Stereotactic Limbic Leucotomy—A Follow-up at 16 Months

Mitchell-Heggs, Nita; Kelly, Desmond; Richardson, Alan

doi:10.1192/bjp.128.3.226

Cited by 139 publications

(52 citation statements)

References 32 publications

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“…17) Neither adverse personality changes nor epilepsy were seen following these operations, and overall improvement was reported in 84% of patients at 20 months postoperatively. 17,19) Long-term side effects of limbic leucotomy are rare, but transient effects such as headache, confusion, lethargy, sphincter disturbances, and perseveration are documented. 17,20) A few studies have attempted to directly compare different procedures.…”

Section: Discussionmentioning

confidence: 99%

“…Improvements in patient symptoms have been determined for OCD (84%) and for schizophrenia (63%). 19,26) Cingulotomy has also been described in combination with anterior capsulotomy in the treatment of uncontrolled aggressive behavior, although improved efficacy over either procedure alone remains unproved. 8,20) These long-term results indicate that stereotactic psychosurgery is a safe and effective method of treating some medically intractable psychiatric illnesses.…”

Section: Discussionmentioning

confidence: 99%

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Review of Long-term Results of Stereotactic Psychosurgery.

Kim

Lee

Choi

2002

Neurol. Med. Chir.(Tokyo)

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Stereotactic psychosurgery is an effective method for treating some medically intractable psychiatric illnesses. However, it is unfamiliar and the long-term clinical results have not been reported in Asia. The long-term results of psychosurgery are evaluated and the neuroanatomical basis is discussed. Twenty-one patients underwent stereotactic psychosurgery for medically intractable psychiatric illnesses since 1993. All were referred from psychiatrists for these disorders. Two patients showed aggressive behavior, 12 had obsessive-compulsive disorder (OCD), and seven had depression with anxiety disorders. Bilateral amygdalotomy and subcaudate tractotomy were performed for aggressive behavior, limbic leucotomy was performed for OCD, and subcaudate tractotomy with or without cingulotomy was performed for depression with anxiety. OCD was evaluated with the Yale-Brown Obsessive Compulsive Scale (YBOCS), the visual analogue scale, the Clinical Global Impression Scale, and the Overt Aggression Scale (OAS). The Mini-Mental State Examination and the Wechsler Adult Intelligence ScaleRevised were used for the evaluation of aggressive behavior. The 17-item Hamilton Depression Rating Scale (HAMD) was used for evaluation of depression. Ventriculography was used in the first seven patients and magnetic resonance imaging-guided stereotaxy was used in the recent 14 cases for localization of the target. The lesions were made with a radiofrequency lesion generator. OAS scores in the two patients with aggressive behavior during follow up declined from 8 to 2 with clinical improvement. All 12 patients with OCD returned to their previous life and showed the mean YBOCS scores decreased from 34 to 3. Ten patients with OCD could be followed up (mean 45 months). All patients returned to their previous social life. In seven patients with depression with anxiety, HAMD scores declined from 28.5 to 16.5. There was no operative mortality and no significant morbidity except for one case of mild transient urinary incontinence. These long-term results indicate that stereotactic psychosurgery is a safe and effective method of treating some medically intractable psychiatric illnesses.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Review of Long-term Results of Stereotactic Psychosurgery.

Kim

Lee

Choi

2002

Neurol. Med. Chir.(Tokyo)

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“…A variety of surgical ablative lesion therapies (anterior cingulotomy [4], anterior capsulotomy [5], subcaudate tractotomy [6], and limbic leucotomy [7,8]) have been used to treat patients who are refractory to noninvasive treatments, including pharmacotherapy, psychotherapy, repetitive transcranial magnetic stimulation, and electroconvulsive therapy. Though these surgical treatments have been reported to be successful in select patients, early reported studies of these procedures lack modern methodological approaches [9].…”

