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Table of Contents    
COMMENTARY
Year : 2017  |  Volume : 65  |  Issue : 4  |  Page : 777-778

Neurosurgery for psychiatric disorders


Department of Neurosurgery and Functional Neurosurgery, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India

Date of Web Publication5-Jul-2017

Correspondence Address:
Paresh K Doshi
Department of Neurosurgery and Functional Neurosurgery, Jaslok Hospital and Research Centre, 15, Dr. G Deshmukh Marg, Mumbai - 400 026, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_521_17

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How to cite this article:
Doshi PK. Neurosurgery for psychiatric disorders. Neurol India 2017;65:777-8

How to cite this URL:
Doshi PK. Neurosurgery for psychiatric disorders. Neurol India [serial online] 2017 [cited 2019 Dec 15];65:777-8. Available from: http://www.neurologyindia.com/text.asp?2017/65/4/777/209522




Neurosurgery for Psychiatric Disorders (NPDs) has one of the most colourful histories in functional neurosurgery. In order to understand the present context of NPD, it is important to visit this history. We can divide the history into three distinct phases. One is the pre-steterotactic era from 1935-1960.[1] This period was dominated by frontal leucotomy and cortical undercutting. According to one estimate, more than 30,000 surgeries were performed in USA and UK. Large number of these surgeries lacked any scientific basis and follow-up; and, were done for personality disorders (schizophrenia) rather than mood disorders. There was a huge backlash from the society and the surgery was banned in several countries, which continues even today, e.g. in Germany and Japan. In the second phase, the role of open surgery became more restricted and the phase was marked by two important inventions, the use of chlorpromazine, a very effective medical treatment; and, the stereotactic apparatus, that made the surgeries more precise. The number of surgeries in this period could not be accurately ascertained as the reporting was erratic. As per surveys and personal communications, Elliot Valenstein estimated that the number of psychosurgical operations performed per year between 1971 and 1976 was in the order of 400-500 in the United States and Canada, 200-250 in Great Britain, 83 in Australia, and 10-61 in countries such as India, Czechoslovakia, and Mexico.[2] The indications had now shifted to mood disorders rather than to personality disorders. These surgeries also laid the foundation for the current surgical targets. The third era is the present period which has a more precise and restricted application of NPD. During this period, the ablative surgery was practised in very few centres around the world, namely in USA, UK, Sweden, New Zealand, Australia and Netherlands. In 1999, Bart Nuttin and his colleagues were the first to replace ablative surgery in patients with obsessive compulsive disorders (OCD) by bilateral high-frequency stimulation of the anterior limb of the internal capsule. The jury is still out as to whether deep brain stimulation (DBS) or ablative surgery should be performed for NPDs.

In order to have a more regulatory oversee and avoid the mistakes of the past, the World Society for Stereotactic And Functional Neurosurgery set up a task force in 2011 (the author being one of the members) to draw the guidelines for NPDs. The task force, after an extensive review of the literature, personal interviews and discussions with various societies, prepared the compilation of guidelines for NPD, which was published in 2013. The most essential element of these guidelines included the statement that these surgeries be done only by trained neurosurgeons under strict ethical adherence. Any centre desirous to start this program should consult these guidelines.[3]

The study by Liu et al., published in this issue reports approximately 67% improvement in the YBOCS scores at the end of five years following anterior capsulotomy for OCD. YBOCS scores improved over 50% in 73% of patients.[4] This is in line with the other published data. The main complications included apathy, executive dysfunction, hypomania, frontal lobe behaviour and urinary incontinence. Additionally, they used pre- and post-operative DTI MRI and PET scanning to assess the fibre connectivity and brain metabolism. The DTI study revealed interesting observations, that the presence of residual transverse fibres correlated with treatment failure, and a smaller decrease in hypermetabolism in the frontal lobe on PET studies occurred in non-responders to the treatment as compared to the responders. However, these studies lacked the necessary caveats of subjecting the patients to cognitive and behavioural therapy before establishing medical refractoriness. Their targeting techniques, which were not modified in line of the current observations (as discussed below), could be one of the reasons for their rate of complications, especially those of the frontal lobe dysfunction.

