Benefits of stereotactic radiosurgical anterior capsulotomy for obsessive-compulsive disorder: a meta-analysis.

OBJECTIVE: Anterior capsulotomy (AC) is a therapeutic option for patients with severe, treatment-resistant obsessive-compulsive disorder (OCD). The procedure can be performed via multiple techniques, with stereotactic radiosurgery (SRS) gaining popularity because of its minimally invasive nature. The risk-benefit profile of AC performed specifically with SRS has not been well characterized. Therefore, the primary objective of this study was to characterize outcomes following stereotactic radiosurgical AC in OCD patients. METHODS: Studies assessing mean Yale-Brown Obsessive Compulsive Scale (Y-BOCS) scores before and after stereotactic radiosurgical AC for OCD were included in this analysis. Inverse-variance fixed-effect modeling was used for pooling, and random-effects estimate of the ratio of means and standard mean differences were calculated at 6 months, 12 months, and the last follow-up for Y-BOCS scores, as well as the last follow-up for the Beck Depression Inventory (BDI)/BDI-II scores. A generalized linear mixed model was used to generate fixed- and random-effects models for categorical outcomes. Univariate random-effects meta-regression was used to evaluate associations between postoperative Y-BOCS scores and study covariates. Adverse events were summed across studies. Publication bias was assessed with Begg's test. RESULTS: Eleven studies with 180 patients were eligible for inclusion. The mean Y-BOCS score decreased from 33.28 to 17.45 at the last-follow up (p < 0.001). Sixty percent of patients were classified as responders and 10% as partial responders, 18% experienced remission, and 4% had worsened Y-BOCS scores. The degree of improvement in the Y-BOCS score correlated with time since surgery (p = 0.046). In the random-effects model, the mean BDI at the last follow-up was not significantly different from that preoperatively. However, in an analysis performed with available paired pre- and postoperative BDI/BDI-II scores, there was significant improvement in the BDI/BDI-II scores postoperatively. Adverse events numbered 235, with headaches, weight change, mood changes, worsened depression/anxiety, and apathy occurring most commonly. CONCLUSIONS: Stereotactic radiosurgical AC is an effective technique for treating OCD. Its efficacy is similar to that of AC performed via other lesioning techniques.

Efficacy and safety of combined deep brain stimulation with capsulotomy for comorbid motor and psychiatric symptoms in Tourette's syndrome: Experience and evidence.

OBJECTIVES: To evaluate the efficacy and safety of combined deep brain stimulation (DBS) with capsulotomy for comorbid motor and psychiatric symptoms in patients with Tourette's syndrome (TS). METHODS: This retrospective cohort study consecutively enrolled TS patients with comorbid motor and psychiatric symptoms who were treated with combined DBS and anterior capsulotomy at our center. Longitudinal motor, psychiatric, and cognitive outcomes and quality of life were assessed. In addition, a systematic review and meta-analysis were performed to summarize the current experience with the available evidence. RESULTS: In total, 5 eligible patients in our cohort and 26 summarized patients in 6 cohorts were included. After a mean 18-month follow-up, our cohort reported that motor symptoms significantly improved by 62.4 % (P = 0.005); psychiatric symptoms of obsessive-compulsive disorder (OCD) and anxiety significantly improved by 87.7 % (P < 0.001) and 78.4 % (P = 0.009); quality of life significantly improved by 61.9 % (P = 0.011); and no significant difference was found in cognitive function (all P > 0.05). Combined surgery resulted in greater improvements in psychiatric outcomes and quality of life than DBS alone. The synthesized findings suggested significant improvements in tics (MD: 57.92, 95 % CI: 41.28-74.56, P < 0.001), OCD (MD: 21.91, 95 % CI: 18.67-25.15, P < 0.001), depression (MD: 18.32, 95 % CI: 13.26-23.38, P < 0.001), anxiety (MD: 13.83, 95 % CI: 11.90-15.76, P < 0.001), and quality of life (MD: 48.22, 95 % CI: 43.68-52.77, P < 0.001). Individual analysis revealed that the pooled treatment effects on motor symptoms, psychiatric symptoms, and quality of life were 78.6 %, 84.5-87.9 %, and 83.0 %, respectively. The overall pooled rate of adverse events was 50.0 %, and all of these adverse events were resolved or alleviated with favorable outcomes. CONCLUSIONS: Combined DBS with capsulotomy is effective for relieving motor and psychiatric symptoms in TS patients, and its safety is acceptable. However, the optimal candidate should be considered, and additional experience is still necessary.

