Atualização sobre o tratamento neurocirúrgico do transtorno obsessivo-compulsivo

Abstract

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.Obsessive-compulsive disorder. Psychosurgery. Neurosurgery. Surgery. Review.O transtorno obsessivo-compulsivo (TOC) responde aos tratamentos habituais (fármacos e psicoterapia) em cerca de 60 a 80% 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-operató-ria: capsulotomia anterior (38 a 100%); cingulotomia anterior (27 a 57%); tractotomia subcaudado (33 a 67%); leucotomia límbica (61 a 69%) e talamotomia central lateral com palidotomia anteromedial (62,5%). 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 aprim...

Assessment and Management of Treatment-Refractory Obsessive-Compulsive Disorder in Children

“…The specifics of each procedure are covered in other reviews in the area. 111,112 Currently, no published controlled studies have demonstrated the efficacy of neurosurgery for the treatment of OCD. Reviews of open studies of neurosurgical procedures in OCD have suggested 50–60% response rates observed after 6–24 months.…”

Resistência e refratariedade no transtorno obsessivo-compulsivo

“…Among several tools that are based in the neuroanatomy, we can mention transcranial magnetic stimulation (TMS), vagus nerve stimulation (VNS) e deep brain stimulation (DBS), in addition to the well-known neurosurgical techniques. 55,56 1. Transcranial magnetic stimulation (TMS) According to the 2003 Cochrane Database Systematic Reviews, three clinical trials have been included in a review on TMS in OCD, and two of them included data that were adequate for the analysis, but did not allow the performance of a metaanalysis.…”

“…Most of them are prospective follow-ups of one or more cohorts of patients who underwent surgery. 55 Only one randomized clinical trial of neurosurgery has been carried out, and it compared the capsulotomy to the cingulotomy, but with a small number of patients. 61 On the other hand, in DES studies of the internal capsule, we found randomized clinical trials, but they involved small samples.…”

“…55 The radiosurgery has the advantage of not requiring cranial opening and the zero risk of hemorrhages and infections. Its efficacy ranges between 37.5 and 70% of the patients.…”

“…Generally speaking, however, the most prevalent adverse effects are isolated cases of seizures, delirium immediately after the surgery, hypomania and, rarely, hemorrhages and neuroinfection. 55 In the radiosurgery, the most frequent side effects are headache episodes. Neuropsychological alterations are rare and, when they occur, their manifestation is mainly by means of apathy symptoms, mental slowness, irritability, aggressiveness and behavioral lack of inhibition.…”