Prospective Assessment of Stereotactic Ablative Surgery for Intractable Major Depression

Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02129, USA.
Biological psychiatry (Impact Factor: 10.26). 06/2008; 64(6):449-54. DOI: 10.1016/j.biopsych.2008.04.009
Source: PubMed

ABSTRACT Despite 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.
Findings 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).
At 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.
Approximately 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.

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Available from: Wael F Asaad, Sep 29, 2015
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    • "Consistent with this hypothesis, emotions such as anxiety and sadness intensify the negative hedonic quality of experimentally-induced pain, a phenomenon that is correlated with hemodynamic activity of the supragenual ACC30. Further, approximately 75% of severely ill MDD patients treated with stereotactic lesions of the supragenual ACC region (dorsal anterior cingulotomy) obtain some benefit from the procedure31. "
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    ABSTRACT: Individuals with major depressive disorder (MDD) display abnormal neurophysiological responses to psychological stress but little is known about their neurophysiological responses to physiological stressors. Using [(15)O-H(2)O] positron emission tomography we assessed whether the regional cerebral blood flow (rCBF) response to arterial cannulation differed between patients with MDD and healthy controls (HCs). Fifty-one MDD patients and 62 HCs were scanned following arterial cannulation and 15 MDD patients and 17 HCs were scanned without arterial cannulation. A region-of-interest analysis showed that a significantly increased rCBF of the anterior cingulate cortex and right amygdala was associated with arterial cannulation in MDD. A whole brain analysis showed increased rCBF of the right post-central gyrus, left temporopolar cortex, and right amygdala during arterial cannulation in MDD patients. The rCBF in the right amygdala was significantly correlated with depression severity. Conceivably, the limbic response to invasive physical stress is greater in MDD subjects than in HCs.
    Scientific Reports 03/2012; 2:308. DOI:10.1038/srep00308 · 5.58 Impact Factor
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    • "Furthermore, the findings of this study accord with previous studies of neuroanatomically specific treatments for mood and anxiety disorders, such as psychosurgery and exogenous brain stimulation. Subcaudate tractotomy, a surgical procedure that interrupts white matter tracts connecting the vmPFC to subcortical structures, has shown efficacy in reducing symptoms of depression and anxiety (Cosgrove, 2000; Shields et al., 2008). And as would be predicted by the results of our study, vegetative symptoms of depression (e.g., changes in appetite, sleep, and energy) were less likely to improve with subcaudate tractotomy than depressed mood or anxiety (Hodgkiss et al., 1995). "
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    ABSTRACT: The neuroanatomical correlates of depression remain unclear. Functional imaging data have associated depression with abnormal patterns of activity in prefrontal cortex (PFC), including the ventromedial (vmPFC) and dorsolateral (dlPFC) sectors. If vmPFC and dlPFC are critical neural substrates for the pathogenesis of depression, then damage to either area should affect the expression of depressive symptoms. Using patients with brain lesions we show that, relative to nonfrontal lesions, bilateral vmPFC lesions are associated with markedly low levels of depression, whereas bilateral dorsal PFC lesions (involving dorsomedial and dorsolateral areas in both hemispheres) are associated with substantially higher levels of depression. These findings demonstrate that vmPFC and dorsal PFC are critically and causally involved in depression, although with very different roles: vmPFC damage confers resistance to depression, whereas dorsal PFC damage confers vulnerability.
    The Journal of Neuroscience : The Official Journal of the Society for Neuroscience 12/2008; 28(47):12341-8. DOI:10.1523/JNEUROSCI.2324-08.2008 · 6.34 Impact Factor
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    ABSTRACT: Advanced treatment options are available from a few tertiary centres for patients with the most severe and treatment-refractory forms of depression and obsessive–compulsive disorder. These treatments include ablative neurosurgery and electrical stimulation procedures directed against different neural targets. They include vagus nerve stimulation (VNS) and deep brain stimulation (DBS). Ablative procedures, such as anterior cingulotomy, are the best established of these alternatives, although the newer electrical stimulation procedures confer potential advantages with respect to surgical morbidity and reversibility. Whilst evidence for VNS as an effective therapy for depression is accruing, DBS remains an experimental treatment, with definitive evidence of efficacy awaited. All neurosurgical procedures used to treat psychiatric disorder should be provided by specialist multidisciplinary teams with expertise in the management of psychiatric disorder by pharmacological and psychological treatment methods. All psychiatric neurosurgical procedures should be subject to detailed long-term clinical audit to determine efficacy and adverse effect burden.
    Psychiatry 04/2009; 8(4):139-143. DOI:10.1016/j.mppsy.2009.01.007
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