Gamma Knife surgery anterior capsulotomy for severe and refractory obsessive-compulsive disorder

Clinical article

Jason P. Sheehan M.D., Ph.D. 1 , 2 , Gregory Patterson R.N., B.S.N. 1 , David Schlesinger Ph.D. 1 , 2 , and Zhiyuan Xu M.D. 1
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  • 1 Departments of Neurological Surgery and
  • 2 Radiation Oncology, University of Virginia, Charlottesville, Virginia
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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.

Abbreviations used in this paper:DBS = deep brain stimulation; GK = Gamma Knife; GKS = GK surgery; OCD = obsessive-compulsive disorder; SRS = stereotactic radiosurgery; SSRI = selective serotonin reuptake inhibitor; UVA = University of Virginia; YBOCS = Yale-Brown Obsessive Compulsive Scale.

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Contributor Notes

Address correspondence to: Jason P. Sheehan, M.D., Ph.D., Department of Neurological Surgery, University of Virginia, Charlottesville, VA 22908. email: jsheehan@virginia.edu.

Please include this information when citing this paper: published online July 5, 2013; DOI: 10.3171/2013.5.JNS13201.

  • 1

    Blomstedt P, , Sjöberg RL, , Hansson M, , Bodlund O, & Hariz MI: Deep brain stimulation in the treatment of obsessive-compulsive disorder. World Neurosurg [epub ahead of print] 2012

    • Search Google Scholar
    • Export Citation
  • 2

    Fineberg NA, , Reghunandanan S, , Brown A, & Pampaloni I: Pharmacotherapy of obsessive-compulsive disorder: evidence-based treatment and beyond. Aust N Z J Psychiatry 47:121141, 2013

    • Search Google Scholar
    • Export Citation
  • 3

    Kessler RC, , Chiu WT, , Demler O, , Merikangas KR, & Walters EE: Prevalence, severity, and comorbidity of 12-month DSMIV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62:617627, 2005. (Erratum in Arch Gen Psychiatry 62: 709, 2005)

    • Search Google Scholar
    • Export Citation
  • 4

    Kondziolka D, , Flickinger JC, & Hudak R: Results following gamma knife radiosurgical anterior capsulotomies for obsessive compulsive disorder. Neurosurgery 68:2833, 2011

    • Search Google Scholar
    • Export Citation
  • 5

    Koran LM, , Hanna GL, , Hollander E, , Nestadt G, & Simpson HB: Practice guideline for the treatment of patients with obsessive-compulsive disorder. Am J Psychiatry 164:7 Suppl 553, 2007

    • Search Google Scholar
    • Export Citation
  • 6

    Lipsman N, , Neimat JS, & Lozano AM: Deep brain stimulation for treatment-refractory obsessive-compulsive disorder: the search for a valid target. Neurosurgery 61:113, 2007

    • Search Google Scholar
    • Export Citation
  • 7

    Lopes AC, , Greenberg BD, , Norén G, , Canteras MM, , Busatto GF, & de Mathis ME, : Treatment of resistant obsessive-compulsive disorder with ventral capsular/ventral striatal gamma capsulotomy: a pilot prospective study. J Neuropsychiatry Clin Neurosci 21:381392, 2009

    • Search Google Scholar
    • Export Citation
  • 8

    Mindus & Jenike MA: Neurosurgical treatment of malignant obsessive compulsive disorder. Psychiatr Clin North Am 15:921938, 1992

  • 9

    Mindus P, & Nyman H: Normalization of personality characteristics in patients with incapacitating anxiety disorders after capsulotomy. Acta Psychiatr Scand 83:283291, 1991

    • Search Google Scholar
    • Export Citation
  • 10

    Mindus P, , Rasmussen SA, & Lindquist C: Neurosurgical treatment for refractory obsessive-compulsive disorder: implications for understanding frontal lobe function. J Neuropsychiatry Clin Neurosci 6:467477, 1994

    • Search Google Scholar
    • Export Citation
  • 11

    Nyman H, , Andréewitch S, , Lundbäck E, & Mindus P: Executive and cognitive functions in patients with extreme obsessive-compulsive disorder treated by capsulotomy. Appl Neuropsychol 8:9198, 2001

    • Search Google Scholar
    • Export Citation
  • 12

    Rück C, , Karlsson A, , Steele JD, , Edman G, , Meyerson BA, & Ericson K, : Capsulotomy for obsessive-compulsive disorder: long-term follow-up of 25 patients. Arch Gen Psychiatry 65:914921, 2008

    • Search Google Scholar
    • Export Citation
  • 13

    Stein DJ, , Denys D, , Gloster AT, , Hollander E, , Leckman JF, & Rauch SL, : Obsessive-compulsive disorder: diagnostic and treatment issues. Psychiatr Clin North Am 32:665685, 2009

    • Search Google Scholar
    • Export Citation

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