Ventral targeted anterior capsulotomy for treatment-resistant depression and obsessive-compulsive disorder: A treatment method with cases.

BACKGROUND: Ablative surgery using bilateral anterior capsulotomy (BAC) is an option for treatment resistant depression (TRD) and obsessive-compulsive disorder (TROCD). The location and extent of the lesion within anterior limb of the internal capsule (ALIC) remains uncertain. Accumulating evidence has suggested that the lesion should be located ventrally while limiting the dorsal extent. Our center is now targeting specific fiber tracts within the lower half of the ALIC. METHOD: Presurgical diffusion tensor Magnetic Resonance Imaging (MRI) was used to identify individual fibre tracts within the ventral aspect of the ALIC in the last two patients who underwent BAC at our center. One patient had TRD and the other had both TROCD and TRD. Radiofrequency-induced thermal lesions were created in the identified targets with lesion volumes between 20 and 229 mm3 (average 95 mm3). FINDINGS: Both patients were responders with neither experiencing significant side effects including compromised executive functions. LIMITATIONS: The generalizability of our findings is limited because the outcome is based on two subjects. CONCLUSION: This work suggests that BAC can be individually tailored and more limited to the ventral aspect of the ALIC and is effective and safe for TRD and TROCD. Accumulating data also suggests that to be clinically effective the length of the capsulotomy should be about 10mm. BAC's use may increase with the growing utilization and mastery of magnetic resonance guided focused ultrasound.

Radiocirugía en el Trastorno Obsesivo-compulsivo, a propósito de un caso clínico / Radiosurgery in Obsessive-compulsive disorder, a case report

No disponible

Psicocirurgia para tratamento de transtorno obsessivo-compulsivo / Psychosurgery for the treatment of obsessive-compulsive disorder

O transtorno obsessivo-compulsivo (TOC) é uma patologia incapacitante tanto na esfera social como na ocupacional. Está associado a uma morbidade bastante alta quando comparado a outras condições psiquiátricas e estima-se atualmente uma prevalência de 2% a 3% na população. Alguns estudos sugerem uma provável relação com uma disfunção do córtex frontal e do cíngulo, envolvendo o circuito de Papez. Esse circuito parece mediar os sintomas ansiosos, visto que lesões cirúrgicas dessas áreas afetam a ansiedade geralmente associada ao TOC. A neurocirurgia ablativa para o tratamento de distúrbios psiquiátricos foi muito utilizada até o desenvolvimento de psicofármacos efetivos. Recentemente, com os avanços técnicos do procedimento cirúrgico, auxiliado pelo conhecimento neurofisiológico, a psicocirurgia tornou-se mais precisa e segura. Porém, sua indicação se restringe como uma alternativa ao tratamento de pacientes com TOC refratário à terapia comportamental e/ou medicamentosa.

The obsessive-compulsive disorder (OCD) is a both socially and occupationally incapacitating disease. It is associated with a quite high morbidity if compared to other psychiatric conditions and currently it is estimated a lifetime prevalence rate of 2% to 3%. Some studies suggest a probable relation with a dysfunction in the cingulate and the frontal cortex, involving the Papez circuit. Anxious symptoms seem to be mediated by that circuit, considering surgical lesions of these areas affect the anxiety usually associated with OCD. The ablative neurosurgery for the treatment of psychiatric disorders was widely used until the development of effective psychopharmacological medication. Recently, thanks to the technical advances of the surgical procedure, aided by the neurophysiological knowledge, the psychosurgery became more accurate and safer. Yet, its indication is restricted as an alternative treatment to refractory OCD patients.

