Deep Brain Stimulation in the Ventral Capsule/Ventral Striatum for the Treatment of Obsessive–Compulsive Disorder: Role of the Bed Nucleus of the Stria Terminalis (original) (raw)
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Update on neurosurgical treatment for obsessive compulsive disorder
Responses to pharmacotherapy and psychotherapy in obsessive-compulsive disorder (OCD) range from 60 to 80% of cases. However, a subset of OCD patients do not respond to adequately conducted treatment trials, leading to severe psychosocial impairment. Stereotactic surgery can be indicated then as the last resource. Five surgical techniques are available, with the following rates of global post-operative improvement: anterior capsulotomy (38-100%); anterior cingulotomy (27-57%); subcaudate tractotomy (33-67%); limbic leucotomy (61-69%), and central lateral thalamotomy/anterior medial pallidotomy (62.5%). The first technique can be conducted as a standard neurosurgery, as radiosurgery or as deep brain stimulation. In the standard neurosurgery neural circuits are interrupted by radiofrequency. In radiosurgery, an actinic lesion is provoked without opening the brain. Deep brain stimulation consists on implanting electrodes which are activated by stimulators. Literature reports a relatively low prevalence of adverse events and complications. Neuropsychological and personality changes are rarely reported. However, there is a lack of randomized controlled trials to prove efficacy and adverse events/complication issues among these surgical procedures. Concluding, there is a recent development in the neurosurgeries for severe psychiatric disorders in the direction of making them more efficacious and safer. These surgeries, when correctly indicated, can profoundly alleviate the suffering of severe OCD patients.
World Neurosurgery, 2020
BACKGROUND: Obsessive-compulsive disorder (OCD) is a chronic disease with a lifetime prevalence of 3% and is associated with severe impairment in familial and sociooccupational functioning. Gamma ventral capsulotomy (GVC) is a treatment choice in carefully chosen patients, with few published reports. In this study, we aimed to report the efficacy and safety of GVC in 21 patients with treatment-resistant OCD.-METHODS: This is a retrospective single-center study. Twenty-one patients meeting the selection criteria were included. Patients were considered responders if there were ‡35% reduction in post-GVC Yale-Brown Obsessive Compulsive Scale scores and considered in remission if scores were £8. The mean and median clinical follow-up durations were 60.7 and 56 months, respectively (range, 38e149 months).-RESULTS: The mean baseline Yale-Brown Obsessive Compulsive Scale score of 35.7 (n [ 21) decreased to 15.3 (n [ 20) at 36 months follow-up evaluation (P < 0.0001). Fifteen patients (75%) achieved a full response. Of those patients, 7 (35%) were considered to be in remission. There were no partial responders, and 5 patients (25%) were classified as nonresponders. The pre-GVC mean Beck Depression InventoryeII score of 35.1 (n [ 21) decreased to 13.8 (n [ 20) at 36 months follow-up evaluation (P < 0.0001). Three patients (14.3%) had a transient post-GVC headache that resolved within a week, and 2 patients (9.5%) had persistent headaches that responded to 2-week oral corticosteroid treatment. A brain cyst developed after GVC in 2 patients (10%). No clinically notable abnormalities were seen on neurologic examination at any follow-up.-CONCLUSIONS: Gamma ventral capsulotomy is a reasonable treatment method in select patients with treatment-resistant OCD.
Gamma Ventral Capsulotomy in Intractable Obsessive-Compulsive Disorder
Biological Psychiatry, 2018
BACKGROUND: Despite the development of effective pharmacologic and cognitive behavioral treatments for obsessive-compulsive disorder (OCD), some patients continue to be treatment-refractory and severely impaired. Fiber tracts connecting orbitofrontal and dorsal anterior cingulate cortex with subcortical nuclei have been the target of neurosurgical lesions as well as deep brain stimulation in these patients. We report on the safety and efficacy of ventral gamma capsulotomy for patients with intractable OCD. METHODS: Fifty-five patients with severely disabling, treatment-refractory OCD received bilateral lesions in the ventral portion of the anterior limb of the internal capsule over a 20-year period using the Leksell Gamma Knife. The patients were prospectively followed over 3 years with psychiatric, neurologic, and neuropsychological assessments of safety and efficacy, as well as structural neuroimaging. RESULTS: Thirty-one of 55 patients (56%) had an improvement in the primary efficacy measure, the Yale-Brown Obsessive Compulsive Scale, of $35% over the 3-year follow-up period. Patients had significant improvements in depression, anxiety, quality of life, and global functioning. Patients tolerated the procedure well without significant acute adverse events. Five patients (9%) developed transient edema that required short courses of dexamethasone. Three patients (5%) developed cysts at long-term follow-up, 1 of whom developed radionecrosis resulting in an ongoing minimally conscious state. CONCLUSIONS: Gamma Knife ventral capsulotomy is an effective radiosurgical procedure for many treatmentrefractory OCD patients. A minority of patients developed cysts at long-term follow-up, 1 of whom had permanent neurological sequelae.
