Edwin H. Cassem

Cerebral metabolic correlates as potential predictors of response to anterior cingulotomy for obsessive compulsive disorder.

BACKGROUNDnAs interventions for severe, treatment-refractory obsessive compulsive disorder (OCD), neurosurgical procedures are associated with only modest efficacy. The purpose of this study was to identify cerebral metabolic correlates as potential predictors of treatment response to anterior cingulotomy for OCD.nnnMETHODSnClinical data were analyzed in the context of a retrospective design. Subjects were 11 patients who underwent stereotactic anterior cingulotomy for OCD. Symptom severity was measured using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) before and at approximately 6 months postoperative. Preoperative F-18-fluorodeoxyglucose-positron emission tomography (FDG-PET) data were available. Statistical parametric mapping methods were used to identify loci of significant correlation between preoperative regional cerebral metabolism and postoperative reduction in Y-BOCS scores.nnnRESULTSnOne locus within right posterior cingulate cortex was identified, where preoperative metabolism was significantly correlated with improvement in OCD symptom severity following cingulotomy. Specifically, higher preoperative rates of metabolism at that locus were associated with better postoperative outcome.nnnCONCLUSIONSnA possible predictor of treatment response was identified for patients with OCD undergoing anterior cingulotomy. Further research, utilizing a prospective design, is indicated to determine the validity and reliability of this finding. If confirmed, an index for noninvasively predicting response to cingulotomy for OCD would be of great value.

Depressive Disorders in the Medically Ill:An Overview

Depressive disorders are far more serious than most people realize, and depressive disorders are disabling affected persons progressively earlier in life. Heavy utilization of medical services, extensive disability and morbidity, and high suicide risk exact a staggering economic toll in the United States annually. Depressive illness is, like pneumonia and septic shock, a dread complication of major medical illness, and depressive illness appears more frequently as the medical illness worsens; diseases affecting the brain may have the highest rates of depressive symptoms. Correctly diagnosing a depressive disorder in a medically ill patient is a clinical challenge that requires systematic, persistent clinical scrutiny. Compassion demands that depressive disorders, when diagnosed, be treated aggressively.

Magnetic Resonance Image-guided Stereotactic Cingulotomy for Intractable Psychiatric Disease

WE DESCRIBE THE modern operative technique of magnetic resonance (MR) image-guided stereotactic cingulotomy and discuss the indications, results, and complications of this procedure. A retrospective analysis of psychiatric outcome was performed for 34 patients with intractable major affective disorder and/or obsessive-compulsive disorder who underwent MR image-guided stereotactic cingulotomy since 1991. Fourteen patients underwent multiple cingulotomies (50 total procedures). Overall, 38% of the patients were classified as responders, 23% as possible responders, and 38% as nonresponders. Of the patients who did not respond to initial cingulotomies and who underwent multiple cingulotomies, 36% became responders, 36% possible responders, and 28% nonresponders. There were no deaths or long-term side effects related to the procedure. The therapeutic results of MR image-guided stereotactic cingulotomy are similar to the results of earlier methods of cingulotomy, and the use of MR imaging offers substantial technical advantages. This procedure also compares favorably with other neurosurgical procedures performed for intractable psychiatric disease with a low rate of undesired side effects. Cingulotomy is safe and well tolerated, with over one-third of the patients demonstrating significant improvement ; however, prospective long-term follow-up studies are needed to further define the role of surgery in treating intractable psychiatric disease.

Deficits in visual cognition and attention following bilateral anterior cingulotomy

A series of eight tests of visual cognitive abilities was used to examine pre- to post-operative performance changes in a patient receiving bilateral anterior cingulotomy. Compared with a set of eight matched control participants, post-operatively, the patient exhibited deficits in (a) the ability to sequence novel cognitive operations required to generate multipart images or rotate perceptual stimuli; (b) the ability to search for, select, and compare images of objects when the instructions did not specify precisely which objects should be visualized; and, (c) the ability to select a controlled and unpracticed response over an automatic one. Other imagery and cognitive tasks were not affected. Results are consistent with the hypothesis that anterior cingulate cortex is a component of an executive control system. One of the anterior cingulates roles may be to monitor on-line processing and signal the motivational significance of current actions or cognitions.

