Diretrizes para a neurocirurgia dos transtornos psiquiátricos graves no Brasil: uma proposta preliminar

Miguel, Eurí­pedes Constantino; Lopes, Antônio Carlos; Guertzenstein, E; Calazas, Maria Elvira Borges; Teixeira, Manoel Jacobsen; Brasil, Marco Antônio Alves

doi:10.1590/s1516-44462004000100005

Cited by 10 publications

(6 citation statements)

References 1 publication

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“…As for any such procedure, the use of GVC for OCD should be restricted to specialized centers with highly experienced teams of psychiatrists and neurosurgeons committed to following up these patients systematically for many years under strict guidelines. 16,43,44 In addition, we urge that an international registry be established to collect systematic data on patient characteristics, procedures, and outcomes related to the use of GVC for the treatment of OCD. 2 and 3; Figure 2; and eFigure 3 and eTables 5, 6, and 7 in Supplement 2 (see Supplement 1 for the retracted article with errors highlighted and replacement article with corrections highlighted).…”

Section: Discussionmentioning

confidence: 99%

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Gamma Ventral Capsulotomy for Obsessive-Compulsive Disorder

et al. 2014

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IMPORTANCE 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.OBJECTIVE To determine the efficacy and safety of a radiosurgery (gamma ventral capsulotomy [GVC]) for intractable OCD. DESIGN, SETTING, AND PARTICIPANTSIn 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.INTERVENTIONS 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. MAIN OUTCOMES AND MEASURESScores on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and the Clinical Global Impression-Improvement (CGI-I) Scale at 1 year. Response was defined as a 35% or greater reduction in Y-BOCS severity and "improved" or "much improved" CGI-I ratings.RESULTS Two of 8 patients randomized to active treatment responded at 12 months, and none of the 8 sham-GVC group patients responded (the absolute difference was not statistically significant: 0.25; 95% CI, Ϫ0.05 to 0.55; P = .11). At 12 months, median Y-BOCS scores were 23.5 in the active group vs 31 in the sham patients (P = .01). The median Y-BOCS scores decreased 28.6% in the active treatment group and 5.8% in the sham group (P = .04988). The median CGI-I scores were 3 and 4 in the active and sham treatment groups, respectively. At 54 months, 3 additional patients in the active group had become responders. Of the 4 sham-GVC patients who later received active GVC, 2 responded by post-GVC month 12. The most serious adverse event was an asymptomatic radiation-induced cyst in 1 patient. CONCLUSIONS AND RELEVANCEIn this preliminary trial, patients with intractable OCD who underwent GVC may have benefitted more than those who underwent sham surgery although the difference did not reach statistical significance. Additional research is necessary to determine if GVC is better than deep-brain stimulation.TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01004302

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Section: Discussionmentioning

confidence: 99%

“…The review panel confirmed the appropriateness of the surgical intervention and that patients adequately understood the risks and benefits associated with the study. 16…”

Section: Methodsmentioning

confidence: 99%

Gamma Ventral Capsulotomy for Obsessive-Compulsive Disorder

et al. 2014

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“…Consistent selection and outcome criteria in future studies will facilitate comparisons and replication. Selection criteria for neurosurgery for OCD (Table 2) have been suggested in recent guidelines [90]. Additional general criteria for the pre-surgical evaluation of psychiatric patients, as well as ethical considerations, were recently described in a multi-national consensus statement [91].…”

Section: Future Challengesmentioning

confidence: 99%

Evolution of gamma knife capsulotomy for intractable obsessive-compulsive disorder

