La estimulación cerebral profunda en el trastorno obsesivo-compulsivo refractario al tratamiento: una revisión sistemática / Deep brain stimulation and treatment-resistant obsessive-compulsive disorder: a systematic review

Introducción: Al menos el 10% de pacientes con trastorno obsesivo-compulsivo (TOC) son refractarios al tratamiento psicofarmacológico. La aparición de nuevas tecnologías neuroquirúrgicas (estimulación cerebral profunda[ECP]) de modulación de la actividad neuronal alterada está posibilitando su extensión a casos graves y refractarios de TOC en los que anteriormente se utilizaban técnicas quirúrgicas no reversibles. El objetivo de este artículo es revisar la evidencia científica existente sobre la eficacia y aplicabilidad de esta técnica en este grupo de pacientes. Método: Se ha realizado una revisión sistemática de la literatura en las bases de datos PubMed/Medline, Embase y PsycINFO usando las palabras clave relacionadas con «deep brain stimulation», «DBS» y «obsessive-compulsive disorder», «OCD». Dos de los autores seleccionaron los artículos, de manera independiente, a partir de sus abstracts y en función de si describían alguno de los aspectos principales de la técnica en el TOC: aplicabilidad; mecanismo de acción; dianas terapéuticas cerebrales; efectividad; efectos secundarios, y coterapias. Toda la información fue sistemáticamente extraída y evaluada. Resultados: El análisis crítico de la evidencia señala que la aplicación de la ECP en el tratamiento del TOC refractario está aportando resultados satisfactorios, con rangos asumibles de efectos secundarios. Sin embargo, todavía no hay evidencia suficiente que permita priorizar el uso de una determinada diana cerebral. La selección de pacientes ha de seguir un análisis de riesgo/beneficio, debiéndose individualizar la decisión de mantener un tratamiento concomitante farmacológico/psicoterapéutico. Conclusiones: La ECP se encuentra todavía en el ámbito de la investigación, pero su aplicación en el TOC-refractario es cada vez más frecuente, produciendo en la mayoría de los estudios una significativa mejoría de los síntomas, y también del funcionamiento y calidad de vida. Es preciso realizar más estudios controlados y aleatorizados sobre su efectividad a largo plazo, y sobre su relación riesgo/beneficio y costes

Introduction: At least 10% of patients with Obsessive-compulsive Disorder (OCD) are refractory to psychopharmacological treatment. The emergence of new technologies for the modulation of altered neuronal activity in Neurosurgery, deep brain stimulation (DBS), has enabled its use in severe and refractory OCD cases. The objective of this article is to review the current scientific evidence on the effectiveness and applicability of this technique to refractory OCD. Method: We systematically reviewed the literature to identify the main characteristics of deep brain stimulation, its use and applicability as treatment for obsessive-compulsive disorder. Therefore, we reviewed PubMed/Medline, Embase and PsycINFO databases, combining the key-words 'Deep brain stimulation', 'DBS' and 'Obsessive-compulsive disorder' 'OCS'. The articles were selected by two of the authors independently, based on the abstracts, and if they described any of the main characteristics of the therapy referring to OCD: applicability; mechanism of action; brain therapeutic targets; efficacy; side-effects; co-therapies. All the information was subsequently extracted and analysed. Results: The critical analysis of the evidence shows that the use of DBS in treatment-resistant OCD is providing satisfactory results regarding efficacy, with assumable side-effects. However, there is insufficient evidence to support the use of any single brain target over another. Patient selection has to be done following analyses of risks/benefits, being advisable to individualize the decision of continuing with concomitant psychopharmacological and psychological treatments. Conclusions: The use of DBS is still considered to be in the field of research, although it is increasingly used in refractory-OCD, producing in the majority of studies significant improvements in symptomatology, and in functionality and quality of life. It is essential to implement random and controlled studies regarding its long-term efficacy, cost-risk analyses and cost/benefit

Deep brain stimulation and treatment-resistant obsessive-compulsive disorder: A systematic review. / La estimulación cerebral profunda en el trastorno obsesivo-compulsivo refractario al tratamiento: una revisión sistemática.

