Complications of capsulotomy in the treatment of psychiatric illness: A systematic review.

For more than half a century, stereotactic neurosurgical procedures have been available in the treatment of patients with severe, debilitating symptoms of treatment-resistant psychiatric conditions such as obsessive-compulsive disorder (OCD). Such surgical interventions include stimulation and lesioning techniques. Capsulotomy is a lesioning procedure targeting the internal capsule. This systematic review aims to explore the safety profile of capsulotomy in the treatment of severe medically-refractory psychiatric illness, focusing on its complications. Methodologically, a literature search was conducted using the terms "psychiatric", "capsulotomy", and "complications" in the PubMed/Medline database until the end of 2022. The search retrieved 41 articles. Following screening for potential suitability, 39 articles relevant to the topic were further analyzed and finally used for this review. No specific assessment tool for risk of bias was used in this study. The vast majority of capsulotomy data in the literature comes from OCD patients, and the main modalities used for this procedure are radiofrequency (RF) ablation, Gamma Knife radiosurgery (GKRS), and magnetic resonance-guided focused ultrasound (MRgFUS). Postoperative complications are usually transient. These include neurological and psychiatric manifestations, cerebrovascular accidents, thromboembolic events, and infections (respiratory, urinary). Common complications are headache, focal edema, and frontal syndrome. Other complications include ataxia, seizures, urinary incontinence, weight gain, and fatigue. Regarding different techniques, urinary incontinence, sleep disorders, fatigue, and disorientation are frequent but transient complications of RF lesioning. Gamma capsulotomy has a risk of adverse radiation effects, such as radiation necrosis, brain edema, and cyst formation. MRgFUS seems to lack many of the inherent risks associated with more invasive treatment modalities. Discussion: Capsulotomy complications, usually transient and self-limited, include neurological and psychiatric manifestations, cerebrovascular accidents, thromboembolic events, and infections. Their occurrence and nature depend on the chosen modality. The principal limitation of this study is the fact that most data come from case reports or case series. As a result, the total number of patients who underwent capsulotomy is limited. Further clinical research is mandatory to improve the safety.