Magnetic Resonance Imaging-Guided Laser Thermal Ventral Capsulotomy for Intractable Obsessive-Compulsive Disorder.

Obsessive-compulsive disorder (OCD) is a disabling condition characterized by intrusive thoughts and repetitive behaviors. A subset of individuals have severe, treatment-resistant illness and are nonresponsive to medication or behavioral therapies. Without response to conventional therapeutic options, surgical intervention becomes an appropriate consideration. To report clinical outcomes and the safety profile of bilateral ventral anterior capsulotomy for OCD using magnetic resonance (MR)-guided laser interstitial thermal therapy (LITT) in 10 patients followed for 6 to 24 mo. A total of 10 patients underwent LITT for severe OCD; 1 patient withdrew prior to follow-up. LITT is a minimally invasive ablative technique performed with precise targeting and use of thermography under MR guidance. Lesions of the ventral anterior limb of the internal capsule by other techniques have been shown to be efficacious in prior studies. A total of 7 of the 9 patients were considered full responders (77.8%; Yale-Brown Obsessive-Compulsive Scale change ≥35%). Adverse effects included transient apathy/amotivation postsurgery (2 patients). One patient had a small tract hemorrhage where the laser fiber traversed the cerebral cortex as well as persistent insomnia postsurgery. One individual died after a drug overdose 7 mo postsurgery, which was judged unrelated to the surgery. LITT ventral capsulotomy was generally well tolerated, with promising evidence of effectiveness in the largest such series to date. Results were comparable to those after gamma knife ventral capsulotomy, as well as ventral anterior limb deep brain stimulation.

McLaughlin NCR ，Lauro PM ，Patrick MT ，Pucci FG ，Barrios-Anderson A ，Greenberg BD ，Rasmussen SA ，Asaad WF ... -  《-》

Interstitial laser anterior capsulotomy for obsessive-compulsive disorder: lesion size and tractography correlate with outcome.

Anterior capsulotomy is a well-established treatment for refractory obsessive-compulsive disorder (OCD). MRI-guided laser interstitial thermal therapy (LITT) allows creation of large, sharply demarcated lesions with the safeguard of real-time imaging. To characterise the outcomes of laser anterior capsulotomy, including radiographical predictors of improvement. Patients with severe OCD refractory to pharmacotherapy and cognitive-behavioural therapy underwent bilateral anterior capsulotomy via LITT. The primary outcome was per cent reduction in Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score over time. Lesion size was measured on postablation MRI. Disconnection of the anterior limb of the internal capsule (ALIC) was assessed via individual and normative tractography. Eighteen patients underwent laser anterior capsulotomy. Median follow-up was 6 months (range 3-51 months). Time occupied by obsessions improved immediately (median Y-BOCS item 1 score 4-1, p=0.002). Mean (±SD) decrease in Y-BOCS score at last follow-up was 46%±32% (16±11 points, p<0.0001). Sixty-one per cent of patients were responders. Seven patients (39%) exhibited transient postoperative apathy. One patient had an asymptomatic intracerebral haemorrhage. Reduction in Y-BOCS score was positively associated with ablation volume (p=0.006). Individual tractography demonstrated durable ALIC disconnection. Normative tractography revealed a dorsal-ventral gradient, with disconnection of orbitofrontal streamlines most strongly associated with a positive response (p<0.0001). Laser anterior capsulotomy resulted in immediate, marked improvement in OCD symptom severity. Larger lesions permit greater disconnection of prefrontal-subcortical pathways involved in OCD. The importance of greater disconnection is presumably related to variation in ALIC structure and the complex role of the PFC in OCD.

Satzer D ，Mahavadi A ，Lacy M ，Grant JE ，Warnke P ... -  《-》

A study of cognitive function in treatment-refractory obsessive-compulsive disorder treated with capsulotomy.

Gong F ，Li P ，Li B ，Zhang S ，Zhang X ，Yang S ，Liu H ，Wang W ... -  《-》

Long-term follow-up of bilateral anterior capsulotomy in patients with refractory obsessive-compulsive disorder.

Obsessive-compulsive disease (OCD) is a severe psychiatric disorder suffers tens of millions of people around the world. There are many treatment options available, however, still nearly 40% of OCD patients do not respond very well to the therapeutic methods. For treatment-refractory OCD patients, bilateral anterior capsulotomy is a potential therapy. 53 (32 men and 21 women) medically intractable OCD patients who underwent MRI guided bilateral anterior capsulotomy from 2003 to 2006 were included in this study. Pre- and post-operative Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Hamilton Depression Scale (HAMD) and Hamilton Anxiety Scale (HAMA) scores were recorded by psychiatrists. FDG-PET was performed pre-operatively and 12 months after the operation to assess the effect of the operation. There was a marked difference in FDG-PET findings before and 12 months after the operation. For OCD symptoms, 20 (37.9%) cases were regarded as OCD symptoms free, 13 (24.5%) cases as significant improved, 8 (15.0%) cases as clinical improved and 12 (22.6%) cases experienced no effects or improvements. There is also a significant difference in Y-BOCS, HAMD and HAMA scores (two-tailed t-test). Our study indicates that bilateral capsulotomy is a precise and relatively safe therapy for refractory OCD, which can improve patients' quality of life and restores their social function. There must be strict inclusion criteria for patients considering of the complications and the irreversibility of this procedure.

Zhan S ，Liu W ，Li D ，Pan S ，Pan Y ，Li Y ，Lin G ，Sun B ... -  《-》

Increased apathy post-interstitial laser capsulotomy for refractory obsessive-compulsive disorder.

MRI guided laser interstitial thermal therapy (M-LITT) capsulotomy has proven to be efficacious in decreasing refractory obsessive-compulsive disorder (OCD) related symptomatology yet capsulotomy either via radiosurgery or radiofrequency ablation has in some patients led to increased apathy following surgery. The current case series aims to investigate objective patient-reported change in apathy, disinhibition, depression, and executive dysfunction following anterior capsulotomy via M-LITT for OCD. Ten consecutive patients pre- and post-M-LITT completed measures of OCD, apathy, disinhibition, executive dysfunction, and depression (Mtime between = 1.3 years; 0.42-3.7 years). Reliable Change Index (RCI) was used to evaluate change in pre- and post-M-LITT. OCD symptom response was evaluated using percent change (Y-BOCS scores: 24-34 % reduction indicating partial response; ≥35% reduction indicating full response). Positive post-surgical change was noted in OCD symptomatology with >65% reporting a partial or full response. However, six patients endorsed increased apathy with half of the non-responders (e.g., less than <24% score reduction on Y-BOCS) reporting increases in apathy. Patients reported relatively stable disinhibition and executive dysfunction, while over half reported a decrease in depression symptoms. Two of the non-responders and one responder endorsed increased apathy despite stable or improved depression symptoms, disinhibition, and executive dysfunction. Most patients in the current cohort achieved full-or-partial OCD recovery. Yet, 60% of patients also reported significant increases in apathy, despite experiencing a decrease in depression symptoms, with stable disinhibition and executive dysfunction. Despite these promising improvements in OCD symptomatology following M-LITT, further investigations of the impact of surgery and lesion location on apathy levels is clearly warranted using objective, quantifiable methods.

Hagy HA ，Lacy M ，Turchmanovych-Hienkel N ，Grant JE ，Biro D ，Warnke PC ... -  《-》