of 1340 cases of lobotomized patients were identified through a review of 29 studies. The indications had varied and were not limited to mental illness. Lobotomy was also performed in some rare cases on patients with peptic ulcers or ulcerative colitis to stop gastrointestinal hemorrhage. The lobotomy techniques were numerous, varying from classic lobotomy to the transorbital injection of radioactive iridium 194. CONCLUSION: We have discussed the psychiatric, societal, and media contexts that led to the emergence of lobotomy. Our aim was to highlight this period in the history of medicine and place the medical practice into perspective.

Can anticancer chemotherapy promote the progression of brain metastases?

Brain metastases natural history from one primary tumor type might be accelerated or favored by using certain systemic chemotherapy. A great deal was described in mice and suggested in human with antiangiogenic drugs, but little is known about the metastatic progression generated by the perverse effect of anticancer drugs. A total of 413 patients who underwent treatment for brain metastasis (2013-2016) were included. The identification of all previous anticancer drugs received by patients from primary tumor diagnosis to brain metastases diagnosis was collated. The median value for the time of first appearance of brain metastasis in all patients was 13.1 months (SD 1.77). The values of brain metastasis-free survival (bMFS) for each primary cancer were: 50.9 months (SD 8.8) for breast, 28.5 months (SD 11.4) for digestive, 27.7 months (SD 18.3) for melanoma, 12.3 months (SD 8.3) for kidney, 1.5 months (SD 0.1) for lung and 26.9 months (SD 18.3) for others (p < 0.009). Through Cox multivariate proportional hazard model, we identified that the only independent factors associated with short bMFS were: lung primary tumor [odd ratio (OR) 0.234, CI 95% 0.16-0.42; p < 0.0001] and mitotic spindle inhibitor (taxanes) chemotherapy [OR 0.609, CI 95% 0.50-0.93; p < 0.001]. Contrariwise, breast primary tumor [odd ratio (OR) 2.372, CI 95% 1.29-4.3; p < 0.005] was an independent factor that proved a significantly longer bMFS. We suggest that anticancer drugs, especially taxane and its derivatives, could promote brain metastases, decreasing free survival. Mechanisms are discussed but still need to be determined.

First clinical use of stereotaxy in humans: the key role of x-ray localization discovered by Gaston Contremoulins.

Although attempts to develop stereotactic approaches to intracranial surgery started in the late 19th century with Dittmar, Zernov, and more famously, Horsley and Clarke, widespread use of the technique for human brain surgery started in the second part of the 20th century. Remarkably, a significant similar surgical procedure had already been performed in the late 19th century by Gaston Contremoulins in France and has remained unknown. Contremoulins used the principles of modern stereotaxy in association with radiography for the first time, allowing the successful removal of intracranial bullets in 2 patients. This surgical premiere, greatly acknowledged in the popular French newspaper L'Illustration in 1897, received little scientific or governmental interest at the time, as it emanated from a young self-taught scientist without official medical education. This surgical innovation was only made possible financially by popular crowdfunding and, despite widespread military use during World War I, with 37,780 patients having benefited from this technique for intra- or extracranial foreign bodies, it never attracted academic or neurosurgical consideration. The authors of this paper describe the historical context of stereotactic developments and the personal history of Contremoulins, who worked in the department of experimental physiology of the French Academy of Sciences led by Étienne-Jules Marey in Paris, and later devoted himself to radiography and radioprotection. The authors also give precise information about his original stereotactic tool "the bullet finder" ("le chercheur de projectiles") and its key concepts.

Timeline metastatic progression: in the wake of the « seed and soil ¼ theory.

Little is known about the natural history of cancer and its evolution to metastasis. Paget was the first to postulate the important role played by microenvironment in metastasis progression. Since, the concept of his "seed and soil" theory has been supported and confirmed. Understanding the chronology and natural course that underlie metastasis is mandatory to deepen this concept and to progress in the development of novel therapeutic strategies. A total of 413 patients who underwent treatment for brain metastasis (2013-2016) were included. The identification of previous and newly diagnosed metastasis was made during the clinical and imaging follow-up. We identified 910 metastases in our series. The 2-, 5-, and 10-year survival estimates were 80% (SD 2), 59.1% (3), and 36% (4), respectively. The median time for first metastasis, referred as metastasis-free survival (MFS) was 15.2 months (SD 1.47). MFS were determined for each metastasis location and were as follows: 7.2 months (SD 8.0) for bone, adrenal 8.4 months (SD 9.4) for adrenal, 13.2 months (SD 1.7) for brain, 14.6 months (SD 5.4) for liver, 25.7 months (SD 11.7) for pleura, 27.7 months (SD 15.9) for peritoneum, 29.8 months (SD 7.2) for spine, 30.2 months (SD 5.2) for lungs, and 54.2 months (SD 12.4) for skin (p < 0.009 log rank). We identified a metastatic timeline process for breast cancer (p < 0.0001 log rank (Mantel-Cox)) and furthermore according to breast subtype cancer (p < 0.0001). We suggest that in addition to Paget's theory, a timeline and a natural history of metastasis exist in patients with cancer. We suppose that some, but not all, primary cancers follow chronological and scheduled metastatic processes to invade organs.

