Psychiatry 2008 - September 2008 - (Page 30)

psychotherapeutic alternatives have been utilized with no benefit, and a detailed informed consent process, which involves both patient and family, are central. Stereotaxis. Advances in neurosurgery now allow precise lesioning techniques via stereotaxis. Stereotaxis is the method by which neurosurgeons visualize the brain as volume in a three-dimensional space. The brain is then referenced to a specific coordinate system that allows for precision in reaching subcortical brain structures with minimal disruption of the surrounding tissue. Neurosurgeons currently use stereotactic techniques with computer-based functional neuroimaging and physiologic recordings to allow for submillimeter accuracy.2 Currently, there are four ablative neurosurgical procedures utilized for treatment-refractory OCD and MDD: cingulotomy, capsulotomy, subcaudate tractotomy, and limbic leucotomy. Each of these procedures seeks to modulate the activity of the neurocircuitry described previously, including the interactions between various components of the frontal cortex and cingulate cortex and their interactions with the basal ganglia and the thalamus. Lesioning procedures. Cingulotomy. Neurosurgery of the cingulate gyrus has been reported since the 1940s, with Freeman and Watts reporting that severing fibers from the cingulate gyrus led to an improvement of anxiety symptoms and Whitty reporting a bilateral resection of the cingulate gyrus in 1952.2 Currently stereotactic, bilateral lesioning of the cingulate gyrus is the most common neurosurgical procedure for treatment refractory psychiatric syndromes, specifically OCD. The cingulate gyrus is critical in corticostriatal-thalamic pathways in mediating the transfer of information from the anterior cingulate cortex to the orbitofrontal cortex and to the limbic system.16 In a cingulotomy, the anterior portion of the cingulate gyrus is lesioned, interrupting tracts 30 Psychiatry 2008 [SEPTEMBER] between the cingulate gyrus and the frontal lobes, eliminating the efferent projections of the anterior cingulate cortex.11 See Figure 3. Results. One retrospective study demonstrated a mean 30-percent improvement in patients (n=33) who underwent cingulotomy for OCD.17 Eighteen of these patients were included in a follow-up study with a 30-percent success rate.18 Jung, et al., followed 17 patients with treatment refractory OCD who had received bilateral stereotactic cingulotomy for a period of 24 months and reported response in eight patients (47%) with a mean reduction of 48 percent in their baseline Yale-Brown Obsessive Compulsive Scale (YBOCS) scores.19 In a recent prospective study, Dougherty, et al.,18 reported on 44 patients undergoing cingulotomy for OCD, with 32 percent meeting criteria for response and 14 percent meeting criteria for partial response at 32 weeks post-surgery. Cosgrove, et al., recently reported on the safety of over 800 cingulotomies performed over a 40-year period at Massachusetts General Hospital, with no deaths and only two infections being reported.20 For intractable major depression, response rates have been high, with a 68-percent response rate (n=198) reported by Ballantine21 and a 60-percent response rate (n=34) by Greenberg, et al.22 A recent study by Steele, et al., reported on eight patients with treatment refractory MDD undergoing anteriorly placed cingulate cortex lesions with beneficial results.21 Capsulotomy. Developed by Lars Leksell and Jean Talairach in the 1940s, the anterior capsulotomy has been in use for treatment refractory OCD and depression for over five decades.2 This surgery targets the anterior limb of the internal capsule, which serves as a relay route between cortical structures and the thalamus. A prospective study of 15 patients who underwent bilateral anterior capsulotomy for OCD reported that 53 percent of the patients showed a 33-percent reduction in symptoms, 29 percent of the cases experienced a 50percent reduction, and 17 percent were improved by as much as 66 percent. Complications were observed in three cases: one with transitory hallucinations, one with a single epileptic seizure, and one case who developed a progressive behavior disorder that became permanent.23 A more recent study by Liu, et al., reported on 35 patients with treatment refractory OCD who underwent stereotactic bilateral capsulotomy with a three-year follow-up. Results were robust: Twenty patients became OCD symptom-free (57%), 10 experienced significant improvement (29%), and five experienced no meaningful improvement (14%).24 Subcaudate tractotomy. Another neurosurgical procedure that is hypothesized to exert its effects by interrupting the relay between the cortex and thalamus via the striatum is subcaudate tractotomy. This procedure was developed by in London by Knight in 1965 and has primarily been used for treatment refractory depression. The target site is a region of white matter localized beneath the head of the caudate known as the substantia innominata.2 Poynton, et al., prospectively studied 23 patients undergoing a stereotactic subcaudate tractotomy for treatment refractory depression. There was no significant correlation except for the six-month assessment when lower Hamilton scores were found to be associated with better global outcome.25 Greenberg, et al., reviewed outcomes with subcaudate tractotomy that included 1,300 patients and reported 40 to 60 percent of patients benefiting.22 Limbic leucotomy. This procedure was developed by Kelly and Richardson in the 1970s. The surgery is essentially a combination of subcaudate tractotomy and cingulotomy. Montoya, et al., conducted preoperative evaluations and postoperative follow-up assessments of efficacy and complications for 21 patients who underwent limbic leucotomy for OCD

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Psychiatry 2008 - September 2008 Editor’s Message Editorial Advisory Board Contents Psych Rx Letters to the Editor Use of Benzodiazepines in the Treatment of Anxiety Functional Neurosurgery in the Treatment of Severe Obsessive Compulsive Disorder and Major Depression: Overview of Disease Circuits and Therapeutic Targeting for the Clinician Treatment of Comorbid Adolescent Cannabis Use and Major Depressive Disorder Risperidone Long-acting Injections: Successful Alternative Deltoid Muscle Injections for Refractory Schizophrenia Alcohol/Substance Misuse and Treatment Nonadherence: Fatal Attraction Transforming the Psychiatric Inpatient Unit from Short-term Pseudo-asylum Care to State-of-the-art Treatment Setting Journal Watch Classified Advertising Information for Authors

Psychiatry 2008 - September 2008

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