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Darin D. Dougherty, Anthony P. Weiss, G. Rees Cosgrove, Nathaniel M. Alpert, Edwin H. Cassem, Andrew A. Nierenberg, Bruce H. Price, Helen S. Mayberg, Alan J. Fischman and Scott L. Rauch

Object. Neurosurgical procedures are a viable intervention for severe, treatment-refractory major depression, although they have been associated with only modest rates of efficacy. The purpose of this study was to identify possible neuroimaging predictors of treatment response to anterior cingulotomy in patients with major depression.

Methods. Thirteen patients underwent stereotactic anterior cingulotomy for treatment-refractory major depression. Symptom severity was measured using the Beck Depression Inventory (BDI) both before and approximately 12 months after surgery. The authors performed [18F]fluorodeoxyglucose—positron emission tomography (PET) studies in all patients preoperatively. Statistical parametric mapping methods were used to test for loci of significant correlation between preoperative regional cerebral metabolism and postoperative reduction in BDI scores.

The mean (± standard deviation) change in the BDI score from the preoperative period (43.7 ± 7.8) to the postoperative period (30.5 ± 21.3) was 33.1 ± 45.4%. Two loci—the left subgenual prefrontal cortex and left thalamus—were identified as sites at which preoperative metabolism was significantly correlated with subsequent improvement in depressive symptom severity following cingulotomy. Specifically, higher preoperative rates of metabolism at these loci were associated with better postoperative results.

Conclusions. Possible PET scanning predictors of treatment response were identified in patients with major depression who had undergone anterior cingulotomy. Further research will be necessary to determine the reproducibility of this finding. If confirmed, the availability of an index for noninvasively predicting a patient's response to cingulotomy for the treatment of major depression would be of great clinical value.

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Scott L. Rauch, Hackjin Kim, Nikos Makris, G. Rees Cosgrove, Edwin H. Cassem, Cary R. Savage, Bruce H. Price, Andrew A. Nierenberg, David Shera, Lee Baer, Bradley Buchbinder, Verne S. Caviness, Michael A. Jenike and David N. Kennedy

Object. The goal of this study was to test hypotheses regarding changes in volume in subcortical structures following anterior cingulotomy.

Methods. Morphometric magnetic resonance (MR) imaging methods were used to assess volume reductions in subcortical regions following anterior cingulate lesioning in nine patients. Magnetic resonance imaging data obtained before and 9 ± 6 months following anterior cingulotomy were subjected to segmentation and subcortical parcellation.

Significant volume reductions were predicted and found bilaterally within the caudate nucleus, but not in the amygdala, thalamus, lenticular nuclei, or hippocampus. Subcortical parcellation revealed that the volume reduction in the caudate nucleus was principally referrable to the body, rather than the head. Furthermore, the magnitude of volume reduction in the caudate body was significantly correlated with total lesion volume.

Conclusions. Taken together, these findings implicate significant connectivity between a region of anterior cingulate cortex (ACC) lesioned during cingulotomy and the caudate body. This unique data set complements published findings in nonhuman primates, and advances our knowledge regarding patterns of cortical—subcortical connectivity involving the ACC in humans. Moreover, these findings indicate changes distant from the site of anterior cingulotomy lesions that may play a role in the clinical response to this neurosurgical procedure.