Dianas quirúrgicas en el tratamiento de enfermedades psiquiátricas. Desde elmovimiento a las emociones / Surgical targets in Psychiatric disorders. From movement to emotions

La estimulación cerebral profunda para las enfermedadespsiquiátricas que son refractarias a los distintostratamientos convencionales, se está realizandoactualmente debido en gran parte a los conocimientosadquiridos en la cirugía para los trastornos del movimiento,sobre todo la enfermedad de Parkinson (EP).La depresión, los trastornos obsesivo-compulsivos(TOC) y el síndrome de Gilles de la Tourette son problemascórtico-estriato-tálamo-corticales relacionados conlos circuitos límbicos de los ganglios basales.En esta revisión se analizan las distintas dianas quirúrgicaspara las diferentes patologías neuro-psiquiátricas.Para el TOC actualmente existen dos dianas,el complejo estriado ventral (VS)-núcleo accumbens(Nacc) y el núcleo subtalámico (NST). Para la depresiónrefractaria, el área subgenual (área 25 de Brodmann)y el VS/Nacc. Para el Tourette, el ventralis oralisinterno y centromediano parafascicularis (Voi, CM/Pf)del tálamo y el globo pálido interno (GPi). En la actualidadno existe una única diana específica en cualquierade las patologías, ya que los resultados clínicos tras laestimulación pueden considerarse similares. Por otrolado, una misma diana quirúrgica puede mejorar diferentespatologías (AU)

Deep brain stimulation (DBS) for psychiatricdisorders refractory to conventional treatments arecurrently been performed based in the knowledgmentobtained in the motor disorder surgery and mainly inParkinson´s disease. Depression, obsessive-compulsivedisorder (OCD) and Tourette syndrome, all of them arecortico-striato-thalamo-cortical pathological processinvolved in the limbic loop of the basal ganglia.This review describes the different targets in thesepathological neuro-psychiatric disorders. For OCDthere are currently two targets, ventral striatum (VS)Accumbens nucleus (Nacc) and the subthalamic nucleus(STN). In refractory depression the subgenual area (25Brodmann area) and VS/Nacc. For Tourette syndromethe ventralis oralis internus and centromedianum/parafascicularis of the thalamus (Voi and CM/Pf) andthe internal part of the globus pallidus (GPi). Currentlythere are no specific surgical target for each pathologicaldisorder because clinical results reported arevery similar after stimulation surgery. In other point,a selected surgical target also may improve differentpathologies (AU)

Neurocirugía y trastorno obsesivo-compulsivo resistente: a propósito de un caso / Neurosurgery and refractory obsessive-compulsive disease: a case report

El tratamiento neuroquirúrgico en psiquiatría es una técnica excepcional que sólo se aplica en algunos trastornos especialmente graves y resistentes al tratamiento convencional. Pero, sin duda, los datos que se van documentando aportan eficacia en aquellos casos en que los tratamientos combinados (fármacos-psicoterapia) no producen mejora y la evolución se dirige hacia el deterioro psicosocial grave. Presentamos un caso clínico, neurocirugía en un trastorno obsesivo-compulsivo, con buenos resultados, lo que parece una buena estrategia para ir difundiendo los resultados de estas técnicas, dada la escasez de estudios controlados publicados

Neurosurgical treatment in psychiatry is an uncommon technique that is only used in some serious mental diseases which are very refractory to conventional treatment. There is no doubt that the documented cases have efficiently contributed to those cases where combined treatment (drug-psychotherapy) does not lead to clear improvement and where the course leads to serious psychosocial deterioration. We present a clinical case of neurosurgery in obsessive compulsive disease with good results. This seems to be a good strategy to make the results of these techniques known because of the shortage of controlled studies published

Resistência e refratariedade no transtorno obsessivo-compulsivo / Resistance and refractoriness in obsessive-compulsive disorder

