Bilateral anterior cingulotomy

Bilateral anterior cingulotomy

Bilateral anterior cingulotomy is a form of psychosurgery, introduced in 1948 as an alternative to lobotomy.

Lesioning of the target area is typically performed using bilateral stereotactic electrode placement and target ablation, which involves transparenchymal access through both hemispheres.

Lauri Laitinen was a pioneer of stereotactic psychosurgery in the 1950s to 1970s, especially by introducing the subgenual cingulotomy.

Indications

Bilateral anterior cingulotomy has been used to treat chronic pain, obsessive compulsive disorder.

In the early years of the twenty-first century it was used in Russia to treat addiction.

The objective of this surgical procedure is the severing of the supracallosal fibres of the cingulum bundle, which pass through the anterior cingulate gyrus.

Early localizationists linked anterior cingulate cortex (ACC: Brodmann’s area 24 and adjacent regions) with emotional behavior, paving the way for bilateral cingulotomy psychosurgery in severe, treatment resistant, cases of obsessive-compulsive disorder, chronic pain, depression, and substance abuse.

Limbic system surgery based on initial cingulotomy offers a durable and effective treatment option for appropriately selected patients with severe obsessive compulsive disorder who have not responded to conventional pharmacotherapy or psychotherapy 1).


There are features of anterior cingulate cortex structure and connectivity that predict clinical response to dorsal anterior cingulotomy for refractory obsessive compulsive disorder. These results suggest that the variability seen in individual responses to a highly consistent, stereotyped procedure may be due to neuroanatomical variation in the patients. Furthermore, these variations may allow us to predict which patients are most likely to respond to cingulotomy, thereby refining our ability to individualize this treatment for refractory psychiatric disorders 2)


The presence of neuropathic pain can severely impinge on emotional regulation and activities of daily living including social activities, resulting in diminished life satisfaction. Unfortunately, the majority of patients with neuropathic pain do not experience an amelioration of symptoms from conventional therapies, even when multimodal therapies are used. Chronic refractory neuropathic pain is usually accompanied by severe depression that is prone to incur suicidal events; thus clinical management of chronic neuropathic pain and depression presents a serious challenge for clinicians and patients

Two patients presented with neuropathic pain and severe depression. The patients had different pain symptoms emerging a few months after central or peripheral nervous system impairment. These symptoms were associated with the development of severe depression, social isolation, and a gradual inability to perform daily activities. Both patients were referred for bilateral anterior cingulotomy. After surgery, both patients showed significant progressive improvements in perceived pain, mental health status, and daily functioning.

Bilateral anterior cingulotomy may serve as an alternative treatment for medically refractory neuropathic pain, especially for patients who also experience depression 3).


Stereotactic anterior cingulotomy has been used in the treatment of patients suffering from refractory oncological pain due to its effects on pain perception. However, the optimal targets as well as suitable candidates and outcome measures have not been well defined. We report our initial experience in the ablation of 2 cingulotomy targets on each side and the use of the Brief Pain Inventory (BPI) as a perioperative assessment tool.

A retrospective review of all patients who underwent stereotactic anterior cingulotomy in our Department between November 2015 and February 2017 was performed. All patients had advanced metastatic cancer with limited prognosis and suffered from intractable oncological pain.

Thirteen patients (10 women and 3 men) underwent 14 cingulotomy procedures. Their mean age was 54 ± 14 years. All patients reported substantial pain relief immediately after the operation. Out of the 6 preoperatively bedridden patients, 3 started ambulating shortly after. At the 1-month follow-up, the mean preoperative Visual Analogue Scale score decreased from 9 ± 0.9 to 4 ± 2.7 (p = 0.003). Mean BPI pain severity and interference scores decreased from levels of 29 ± 4 and 55 ± 12 to 16 ± 12 (p = 0.028) and 37 ± 15 (p = 0.043), respectively. During the 1- and 3-month follow-up visits, 9/11 patients (82%) and 5/7 patients (71%) available for follow-up reported substantial pain relief. No patient reported worsening of pain during the study period. Neuropsychological analyses of 6 patients showed stable cognitive functions with a mild nonsignificant decline in focused attention and executive functions. Adverse events included transient confusion or mild apathy in 5 patients (38%) lasting 1-4 weeks.