Neuroplasticity and the brain connectome: what can Jean Talairach's reflections bring to modern psychosurgery?

Contrary to common psychosurgical practice in the 1950s, Dr. Jean Talairach had the intuition, based on clinical experience, that the brain connectome and neuroplasticity had a role to play in psychosurgery. Due to the remarkable progress of pharmacology at that time and to the technical limits of neurosurgery, these concepts were not put into practice. Currently, these concepts are being confirmed by modern techniques such as neuroimaging and computational neurosciences, and could pave the way for therapeutic innovation in psychiatry. Psychosurgery commonly uses a localizationist approach, based on the idea that a lesion to a specific area is responsible for a deficit opposite to its function. To psychosurgeons such as Walter Freeman, who performed extensive lesions causing apparently inevitable deficit, Talairach answered with clinical data: complex psychic functions cannot be described that simply, because the same lesion does not provoke the same deficit in different patients. Moreover, cognitive impairment did not always follow efficacious psychosurgery. Talairach suggested that selectively destructing part of a network could open the door to a new organization, and that early psychotherapy could encourage this psychoplasticity. Talairach did not have the opportunity to put these concepts into practice in psychiatric diseases because of the sudden availability of neuroleptics, but connectomics and neuroplasticity gave rise to major advances in intraparenchymal neurosurgery, from epilepsy to low-grade glioma. In psychiatry, alongside long-standing theories implicating focal lesions and diffuse pathological processes, neuroimaging techniques are currently being developed. In mentally healthy individuals, combining diffusion tensor imaging with functional MRI, magnetoencephalography, and electroencephalography allows the determination of a comprehensive map of neural connections in the brain on many spatial scales, the so-called connectome. Ultimately, global neurocomputational models could predict physiological activity, behavior, and subjective feeling, and describe neuropsychiatric disorders. Connectomic studies comparing psychiatric patients with controls have already confirmed the early intuitions of Talairach. As a striking example, massive dysconnectivity has been found in schizophrenia, leading some authors to propose a "dysconnection hypothesis." Alterations of the connectome have also been demonstrated in obsessive-compulsive disorder and depression. Furthermore, normalization of the functional dysconnectivity has been observed following clinical improvement in several therapeutic interventions, from psychotherapy to pharmacological treatments. Provided that mental disorders result from abnormal structural or functional wiring, targeted psychosurgery would require that one be able: 1) to identify the pathological network involved in a given patient; 2) to use neurostimulation to safely create a reversible and durable alteration, mimicking a lesion, in a network compatible with neuroplasticity; and 3) to predict which functional lesion would result in adapted neuronal plasticity and/or to guide neuronal plasticity to promote recovery. All these conditions, already suggested by Talairach, could now be achievable considering modern biomarkers and surgical progress.

Evaluation of the quality of information on the Internet available to patients undergoing cervical spine surgery.

OBJECTIVE: To evaluate the quality of information available on the Internet to patients with a cervical pathology undergoing elective cervical spine surgery. METHODS: Six key words ("cervical discectomy," "cervical foraminotomy," "cervical fusion," "cervical disc replacement," "cervical arthroplasty," "cervical artificial disc") were entered into two different search engines (Google, Yahoo!). For each key word, the first 50 websites were evaluated for accessibility, comprehensibility, and website quality using the DISCERN tool, transparency and honesty criteria, and an accuracy and exhaustivity scale. RESULTS: Of 5,098,500 evaluable websites, 600 were visited; 97 (16%) of these websites were evaluated for quality and comprehensiveness. Overall, 3% of sites obtained an excellent global quality score, 7% obtained a good score, 25% obtained an above average score, 15% obtained an average score, 37% obtained a poor score, and 13% obtained a very poor score. High-quality websites were affiliated with a professional society (P = 0.021), had bibliographical references (P = 0.030), and had a recent update within 6 months (r = 0.277, P < 0.001). No correlation between global quality score and other variables was observed. CONCLUSIONS: This study shows that the search for medical information on the Internet is time-consuming and often disappointing. The Internet is a potentially misleading source of information. Surgeons and professional societies must use the Internet as an ally in providing optimal information to patients.

