April 23, 2012 (Miami, Florida) — Cingulotomy appears to be an effective and durable option for many patients who have severe treatment-refractory obsessive-compulsive disorder (OCD).
Here at the American Association of Neurological Surgeons (AANS) 80th Annual Meeting, Sameer Sheth, MD, PhD, from the Department of Neurosurgery at Massachusetts General Hospital in Boston, presented data demonstrating that 69% of patients achieved at least a partial response.
OCD is among the most common mental illness in the United States, and is accompanied by high rates of depression and suicidal ideation. Standard pharmacologic and behavioral therapy is ineffective for 30% to 60% of patients.
For the study conducted by Dr. Sheth and colleagues, a multidisciplinary committee of psychiatrists, neurologists, and neurosurgeons selected patients with severe OCD and functional impairment for whom behavioral therapy and several trials of drugs had failed.
Stereotactic surgery using radio frequency ablation was performed while the patient was awake. The target was 2 cm posterior to the most anterior point of the frontal horn of the lateral ventricle, 0.7 cm lateral to the midline, and 0.5 cm superior to the corpus callosum. A single-lesion pair was performed prior to 2000, and a triple-lesson pair was subsequently used.
The primary outcome measure was the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score, which ranges from 0 to 40. A full response was defined as a decrease in score of 35% or more; a partial response was defined as a decrease of 25% to 35%.
The researchers examined prospective data from 1989 to 2009 on 63 patients (mean age, 35 years; 41 men, 22 women). There were sufficient follow-up data for 59 patients (follow-up interval, 64 months). The preoperative Y-BOCS score was 31, indicating severe OCD.
Outcomes Over Time (n = 59)
|Outcome||Initial Assessment at 11 Months||Final Assessment at 64 Months|
"Of the 24 patients with at least a partial response at the initial evaluation, 20 (83%) retained that response at the final evaluation," Dr. Sheth said. "The mean decrease in the Y-BOCS score was 36% for the entire group, and the mean decrease in the [Beck Depression Inventory] scale was 17%." Age, sex, or type of obsessive or compulsive symptoms did not predict a response.
A subgroup analysis showed that 33 patients underwent cingulotomy alone, and 30 later underwent a repeat cingulotomy or a subcaudate tractotomy, "usually following an insufficient response to the initial procedure," Dr. Sheth reported. There was no significant difference in outcome between the single- and multiple-procedure groups (P = .24) or between the single- and triple-lesion procedures (P = .51).
There were 19 adverse events but no intracranial hemorrhages. Twelve of the events — consisting of memory difficulty, urinary retention/incontinence, and abulia — were short term and resolved after a few days. There were 3 cases of seizure, 1 of which required long-term antiepileptic drugs; 1 case of pulmonary embolus on a long flight; 1 case of subdural empyema requiring craniotomy; and 2 suicides, both with preoperative depression and 1 with a history of suicide attempts.
Dr. Sheth concluded that because "these patients had severe treatment-refractory disease for years or decades, and were therefore incapacitated by this illness," the 69% full or partial response "is significant."
The procedure gave durable results for many years and appears to be an effective treatment for appropriately selected patients with severe treatment-refractory OCD.
Dr. Sheth noted that it would be interesting to compare these results with relatively newer therapies, such as deep brain stimulation (DBS).
Paul Larson, MD, associate clinical professor and vice chair of neurological surgery at the University of California at San Francisco, and chief of the neurosurgery service at the Veterans Affairs Medical Center in San Francisco, praised the study as "a very nice body of work over a lot of years."
As Dr. Sheth mentioned, it would be good to compare cingulotomy with DBS; Dr. Larson cited a study of DBS for the treatment of OCD. "If you look at the long-term outcomes of these 2 studies, they're actually quite similar. They are within a few percentage points of each other," he said. Differences might be in how the modalities treat comorbid depression hoarding, a subtype of OCD. DBS so far appears better at treating depression, but cingulotomy might win for hoarding.
DBS requires surgical implantation, multiple programming sessions, and battery changes. Dr. Larson cautioned that cingulotomy is not necessarily a "1-stop" procedure. He said the Massachusetts General Hospital group is probably a world leader, and even then, 50% of their patients required a second intracranial procedure and 5 patients required 3. "I think the bottom line is that all of these treatments are complex, they're complicated, and we should not think about DBS and lesioning as being mutually exclusive. We should think of them as 2 different tools that we can use in our armamentarium to treat these very complicated patients," he advised.
Dr. Sheth has disclosed no relevant financial relationships. Dr. Larson reports being a speaker for Medtronic and receiving research grant support from St. Jude Medical Center.
American Association of Neurological Surgeons (AANS) 80th Annual Meeting: Abstract 701. Presented April 17, 2012.
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