Gamma ventral capsulotomy for obsessive-compulsive disorder: a randomized clinical trial
JAMA psychiatry, 2014
Select cases of intractable obsessive-compulsive disorder (OCD) have undergone neurosurgical ablation for more than half a century. However, to our knowledge, there have been no randomized clinical trials of such procedures for the treatment of any psychiatric disorder. To determine the efficacy and safety of a radiosurgery (gamma ventral capsulotomy [GVC]) for intractable OCD. In a double-blind, placebo-controlled, randomized clinical trial, 16 patients with intractable OCD were randomized to active (n = 8) or sham (n = 8) GVC. Blinding was maintained for 12 months. After unblinding, sham-group patients were offered active GVC. Patients randomized to active GVC had 2 distinct isocenters on each side irradiated at the ventral border of the anterior limb of the internal capsule. The patients randomized to sham GVC received simulated radiosurgery using the same equipment. Scores on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and the Clinical Global Impression-Improvement (CGI-I...
Neuropsychiatric Disease and Treatment, 2014
Objective: Deep-brain stimulation (DBS) for treating refractory obsessive-compulsive disorder (OCD) has shown positive results in small clinical trials. Ventral capsule/ventral striatum (VC/ VS) is one of the promising targets; however, whether or not acute stimulation test can provide substantial information for chronic stimulation is not yet known. We evaluated postoperative test stimulation and examined the relationship of acute simulation-induced smile/laughter and 15-month clinical outcome. Methods: Four adult patients with refractory OCD were implanted with Model 3387 leads bilaterally in an area of VC/VS. Postoperative test stimulation was performed at least 2 weeks after surgery. We performed double-blinded postoperative test stimulation with different contact and voltage. The relationship of stimulation-induced smile/laughter and chronic response was examined. Results: Patients presented smile, laughter, euphoria, increased heart rate, increased blood pressure, smell, chest vibration, dizziness, nausea, heat, or increased sexual drive during acute stimulation. We found that the higher the percentage of smile/laughter (34.3%, 31.3%, 56.3%, and 12.5% for four cases), the greater the reduction in the Yale-Brown Obsessive Compulsive Scale (30.6%, 38.9%, 58.8%, and 7.7% respectively at 15-month DBS). Conclusion: This study showed that acute DBS of the VC/VS might cause mood change, cardiovascular, sensory, or motor effects. These effects were transient or habituated over six months. We suggest stimulation-induced smile/laughter may be a possible predictor for longterm DBS outcome. Larger studies, genetic studies, and imaging studies are needed to evaluate the effects of different parameters and possible predictors in the treatment of OCD.
Bilateral stereotactic anterior capsulotomy for obsessive-compulsive disorder: long-term follow-up
Journal of Neurology, Neurosurgery & Psychiatry, 2013
Background and purpose Psychosurgery, such as anterior capsulotomy, is a therapeutic option for treatment-resistant obsessive-compulsive disorder (OCD). In this paper, we present a prospective, long-term follow-up study aimed at evaluating both the efficacy and the safety of anterior capsulotomy for the treatment of severe, refractory OCD. Methods Twenty-four patients were surgically treated in our centre between 1997 and 2009, 19 of whom were included in this study. Patients were assessed at 3, 6, 12, and 24 months and last follow-up (mean of 7 years) was carried out by phone. OCD symptom severity was evaluated using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). A patient with an improvement rate of over 35% in the Y-BOCS score was considered a responder, while a patient with a 25% improvement was considered a partial responder. Results With a mean improvement of 31% in the Y-BOCS score at long-term follow-up, 36.8% of the patients responded fully to the procedure and 10.5% were considered partial responders, for an overall response rate of 47.3% of patients. At the end of the study, 3/19 patients had recovered (Y-BOCS score <8) and 3/19 were in remission (Y-BOCS score <16). No cases of mortality were reported and the overall adverse event rate was 57.9%. Only 2 patients had permanent surgical complications. Conclusions Anterior capsulotomy is an effective and safe technique for the treatment of severe refractory OCD in patients who have no other alternative to improve their symptoms.