INTRODUCTION: At least 10% of patients with Obsessive-compulsive Disorder (OCD) are refractory to psychopharmacological treatment. The emergence of new technologies for the modulation of altered neuronal activity in Neurosurgery, deep brain stimulation (DBS), has enabled its use in severe and refractory OCD cases. The objective of this article is to review the current scientific evidence on the effectiveness and applicability of this technique to refractory OCD. METHOD: We systematically reviewed the literature to identify the main characteristics of deep brain stimulation, its use and applicability as treatment for obsessive-compulsive disorder. Therefore, we reviewed PubMed/Medline, Embase and PsycINFO databases, combining the key-words 'Deep brain stimulation', 'DBS' and 'Obsessive-compulsive disorder' 'OCS'. The articles were selected by two of the authors independently, based on the abstracts, and if they described any of the main characteristics of the therapy referring to OCD: applicability; mechanism of action; brain therapeutic targets; efficacy; side-effects; co-therapies. All the information was subsequently extracted and analysed. RESULTS: The critical analysis of the evidence shows that the use of DBS in treatment-resistant OCD is providing satisfactory results regarding efficacy, with assumable side-effects. However, there is insufficient evidence to support the use of any single brain target over another. Patient selection has to be done following analyses of risks/benefits, being advisable to individualize the decision of continuing with concomitant psychopharmacological and psychological treatments. CONCLUSIONS: The use of DBS is still considered to be in the field of research, although it is increasingly used in refractory-OCD, producing in the majority of studies significant improvements in symptomatology, and in functionality and quality of life. It is essential to implement random and controlled studies regarding its long-term efficacy, cost-risk analyses and cost/benefit.

Eficacia y seguridad del mapeo por estimulación eléctrica intraoperatoria para la extirpación de gliomas OMS grado ii y iii en áreas cerebrales elocuentes / Efficacy and safety of intraoperative electrical stimulation mapping for resection of WHO grade ii and iii gliomas within eloquent areas

Fundamento y objetivo: La técnica de mapeo por estimulación eléctrica intraoperatoria (EEI) es cada vez más utilizada para la extirpación de gliomas OMS grado ii (GGII) y iii (GGIII) en áreas elocuentes, pero son muy pocos los estudios que comparan esta técnica con la cirugía convencional (sin EEI). En este trabajo se compara el grado de resección tumoral, las secuelas, el control de la epilepsia y la calidad de vida en 2 series de pacientes operados con y sin mapeo por EEI.Pacientes y método: Se compararon los resultados en 2 series de pacientes operados de GGII y GGIII en áreas elocuentes en el mismo centro. Período A (2004-2009): 17 pacientes operados sin utilizar EEI. Período B (2009-2010): 19 pacientes operados utilizando EEI.Resultados: El porcentaje tumoral extirpado fue del 54,7% en el período A y del 79,9% en el período B (p=0,006). A los 6 meses de la cirugía, 8 pacientes del período A y uno del período B desarrollaron morbilidad neurológica (p=0,015; odds ratio [OR] 16, intervalo de confianza del 95% [IC 95%] 1,7-148,3). Dos pacientes del período A con epilepsia farmacorresistente y 8 del período B mejoraron el control de las crisis epilépticas (p=0,05; OR 42, IC 95% 2,1-825,7). Nueve pacientes del período A y 18 del período B volvieron a la misma situación laboral que antes de la cirugía (p=0,015; OR 16, IC 95% 1,7-148,4).Conclusiones: La comparación entre las cirugías convencional y con mapeo por EEI revela que esta última aumenta el grado de resección tumoral en un 25,2%, reduce el riesgo de secuelas permanentes en un 48,1%, mejora el control de la epilepsia en formas farmacorresistentes y preserva la calidad de vida (AU)

