| Autor: |
Miguel EC; Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil. ecmiguel@usp.br., Lopes AC; Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil., McLaughlin NCR; Departments of Psychiatry and Human Behavior and Neurosurgery, Warren Alpert Medical School of Brown University and Veterans Affairs Medical Center of Providence, Providence, RI, USA., Norén G; Departments of Psychiatry and Human Behavior and Neurosurgery, Warren Alpert Medical School of Brown University and Veterans Affairs Medical Center of Providence, Providence, RI, USA., Gentil AF; Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil., Hamani C; Division of Neurosurgery, Sunnybrook Health Sciences Centre, Harquail Centre for Neuromodulation, University of Toronto, Toronto, Ontario, Canada., Shavitt RG; Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil., Batistuzzo MC; Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil., Vattimo EFQ; Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil., Canteras M; Discipline of Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil., De Salles A; Hospital do Coração, São Paulo, Brazil., Gorgulho A; Hospital do Coração, São Paulo, Brazil., Salvajoli JV; Hospital do Coração, São Paulo, Brazil., Fonoff ET; Department of Neurology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil., Paddick I; National Hospital for Neurology and Neurosurgery, London, UK., Hoexter MQ; Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil., Lindquist C; Gamma Knife Centre, BUPA Cromwell Hospital, London, UK., Haber SN; University of Rochester School of Medicine, Rochester, New York, USA.; McLean Hospital, Harvard University, Boston, USA., Greenberg BD; Departments of Psychiatry and Human Behavior and Neurosurgery, Warren Alpert Medical School of Brown University and Veterans Affairs Medical Center of Providence, Providence, RI, USA., Sheth SA; Discipline of Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil. |
| Abstrakt: |
For more than half a century, stereotactic neurosurgical procedures have been available to treat patients with severe, debilitating symptoms of obsessive-compulsive disorder (OCD) that have proven refractory to extensive, appropriate pharmacological, and psychological treatment. Although reliable predictors of outcome remain elusive, the establishment of narrower selection criteria for neurosurgical candidacy, together with a better understanding of the functional neuroanatomy implicated in OCD, has resulted in improved clinical efficacy for an array of ablative and non-ablative intervention techniques targeting the cingulum, internal capsule, and other limbic regions. It was against this backdrop that gamma knife capsulotomy (GKC) for OCD was developed. In this paper, we review the history of this stereotactic radiosurgical procedure, from its inception to recent advances. We perform a systematic review of the existing literature and also provide a narrative account of the evolution of the procedure, detailing how the procedure has changed over time, and has been shaped by forces of evidence and innovation. As the procedure has evolved and adverse events have decreased considerably, favorable response rates have remained attainable for approximately one-half to two-thirds of individuals treated at experienced centers. A reduction in obsessive-compulsive symptom severity may result not only from direct modulation of OCD neural pathways but also from enhanced efficacy of pharmacological and psychological therapies working in a synergistic fashion with GKC. Possible complications include frontal lobe edema and even the rare formation of delayed radionecrotic cysts. These adverse events have become much less common with new radiation dose and targeting strategies. Detailed neuropsychological assessments from recent studies suggest that cognitive function is not impaired, and in some domains may even improve following treatment. We conclude this review with discussions covering topics essential for further progress of this therapy, including suggestions for future trial design given the unique features of GKC therapy, considerations for optimizing stereotactic targeting and dose planning using biophysical models, and the use of advanced imaging techniques to understand circuitry and predict response. GKC, and in particular its modern variant, gamma ventral capsulotomy, continues to be a reliable treatment option for selected cases of otherwise highly refractory OCD. |
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