OBJETIVO E MÉTODO: Apesar de existirem terapêuticas eficazes para o tratamento do transtorno obsessivo-compulsivo, uma parcela significativa dos pacientes acometidos por tal condição não alcança ou não mantém a remissão dos sintomas mesmo com tratamento adequado. O alívio do sofrimento destes pacientes com os tratamentos existentes representa um desafio para o clínico, que, nestas situações, se vê, freqüentemente, sem respostas satisfatórias. O objetivo desta revisão da literatura é avaliar os conceitos e critérios de resistência e refratariedade ao tratamento, abordar os aspectos intrínsecos e extrínsecos à fenomenologia descritiva do transtorno obsessivo-compulsivo que possam influenciar a resposta aos tratamentos convencionais preconizados, e propor um fluxo de alternativas terapêuticas para casos resistentes e refratários às diversas abordagens. CONCLUSÃO: A literatura evidencia que tanto aspectos intrínsecos à fenomenologia do transtorno obsessivo-compulsivo, quanto aspectos extrínsecos podem colaborar para que pelo menos 30 por cento dos pacientes não obtenham o resultado desejado. Várias alternativas de tratamento e/ou de potencialização, sejam psicofarmacológicas, biológicas ou psicoterápicas, estão disponíveis, mas vários estudos ainda são necessários para que as evidências apontem na direção mais adequada para a remissão dos sintomas.

OBJECTIVE AND METHOD: Despite the existence of effective therapeutic alternatives for obsessive-compulsive disorder, a significant number of patients does not achieve or does not maintain remission after adequate treatment. The relief of these patients’ suffering with the available treatments is a clinical challenge related to many unanswered questions. The objective of this literature review is to evaluate the current concepts of treatment resistance and refractoriness, to describe the intrinsic and extrinsic factors of obsessive-compulsive disorder’s phenomenology that might influence treatment response to conventional treatment, and to present a fluxogram of therapeutic alternatives for resistant or refractory obsessive compulsive disorder patients. CONCLUSION: The literature evinces that intrinsic and/or extrinsic phenomenological aspects of obsessive-compulsive disorder may collaborate to the fact that, at least 30 percent of obsessive-compulsive disorder patients do not respond to conventional treatment. Several therapeutic or augmentation alternatives, psychopharmacological, biological or even psychotherapeutical exists, but more studies are necessary to evince the correct way to symptom remission.

Psicocirugía en un paciente con trastorno obsesivo compulsivo resistente / Psychosurgery in a patient with refractory obsessive-compulsive disorder

El término psicocirugía fue introducido por primera vez por Egaz Moniz en 1937 para los procedimientos ablativos o resectivos del lóbulo frontal para disminuir síntomas psiquiátricos. La psicocirugía es un tratamiento disponible actualmente en varios centros mundiales, como tratamiento definitivo en pacientes bien seleccionados para enfermedades como el trastorno obsesivo-compulsivo resistente (TOC-R) y la agresividad resistente (AR) al tratamiento. En México no existen comités multidisciplinarios para el tratamiento de estas enfermedades psiquiátricas, ya que este tipo de pacientes tiene períodos de estancias hospitalarias prolongados e incapacidad laboral y personal, ésta es una alternativa no convencional que ha brindado la oportunidad de reincorporar a este tipo de pacientes y llevar una mejor observancia del tratamiento, se sabe que los centros más destacados en este ámbito están en Inglaterra, Estados Unidos y Chile. El presente artículo es un reporte de un caso en el que se demuestra la efectividad del procedimiento para disminuir los síntomas obsesivo y compulsivo resistentes, y al mismo tiempo corroborar que las funciones mentales superiores no están afectadas

The term psychosurgery was first used by Egaz Moniz in 1937 to describe ablative or resective procedures in the frontal lobe to reduce psychiatric symptoms. Psychosurgery is currently available in various centers throughout the world as the definitive treatment in selected patients with disorders such as refractory obsessive-compulsive syndrome and refractory aggression. In Mexico, multidisciplinary committees for the treatment of these psychiatric disorders are lacking since this type of patient undergoes long periods of hospitalization, as well as occupational and personal disability. Psychosurgery is an unconventional alternative that offers the possibility of reintegrating this type of patient and of achieving greater treatment compliance. The most important centers for psychosurgery are found in England, the USA and Chile. The present article reports a case that demonstrates the effectiveness of psychosurgery in reducing refractory obsessive-compulsive symptoms and corroborates that higher mental functions are left intact