Magnetic Resonance Imaging-guided Stereotactic Limbic Leukotomy for Treatment of Intractable Psychiatric Disease

OBJECTIVE To assess the efficacy and complication rates of magnetic resonance imaging-guided stereotactic limbic leukotomy for the treatment of intractable major depressive disorder (MDD) and obsessive-compulsive disorder (OCD). METHODS We conducted preoperative evaluations and postoperative follow-up assessments of efficacy and complications for 21 patients who underwent limbic leukotomy. Efficacy was based on physician- and patient-rated global assessments of functioning, as well as evaluations using disease-specific rating scales commonly used in studies of MDD and OCD. RESULTS The mean time from limbic leukotomy to follow-up assessment was 26 months. On the basis of standard outcome measures, 36 to 50% of patients were considered to be treatment responders. Although permanent surgical morbidity was rare, there were reports of postoperative sequelae, including apathy, urinary incontinence, and memory complaints, which occurred in a substantial minority of cases. CONCLUSION For this cohort of 21 patients with chronic severe MDD or OCD, who had experienced failure with an exhaustive array of previous treatments, limbic leukotomy was associated with substantial benefit for 36 to 50%. This rate is comparable to those of previous studies of limbic system surgery and indicates that limbic leukotomy is a feasible treatment option for severe, treatment-refractory MDD or OCD. Adverse consequences associated with the procedure included affective, cognitive, and visceromotor sequelae, which were generally transient.

Prospective Assessment of Stereotactic Ablative Surgery for Intractable Major Depression

BACKGROUNDnDespite therapeutic advances for major depression, a subset of patients with this disorder does not respond to conventional treatment. Stereotactic ablative procedures such as anterior cingulotomy have been performed in severely affected, treatment-resistant patients, but the long-term results of such procedures are not fully understood.nnnMETHODSnFindings are reported for 33 patients with severe treatment-resistant major depression who underwent ablative stereotactic procedures (dorsal anterior cingulotomy followed if necessary by subcaudate tractotomy). Preoperative and long-term postoperative Beck Depression Inventory scores were obtained along with postoperative Clinical Global Improvement values. Both were analyzed to evaluate patients responses to the surgical procedure(s).nnnRESULTSnAt mean follow-up of 30 months after one or more stereotactic ablative procedures, 11 patients (33.3%) were classified as responders, 14 (42.4%) were partial responders, and 8 (24.2%) did not respond to the surgical procedure(s). Among those (17) who underwent only one procedure, seven (41.2%) responded, whereas six (35.3%) and four (23.5%) showed partial or no response, respectively. Among patients who required multiple surgical procedures, four patients (25%) responded, whereas eight (50%) and four (25%) patients demonstrated partial or no responses, respectively, at long-term follow-up evaluations.nnnCONCLUSIONSnApproximately 75% of depression patients previously resistant to antidepressant therapies received partial or substantial benefit from stereotactic ablative procedures. Those requiring only a single anterior cingulotomy tended to demonstrate more pronounced responses than patients who underwent multiple surgical procedures.

A Magnetic Resonance Imaging Study of Regional Cortical Volumes Following Stereotactic Anterior Cingulotomy

The purpose of this study was to test the hypothesis that orbitofrontal cortical volume would be reduced following anterior cingulotomy for obsessive-compulsive disorder (OCD). Whole brain cortical parcellation was performed on magnetic resonance imaging (MRI) data from nine patients, before and 9 (+/-6) months following anterior cingulotomy. No significant volumetric reductions were found in the orbitofrontal cortex. Exploratory findings of reduced volume in ventral temporo-fusiform and posterior cingulate regions were consistent with chance differences, in the face of multiple comparisons. Therefore, though the circumscribed lesions of anterior cingulotomy have recently been associated with corresponding volumetric reductions in the caudate nucleus, no comparable volumetric reductions are evident in cortical territories. Taken together, these results are most consistent with a model of cingulo-striatal perturbation as a putative mechanism for the efficacy of this procedure. While limitations in sensitivity may have also contributed to these negative findings, the methods employed have previously proven sufficient to detect cortical volumetric abnormalities in OCD. The current results may reflect a relatively diffuse pattern of cortico-cortical connections involving the neurons at the site of cingulotomy lesions. Future functional neuroimaging studies are warranted to assess possible cortical or subcortical metabolic changes associated with anterior cingulotomy, as well as predictors of treatment response.

