scholarly journals Efficacy of Gamma Knife Radiosurgery in Refractory Obsessive-Compulsive Disorder: An Indian Experience

Author(s):  
Sanjeev Pattankar ◽  
Milind Sankhe ◽  
Kersi Chavda

Abstract Background Obsessive-compulsive disorder (OCD) is a chronic debilitating psychiatric condition with adverse impact on patient's sociooccupational health. Refractoriness to pharmacotherapy and psychotherapy is not uncommon. Gamma Knife radiosurgery (GKRS) is the comprehensively used and reviewed treatment modality in refractory OCD worldwide. In India, the past two decades of increasing GKRS availability has failed to create the necessary local awareness of its usefulness in refractory OCD. Limited native literature deepens the problem. Objective To analyze our experience with GKRS in refractory OCD, and report the safety and efficacy/long-term outcome in patients using the Yale–Brown Obsessive-Compulsive Scale (Y-BOCS). Materials and Methods A retrospective review of patients receiving GKRS for refractory OCD between 2000 and 2020 was carried out. Case files of the eligible (n = 9) patients were reviewed for clinical, radiotherapeutic, and outcome data. Additionally, patients were contacted via telephone to enquire about their experiences, and to obtain retroactive consent for GKRS in June 2021. Information obtained was collated, computed, and analyzed. Results Male-to-female sex ratio was 8:1. Mean age at the time of GKRS and mean duration of OCD prior to GKRS was 30.1 ± 9.4 and 10.2 ± 5.8 years, respectively. Mean baseline Y-BOCS score was 29.6 ± 4.7. Our first patient received cingulotomy, while the rest underwent anterior capsulotomy. Median margin dose (50% isodose) was 70 Gy. Also, 23.8 ± 7.7 was the mean Y-BOCS score at the last follow-up (median = 30 months). Overall, 44.4% patients showed full/partial response (≥25% reduction in Y-BOCS score) at the last follow-up. In anterior capsulotomy (eight patients), patients with moderate/severe OCD showed better response (4/5 responders) than those with extreme OCD (0/3 responders). Single case of cingulotomy resulted in no response (<25% reduction in Y-BOCS score). No adverse radiation effects were noted. Also, 55.6% patients gave retroactive consent telephonically. Conclusion GKRS is a safe and effective noninvasive treatment modality for refractory OCD. Ventral anterior capsule is the preferred target. Maximum radiation doses of 120 to 160 Gy are well tolerated. Extremely severe OCD cases fared poorer. Proper awareness about the availability and efficacy of GKRS in refractory OCD is required in India.

Neurosurgery ◽  
2011 ◽  
Vol 68 (1) ◽  
pp. 28-33 ◽  
Author(s):  
Douglas. Kondziolka ◽  
John C. Flickinger ◽  
Robert. Hudak

Abstract BACKGROUND: Obsessive compulsive disorder (OCD), in its severe form, can cause tremendous disability for affected patients. OBJECTIVE: To evaluate the results following bilateral radiosurgical anterior capsulotomy for severe medically refractory OCD. METHODS: We performed gamma knife anterior capsulotomy (GKAC) on 3 patients with extreme, medically intractable OCD. According to our protocol, all patients were evaluated by at least 2 psychiatrists who recommended surgery. The patient had to request the procedure, and had to have severe OCD according to the Yale-Brown Obsessive Compulsive Scale (YBOCS). Patient ages were 37, 55, and 40 years, and pre-radiosurgery YBOCS scores were 34/40, 39/40, and 39/40. Bilateral lesions were created with 2 4-mm isocenters to create an oval volume in the ventral internal capsule at the putaminal midpoint. A maximum dose of 140 or 150 Gy was used. RESULTS: There was no morbidity after the procedure, and all patients returned immediately to baseline function. All patients noted significant functional improvements, and reduction in OCD behavior. Follow-up was at 55, 42, and 28 months. The first patient reduced her YBOCS score from 34 to 24. One patient with compulsive skin picking and an open wound had later healing of the chronic wound and a reduction in the YBOCS score from 39 to 8. At 28 months, the third patient is living and working independently, and her YBOCS score is 18. CONCLUSION: Within a strict protocol, gamma knife radiosurgery provided improvement of OCD behavior with no adverse effects. This technique should be evaluated further in patients with severe and disabling behavioral disorders.


2019 ◽  
Vol 131 (2) ◽  
pp. 376-383 ◽  
Author(s):  
Giorgio Spatola ◽  
Roberto Martinez-Alvarez ◽  
Nuria Martínez-Moreno ◽  
German Rey ◽  
Juan Linera ◽  
...  

