Consensus on guidelines for stereotactic neurosurgery for psychiatric disorders

Abstract

BackgroundFor patients with psychiatric illnesses remaining refractory to ‘standard’ therapies, neurosurgical procedures may be considered. Guidelines for safe and ethical conduct of such procedures have previously and independently been proposed by various local and regional expert groups.MethodsTo expand on these earlier documents, representative members of continental and international psychiatric and neurosurgical societies, joined efforts to further elaborate and adopt a pragmatic worldwide set of guidelines. These are intended to address a broad range of neuropsychiatric disorders, brain targets and neurosurgical techniques, taking into account cultural and social heterogeneities of healthcare environments.FindingsThe proposed consensus document highlights that, while stereotactic ablative procedures such as cingulotomy and capsulotomy for depression and obsessive-compulsive disorder are considered ‘established’ in some countries, they still lack level I evidence. Further, it is noted that deep brain stimulation in any brain target hitherto tried, and for any psychiatric or behavioural disorder, still remains at an investigational stage. Researchers are encouraged to design randomised controlled trials, based on scientific and data-driven rationales for disease and brain target selection. Experienced multidisciplinary teams are a mandatory requirement for the safe and ethical conduct of any psychiatric neurosurgery, ensuring documented refractoriness of patients, proper consent procedures that respect patient's capacity and autonomy, multifaceted preoperative as well as postoperative long-term follow-up evaluation, and reporting of effects and side effects for all patients.InterpretationThis consensus document on ethical and scientific conduct of psychiatric surgery worldwide is designed to enhance patient safety.

Tedaviye Dirençli Obsesif Kompulsif Bozuklukta Cerrahi Yaklaşımlar : Lökotomiden Gama Bıçağı Cerrahisine

“…Hastalara Ruhsal Bozukluklar Tanısal ve Sayımsal El Kitabı (DSM) tanı kriterlerine göre OKB tanısının konmuş olması, 18-55 yaş arasında olmaları, en az 5 yıldır hastalığın devam etmesi, Yale-Brown Obsesyon Kompulsiyon Ölçeği (Y-BOCS) puanının 26'dan fazla yada obsesyon yada kompulsiyon alt ölçek puanlarının her birinin 13'ten fazla olması ve dirençli OKB tanısının konulmuş olması gerekmektedir. Dirençli OKB tanısının konulabilmesi için ise en az 3 çeşit SSRI ve klomipraminin kullanılmış olması, her bir ilacın en az 12 hafta etkin dozda kullanılmış olması, bilişsel davranışçı terapinin en az 20 saat uygulanmış olması, takiplerinde ölçek puanlarında anlamlı değişikliğin olmaması, en az iki çeşit ilaç eklenmesine (benzodiazepin, atipik antipsikotik gibi) rağmen düzelmenin olmaması gerekmektedir [19][20][21][22] . Demans, 18 yaşından küçük ve 55 yaşından büyük olmak(bazı yayınlarda 65 yaşın üzerinde olmak), antisosyal ya da paranoid kişilik bozukluğunun olması, madde bağımlılığının olması, gebelik ya da laktasyon, zeka geriliği bu yöntemin uygulanamayacağı durumlardandır 20,21 .…”

Gamma Knife for Functional Diseases

“…Gamma knife capsulotomy should be regarded as a part of a multidisciplinary therapeutic approach to these challenging patients. We recently participated in the preparation of a consensus document, designed to enhance patient safety, on the ethical and scientific conduct of psychiatric surgery worldwide [78]. In line with this guideline document, we would like to highlight that "the nature of these and many other procedures in neurosurgery, including DBS for psychiatric disorders, remains at a 'proof-of-principle' investigational stage of development" [78,79].…”

The New Era of Neuromodulation

“…The latest published paper on this issue, the initiative behind which was taken by a group of neurosurgeons from the World Society for Stereotactic and Functional Neurosurgery (WSSFN), is entitled "Consensus on Guidelines for Stereotactic Neurosurgery for Psychiatric Disorders" [14]. This paper was authored by a worldwide group of neurosurgeons, psychiatrists, neurologists, and ethicists as well as representatives of various national, regional, and international neurosurgical and psychiatric societies.…”