Dorsal anterior cingulotomy and anterior capsulotomy for severe, refractory obsessive-compulsive disorder: a systematic review of observational studies

Abstract

OBJECT The object of this study was to perform a systematic review, according to Preferred Reporting Items of Systematic reviews and Meta-Analyses (PRISMA) and Agency for Healthcare Research and Quality (AHRQ) guidelines, of the clinical efficacy and adverse effect profile of dorsal anterior cingulotomy compared with anterior capsulotomy for the treatment of severe, refractory obsessive-compulsive disorder (OCD). METHODS The authors included studies comparing objective clinical measures before and after cingulotomy or capsulotomy (surgical and radiosurgical) in patients with OCD. Only papers reporting the most current follow-up data for each group of investigators were included. Studies reporting results on patients undergoing one or more procedures other than cingulotomy or capsulotomy were excluded. Case reports and studies with a mean follow-up shorter than 12 months were excluded. Clinical response was defined in terms of a change in the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score. The authors searched MEDLINE, PubMed, PsycINFO, Scopus, and Web of Knowledge through October 2013. English and non-English articles and abstracts were reviewed. RESULTS Ten studies involving 193 participants evaluated the length of follow-up, change in the Y-BOCS score, and postoperative adverse events (AEs) after cingulotomy (n = 2 studies, n = 81 participants) or capsulotomy (n = 8 studies, n = 112 participants). The average time to the last follow-up was 47 months for cingulotomy and 60 months for capsulotomy. The mean reduction in the Y-BOCS score at 12 months’ follow-up was 37% for cingulotomy and 55% for capsulotomy. At the last follow-up, the mean reduction in Y-BOCS score was 37% for cingulotomy and 57% for capsulotomy. The average full response rate to cingulotomy at the last follow-up was 41% (range 38%–47%, n = 2 studies, n = 51 participants), and to capsulotomy was 54% (range 37%–80%, n = 5 studies, n = 50 participants). The rate of transient AEs was 14.3% across cingulotomy studies (n = 116 procedures) and 56.2% across capsulotomy studies (n = 112 procedures). The rate of serious or permanent AEs was 5.2% across cingulotomy studies and 21.4% across capsulotomy studies. CONCLUSIONS This systematic review of the literature supports the efficacy of both dorsal anterior cingulotomy and anterior capsulotomy in this highly treatment-refractory population. The observational nature of available data limits the ability to directly compare these procedures. Controlled or head-to-head studies are necessary to identify differences in efficacy or AEs and may lead to the individualization of treatment recommendations.

Randomized clinical trial of deep brain stimulation for poststroke pain

“…Anterior capsulotomy is a stereotactic procedure in which the reciprocal projections between the orbitofrontal cortex and the thalamus are lesioned. This procedure has been shown to alleviate obsessive symptoms and anxiety and demonstrates the relevance of the fibers projecting through the ALIC in the control of emotion and behavior. Radiofrequency ablation of the anterior cingulate has also shown the ability to alleviate symptoms in OCD as well as pain in chronic cancer and noncancer pain .…”

“…This procedure has been shown to alleviate obsessive symptoms and anxiety and demonstrates the relevance of the fibers projecting through the ALIC in the control of emotion and behavior. Radiofrequency ablation of the anterior cingulate has also shown the ability to alleviate symptoms in OCD as well as pain in chronic cancer and noncancer pain . Although these ablative procedures can be effective, there are significant concerns for cognitive changes at follow‐up and the risk for deterioration of executive function …”

“…Radiofrequency ablation of the anterior cingulate has also shown the ability to alleviate symptoms in OCD as well as pain in chronic cancer and noncancer pain. [20][21][22][23] Although these ablative procedures can be effective, there are significant concerns for cognitive changes at follow-up and the risk for deterioration of executive function. 24 DBS is a reversible and adjustable therapy that allows for adverse effects to be managed and clinical efficacy to be optimized.…”

Charting the road forward in psychiatric neurosurgery: proceedings of the 2016 American Society for Stereotactic and Functional Neurosurgery workshop on neuromodulation for psychiatric disorders

“…A recent report described a 47% full and 22% partial response to cingulotomy and limbic leucotomy for severe OCD 45. Another comparison of anterior capsulotomy to cingulotomy found a comparable response rate of 54% and 41%, respectively 46. A recent retrospective comparison of capsulotomy to VC/VS DBS (thus comparing interventions in the same region) found a significant advantage in Yale-Brown Obsessive Compulsive Scale (YBOCS) reduction (51% vs 40%) and remission rate favouring capsulotomy 47…”

Neurotherapeutic Interventions for Psychiatric Illness

“…For the open procedures, active versus sham comparisons of outcome are not feasible. However, unblinded, long-term, prospective studies have demonstrated response rates as high as 69% for intractable OCD 6 and 75% for TRD 7 for anterior cingulotomy and/or subcaudate tractotomy and 54% for anterior capsulotomy for intractable OCD 8 . Ablative limbic system surgery is not currently typically used to treat any other psychiatric disorders.…”