OBJECTIVEObsessive-compulsive disorder (OCD) is a severe psychiatric condition. The authors present their experience with Gamma Knife radiosurgery (GKRS) in the treatment of patients with OCD resistant to any medical therapy.METHODSPatients with severe OCD resistant to all pharmacological and psychiatric treatments who were treated with anterior GKRS capsulotomy were retrospectively reviewed. These patients were submitted to a physical, neurological, and neuropsychological examination together with structural and functional MRI before and after GKRS treatment. Strict study inclusion criteria were applied. Radiosurgical capsulotomy was performed using two 4-mm isocenters targeted at the midputaminal point of the anterior limb of the capsule. A maximal dose of 120 Gy was prescribed for each side. Clinical global changes were assessed using the Clinical Global Impression (CGI) scale, Global Assessment of Functioning (GAF) scale, EQ-5D, Beck Depression Inventory (BDI), and State-Trait Anxiety Inventory (STAI). OCD symptoms were determined by the Yale–Brown Obsessive Compulsive Scale (Y-BOCS).RESULTSTen patients with medically refractory OCD (5 women and 5 men) treated between 2006 and 2015 were included in this study. Median age at diagnosis was 22 years, median duration of illness at the time of radiosurgery was 14.5 years, and median age at treatment was 38.8 years. Before GKRS, the median Y-BOCS score was 34.5 with a median obsession score of 18 and compulsion score of 17. Seven (70%) of 10 patients achieved a full response at their last follow-up, 2 patients were nonresponders, and 1 patient was a partial responder. Evaluation of the Y-BOCS, BDI, STAI-Trait, STAI-State, GAF, and EQ-5D showed statistically significant improvement at the last follow-up after GKRS. Neurological examinations were normal in all patients at each visit. At last follow-up, none of the patients had experienced any significant adverse neuropsychological effects or personality changes.CONCLUSIONSGKRS anterior capsulotomy is effective and well tolerated with a maximal dose of 120 Gy. It reduces both obsessions and compulsions, improves quality of life, and diminishes depression and anxiety.


2013 ◽  
Vol 84 (11) ◽  
pp. 1208-1213 ◽  
Author(s):  
Myreille D'Astous ◽  
Sylvine Cottin ◽  
Martin Roy ◽  
Claude Picard ◽  
Léo Cantin

2021 ◽  
pp. jnnp-2021-327730
Author(s):  
David Satzer ◽  
Anil Mahavadi ◽  
Maureen Lacy ◽  
Jon E Grant ◽  
Peter Warnke

BackgroundAnterior capsulotomy is a well-established treatment for refractory obsessive–compulsive disorder (OCD). MRI-guided laser interstitial thermal therapy (LITT) allows creation of large, sharply demarcated lesions with the safeguard of real-time imaging.ObjectiveTo characterise the outcomes of laser anterior capsulotomy, including radiographical predictors of improvement.MethodsPatients with severe OCD refractory to pharmacotherapy and cognitive–behavioural therapy underwent bilateral anterior capsulotomy via LITT. The primary outcome was per cent reduction in Yale-Brown Obsessive–Compulsive Scale (Y-BOCS) score over time. Lesion size was measured on postablation MRI. Disconnection of the anterior limb of the internal capsule (ALIC) was assessed via individual and normative tractography.ResultsEighteen patients underwent laser anterior capsulotomy. Median follow-up was 6 months (range 3–51 months). Time occupied by obsessions improved immediately (median Y-BOCS item 1 score 4–1, p=0.002). Mean (±SD) decrease in Y-BOCS score at last follow-up was 46%±32% (16±11 points, p<0.0001). Sixty-one per cent of patients were responders. Seven patients (39%) exhibited transient postoperative apathy. One patient had an asymptomatic intracerebral haemorrhage. Reduction in Y-BOCS score was positively associated with ablation volume (p=0.006). Individual tractography demonstrated durable ALIC disconnection. Normative tractography revealed a dorsal–ventral gradient, with disconnection of orbitofrontal streamlines most strongly associated with a positive response (p<0.0001).ConclusionsLaser anterior capsulotomy resulted in immediate, marked improvement in OCD symptom severity. Larger lesions permit greater disconnection of prefrontal–subcortical pathways involved in OCD. The importance of greater disconnection is presumably related to variation in ALIC structure and the complex role of the PFC in OCD.


