Assessing evidence quality in research reporting neurocognitive outcomes following paediatric temporal lobe surgery for epilepsy.

PURPOSE: RCTs are the gold standard in determining intervention efficacy with journal impact factor assumed to index research quality. Flint et al's (2017) systematic review examined neurocognitive outcomes following paediatric temporal lobe epilepsy surgery. Retrieved evidence was restricted to non-RCTs, which pose greater risk of bias and thus diminish research quality. The current study evaluated risk of bias in sources retrieved by Flint et al. and explored whether impact factor related to research quality within this selected field. METHODS: Methodological and reporting bias was evaluated using categories of bias specified by Cochrane. The relationship between the identified number of biases and journal impact factors of retrieved sources was examined. RESULTS: All studies carried substantial risk for bias. Methodology bias included low sample size (76.71%; 56/73), risk of confounding cognitive outcomes due to failure to report pre-surgery neurocognitive data (21.92%; 16/73) and to determine whether patients were prescribed antiepileptic drugs at follow-up (53.42%; 39/73). Reporting bias included overstating claims based on findings (53.42%; 39/73), failure to report individual patient characteristics (66%; 33/50) and omitting the nature of surgical interventions (15.07%; 11/73). The number of sources of common bias within studies was not associated significantly with journal impact factor (p = .878). CONCLUSION: This evaluation highlights risk of bias when sources are predominantly uncontrolled non-RCTs and provides evidence that journal impact factor is not a reliable indicator of quality within this field. Authors should limit bias in their methods and reporting of results, to ensure the highest quality evidence possible is used to inform treatment decisions and prognosis.

Comparative Evaluation of Magnetic Resonance-Guided Focused Ultrasound Surgery for Essential Tremor.

BACKGROUND: Treatment options for patients with drug-resistant essential tremor (ET) are limited. Magnetic resonance-guided focused ultrasound surgery (MRgFUS) is an emerging technique to treat refractory ET. OBJECTIVES: To present MRgFUS as an alternative to radiofrequency (RF) thalamotomy or deep brain stimulation (DBS) for ET treatment. METHODS: We retrospectively analyzed 59 patients who underwent unilateral surgery for drug-resistant ET. Treatments included RF thalamotomy (n = 17), DBS (n = 19), and MRgFUS (n = 23). The outcomes measured were tremor severity and treatment-related complications. RESULTS: At 1 month postoperatively, 100% of RF thalamotomy patients, 89.5% of DBS patients, and 91.3% of MRgFUS patients exhibited absent/mild tremor (successful treatment); other patients exhibited partial relief. At 12 months postoperatively, treatment success for each procedure was observed in 70.6, 84.2, and 78.3% of patients, respectively. At 1 month postoperatively, treatment-related complications had occurred in 58.8, 5.3, and 13.0% of patients, respectively. At 12 months postoperatively, side effects persisted in 11.8, 21.1, and 4.4% of patients, respectively. No statistical differences in treatment success were observed between treatments or over time. Complication rates differed between treatment modalities (p < 0.01) and were lowest in the MRgFUS group. CONCLUSIONS: Patients with drug-resistant ET received equivalent results from RF thalamotomy, DBS, and MRgFUS. DBS and MRgFUS resulted in fewer treatment-related complications.

International recommendation for a comprehensive neuropathologic workup of epilepsy surgery brain tissue: A consensus Task Force report from the ILAE Commission on Diagnostic Methods.

Epilepsy surgery is an effective treatment in many patients with drug-resistant focal epilepsies. An early decision for surgical therapy is facilitated by a magnetic resonance imaging (MRI)-visible brain lesion congruent with the electrophysiologically abnormal brain region. Recent advances in the pathologic diagnosis and classification of epileptogenic brain lesions are helpful for clinical correlation, outcome stratification, and patient management. However, application of international consensus classification systems to common epileptic pathologies (e.g., focal cortical dysplasia [FCD] and hippocampal sclerosis [HS]) necessitates standardized protocols for neuropathologic workup of epilepsy surgery specimens. To this end, the Task Force of Neuropathology from the International League Against Epilepsy (ILAE) Commission on Diagnostic Methods developed a consensus standard operational procedure for tissue inspection, distribution, and processing. The aims are to provide a systematic framework for histopathologic workup, meeting minimal standards and maximizing current and future opportunities for morphofunctional correlations and molecular studies for both clinical care and research. Whenever feasible, anatomically intact surgical specimens are desirable to enable systematic analysis in selective hippocampectomies, temporal lobe resections, and lesional or nonlesional neocortical samples. Correct orientation of sample and the sample's relation to neurophysiologically aberrant sites requires good communication between pathology and neurosurgical teams. Systematic tissue sampling of 5-mm slabs along a defined anatomic axis and application of a limited immunohistochemical panel will ensure a reliable differential diagnosis of main pathologies encountered in epilepsy surgery.

Biological basis for the surgical treatment of depression.

An estimated 20% of patients with major depression are refractory to existing therapies. The purpose of this review is to provide a theoretical and neuroscientific framework in which to interpret new work in the field of surgical treatment for depression. This review focuses on existing clinical and imaging data, current disease models, and results of recent case reports and patient series that together may inform the construction of appropriate clinical trials for the surgical treatment of refractory depression.

Stereotactic amygdalotomy in the management of severe aggressive behavioral disorders.

