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Psychosurgery: Review of Latest Concepts and Applications Review 29 Psychosurgery: Review of Latest Concepts and Applications Sabri Aydin 1 Bashar Abuzayed 1 1 Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul Address for correspondence and reprint requests Bashar Abuzayed, University, Istanbul, Turkey M.D., Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, K.M.P. Fatih, Istanbul 34089, Turkey J Neurol Surg A 2013;74:29–46. (e-mail: [email protected]). Abstract Although the utilization of psychosurgery has commenced in early 19th century, when compared with other neurosurgical fields, it faced many obstacles resulting in the delay of advancement of this type of surgical methodology. This was due to the insufficient knowledge of both neural networks of the brain and the pathophysiology of psychiatric diseases. The aggressive surgical treatment modalities with high mortality and morbid- ity rates, the controversial ethical concerns, and the introduction of antipsychotic drugs were also among those obstacles. With the recent advancements in the field of neuroscience more accurate knowledge was gained in this fieldofferingnewideas for the management of these diseases. Also, the recent technological developments Keywords aided the surgeons to define more sophisticated and minimally invasive techniques ► deep brain during the surgical procedures. Maybe the most important factor in the rerising of stimulation psychosurgery is the assemblage of the experts, clinicians, and researchers in various ► neural networks fields of neurosciences implementing a multidisciplinary approach. In this article, the ► neuromodulation authors aim to review the latest concepts of the pathophysiology and the recent ► psychiatric disorders advancements of the surgical treatment of psychiatric diseases from a neurosurgical ► psychosurgery point of view. Introduction omy in 1935.8,22 Moniz's initial trial resulted in no deaths or serious morbidities, which were seen in the other treat- Psychosurgery existed long before the advent of the frontal ments available for psychological disorders, such as insulin lobotomy. There is an archeological evidence of human skull coma or electric shock therapy. The leukotomy appeared as a trephinations as long as 5000 years ago in Europe and viable alternative and tens of thousands of these procedures Northern Africa which were performed on the basis of the were performed, however, without adequate research dem- psychological and spiritual understandings of that time.22 onstrating the safety of the procedure or a substantial Gottlieb Burckhardt (1836 to 1907), a Swiss psychiatrist, was benefit for the patient. Freeman and Watts developed a the first physician to perform modern psychosurgery, in modification, the “transorbital leukotomy” and performed which the contemporary theories about brain-behavior and it in 600 patients.27 Outcomes were generally favorable, brain-language relationships were interconnected and prac- although the procedure was associated with significant This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. tically applied to patient care.77 However, the landmark text morbidity. Further modifications of the leukotomy resulted was dedicated to the Portuguese neurologist Egas Moniz in “open” techniques and included bilateral inferior leukot- (1874 to 1955)77 who proposed that the prefrontal region of omy, bimedial frontal leukotomy, orbital gyrus undercut- the brain was the “psychic center” of a person. Moniz ting, cerebral topectomies, and anterior cingulotomies.19 It instructed his surgical partner, Almeida Lima, to develop was revealed that these procedures were not being used as the “leukotome,” a device that functioned as a neurosurgical ultima ratio in otherwise untreatable patients with reported apple corer, and they performed the first prefrontal leukot- cases in which little investigation was done before the received © 2013 Georg Thieme Verlag KG DOI http://dx.doi.org/ April 13, 2011 Stuttgart · New York 10.1055/s-0032-1304805. accepted after revision ISSN 2193-6315. October 10, 2011 published online October 26, 2012 30 Psychosurgery: Review of Latest Concepts and Applications Aydin, Abuzayed operations. Neurosurgeons began to think of the Overview of the Neuroanatomy of Behavior procedures as imprecise and potentially dangerous and Emotional Brain psychiatrists thought of them as ineffective and unnecessar- The emotional brain consists of the regions involved in the ily invasive. Papez circuit (the hippocampus, the fornix, the mammillary With the introduction of the psychoactive drugs in 1954 bodies, the mammillothalamic tract, the anterior thalamic, the and the development of further drugs, it soon became clear subgenual cingulate (SCG) [Brodman