Prospective Assessment of Stereotactic Ablative Surgery for Intractable Major Depression

Shields, Donald C.; Asaad, Wael F.; Eskandar, Emad N.; Jain, Felipe A.; Cosgrove, G. Rees; Flaherty, Alice W.; Cassem, Edwin H.; Price, Bruce H.; Rauch, Scott L.; Dougherty, Darin D.

doi:10.1016/j.biopsych.2008.04.009

Cited by 97 publications

(72 citation statements)

References 25 publications

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“…It is therefore possible that whereas the initial improvement in depressive symptoms is substantial, it is less durable than the improvement in OCD symptoms, especially given the fact that these patients' eligibility for surgery was based primarily on OCD rather than depressive symptoms. Indeed, the mean preoperative BDI for patients at our institution, whose primary indication for cingulotomy was MDD, was 39, 23 compared with the mean preoperative BDI of 27 in the current cohort. Correspondingly, the BDI at last follow-up for the MDD group in that earlier study was 21, a final end point very similar to the BDI of 19 for the current OCD group.…”

Section: Discussionmentioning

confidence: 99%

Limbic system surgery for treatment-refractory obsessive-compulsive disorder: a prospective long-term follow-up of 64 patients

Sheth¹,

Neal²,

Tangherlini³

et al. 2013

JNS

Self Cite

104

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O bsessive-cOmpulsive disorder is a psychiatric illness characterized by intrusive, recurrent thoughts (obsessions) coupled with repetitive behaviors that are performed in an attempt to reduce anxiety (compulsions). These obsessions and compulsions can cause severe emotional distress, financial hardship, and social isolation. With a lifetime prevalence of approximately 2%-3%, 22 OCD is among the most common mental illnesses in the US, and of patients in whom OCD is diagnosed, one-half experience severe symptoms.15 Obsessive-compulsive disorder is also associated with high rates of comorbid MDD and suicidal ideations. 21Standard treatment for patients with OCD includes a combination of psychotherapy and pharmacotherapy; however, 40%-60% of patients do not respond satisfac- Object. Obsessive-compulsive disorder (OCD) is a common and disabling psychiatric illness, and in a significant proportion of patients with OCD the disease is refractory to conventional pharmacotherapy and psychotherapy. For more than half a century, patients with severe, treatment-resistant OCD have been treated with stereotactic limbic system lesions, including dorsal anterior cingulotomy. The authors present their results describing the efficacy and durability of limbic system surgery for OCD, characterizing a large cohort of patients treated at a single institution with a mean follow-up of more than 5 years.Methods. The authors identified 64 consecutive patients undergoing cingulotomy for refractory OCD at the Massachusetts General Hospital between 1989 and 2009. Changes in OCD and major depressive disorder symptom severity were assessed at both the initial and most recent postoperative follow-up by using the Yale-Brown Obsessive Compulsive Scale and the Beck Depression Inventory, respectively. Full and partial OCD symptom responses were defined as Yale-Brown Obsessive Compulsive Scale score reductions of ≥ 35% and 25%-34%, respectively.Results. Regarding OCD symptom improvement, at the first postoperative follow-up (mean 10.7 months), 35% of patients demonstrated a full response and 7% were partial responders. Thirty patients had a subsequent procedure (repeat cingulotomy or subcaudate tractotomy). By the most recent follow-up (mean 63.8 months), rates climbed to 47% and 22% for full and partial responses, respectively. Of the 24 patients with at least a partial response at initial follow-up, 20 (83%) retained at least a partial response at final follow-up. Comorbid major depressive disorder severity decreased by 17% at the most recent follow-up.Conclusions. Limbic system surgery based on initial cingulotomy offers a durable and effective treatment option for appropriately selected patients with severe OCD who have not responded to conventional pharmacotherapy or psychotherapy. See the corresponding editorial in this issue, pp 489-490.