OBJECT: Stereotactic amygdalotomy has been utilized as a surgical treatment for severe aggressive behavioral disorders. Several clinical studies have been reported since the first description of the procedure. In the current study, the authors reviewed the literature and evaluated the surgical results, neuropsychological outcome, and complication rate in patients who had undergone stereotactic amygdalotomy for severe aggressive behavioral disorders. METHODS: The PubMed database was searched using the following terms: "amygdalotomy," "amygdalectomy," "amygdaloidectomy," "psychosurgery," "aggressive disorder," and "behavioral disorder." Clinical series with more than 5 patients undergoing stereotactic amygdalotomy for aggressive or other behavioral disorders were included in this review. The surgical technique, anatomical target, improvement in psychiatric symptomatology, postoperative employment and social rehabilitation, postoperative neurocognitive function, procedure-related complications, and long-term follow-up were evaluated. RESULTS: Thirteen clinical studies met our inclusion criteria. Reported postoperative improvement in aggressive behavior varied between 33 and 100%. Procedure-related complication rates ranged from 0 to 42%, whereas the mortality rate was as high as 3.8%. In the majority of the reviewed clinical series, the performance of stereotactic amygdalotomy did not compromise a patient's learning, language, and intellectual capabilities. The long-term follow-up, although very limited, revealed that initially observed improvement was maintained in most cases. CONCLUSIONS: Stereotactic amygdalotomy can be considered a valid surgical treatment option for carefully selected patients with medically refractory aggressive behavioral disorders. Recent advances in imaging and stereotactic navigation can further improve outcome and minimize the complication rate associated with this psychosurgical procedure.

Frameless stereotactic subcaudate tractotomy for intractable obsessive-compulsive disorder.

Obsessive-compulsive disorder (OCD) is a chronic, disabling disorder. Psychosurgery may be indicated for a subset of patients for whom no conventional treatment is satisfactory. This paper focuses on the stereotactic subcaudate tractotomy (SST). Thus far, these procedures have been carried out using frame-based stereotactic techniques. However, modern - highly accurate - frameless stereotactic procedures have successfully been introduced in neurosurgical practice. We developed a novel frameless stereotactic subcaudate tractotomy procedure with promising initial results in a patient suffering from intractable OCD. This is the first report on frameless SST. Future studies should examine whether other ablative stereotactic psychosurgery procedures can be done using frameless stereotactic methods.

The role of psychosurgery in the treatment of selected cases of refractory schizophrenia: a reappraisal.

Prefrontal lobotomy (i.e. leukotomy) was widely performed for the treatment of schizophrenia during the late 1930s and 1940s but met with growing disrepute after the introduction of effective antipsychotic agents in the early 1950s. While non-invasive methods of treatment are undeniably preferable to somatic interventions for the management of psychiatric illnesses, there nevertheless continues to be a valid role for leukotomy in the treatment of patients with severe, chronic, refractory schizophrenia, particularly when the patient poses a risk to himself and/or to society. The present article traces the history of leukotomy in the treatment of schizophrenia, and reviews the author's experience with this surgical procedure in 16 patients who fulfilled the above criteria and underwent leukotomy during the years spanning 1985 1996. This operation reduced aggression and/or produced marked to slight improvement in all patients, and in no case led to adverse consequences. Thus, leukotomy is recommended as a legitimate treatment modality in selected patients with schizophrenia.

The present status of psychosurgery in Australia and New Zealand.

OBJECTIVES: To assess the extent and nature of psychosurgery currently being performed in Australia and New Zealand, and the present status of legislation regulating its practice. METHODS: Details of current legislation were obtained through inspection of statutes and direct communication with Departments of Health. All full and associate members of the Neurosurgical Society of Australasia were surveyed by postal questionnaire. Ninety-eight neurosurgeons were surveyed, of whom 72 (73%) replied. RESULTS: In the 1980s a mean of nine (SD, 5.9) operations were performed per year; about two were performed per year in the late 1980s. Ninety per cent of these operations were performed at one centre in Sydney. The most common indications were severe and medically intractable depression and obsessive-compulsive disorder. Surgery is now exclusively stereotactic and involves the creation of lesions in the orbitomedial frontal or cingulate tracts or a combination of the two. The nature and type of surgery are comparable to those in other centres in the Western world. Regulatory legislation is in place in most, but not all, States in Australia and in New Zealand. CONCLUSIONS: Further developments of other forms of psychiatric treatments may make psychosurgery, in its present form and at its present level of validation, redundant. If it is to have a resurgence, it would have to be based on a much sounder theoretical premise, and a stronger demonstration of efficacy and predictability of effect.

The ethics of therapeutic modality choice.

Psychiatrists usually select therapeutic modalities for their patients on the basis of empirical and theoretical considerations. Only in special circumstances (e.g., psychosurgery) are ethical concerns primary. Yet every therapeutic decision involves questions of value and requires ethical justification. The author outlines four resources for ethical direction in therapy: a general systems or biopsychosocial formulation of the clinical problem, the historic ethical commitments of the medical profession, the patient's informed perspective, and the psychiatrist's own values. Finally, a method is proposed for the resolution of conflicts among these four perspectives in individual cases.

[Psychosurgery today (author's transl)]. / Psychochirurgie heute.

After discussion of the historical and neurophysiological bases of psychosurgery a report on personal experience in different indications is given. Finally, the present degree of informedness of doctors and the media on psychosurgery is discussed.

The incidence of psychosurgery in the United States, 1971--1973.

As part of the work of the APA Task Force on Psychosurgery, the author surveyed 1,901 neurosurgeons on how many psychosurgical procedures they performed in 1971, 1972 and 1973. A total of 1.481 questionnaires were returned: 195 neurosurgeons indicated they had performed a total of 476 procedures for intractable pain and 1.039 procedures for psychiatric conditions. Excluding the procedures reported by 4 neurosurgeons who performed more than 20 psychosurgical operations in any one of the three years, the number of psychosurgical operations in 575 for the three years, which the author suggests should allay fears about the abuse of psychosurgery.