Neurosurgery ◽  
2011 ◽  
Vol 69 (3) ◽  
pp. E745-E751 ◽  
Author(s):  
Johan Barbier ◽  
Loes Gabriëls ◽  
Koen van Laere ◽  
Bart Nuttin

Abstract BACKGROUND AND IMPORTANCE: State-of-the-art treatment of anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) often proves ineffective. Both disorders have common features, and anterior capsulotomy is a last-resort treatment for OCD. We document the effect of bilateral anterior capsulotomy in a patient with comorbid AN and OCD. CLINICAL PRESENTATION: A 38-year-old woman with life-threatening, chronic, treatment-refractory AN and OCD underwent anterior capsulotomy. Psychiatric and neuropsychological evaluations at baseline and at follow-up document the severity and progress of the case. Bilateral anterior capsulotomy resulted in normalization of eating pattern and weight and a significant decrease of food-related and overall obsessive-compulsive symptoms. Psychiatric evaluations and exposure to food cues confirmed the clinical improvement that was evident immediately after surgery and sustained at 3-month follow-up. CONCLUSION: This case report suggests that bilateral anterior capsulotomy can be a therapeutic option for patients with comorbid AN and OCD. However, a well-controlled study is warranted.


2013 ◽  
Vol 119 (5) ◽  
pp. 1112-1118 ◽  
Author(s):  
Jason P. Sheehan ◽  
Gregory Patterson ◽  
David Schlesinger ◽  
Zhiyuan Xu

Object Obsessive-compulsive disorder (OCD) is a challenging psychiatric condition associated with anxiety and ritualistic behaviors. Although medical management and psychiatric therapy are effective for many patients, severe and extreme cases may prove refractory to these approaches. The authors evaluated their experience with Gamma Knife (GK) capsulotomy in treating patients with severe OCD. Methods A retrospective review of an institutional review board–approved prospective clinical GK database was conducted for patients treated for severe OCD. All patients were evaluated preoperatively by at least one psychiatrist, and their condition was deemed refractory to pharmacological and psychiatric therapy. Results Five patients were identified. Gamma Knife surgery with the GK Perfexion unit was used to target the anterior limb of the internal capsule bilaterally. A single 4-mm isocenter was used; maximum radiation doses of 140–160 Gy were delivered. All 5 patients were preoperatively and postoperatively assessed for clinical response by using both subjective and objective metrics, including the Yale-Brown Obsessive Compulsive Scale (YBOCS); 4 of the 5 patients had postoperative radiological follow-up. The median clinical follow-up was 24 months (range 6–33 months). At the time of radiosurgery, all patients had YBOCS scores in the severe or extreme range (median 32, range 31–34). At the last follow-up, 4 (80%) of the 5 patients showed marked clinical improvement; in the remaining patient (20%), mild improvement was seen. The median YBOCS score was 13 (range 12–31) at the last follow-up. Neuroimaging studies at 6 months after GK treatment demonstrated a small area of enhancement corresponding to the site of the isocenter and some mild T2 signal changes in the internal capsule. No adverse clinical effects were noted from the radiosurgery. Conclusions For patients with severe OCD refractory to medications and psychiatric therapy, GK capsulotomy afforded clinical improvement. Further study of this approach seems warranted.


2015 ◽  
Vol 122 (5) ◽  
pp. 1028-1037 ◽  
Author(s):  
Joshua Pepper ◽  
Marwan Hariz ◽  
Ludvic Zrinzo

Obsessive-compulsive disorder (OCD) is a chronic and debilitating psychiatric condition. Traditionally, anterior capsulotomy (AC) was an established procedure for treatment of patients with refractory OCD. Over recent decades, deep brain stimulation (DBS) has gained popularity. In this paper the authors review the published literature and compare the outcome of AC and DBS targeting of the area of the ventral capsule/ventral striatum (VC/VS) and nucleus accumbens (NAcc). Patients in published cases were grouped according to whether they received AC or DBS and according to their preoperative scores on the Yale-Brown Obsessive-Compulsive Scale (YBOCS), and then separated according to outcome measures: remission (YBOCS score < 8); response (≥ 35% improvement in YBOCS score); nonresponse (< 35% improvement in YBOCS score); and unfavorable (i.e., worsening of the baseline YBOCS score). Twenty studies were identified reporting on 170 patients; 62 patients underwent DBS of the VC/VS or the NAcc (mean age 38 years, follow-up 19 months, baseline YBOCS score of 33), and 108 patients underwent AC (mean age 36 years, follow-up 61 months, baseline YBOCS score of 30). In patients treated with DBS there was a 40% decrease in YBOCS score, compared with a 51% decrease for those who underwent AC (p = 0.004). Patients who underwent AC were 9% more likely to go into remission than patients treated with DBS (p = 0.02). No difference in complication rates was noted. Anterior capsulotomy is an efficient procedure for refractory OCD. Deep brain stimulation in the VC/VS and NAcc area is an emerging and promising therapy. The current popularity of DBS over ablative surgery for OCD is not due to nonefficacy of AC, but possibly because DBS is perceived as more acceptable by clinicians and patients.


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