Background and objective: Despite the growing use of intraoperative electrical stimulation (IES) mapping for the resection of WHO grade ii and iii gliomas (GGII and GGIII) in eloquent areas, few studies have compared 2 series with and without IES. The present study compares 2 series of patients operated with and without IES at the same institution, analyzing the extent of resection, neurological morbidity, epilepsy prognosis and quality of life.Patients and methods: The surgical results in 2 series of patients with GGII and GGIII within eloquent were compared. Period A (2004-2009): 17 patients operated without IES. Period B (2009-2010): 19 patients operated with IES. Results: The extent of tumor resection was 54.7% in group A and 79.9% in group B (P=.006). Six months after surgery, neurological morbidity was present in 8 patients of group A and one patient of group B (P=.015; odds ratio [OR] 16, 95% confidence interval [95% CI] 1.7-148.3). Two patients of group A with refractory epilepsy, and 8 patients of group B improved epilepsy control (P=.05; OR 42, 95% CI 2.1-825.7). Nine patients of group A and 18 patients of group B returned to the same socio-professional situation as before surgery (P=.015; OR 16, 95% CI 1.7-148.4). Conclusions: The comparison of IES mapping surgery to conventional surgery revealed that the former enables to: increase in 25.2% the extent of tumor resection, decrease in 48.1% the risk of permanent sequelae, improve epilepsy control and preserve quality of life (AU)

[Efficacy and safety of intraoperative electrical stimulation mapping for resection of WHO grade ii and iii gliomas within eloquent areas]. / Eficacia y seguridad del mapeo por estimulación eléctrica intraoperatoria para la extirpación de gliomas OMS grado ii y iii en áreas cerebrales elocuentes.

BACKGROUND AND OBJECTIVE: Despite the growing use of intraoperative electrical stimulation (IES) mapping for the resection of WHO grade ii and iii gliomas (GGII and GGIII) in eloquent areas, few studies have compared 2 series with and without IES. The present study compares 2 series of patients operated with and without IES at the same institution, analyzing the extent of resection, neurological morbidity, epilepsy prognosis and quality of life. PATIENTS AND METHODS: The surgical results in 2 series of patients with GGII and GGIII within eloquent were compared. Period A (2004-2009): 17 patients operated without IES. Period B (2009-2010): 19 patients operated with IES. RESULTS: The extent of tumor resection was 54.7% in group A and 79.9% in group B (P=.006). Six months after surgery, neurological morbidity was present in 8 patients of group A and one patient of group B (P=.015; odds ratio [OR] 16, 95% confidence interval [95% CI] 1.7-148.3). Two patients of group A with refractory epilepsy, and 8 patients of group B improved epilepsy control (P=.05; OR 42, 95% CI 2.1-825.7). Nine patients of group A and 18 patients of group B returned to the same socio-professional situation as before surgery (P=.015; OR 16, 95% CI 1.7-148.4). CONCLUSIONS: The comparison of IES mapping surgery to conventional surgery revealed that the former enables to: increase in 25.2% the extent of tumor resection, decrease in 48.1% the risk of permanent sequelae, improve epilepsy control and preserve quality of life.

[Controversy in the management of WHO grade II gliomas in eloquent brain areas: recent literature review]. / Controversias en el tratamiento de los gliomas OMS grado II localizados en áreas elocuentes: revisión de la bibliografía reciente.