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Section: Discussionmentioning

confidence: 99%

Limbic system surgery for treatment-refractory obsessive-compulsive disorder: a prospective long-term follow-up of 64 patients

Sheth¹,

Neal²,

Tangherlini³

et al. 2013

JNS

Self Cite

104

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“…The lesions of cingulotomy target the cingulum bundle within the anterior cingulate gyrus, and also involve part of the anterior cingulate cortex. Response rates to ACING for depression are typically in the region of 30-50% [15,16,17], although multiple factors may influence the likelihood of response.…”

Section: Introductionmentioning

confidence: 99%

Neurosurgical Treatments for Patients with Chronic, Treatment-Refractory Depression: A Retrospective, Consecutive, Case Series Comparison of Anterior Capsulotomy, Anterior Cingulotomy and Vagus Nerve Stimulation

Christmas

Matthews²

2015

Stereotact Funct Neurosurg

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Background: The evidence base to guide therapeutic choices for patients with chronic and treatment-refractory depression (TRD) remains weak. There is limited comparative information available to guide the choice of intervention for patients with the most severe and disabling forms of illness. Objectives: The aim of this work was to describe the 12-month clinical outcomes of patients with chronic TRD treated with anterior capsulotomy (ACAPS; n = 5), anterior cingulotomy (ACING; n = 5) or vagus nerve stimulation (VNS; n = 5). Methods: We performed a retrospective, consecutive, case series comparison. Results: With clinical response defined as a ≥50% reduction from the baseline MADRS score, response rates were 40% for ACAPS, 60% for ACING and 20% for VNS. Adverse effects from all three procedures were relatively mild, consistent with previous reports and, in most cases, transient. Adverse effects from VNS were related to active stimulation, and were modifiable and diminished in severity over time. There were no deaths. Conclusions: Although based on a small sample, our data represent a unique comparison of ACAPS, ACING and VNS for chronic TRD. The three cohorts were broadly equivalent in terms of baseline clinical characteristics, indices of chronicity, illness severity and estimates of previous failed treatments. ACING and ACAPS, but not VNS, were associated with favourable response rates at 12 months.

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“…More recently, Shields et al [30] evaluated the effects of anterior cingulotomy on 33 patients with TRD at Massachusetts General Hospital. Each patient first underwent a bilateral anterior cingulotomy with single lesions [30].…”

Section: Anterior Cingulotomymentioning

confidence: 99%

“…Each patient first underwent a bilateral anterior cingulotomy with single lesions [30]. Additional lesions were created (up to 3 lesions bilaterally) if the patient failed to respond to this first procedure [30]. However, the authors noted that many of the early patients failed to respond to single bilateral lesions, and as a result, refined their initial cingulotomy surgery to include 3 bilateral lesion targets.…”

Section: Anterior Cingulotomymentioning

confidence: 99%

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The History and Future of Ablative Neurosurgery for Major Depressive Disorder

Volpini¹,

Giacobbe

Cosgrove

et al. 2017

Stereotact Funct Neurosurg

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Background: There is an urgent need to develop safe and effective treatments for patients with treatment-resistant depression (TRD). Several neurosurgical procedures have been developed to treat the dysfunctional brain circuits implicated in major depression. Objectives: This review describes the most common ablative procedures used to treat major depressive disorder: anterior cingulotomy, subcaudate tractotomy, limbic leucotomy, and anterior capsulotomy. The efficacy and safety of each are discussed and compared with other current and emerging modalities, including deep brain stimulation (DBS) and MR-guided focused ultrasound (MRgFUS). Methods: The PubMed and MEDLINE electronic databases were used in this study, through July 2016. Keywords, including “treatment resistant depression,” and “ablative neurosurgery,” etc. were used to generate reference hits. Results: Approximately a third to half of patients who underwent ablative procedures achieved a treatment response and/or remission. The efficacy and safety profiles corresponding to both ablative procedures and DBS were very similar. Conclusions: The longitudinal experience with ablative procedures shows that there remains an important role for accurate, discrete lesions in disrupting affective circuitry in the treatment of TRD. New modalities, such as MRgFUS, have the potential to further improve the accuracy of ablative procedures, while enhancing safety by obviating the need for open brain surgery.

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Prospective Assessment of Stereotactic Ablative Surgery for Intractable Major Depression

Cited by 97 publications

References 25 publications

Limbic system surgery for treatment-refractory obsessive-compulsive disorder: a prospective long-term follow-up of 64 patients

Limbic system surgery for treatment-refractory obsessive-compulsive disorder: a prospective long-term follow-up of 64 patients

Neurosurgical Treatments for Patients with Chronic, Treatment-Refractory Depression: A Retrospective, Consecutive, Case Series Comparison of Anterior Capsulotomy, Anterior Cingulotomy and Vagus Nerve Stimulation

The History and Future of Ablative Neurosurgery for Major Depressive Disorder

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