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Gamma Ventral Capsulotomy in Intractable Obsessive-Compulsive Disorder

Published:December 15, 2017DOI:https://doi.org/10.1016/j.biopsych.2017.11.034

      Abstract

      Background

      Despite the development of effective pharmacologic and cognitive behavioral treatments for obsessive-compulsive disorder (OCD), some patients continue to be treatment-refractory and severely impaired. Fiber tracts connecting orbitofrontal and dorsal anterior cingulate cortex with subcortical nuclei have been the target of neurosurgical lesions as well as deep brain stimulation in these patients. We report on the safety and efficacy of ventral gamma capsulotomy for patients with intractable OCD.

      Methods

      Fifty-five patients with severely disabling, treatment-refractory OCD received bilateral lesions in the ventral portion of the anterior limb of the internal capsule over a 20-year period using the Leksell Gamma Knife. The patients were prospectively followed over 3 years with psychiatric, neurologic, and neuropsychological assessments of safety and efficacy, as well as structural neuroimaging.

      Results

      Thirty-one of 55 patients (56%) had an improvement in the primary efficacy measure, the Yale-Brown Obsessive Compulsive Scale, of ≥35% over the 3-year follow-up period. Patients had significant improvements in depression, anxiety, quality of life, and global functioning. Patients tolerated the procedure well without significant acute adverse events. Five patients (9%) developed transient edema that required short courses of dexamethasone. Three patients (5%) developed cysts at long-term follow-up, 1 of whom developed radionecrosis resulting in an ongoing minimally conscious state.

      Conclusions

      Gamma Knife ventral capsulotomy is an effective radiosurgical procedure for many treatment-refractory OCD patients. A minority of patients developed cysts at long-term follow-up, 1 of whom had permanent neurological sequelae.

      Keywords

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      Linked Article

      • Stereotactic Radiosurgical Capsulotomy for the Treatment of Refractory Obsessive-Compulsive Disorder
        Biological PsychiatryVol. 84Issue 5
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          Surgical interventions for psychiatric disorders are as old as the field of stereotactic neurosurgery. Indeed, the first stereotactic neurosurgical procedures in humans, performed in the late 1940s, were for psychiatric indications (1). Thermocoagulation probes were introduced through small incisions and burr holes using coordinates determined from ventricular anatomy visualized using pneumoencephalography. These early procedures created targeted lesions in gray matter structures (e.g., the thalamic nuclei in thalamotomy) or white matter connections between them (e.g., the anterior limb of the internal capsule [ALIC] in capsulotomy).
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