Journal of Affective Disorders, 2010
Background: For treatment-refractory Obsessive-Compulsive-Disorder (OCD) patients, anterior capsulotomy is a potential therapy. We investigated what kinds of cognitive deficits treatmentrefractory patients have and how anterior capsulotomy modifies their clinical and cognitive profiles. Methods: Ten treatment-refractory OCD patients were examined in two groups (operated and non-operated) with 5 participants in each group, matched for symptom severity, gender, age and education. The operated group was treated with anterior capsulotomy; the non-operated group was treated only with pharmaco-and psychotherapy. The Yale-Brown Obsessive-Compulsive Rating Scale (Y-BOCS) was used to measure OCD symptoms, and ten neuropsychological tests were used to measure cognitive functioning. Results: In the operated group, the score of Y-BOCS score significantly decreased during the twoyear follow-up period. Additionally, we found a significant increase in neuropsychological test scores on the Wechsler Intelligence Test (MAWI), California Sorting Test Part A (CST-A), Stroop Test Interference Score (STR-I), Verbal Fluency Test and Iowa Gambling Test. As a negative result, we observed intrusion errors in the Category Fluency Test. In the non-operated group significant improvement was found in Y-BOCS scores. At follow-up, we found significant differences between the operated and non-operated groups on three neuropsychological tests: Trail Making Test Part B, Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) Attention Index and RBANS Language Index, with better performance in the non-operated group. Conclusions: Both treatment methods (i.e. anterior capsulotomy and pharmaco-and psychotherapy) seem effective in reducing OCD symptoms and cognitive deficits, but, importantly, to different degrees. The clinical and neuropsychological improvements were more impressive in the operated group.
Precision surgery for obsessive compulsive disorder—which is the proper target?
Annals of Translational Medicine
Obsessive-compulsive disorder (OCD) is a mental health condition in which recurring, anxiety-inducing thoughts or urges (obsessions) are usually followed by uncontrolled mental or behavioral acts (compulsions) being the cause of major illness related disability (1). Patients diagnosed with OCD resistant to medical and psychiatrical treatment may be contemplated for surgery. The original operations sought to produce lesions at different points within the circuit of Papez (considered the substrate of emotions) such as the cingulate bundle, the anterior thalamo-cortical connections or the anterior limb of the internal capsule (ALIC), among others (2). However, the results of these operations, regardless of the target chosen, ranged about 50% of good results. Curiously, the same lesions applied to a different psychiatric disease, major depression, yielded similar outcomes. Deep brain stimulation (DBS) for OCD has been later introduced to substitute the lesioning procedures, the main arguments being that the possible side effects of the technique can be reverted by turning the stimulator off, and that the therapeutic effect can be modulated by changing the stimulation parameters. DBS for OCD has targeted regions similar to those formerly subjected to lesions, which are considered components of the reward and motivation system, such as the nucleus accumbens (NAcc), the ventral capsule/ventral striatum (VC/VS), the anteriomedial (limbic) portion of the subthalamic nucleus (amSTN), the ALIC, the inferior thalamic peduncle and the bed nucleus of the stria terminalis (BNST), which are among the components of the motivational and reward system (3,4).
Journal of Neuropsychiatry and Clinical Neurosciences, 2009
A subgroup of obsessive-compulsive disorder (OCD) patients remains refractory to conventional treatments. For them, a new stereotactic radiosurgery has been recently developed: the ventral capsular/ventral striatal (VC/VS) gamma capsulotomy. The authors aim to report efficacy and adverse events of VC/VS gamma capsulotomy. Five refractory OCD patients were selected. The authors assessed OCD, anxiety and depressive symptoms, and side effects pre-and postoperatively. Three patients (60%) met response criteria 48 months after surgery. Adverse effects were episodic and transient. Ventral capsular/ventral striatal gamma capsulotomy holds therapeutic promise, with few adverse effects.