Terrorism, Posttraumatic Stress, Spiritual Coping, and Mental Health

This study examines stress and coping in relation to mental health and spiritual outcomes following the 9/11 terrorist attacks. In November 2001, a survey was mailed to a stratified, randomized sample of registered voters from six communities in Massachusetts (n = 231) and New York City (n = 58). The Short PTSD Rating Interview (SPRINT) posttraumatic stress scale, positive and negative spiritual coping, spiritual outcomes, the Short Form‐36 (SF‐36) Health Survey Mental Health subscale, and measures of prayer, church attendance and seeking social support comprised the questionnaire. Residents averaged between partial to full levels of posttraumatic stress, highest in New York City residents, but unrelated to knowing someone injured/killed in the tragedy. Seeking time with family and friends, positive spiritual coping attitudes, prayer, and attending a religious service were strongly related to positive spiritual outcomes. A decreased mental health score correlated with high stress score and negative spiritual coping. The study supported the observation of widespread secondary stress response to terrorist attacks, turning toward faith to cope with this tragedy, and the negative association of both stress and negative spiritual coping attitudes on mental health.

What is the role of psychiatric neurosurgery in the 21st Century

Neurosurgical treatments are not to be entered into lightly for any indication. It is especially understandable that concerns have been raised regarding the prudence of neurosurgical interventions for psychiatric indications, given the history surrounding the crude freehand procedures arising during the middle of the 20th century. 1-3 Early enthusiasm about frontal lobotomies led to widespread and relatively indiscriminant use during the era prior to the advent of contemporary psychop-harmacologic therapies. However, the past five decades have witnessed an essential evolution in neurosurgical treatment for severe, treatment-refractory obsessive compulsive disorder (OCD) and major depression (MD). 1,2 In particular, advances have been achieved with respect to: the standards and practices for patient selection, refinement of surgical methods, evidence of effectiveness, experience regarding adverse effects, and investigation of relevant neuroscience. Anterior cingulotomy, anterior capsulotomy, subcaudate trac-totomy, and limbic leucotomy are now regarded as accepted (non-experimental) treatments for severe and treatment refrac-tory forms of OCD and/or MD. 1,2 The critical principles of patient selection include informed consent and a process by which multidisciplinary review of candidate cases ensures accurate diagnosis, sufficient severity of illness, assessment of potential contraindications, and that an exhaustive array of non-surgical therapies have already been tried and failed. Data have accrued to indicate modest response rates (35-70% depending on the patient sample and criteria for response), which can be life saving in these most severe and otherwise treatment unresponsive cases of OCD and MD. Clinical improvement is typically achieved over several weeks to months post-operatively , and for some of these procedures, repeat surgery is an option in the face of incomplete response. Anticipated temporary post-operative discomforts include headache, nausea and edema. The risks of more serious adverse events, including infection, urinary difficulties, weight gain, seizures, cerebral hemorrhage or infarct, and cognitive deficits, are real, but esti-mable, relatively infrequent, and usually transient. 1,2,4 As with any therapeutic options, the available detailed information regarding potential risks and benefits comprise essential elements of the informed consent process. Under no circumstances should psychiatric neurosurgery be performed against a patients will or in the context of coercion. Further, as neurosurgical inter-What is the role of psychiatric neurosurgery in the 21st Century? Editorial (invited authors) vention should not be considered a substitute for psychiatric care, arrangements for ongoing post-operative treatment under the supervision of a psychiatrist is required. It is important to keep in mind that different standards exist for establishing medical (e.g., pharmacological) vs. …