Neurosurgery, University of Chicago Biological Sciences Division, Chicago, Illinois, USA.
Neurosurgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA.
J Neurol Neurosurg Psychiatry. 2022 Mar;93(3):317-323. doi: 10.1136/jnnp-2021-327730. Epub 2021 Oct 29.
Anterior 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.
To characterise the outcomes of laser anterior capsulotomy, including radiographical predictors of improvement.
Patients 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.
Eighteen 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).
Laser 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.
前囊切开术是治疗难治性强迫症（OCD）的一种成熟治疗方法。MRI 引导激光间质热疗（LITT）允许创建大的、明显界限分明的病变，并具有实时成像的保护。
描述激光前囊切开术的结果，包括改善的放射学预测指标。
患有严重强迫症且对药物治疗和认知行为疗法无反应的患者通过 LITT 行双侧前囊切开术。主要结局是耶鲁-布朗强迫症量表（Y-BOCS）评分随时间的百分比降低。在消融后 MRI 上测量病变大小。通过个体和规范轨迹描记术评估内囊前肢（ALIC）的断开。
18 名患者接受了激光前囊切开术。中位随访时间为 6 个月（范围 3-51 个月）。强迫观念的时间立即改善（中位数 Y-BOCS 项目 1 评分 4-1，p=0.002）。最后一次随访时 Y-BOCS 评分的平均（±SD）降低 46%±32%（16±11 分，p<0.0001）。61%的患者为应答者。7 名患者（39%）出现短暂术后淡漠。1 名患者出现无症状性脑出血。Y-BOCS 评分的降低与消融体积呈正相关（p=0.006）。个体轨迹描记术显示 ALIC 持续断开。规范轨迹描记术显示背侧-腹侧梯度，眶额前皮质束线的断开与阳性反应最密切相关（p<0.0001）。
激光前囊切开术可立即显著改善 OCD 症状严重程度。较大的病变允许前脑-皮质下通路的更大断开，这些通路与 OCD 有关。更大断开的重要性可能与 ALIC 结构的变化和 PFC 在 OCD 中的复杂作用有关。
