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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Article info
Publication history
Published online: December 15, 2017
Accepted:
November 17,
2017
Received in revised form:
September 26,
2017
Received:
February 17,
2017
Identification
Copyright
© 2017 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.
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- Stereotactic Radiosurgical Capsulotomy for the Treatment of Refractory Obsessive-Compulsive DisorderBiological PsychiatryVol. 84Issue 5
- PreviewSurgical 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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