Atualização sobre o tratamento neurocirúrgico do transtorno obsessivo-compulsivo / Update on neurosurgical treatment for obsessive compulsive disorder

O transtorno obsessivo-compulsivo (TOC) responde aos tratamentos habituais (fármacos e psicoterapia) em cerca de 60 a 80 por cento dos casos. Existe, assim, uma parcela de pacientes resistente aos tratamentos usuais, mesmo que adequadamente conduzidos, com grave prejuízo psicossocial. Nestas situações, a neurocirurgia pode ser indicada. Existem cinco técnicas cirúrgicas disponíveis, com as seguintes taxas de melhora global pós-operatória: capsulotomia anterior (38 a 100 por cento); cingulotomia anterior (27 a 57 por cento); tractotomia subcaudado (33 a 67 por cento); leucotomia límbica (61 a 69 por cento) e talamotomia central lateral com palidotomia anteromedial (62,5 por cento). A capsulotomia anterior pode ser realizada através de diferentes técnicas: neurocirurgia padrão, radiocirurgia ou estimulação cerebral profunda. Na neurocirurgia padrão, circuitos neurais são interrompidos por radiofreqüência via trepanação no crânio. Na radiocirurgia, uma lesão actínica é induzida sem a necessidade de abertura do crânio. A estimulação cerebral profunda consiste na implantação de eletrodos ativados a partir de estimuladores. A literatura indica taxas relativamente baixas de eventos adversos e complicações, sendo raramente descritas alterações neuropsicológicas e de personalidade. Cumpre ressaltar, no entanto, a falta de ensaios clínicos randomizados que comprovem a eficácia e investiguem os eventos adversos ou complicações dos procedimentos cirúrgicos acima mencionados. Concluindo, há um recente aprimoramento das neurocirurgias dos transtornos psiquiátricos graves no sentido de torná-las cada vez mais eficazes e seguras. Estas cirurgias, quando adequadamente indicadas, podem trazer alívio substancial ao sofrimento de pacientes com TOC grave.

Eficacia de la psicocirugía en el trastorno obsesivo-compulsivo. Resultados preliminares (septiembre, 2002) / Effectiveness of psychosurgery in obsessive-compulsive disorder.

Tras una concisa introducción al trastorno obsesivo-compulsivo (T.O.C.) resistente, a la historia de la psicocirugía y en concreto a la técnica neuroquirúrgica de la capsulotomía bilateral anterior, se describe el Protocolo de Psicocirugía del T.O.C. resistente del Hospital de Mutua de Terrassa. Dicho protocolo se halla en marcha desde 1998, habiéndose valorado 38 solicitudes y dando lugar a 18 intervenciones de psicocirugía mediante capsulotomía bilateral anterior por termocoagulación, hasta Septiembre de 2002 y de su seguimiento durante un año. Se informa de los resultados preliminares valorándose: La Escala de Yale-Brown para Obsesiones-Compulsiones (Y-BOCS) total y las subescalas para obsesiones y compulsiones, los cuestionarios de Hamilton y Beck para depresión y STAI-estado para la ansiedad y la Escala de Evolución de la Actividad Global (E.E.A.G.) del Eje V del DSM-IV. Así como de una batería básica de evolución neuropsicologica compuesta por: los cubos de Kohs, la medida de la memoria visual inmediata y a medio plazo (WMS-R) del test del trazo A y B (TMT). Como medida principal de respuesta la escala Y-BOCS basal de 29,4 paso a 19,1 al mes y al 17,3 al año, con una mejoría media del 332 por ciento al mes. Un 53 por ciento de pacientes mejoraron, tomando como criterio de respuesta la disminución del 33 por ciento de su puntuación basal en la Y-BOCS total. No se objetivó empeoramiento en ninguna de las escalas neuropsicologicas utilizadas. Tan sólo 3 pacientes presentaron complicaciones tras la capsulotomía (AU)