Radiosurgery for the treatment of psychiatric disorders: a review.

Radiosurgery for psychiatric disorders has been performed for more than 50 years. The use of deep brain stimulation has recently been expanded to the investigational treatment of specific psychiatric disorders. A literature review of past studies incorporating radiosurgical stereotactic lesions for psychiatric disorders was performed to provide historic context and possible guidance for current and future attempts at treating psychiatric disorders, especially by gamma capsulotomy. The anatomic target localization, dose selection, and the outcome of the radiosurgical procedures were reviewed, and the evolutions of lesioning strategies were analyzed with particular emphasis on the dose selection. Large-scale prospective studies with strict inclusion and well-defined, objective outcome criteria are necessary for defining the role of radiosurgery for the treatment of psychiatric disorders.

Radiosurgical treatment for epilepsy associated with cavernomas.

Cavernous malformations (CMs) are congenital vascular malformations of the brain, which often present with drug-resistant epilepsy. Microsurgical excision remains the preferred approach for cortical-subcortical epileptogenic CMs that are not located in functional cortex. For patients presenting with seizures arising from eloquent cortex surrounding the lesion, radiosurgery appears to be a suitable alternative. We evaluated the effectiveness of Gamma Knife (GK) surgery in the management of drug-resistant seizures associated with CMs in a retrospective multicenter study. Forty-nine patients with cortical or subcortical CMs with severe long-term drug-resistant epilepsy underwent radiosurgery. The mean duration of epilepsy before these GK procedures was 7.5 (±9.3) years. The mean frequency of seizures was 6.9/month (±14). The mean marginal radiation dose was 19.17 Gy. At the last follow-up examination, 53% were seizure free. A highly significant decrease in the number of seizures was achieved for another 20%. The remaining 26% of patients showed little or no improvement. The morbidity was low. Radiosurgery is a promising management modality for epilepsy associated with CMs. The determination of the extent of the epileptogenic zone in CMs and dose selection are the critical steps towards successful radiosurgical outcome. Further prospective work is necessary to validate our data.

Endoscopic treatment of distal choroidal artery aneurysm.

Distal choroidal artery aneurysms stemming from the lateral wall of the ventricles are rare and are mostly associated with moyamoya disease. The treatment of these aneurysms is difficult because of their deep location. The authors report the case of a 50-year-old woman followed for moyamoya disease presenting with 2 intraventricular hemorrhages. Cerebral angiography showed an aneurysm located on the left distal choroidal artery. Magnetic resonance imaging also demonstrated that the lesion protruded from the lateral wall of the trigone of the left lateral ventricle. Using MR imaging-guided stereotactic localization, the aneurysm was accurately reached endoscopically and successfully resected from the parent artery. The patient was discharged neurologically intact. To the best of the authors' knowledge, this is the first report of a successfully endoscopically treated distal anterior choroidal artery aneurysm. Endoscopic surgery may be added to the armamentarium of procedures used to treat intraventricular aneurysms.

Gamma knife radiosurgery for glossopharyngeal neuralgia: Marseille experience.

PURPOSE: Although Gamma Knife radiosurgery (GKR) is widely recognized as an effective and minimally invasive treatment for intractable trigeminal neuralgia, its role in glossopharyngeal neuralgia (GPN) has not yet been determined. METHODS: Between January 2002 and February 2009, 7 patients with medically intractable GPN were treated using GKR. Indication for GKR was the presence of medically intractable GPN, patient's refusal for open surgery or contraindication to microvascular decompression. Patients underwent preoperative investigation and were evaluated postoperatively with periodic assessment of pain relief and neurological function. Seven patients, 5 males and 2 females, with mean age 62 (range 36-83) presented with symptoms for an average of 28 months (range 8-72). Four patients had a neurovascular conflict. Patients were treated with a dose ranging from 60 to 80 Gy, targeted on the cisternal segment (n=2) or glossopharyngeal meatus (GPM) (n=5). RESULTS: Outcome was favorable with cure of GPN in 5 of 7 patients (71%) in the short-term (3 months post GKR) and 4 of 7 (57%) patients in the long term (&#62; 7 months, mean 16 months). One patient required 2 treatments because of a recurrence of symptoms and was treated with a maximum doses of 60 and 70 Gy, respectively. There were no neurological complications. CONCLUSIONS: All patients with GPM as a target that received a dose greater than 75 Gy were cured at long-term follow-up. The 2 patients with cisternal segment as the target and received a dose lower than 70 Gy were not cured of their GPN. There were no neurological deficits involving the lower cranial nerves. It will be necessary to investigate the optimal radiation dose and target of GKR for GPN in order to achieve long-term pain relief.