Recent studies have shown that diffuse grade II gliomas (GGII) located in eloquent brain areas represent over 80% of all GGII. The optimal management of these tumours is still controversial. It has long been considered that surgery is not an option for GGII within eloquent areas, due to the high risk of inducing postoperative sequelae in patients with normal neurological explorations. However, the safety of these surgeries has significantly improved in recent years due to the rapid development of techniques enabling a precise mapping of brain functions. Noninvasive functional neuroimaging techniques have been recently developed, enabling cortical mapping of the entire brain prior to surgical procedures. Such precise data provide a preoperative estimation of the location of eloquent areas in relation to the tumour, which is essential for surgical planning and preoperative assessment of morbidity for various surgical approaches. The intraoperative electrical stimulation (IES) mapping technique consists in the application of a bipolar electrode on the brain tissue, enabling an accurate location of brain functions. This provides unique assistance in GGII resection, as it generates a discrete and transient "virtual" lesion within the eloquent tissue. Tumour removal is then tailored according to functional boundaries in order to optimise the quality of resection and to minimise the risk of postoperative sequelae, preserving quality of life. For patients with a GGII in an eloquent area, the possibility of an early resection should be evaluated by a multidisciplinary neuro-oncology team specialising in the management of such tumours.

Controversias en el tratamiento de los gliomas OMS grado II localizados en áreas elocuentes: revisión de la bibliografía reciente / Controversy in the management of WHO grade II gliomas in eloquent brain areas: recent literature review

Estudios recientes han demostrado que los gliomas difusos de grado II (GGII), localizados en áreas elocuentes del cerebro, representan más del 80% del total de los GGII. El tratamiento de los GGII en áreas elocuentes es todavía hoy controvertido. El abordaje clásico de un GGII en un área elocuente considera que no es posible plantear una cirugía, porque hay un riesgo alto de secuelas neurológicas en un paciente con una exploración neurológica normal. Sin embargo, en los últimos años ha aumentado de forma significativa la seguridad de las cirugías de estos tumores, gracias al desarrollo de técnicas para mapear con precisión la función cerebral. Mediante las técnicas no invasivas de neuroimagen funcional, se obtiene un mapa de la función cortical de todo el cerebro, lo que es de gran ayuda para anticipar los hallazgos durante la cirugía y para planificar el abordaje. La técnica de mapeo por estimulación eléctrica intraoperatoria consiste en la aplicación, durante la intervención quirúrgica, de un electrodo bipolar sobre el tejido cerebral, lo que permite localizar las funciones con gran precisión. Esta técnica se considera hoy día como el procedimiento de elección para realizar una cirugía de un GGII en un área elocuente con seguridad, ya que ha demostrado ser capaz de aumentar el grado de resección y reducir de forma importante el riesgo de secuelas. En todo paciente con la sospecha de un GGII en un área elocuente, debe valorarse la posibilidad de una extirpación tumoral temprana por parte de un equipo multidisciplinario de profesionales especializados en el manejo de estos tumores (AU)

Recent studies have shown that diffuse grade II gliomas (GGII) located in eloquent brain areas represent over 80% of all GGII. The optimal management of these tumours is still controversial. It has long been considered that surgery is not an option for GGII within eloquent areas, due to the high risk of inducing postoperative sequelae in patients with normal neurological explorations. However, the safety of these surgeries has significantly improved in recent years due to the rapid development of techniques enabling a precise mapping of brain functions. Noninvasive functional neuroimaging techniques have been recently developed, enabling cortical mapping of the entire brain prior to surgical procedures. Such precise data provide a preoperative estimation of the location of eloquent areas in relation to the tumour, which is essential for surgical planning and preoperative assessment of morbidity for various surgical approaches. The intraoperative electrical stimulation (IES) mapping technique consists in the application of a bipolar electrode on the brain tissue, enabling an accurate location of brain functions. This provides unique assistance in GGII resection, as it generates a discrete and transient "virtual" lesion within the eloquent tissue. Tumour removal is then tailored according to functional boundaries in order to optimise the quality of resection and to minimise the risk of postoperative sequelae, preserving quality of life. For patients with a GGII in an eloquent area, the possibility of an early resection should be evaluated by a multidisciplinary neuro-oncology team specialising in the management of such tumours (AU)