Evolution of the target

Anterior limb of the internal capsule (ALIC) has been the most commonly selected target for OCD surgery.[5] Several techniques have been used to modulate the same, including gamma knife radiosurgery, radiofrequency ablation or DBS. The surgical target is of considerable interest, as over a period of time, several structures in the neighbouring area have been found to be effective in controlling the symptoms of OCD. These include nucleus accumbens (NAc) and bed nucleus of striae terminalis (BST). The capsulotomy may have actually involved these structures as well. Over a period of time, the ALIC target itself has evolved.[5] The traditional target used to be much more anterior from the anterior border of anterior commissure (AC) ranging from 7-15 mm. However, based on the observations of DBS, current requirements and success rates by Ali Rezai's and Bart Nuttin's group,[3] the target has been moved more posteriorly and is now only couple of mm. anterior to the AC. Our experience also supports this observation.

Nucleus accumbens, a new target for multiple behavioural disorders

NAc has been found to be a target of increasing interest. It is located at the base of the ALIC [Figure 1]. It receives afferents from ventral tegmental area and substantia nigra that are dopaminergic in nature; and, also receives glutamatergic inputs from the thalamus, amygdala, prefrontal cortex, hippocampus, subiculum etc. The efferents go to stria terminalis, preoptic region, nucleus parataenialis, nucleus mediodorsalis thalami, lateral habenular nucleus, substantia nigra-ventral tegmental area, the lateral hypothalamus, cingulum, thalamus, globus pallidus, and subpallidal region.[6] Due to its connections and cytoarchitecture, the NAc has been said to be the functional interface between the limbic and motor systems. Patients with mood disorders have been found to have lesser activation of NAc on positron emission tomographic (PET) imaging and a smaller volume of NAc detectable on magnetic resonance imaging (MRI). NAc has been used as a target for ablative and DBS surgeries for depression and OCD. We have an experience of four cases of OCD who underwent lesioning of NAc/ALIC with a favourable outcome.[7] Two patient had a YBOCS of 40/40. The average YBOCS improved from 39.25 to 8.06 (80% improvement). One patient underwent DBS and his YBOCS score improved from 38 to 14. Recently, we used NAc DBS to control the aggression and obsessive compulsive behaviour in one severely autistic patient. At two months follow up, NAc stimulation has completely controlled her aggression and behaviour. She has also started interacting socially and has been found to have improvement in her autism.
Figure 1: T2 weighted MRI 4 mm anterior to the posterior border of anterior commissure. Note the NAc target (red dot) and its relation to the bottom of the internal capsule (4 mm below the AC-PC plane)

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  Conclusion Top


We are at the cusp of a revolution. NPD has much further reaching implications than only treating OCD or depression. It is finding applications in the treatment of anorexia nervosa, addiction, obesity and many other disorders. At this juncture, it is important to remind ourselves not to commit the mistakes of our predecessors, i.e. to avoid the indiscriminate use of NPD. NPD should be performed only in institutions, under strict supervision of scientific and ethical bodies to regulate and monitor the progress. Understanding of the neurobiology of the disease and structural mapping of the brain will further help to improve the outcome.



 
  References Top

1.
Neumaier F, Paterno M, Alpdogan S, Tevoufouet EE, Schneider T, Hescheler J, et al. Surgical approaches in psychiatry: A survey of the world literature on psychosurgery. World Neurosurg 2017;97:603-34.e8.  Back to cited text no. 1
    
2.
Valenstein ES. Brain stimulation and behavior control. Nebr Symp Motiv 1975;22:251-92.  Back to cited text no. 2
[PUBMED]    
3.
Nuttin B, Wu H, Mayberg H, Hariz M, Gabriëls L, Galert T, et al. Consensus on guidelines for stereotactic neurosurgery for psychiatric disorders. J Neurol Neurosurg Psychiatry. 2014;85:1003-8.  Back to cited text no. 3
    
4.
Liu HB, Qi Z, Wang W. Bilateral anterior capsulotomy for patients with refractory obsessive-compulsive disorder: A multi-centre, long-term follow-up study. Neurol India 2017;65:770-76.  Back to cited text no. 4
  [Full text]  
5.
Naesstrom M, Blomstedt P, Bodlund O. A systematic review of psychiatric indications for deep brain stimulation, with focus on major depressive and obsessive-compulsive disorder. Nord J Psychiatry 2016;70:483-91.  Back to cited text no. 5
    
6.
Salgado S, Kaplitt MG. The nucleus accumbens: A comprehensive review. Stereotact Funct Neurosurg 2015;93:75-93.  Back to cited text no. 6
[PUBMED]    
7.
Doshi PK. Anterior capsulotomy for refractory OCD:First case as per the core group guidelines. Indian J Psychiatry 2011;53:270-73.  Back to cited text no. 7
[PUBMED]  [Full text]  


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