et al. 2018

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For more than half a century, stereotactic neurosurgical procedures have been available to treat patients with severe, debilitating symptoms of obsessive-compulsive disorder (OCD) that have proven refractory to extensive, appropriate pharmacological, and psychological treatment. Although reliable predictors of outcome remain elusive, the establishment of narrower selection criteria for neurosurgical candidacy, together with a better understanding of the functional neuroanatomy implicated in OCD, has resulted in improved clinical efficacy for an array of ablative and non-ablative intervention techniques targeting the cingulum, internal capsule, and other limbic regions. It was against this backdrop that gamma knife capsulotomy (GKC) for OCD was developed. In this paper, we review the history of this stereotactic radiosurgical procedure, from its inception to recent advances. We perform a systematic review of the existing literature and also provide a narrative account of the evolution of the procedure, detailing how the procedure has changed over time, and has been shaped by forces of evidence and innovation. As the procedure has evolved and adverse events have decreased considerably, favorable response rates have remained attainable for approximately one-half to two-thirds of individuals treated at experienced centers. A reduction in obsessive-compulsive symptom severity may result not only from direct modulation of OCD neural pathways but also from enhanced efficacy of pharmacological and psychological therapies working in a synergistic fashion with GKC. Possible complications include frontal lobe edema and even the rare formation of delayed radionecrotic cysts. These adverse events have become much less common with new radiation dose and targeting strategies. Detailed neuropsychological assessments from recent studies suggest that cognitive function is not impaired, and in some domains may even improve following treatment. We conclude this review with discussions covering topics essential for further progress of this therapy, including suggestions for future trial design given the unique features of GKC therapy, considerations for optimizing stereotactic targeting and dose planning using biophysical models, and the use of advanced imaging techniques to understand circuitry and predict response. GKC, and in particular its modern variant, gamma ventral capsulotomy, continues to be a reliable treatment option for selected cases of otherwise highly refractory OCD.

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“…Patients were selected for GKS in accordance with estab-lished criteria. 25 Each participant had a score of ≥20 on the Yale-Brown Obsessive Compulsive Scale (YBOCS) and had experienced symptoms of OCD for a minimum of 4 years, with the majority having endured the condition for more than 10 years. Recruitment was limited to those demonstrating inadequate responses to a minimum of three serotonin reuptake inhibitors, including clomipramine, or a combination at least two pharmacological agents, including antipsychotics or clomipramine or to individuals who participated in 20 or more hours of exposure and response prevention therapy but continued to exhibit moderate to severe symptoms.…”

Section: Participantsmentioning

confidence: 99%

Characteristics of Patients With Intractable Obsessive-Compulsive Disorder With High/Low Responsiveness to Gamma Knife Surgery

Jang,

Kim,

Park

et al. 2024

Psychiatry Investig

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Objective Obsessive-compulsive disorder (OCD) is a psychiatric condition that causes significant distress and social costs and often follows a chronic course with frequent relapses. Approximately 20% of patients do not respond to medication or cognitive behavioral therapy; gamma knife surgery (GKS) has been proposed as a treatment option for these patients. However, research on GKS for OCD patients is rare.Methods In this study, 10 patients with treatment-resistant OCD underwent GKS, and the treatment response and side effects were assessed. The improvement in patients’ obsessive-compulsive symptoms was evaluated using the Yale-Brown Obsessive Compulsive Scale (YBOCS) scores following GKS. Additionally, the characteristics distinguishing the groups with favorable responses to GKS from those with less favorable responses were examined.Results GKS was well tolerated, and patients demonstrated a statistically significant reduction in YBOCS scores before and after GKS (p=0.016). Patients that responded to GKS exhibited distinct characteristics from those who did not respond. Patients who responded poorly tended to present an earlier age of onset, a longer duration of illness, more frequent hospitalizations, poorer social functioning, and a greater incidence of suicide attempts/thoughts.Conclusion This study not only demonstrated that GKS is a safe and effective treatment method for intractable OCD but also revealed characteristics distinguishing patients who respond well to GKS from those who do not. These results may aid in the selection of patients for future application of GKS.

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Diretrizes para a neurocirurgia dos transtornos psiquiátricos graves no Brasil: uma proposta preliminar

Cited by 10 publications

References 1 publication

Gamma Ventral Capsulotomy for Obsessive-Compulsive Disorder

Gamma Ventral Capsulotomy for Obsessive-Compulsive Disorder

Evolution of gamma knife capsulotomy for intractable obsessive-compulsive disorder

Characteristics of Patients With Intractable Obsessive-Compulsive Disorder With High/Low Responsiveness to Gamma Knife Surgery

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