OCD and Psychosurgery

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IS GAMMA-KNIFE SURGERY (RADIOSURGERY) EFFECTIVE TREATMENT FOR REFRACTORY OCD?

Best Available Evidence: Lippitz, B.E, Mindus, P., et al. Lesion Topography and Outcome After Thermocapsulotomy or Gamma-Knife Capsulotomy for Obsessive-Compulsive Disorder: Relevance of the Right Hemisphere. Neurosurgery, 44(3): 452-58, March '99.

Design: Retrospective case review

Subjects: 35 Consecutive patients receiving bilateral Thermocapsulotomy(TC) or Gamma-Knife Capsulotomy(GC) for intractable (minimum duration of illness 5 years, all non-surgical treatment options exhausted systematically) at Karolinska Hospital, Stockholm, Sweden between 1976 and 1989.

Outcome Measures: Pre- and post- YBOCS and Comprehensive Psychopathological Rating Scale-OCD subscale and long-term postoperative MRI lesion location

Data: In 29 subjects for which above outcome measures were available (TC n=19, 7 male and 12 female; GC n=10, 5 male and 5 female; median age 40 years; all but one right-handed). Median duration of MRI follow-up 8.4 years

  1. Good outcome (50-100% improvement in rating scales): 9 of 19 in TC group, 7 of 10 in GC group - common denominator in ALL cases was lesion in MIDDLE portion of ant. Limb on RIGHT
  2. Intermediate outcome (5-49% improvement): 5 of 19 in TC group, 1 of 10 in GC group - in 4 of 6 only PART of middle ant. limb compromised (In other 2 cases right-sided lesions appeared identical to those in the good outcome group)
  3. Poor outcome (<5% improvement): 5 of 19 in TC group, 2 of 10 in GC group - most lesions by MRI located in ANTERIOR portion of ant. limb, one in posterior portion

Limitations: 6 patients unaccounted for, not blinded, not prospective (underway by primary author), detailed psychiatric outcome and patient demographic characteristics not available (in progress), morbidity and mortality not included

Strengths: Same MRI scanner and protocol used for all patients, single surgical group performing procedure

Clinical Bottom Line: Best evidence supports targeting middle portion of anterior limb of right internal capsule with gamma-knife radiosurgery technique may be an effective treatment for patients with significant debilitation following psychopharmacologic and psychotherapeutic treatment of Obsessive-Compulsive Disorder

Presented by Edward McGonigle, MD

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