Lesion analysis for cingulotomy and limbic leucotomy: Comparison and correlation with clinical outcomes - Clinical article

Article (PDF Available)inJournal of Neurosurgery 120(1) · November 2013with55 Reads
DOI: 10.3171/2013.9.JNS13839 · Source: PubMed
Object: Cingulotomy and limbic leucotomy are lesioning surgeries with demonstrated benefit for medically intractable psychiatric illnesses. They represent significant refinements of the prefrontal lobotomy used from the 1930s through the 1950s. However, the associations between anatomical characterization of these lesions and outcome data are not well understood. To elucidate these procedures and associations, the authors sought to define and compare the neuroanatomy of cingulotomy and limbic leucotomy and to test a method that uses neuroanatomical data and voxel-based lesion-symptom mapping (VLSM) to reveal potential refinements to modern psychiatric neurosurgical procedures. Methods: T1-weighted MR images of patients who had undergone cingulotomy and limbic leucotomy were segmented and registered onto the Montreal Neurological Institute T1-weighted template brain MNI152. Using an atlas-based approach, the authors calculated, by case, the percentage of each anatomical structure affected by the lesion. Because of the infrequency of modern lesion procedures and the requirement for higher-resolution clinical imaging, the sample size was small. The pilot study correlated cingulotomy and limbic leucotomy lesion characteristics with clinical outcomes for patients with obsessive-compulsive disorder. For this study, preoperative and postoperative Yale-Brown Obsessive Compulsive Scale scores for 11 cingulotomy patients and 8 limbic leucotomy patients were obtained, and lesion masks were defined and compared anatomically by using an atlas-based method. Statistically significant voxels were additionally calculated by using VLSM techniques that correlated lesion characteristics with postoperative scores. Results: Mean lesion volumes were 13.3 ml for cingulotomy and 11.8 ml for limbic leucotomy. As expected, cingulotomy was isolated to the anterior cingulum. The subcaudate tractotomy portion of limbic leucotomy additionally affected Brodmann area 25, the medial orbitofrontal cortex, and the nucleus accumbens. Initial results indicated that the dorsolateral regions of the cingulotomy lesion and the posteroventral regions of the subcaudate tractotomy lesion were associated with improved postoperative Yale-Brown Obsessive Compulsive Scale scores. Conclusions: Cingulotomy and limbic leucotomy are lesioning surgeries that target pathological circuits implicated in psychiatric disease. Lesion analysis and VLSM contextualize outcome data and have the potential to be useful for improving lesioning neurosurgical procedures.
    • "ACING continues to be used for a small number of patients with intractable mood and/or obsessive compulsive disorder (OCD) (Rauch et al., 2000; Steele et al., 2008) and intractable pain (Pereira et al., 2014). It is important to note that the ACING procedure differs significantly between centres with, for example, some centres using a single bilateral lesion that may be repeated after a year depending on clinical response (Steele et al., 2008), and other centres using three bilateral lesions on a single occasion (Yang et al., 2014). In addition, the clinical indication (e.g. "
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    • "Unless visualization of the various fiber tracts in this region is done in a manner that reveals pathway specificity, there will be little clarity regarding target engagement or the correlation of any specific circuitry to therapeutic effect. We identified this problem and addressed it to a certain extent in two recent papers examining which gray and white matter structures were lesioned by subcaudate tractotomy in a cohort identified from a Massachusetts General Hospital database of patients maintained since 1992 (Yang et al. 2014) and mapping the anatomy of fibers of passage in the VC/VS region in normal subjects using DTI probabilistic tractography (Yang et al. 2015). Probabilistic tractography is useful for a general understanding of the topographic arrangement of the fibers of passage. "
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    • "Recent tractographic analyses of OFC-related white matter tracts in nonhuman primates [77] and healthy humans [78] have shed light on the anatomic organization of OFC subdivisions projecting to the thalamus and brain stem. Building on these characterizations, a similar study of OCD patients who had undergone SCT recapitulated these findings and found that the best clinical outcomes may be associated with a target in the ventral aspect of medial OFC white matter tracts [12] . This study proves, in principle, the ability of current modalities to localize an optimal target along a white matter tract for therapeutic relief, and can in theory be applied to more psychiatric disorders. "
    [Show abstract] [Hide abstract] ABSTRACT: The limbic system is a network of interconnected brain regions regulating emotion, memory, and behavior. Pathology of the limbic system can manifest as psychiatric disease, including obsessive-compulsive disorder and major depressive disorder. For patients with these disorders who have not responded to standard pharmacological and cognitive-behavioral therapy, ablative surgery is a neurosurgical treatment option. The major ablative limbic system procedures currently used are anterior capsulotomy, dorsal anterior cingulotomy, subcaudate tractotomy, and limbic leucotomy. In this review, we include a brief history of ablative limbic system surgery leading up to its current form. Mechanistic justification for these procedures is considered in a discussion of the pathophysiology of psychiatric disease. We then discuss therapeutic efficacy as demonstrated by recent trials. Finally, we consider future directions, including the search for predictors of treatment response, the development of more precise targeting methods, and the use of advances in neuroimaging to track treatment response.
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