Stereotactic cingulotomy and capsulotomy for obsessive-compulsive disorders: Indications and comparative results.

Stereotactic cingulotomy and capsulotomy have been used to treat obsessive-compulsive disorders (OCD) and treatment-resistant depression since the 1950s-60s. To date, these surgical procedures have gained a number of advancements due to progress of neuroimaging and upgrading of stereotactic technique. The effectiveness of operations is related to the restoration of the normal level of limbic regulation in treated patients. In cases of OCD, capsulotomy is somewhat more effective, while cingulotomy has a more favorable safety profile. Moreover, clinical experience shows that these procedures may be efficient for management not only OCD itself, but for obsessive-compulsive symptoms in cases of other mental diseases, such as Tourette syndrome and schizophrenia, thus may be considered in carefully selected patients. An individualized treatment strategy, including staged stereotactic interventions, seems most promising for attainment of the best possible outcomes, and may allow to achieve socialization of 75% of the operated patients with minimal pharmacological support. Other potential stereotactic targets for management of OCD, which selection may depend on detail of clinical manifestation of disease, include thalamic nuclei, nucleus accumbens, globus pallidus, the amygdala, etc., and are currently under active evaluation, and their use is tremendously facilitated by the development of deep brain stimulation techniques. Nevertheless, cingulotomy and capsulotomy still remain highly relevant for treatment of patients with therapy-resistant mental disorders.

Stereotactic surgeries for abuse syndromes: Patient selection and results.

It is known that in present time heroin addiction is the most widespread and difficult to treat. It includes two factors: physical and psychological addiction. The vast majority of patients remained mentally addicted to drugs after physical drug addiction has been eliminated and the organism has been completely detoxed. It is an indomitable desire to take drugs. Neurophysiological mechanisms are in base of psychological dependence. It is similar to those that implement obsessive states (obsessive-compulsive disorders). The central role in these neurophysiological mechanisms is played by limbic system of the brain that provides emotional and motivational behavior of humans (and animals). It was shown that the treatment of medical-resistant forms of obsessive-compulsive disorders requires stereotactic impacts on various structures of the limbic system, including cingulate gyrus. According to literature data, there was several hundred stereotactic effects on the cingulate gyrus in the world. About 1000 stereotactic operations have been performed in our country as a mental addiction of heroin dependent patients' treatment. The efficiency was of about 70%.

Stereotactic Cryodestruction of Gliomas.

Surgical resection of gliomas affecting functionally important brain structures is associated with high risk of permanent postoperative neurological deficit and deterioration of the patient's quality of life. The availability of modern neuroimaging and neuronavigation permits the application of minimally invasive stereotactic cryodestruction of the tumor in such cases. The authors used this treatment in 88 patients with supratentorial gliomas of various WHO histopathological grades not suitable for microsurgical resection. Postoperative mortality (1.1%) and rate of surgical complications (11.4%) were comparable to reported results of stereotactic brain tumor biopsy, whereas the rate of neurological morbidity (42%) was comparable to outcome after resection of gliomas within eloquent brain areas. The majority of complications were temporary, and permanent deterioration of neurological function was noted in 8% of cases only. The median survival after treatment in patients with glioblastoma and anaplastic astrocytoma was 12.4 and 46.9 months, respectively, and was not reached in cases of diffuse astrocytoma, which compared favorably both with historical controls and literature data. Therefore, it seems reasonable to consider stereotactic cryodestruction in multimodality management strategies of "unresectable" intracranial gliomas, and further studies directed at evaluation of its efficacy are definitely needed.