Section: Introductionmentioning

confidence: 99%

Deep Brain Stimulation for Treatment-resistant Depression: Systematic Review of Clinical Outcomes

et al. 2014

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Major depressive disorder (MDD) is a widespread, severe, debilitating disorder that markedly diminishes quality of life. Medication is commonly effective, but 20-30 % of patients are refractory to medical therapy. The surgical treatment of psychiatric disorders has a negative stigma associated with it owing to historical abuses. Various ablative surgeries for MDD have been attempted with marginal success, but these studies lacked standardized outcome measures. The recent development of neuromodulation therapy, especially deep brain stimulation (DBS), has enabled controlled studies with sham stimulation and presents a potential therapeutic option that is both reversible and adjustable. We performed a systematic review of the literature pertaining to DBS for treatment-resistant depression to evaluate the safety and efficacy of this procedure. We included only studies using validated outcome measures. Our review identified 22 clinical research papers with 5 unique DBS approaches using different targets, including nucleus accumbens, ventral striatum/ventral capsule, subgenual cingulate cortex, lateral habenula, inferior thalamic nucleus, and medial forebrain bundle. Among the 22 published studies, only 3 were controlled trials, and 2, as yet unpublished, multicenter, randomized, controlled trials evaluating the efficacy of subgenual cingulate cortex and ventral striatum/ventral capsule DBS were recently discontinued owing to inefficacy based on futility analyses. Overall, the published response rate to DBS therapy, defined as the percentage of patients with>50 % improvement on the Hamilton Depression Rating Scale, is reported to be 40-70 %, and outcomes were comparable across studies. We conclude that DBS for MDD shows promise, but remains experimental and further accumulation of data is warranted.

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“…LL most likely was the most effective treatment for depression during the lesion era. The method, introduced in 1973 by Kelly and Richardson (Mitchell-Heggs et al, 1976;Kelly et al, 1973), was based on the possibility that a dual lesion technique should produce better functional results compared with either single-lesion method alone. Our connectivity analysis demarcated the influenced tracts to the medial frontal, orbitofrontal, frontal polar, and subcallosal cortex.…”

Section: Discussionmentioning

confidence: 99%

“…(iv) Stereotactic limbic leucotomy (LL) is a combination of both bilateral ACT and SCT (Richardson, 1973). In diverse studies, rates of improvement of 50% (Mitchell-Heggs et al, 1976, Kim et al, 2002 to 78% (Cosgrove and Rauch, 2003;Montoya et al, 2002) have been reported (Mitchell-Heggs et al, 1976;Kim et al, 2002;Kelly et al, 1973;Diering and Bell, 1991). Thus, LL stands out as the clinically most effective lesioning procedure for depression.…”

Section: Introductionmentioning

confidence: 99%

Tractographic Analysis of Historical Lesion Surgery for Depression

Schoene-Bake

Parpaley

Weber

et al. 2010

Neuropsychopharmacol

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Various surgical brain ablation procedures for the treatment of refractory depression were developed in the twentieth century. Most notably, key target sites were (i) the anterior cingulum, (ii) the anterior limb of the internal capsule, and (iii) the subcaudate white matter, which were regarded as effective targets. Long-term symptom remissions were better following lesions of the anterior internal capsule and subcaudate white matter than of the cingulum. It is possible that the observed clinical improvements of these various surgical procedures may reflect shared influences on presently unspecified brain affect-regulating networks. Such possibilities can now be analyzed using modern brain connectivity procedures such as diffusion tensor imaging (DTI) tractography. We determined whether the shared connectivities of the above lesion sites in healthy volunteers might explain the therapeutic effects of the various surgical approaches. Accordingly, modestly sized historical lesions, especially of the anatomical overlap areas, were 'implanted' in brain-MRI scans of 53 healthy subjects. These were entered as seed regions for probabilistic DTI connectivity reconstructions. We analyzed for the shared connectivities of bilateral anterior capsulotomy, anterior cingulotomy, subcaudate tractotomy, and stereotactic limbic leucotomy (a combination of the last two lesion sites). Shared connectivities between the four surgical approaches mapped onto the most mediobasal aspects of bilateral frontal lobe fibers, including the forceps minor and the anterior thalamic radiations that contacted subgenual cingulate regions. Anatomically, convergence of these shared connectivities may derive from the superolateral branch of the medial forebrain bundle (MFB), a structure that connects these frontal areas to the origin of the mesolimbic dopaminergic 'reward' system in the midbrain ventral tegmental area. Thus, all four surgical anti-depressant approaches may be promoting positive affect by converging influences onto the MFB.

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Stereotactic Limbic Leucotomy—A Follow-up at 16 Months

Cited by 139 publications

References 32 publications

Review of Long-term Results of Stereotactic Psychosurgery.

Review of Long-term Results of Stereotactic Psychosurgery.

Deep Brain Stimulation for Treatment-resistant Depression: Systematic Review of Clinical Outcomes

Tractographic Analysis of Historical Lesion Surgery for Depression

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