Bilateral thermal capsulotomy with MR-guided focused ultrasound for patients with treatment-refractory obsessive-compulsive disorder: a proof-of-concept study

Abstract

Despite optimal pharmacotherapy and cognitive-behavioral treatments, a proportion of patients with obsessive-compulsive disorder (OCD) remain refractory to treatment. Neurosurgical ablative or nondestructive stimulation procedures to treat these refractory patients have been investigated. However, despite the potential benefits of these surgical procedures, patients show significant surgery-related complications. This preliminary study investigated the use of bilateral thermal capsulotomy for patients with treatment-refractory OCD using magnetic resonance-guided focused ultrasound (MRgFUS) as a novel, minimally invasive, non-cranium-opening surgical technique. Between February and May 2013, four patients with medically refractory OCD were treated with MRgFUS to ablate the anterior limb of the internal capsule. Patients underwent comprehensive neuropsychological evaluations and imaging at baseline, 1 week, 1 month and 6 months following treatment. Outcomes were measured with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Hamilton Rating Scale for Depression (HAM-D) and the Hamilton Rating Scale for Anxiety (HAM-A), and treatment-related adverse events were evaluated. The results showed gradual improvements in Y-BOCS scores (a mean improvement of 33%) over the 6-month follow-up period, and all patients showed almost immediate and sustained improvements in depression (a mean reduction of 61.1%) and anxiety (a mean reduction of 69.4%). No patients demonstrated any side effects (physical or neuropsychological) in relation to the procedure. In addition, there were no significant differences found in the comprehensive neuropsychological test scores between the baseline and 6-month time points. This study demonstrates that bilateral thermal capsulotomy with MRgFUS can be used without inducing side effects to treat patients with medically refractory OCD. If larger trials validate the safety, effectiveness and long-term durability of this new approach, this procedure could considerably change the clinical management of treatment-refractory OCD.

Psychosurgery, ethics, and media: a history of Walter Freeman and the lobotomy

“…21 Despite Freeman's controversial legacy, his neurosurgeon contemporaries continued to recognize the therapeutic potential of psychosurgery, and they refined and modified Freeman's conception of the frontal lobotomy. In 1949, William Beecher Scoville pioneered methods of orbital undercutting, which separated abnormal cortex from normal white matter tracts and facilitated targeted ablation of abnormal tissue.…”

The use of transcranial focused ultrasound in CNS diseases

“…Jung и соавт. [35] опубликовали работу по исполь-зованию ФУЗ при лечении обсессивно-компульсивных расстройств. У 4 пациентов были проведены двусторон-ние деструкции в области передней ножки внутренней капсулы.…”

“…Объем, локализация и МР-харак-теристики очагов, получаемых при ультразвуковой де-струкции, совпадают с таковыми при радиочастотной термоабляции [22,36,37]. При этом эффективность уль-тразвуковой деструкции представляется сопоставимой с эффективностью радиочастотной термоабляции, а также стимуляции глубинных структур [18,19,22,32,35,[38][39][40][41][42][43][44]. Из всех деструктивных методик ФУЗ представляется наи-более оптимальной, так как эта процедура, в отличие от прямой стереотаксической радиочастотной абляции, ис-ключает риски внутримозговых кровоизлияний, инфици-рования и др., и по сравнению с радиохирургическим ле-чением характеризуется возможностью физиологической верификации, предсказуемостью результата и быстрым развитием эффекта [19,[45][46][47].…”

Image-guided Stereotactic Neurosurgery: Practices and Pitfalls

“…Because energy absorption in the ultrasound beam path is low, surrounding normal tissue is spared. MRgFUS enables ultrasonic energy to be focused through the intact skull, allowing application in psychosurgery and functional neurosurgery, such as thalamotomy for ET and, subthalamotomy for PD (33)(34)(35). Another potential approach in cases of central nervous system (CNS) tumor disrupts the blood-brain barrier (BBB) and delivers therapeutic agents directly into the brain.…”