area 25 or Cg25], that these pharmaceutical therapies were safer and often the parahippocampal gyrus, and the entorhinal cortex) with more effective than the surgical procedures.22 However, the amygdala, the hypothalamus, the nucleus accumbens psychosurgical procedures continued to be performed in (NAcc), and the orbitofrontal cortex47 (►Fig. 1). The emotional the United States and other countries and some clinicians circuits do indeed form a border or connection point between believed that it was underused.22 The development of ste- the neocortex (mediating external stimuli) and the hypotha- reotactic neurosurgery, which allowed more precise anatom- lamic and brainstem structures (mediating internal stimuli).38 ical targeting, led to safer and more effective means of Major pathways of the emotional system are demonstrated in operating on brain diseases. Also, there was an expanded ►Fig. 2. The cingulate cortex is considered as the receptive understanding of the neural circuitry involved in the patho- cortical region regarding emotional stimuli. The cingulate genesis of neurologic and psychiatric disorders. Success in the cortex projects to the hippocampus, which then projects to field of movement disorders with ablation of deep brain the hypothalamus by the fornix to elicit behavioral, endocrine, targets encouraged the development of similar ablative pro- and autonomic responses to emotional stimuli.49,64 The mam- cedures for treating mental illness. These operations included millary bodies receive afferent projections from the hippocam- the limbic leukotomy, subcaudate tractotomy, anterior inter- pus via the fornix, and then project to the anterior thalamus nal capsulotomy, and cingulotomy.21 nucleus to provide efferents to the cingulate gyrus.38 The Now, with the marked development of modern imaging hippocampal formation, located under the parahippocampal and concept driven psychiatric interventions, newer surgical gyrus along the medial temporal lobe, is made up of the therapies focusing on neural modulation were introduced, hippocampus, the dentate gyrus, and the subiculum. Its prima- including the electrical stimulation of the vagus nerve (VNS) ry functions are learning, memory, and recognition of novel- and deep brain stimulation (DBS).6 These methods were ty.38 Afferents are from the entorhinal cortex, the septal nuclei found more acceptable from the ethical standpoint because (indirectly via the entorhinal cortex and directly via the fornix), they are relatively noninvasive and reversible.56 With ongo- the amygdala, supramammillary area of the hypothalamus, and ing laboratory and clinical researches introducing new ther- the brainstem (raphe nuclei, locus coeruleus, and ventral apeutic targets, the spectrum of psychiatric disorders that are tegmentum).99 The primary efferent projection of the hippo- treated with DBS continues to grow. campal formation is the fornix.99 Ventrally to the foramen This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Figure 1 A drawing demonstrating the anatomy of the limbic system. Journal of Neurological Surgery—Part A Vol. 74 No. A1/2013 Psychosurgery: Review of Latest Concepts and Applications Aydin, Abuzayed 31 Figure 2 A schematic drawing demonstarting the major pathways of the limbic system. Monro, the fornix divides at the anterior commissure into nections, the amygdala generates drive of activity and precommissural (projecting to septal nuclei) and postcommis- modulates endocrine activity, sexuality, reproduction, and sural fibers (projecting to mammillary body, hypothalamus, autonomic responses.38 Bilateral destruction of the amyglada septal region, medial frontal cortex, anterior thalamus, and can produce the Klüver–Bucy syndrome (docility, hyperorality, tegmentum). The majority of fibers that enter the fornix and hypersexuality) and decreased conditioned fear response originate in the subiculum, which in turn receives extensive and decreased ability to recognize the meaningfulness of facial input from the hippocampus and dentate gyrus.47 Damage to and vocal expressions of anger in others.64 the hippocampus results in inability to convert recent memo- ries into long-term memories and inability to store them. The Hypothalamus amygdaloid complex is made up of several nuclei that are The hypothalamus governs body homeostasis by modulating grouped into the basolateral (receive the lateral olfactory tract the activity of the autonomic nervous system, the endocrine projections) and the corticomedial groups (receive indirect system, and the limbic system. It also has a role in emotional olfactory projections via the pyriform cortex).47 The largest behavior. Hypothalamic efferents reach the cortex via a relay input to the amygdala is from the
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