Patients selection for psychiatric neurosurgery: pitfalls and considerations.

Neurosurgical interventions (destructive or neuromodulation) are considered as a therapeutic option for patients with treatment resistant mental disorders. However, the issues of indications and contraindications for psychiatric surgery, method and patient selection remain unresolved. This article discusses possible problems and contradictions in the selection of patients, the need for an interdisciplinary team to work to solve the question of the feasibility of using neurosurgical methods. The authors have identified the main problems that increase the risks of selection and lead to a lack of results or low efficiency of neurosurgical intervention, namely: (1) diagnostic errors or inaccuracies; (2) inconclusive data on therapeutic resistance; (3) lack of a common understanding of the goals and desired results among participants in the selection of patients for neurosurgery. Possible predictors of surgical outcome and ethical issues are also discussed. Neurosurgical interventions as a treatment option for psychiatric disorders are not officially approved in most countries. So an appropriate algorithm for patient selection and clear criteria for outcome measures are needed.

Gamma Knife capsulotomy for correction of obsessive-compulsive symptoms in a patient with schizophrenia: Case report.

The treatment of mental illnesses that are resistant to conservative therapy poses a serious problem. Surgical methods with proven efficacy have been proposed for only a small group of psychiatric diseases, while in practice non-classical clinical situations are seen rather often. A 36-year-old man with a 18-year history of "schizophrenia with a predominant obsessive-compulsive syndrome" was referred to the Burdenko National Medical Research Center of Neurosurgery for consideration of neurosurgical treatment. Based on results of longitudinal independent evaluations of the patient in several specialized clinical centers the disease was considered resistant to medical therapy. Radiosurgical procedure was performed by means of Leksell Gamma Knife Perfexion™ (Elekta AB; Stockholm, Sweden). Ventral portion of the anterior limb of internal capsule was targeted with two 4-mm isocenters on each side, with prescription dose at 50% isodose line of 80 Gy and a maximal dose of 160 Gy. No obvious complications or side effects were noted during 13-month follow-up after radiosurgery. Gradual clinical improvement was observed with 25% reduction of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score at 13 months after treatment. Similarly, the Hospital Anxiety and Depression Scale (HADS) anxiety and depression scores decreased by 24% and 58%, respectively. This is the first published case of radiosurgical treatment of a psychiatric disorder in Russia. It demonstrates the potential efficacy of Gamma Knife capsulotomy for non-classical forms of obsessive-compulsive disorder comorbid with schizophrenia. Nevertheless, definitive conclusions about the reliability of this radiosurgical indication can only be made based on the results of larger studies.

Neurosurgical management of Tourette syndrome: A literature review and analysis of a case series treated with deep brain stimulation.

Tourette syndrome (TS) is a heterogeneous disorder, which clinical presentation includes both multiple motor and vocal tics and commonly associated psychiatric conditions (obsessive-compulsive disorder, attention deficit hyperactivity disorder, depression, anxiety, etc.). Treatment options primarily consist of non-pharmacological interventions (habit reversal training, relaxation techniques, cognitive behavioral therapy, and social rehabilitation) and pharmacotherapy. In case of the intractable forms, neurosurgical treatment may be considered, primarily deep brain stimulation (DBS). DBS appear to be effective in medically intractable TS patients, although, the preferential brain target is still not defined. The majority of studies describe small number of cases and the issues of appropriate patient selection and ethics remain to be clarified. In this article, we review the main points in management of TS, discuss possible indications and contraindications for neurosurgical treatment, and analyze our experience of DBS in a case series of refractory TS patients with the focus on target selection and individual outcomes.

Microsurgical Treatment of Colloid Cysts of the Third Ventricle.

BACKGROUND: This study analyzes the results of surgical treatment in 377 patients with colloid cysts (CCs) of the third ventricle who were treated at the Burdenko Neurosurgery Institute from 1981 to 2015. Operations were performed by a single surgeon (the first author of the article). METHODS: The transcallosal approach was used to remove CCs in 97% of cases. Total cyst removal was performed in 96% of cases (in 4% of cases, a small cyst capsule fragment was left on the veins and fornix); in 3 cases, the cyst recurred, which required its repeated removal. RESULTS: Hydrocephalus symptoms regressed in 98% of patients. The most frequent complications in the early postoperative period were memory impairments of varying severity, with a tendency to regress by the time of discharge. Two patients had an intraventricular hematoma, which required operative exploration in 1 patient. There were 4 cases of meningitis (including 1 shunt-associated meningitis) and 5 cases of transient pyramidal insufficiency. CONCLUSIONS: We made a preliminary assessment of the reasonability of the infratentorial supracerebellar approach for removal of CCs in 10 cases.