Bilateral Cingulotomy and Anterior Capsulotomy Applied to Patients with Aggressiveness

Abstract

Objective: To perform a preliminary study on the effects and safety of bilateral cingulotomy and anterior capsulotomy in patients with aggressive behavior. Patients and Methods: Twenty-three psychiatric patients showing aggressive behavior refractory to conventional treatment were initially evaluated. The subjects were clinically selected using the Overt Aggression Scale (OAS) and the Global Assessment of Functioning Scale (GAF). Each case was carefully reviewed by the Ethics Committee of Mexico’s General Hospital. Once selection criteria were met, stereotactic lesions were made using radiofrequency on the anterior limb of the internal capsule and supragenual cingulum. Statistical differences were evaluated with a Wilcoxon test at 6 months and at 4 years. Results: Ten patients underwent surgery. Their OAS and GAF scores decreased after the procedure at the 6-month (p < 0.05) and at the 4-year (p = 0.068) follow-up. Four patients showed mild and transitory postsurgical complications (hyperphagia and somnolence). Conclusions: Bilateral anterior capsulotomy in combination with cingulotomy may reduce aggressive behavior and improve clinical evaluations. Very strict clinical and ethical evaluations were applied prior to considering patients for this treatment.

Long-Term Follow-Up of MRI-Guided Bilateral Anterior Capsulotomy in Patients with Refractory Schizophrenia

“…Secondly, there are case reports indicating the possible effects of bilateral anterior capsulotomy in schizophrenia. Jimenez et al [39] reported that combined bilateral anterior capsulotomy and cingulotomy successfully reduced aggressive behavior and improved clinical evaluations in 23 schizophrenia patients. Lastly, the anterior limb of the internal capsule (ALIC) serves as a relay route between cortical structures (such as prefrontal cortex, PFC) and the thalamus; the dorsolateral PFC region of the frontal lobe is involved in attention, affect and working memory, all of which are reported to be abnormal in schizophrenia [40,41].…”

Answer to the Comment by Lévêque et al. on ‘Bilateral Cingulotomy and Anterior Capsulotomy Applied to Patients with Aggressiveness'

“…We appreciate a lot the interest in our paper ‘Bilateral cingulotomy and anterior capsulotomy applied to patients with aggressiveness' published in Stereotactic and Functional Neurosurgery [1]. However, Lévêque et al wrote the title as ‘Bilateral anterior capsulotomy and cingulotomy applied to patients with aggressiveness' [2].…”

“…In the first series reported [3], 12 patients underwent bilateral anterior capsulotomy and cingulotomy and were evaluated by the Mayo-Portland Adaptability Inventory and Global Assessment Functioning Scale because those were the accessible instruments at that moment. A year later, a second series [1] was treated with the same surgery procedure but studied by the Overt Aggression Scale and Global Assessment of Functioning Scale. Those series have 4 cases in common (No.…”

“…(I) Finally, in ‘Bilateral cingulotomy and anterior capsulotomy applied to patients with aggressiveness' [1], the Discussion section has a special paragraph where we accept the necessity to create a specific forum to review this ethical issue. Probably, other authors consider psychosurgery as a no-safety procedure for aggressive behavior or as a social control manner, but our professional group is formed by highly specialized psychiatrists, functional neurosurgeons and neuropsychologists.…”

Care and Prudence as Main Directive in Clinical Research on Neurosurgical Intervention for Schizophrenia

“…It would be most useful (and ethically justified) to see a power calculation, based on an estimated effect size (e.g. taken from the study of Jimenez et al [2]) to determine the size of the sample needed to demonstrate safety and efficacy.…”