The initial experience indicates that double stereotactic cingulotomy is safe and effective in alleviating refractory oncological pain 4).

Case series

Four MRgLITT bilateral cingulotomy procedures were performed in 3 patients. Two patients had a single MRgLITT procedure while the third had repeat ablation after pain recurrence. First time ablation coordinates were (medians): x = 7.9 mm (range, 6.9-8.6); y = 20.5 mm (range, 20-22); z = 6.9 mm (range, 2.9-7.0) above the lateral ventricle roof. Median trajectory length was 85.5 mm (range, 80-90). Median ablation volume was 1.5 cm3 (range, 0.6-1.2). Median ablation time was 257 seconds (range, 136-338) per cingulum and power was 10.0 Watts (range, 10-11). Median preoperative pain severity (PSS) and interference scores (PIS) were 7.7 (range, 7.5-9.3) and 9.9 (range, 9.7-10.0), respectively. Median postoperative PSS and PIS scores were 1.6 (range, 1.0-2.8) and 2.0 (range, 0.3-2.6), respectively.

MRgLITT cingulotomy is well tolerated for treatment of cancer pain and can be easily performed framelessly for appropriate candidates 5).


Seven patients suffering from refractory OCD underwent stereotactic surgery and were followed for 12 months. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was used to assess the efficacy. The test was taken before and 6 and 12 months after surgery.

The mean Y-BOCS scores decreased significantly from 32.9 ± 4.7 at baseline to 20.6 ± 5.3 after 12 months. Five out of the 7 patients showed a decrease of more than 35%. During the 12-month follow-up, the effective rate had increased from 28.6 to 71.4%. There were no significant adverse effects observed after surgery.

The BACI and BACA were effective for the treatment of refractory OCD, and no significant adverse effects on long-term follow-up were found 6).


Bilateral radiofrequency cingulotomy was performed in 10 patients. The technique involved stereotaxis using magnetic resonance guidance and local anesthesia, with the placement of a radiofrequency lesion (75 degrees, 60s). Of the 10 patients, 8 had metastatic lesions with musculoskeletal (6) or neurogenic (2) pain. Pain relief was judged excellent (4 patients), fair (1), poor (2) and excellent for 6 months poor in the last patient. The two benign lesions were neurofibromatosis with neurogenic pain and thalamic pain from an old stroke. Pain relief (with 1 year follow-up) in this group was judged excellent in one and poor in the other (thalamic pain) 7).


Forty-two patients out of 300 who had undergone bilateral stereotactic cingulotomies were studied by means of computerized tomography (CT). The appearance showed bilateral encephalomalacia, measuring on the average 5 X 7 mm2, located in the cingulate gyrus. These induced lesions had attenuation values similar to cerebrospinal fluid and did not enhance with contrast. CT is a useful technique for initial evaluation, management, and follow up of these patients 8).

Case reports

Huotarinen et al., found 1 patient alive who underwent subgenual cingulotomy in 1971 for obsessive thoughts, anxiety, and compulsions, diagnosed at that time as “schizophrenia psychoneurotica.” MRI showed bilateral subgenual cingulotomy lesions (254 and 160 mm3, respectively). The coordinates of the center of the lesions in relation to the midcommissural point for the right and left, respectively, were: 7.1 and 7.9 mm lateral; 0.2 mm inferior and 1.4 mm superior, and 33.0 and 33.9 anterior, confirming correct subgenual targeting. The patient reported retrospective satisfactory results.

The lesion in this patient was found to be in the expected location, which gives some verification of the correct placement of Laitinen’s subgenus cingulotomy target 9).


A case of debilitating thoracic wall pain due to malignant mesothelioma relieved by bilateral anterior cingulotomy is described and changes in dyspnoea investigated.

Improvements in pain, dyspnoea and the extent to which either symptom bothered the patient was seen for 2 months after surgery before disease progression led to death 5 months after surgery. Quality of life improvements were also seen for 2 months after surgery and pain relief was sustained from surgery to death. Arterial blood gas and lung function tests were unchanged by surgery, suggesting a reduction in pain and dyspnoea awareness by cingulotomy.

Bilateral anterior cingulotomy effectively relieved both pain and dyspnoea. The role of the anterior cingulate cortex in pain and autonomic control of respiration is discussed alongside the evidence for this palliative procedure for cancer pain 10).

Books

by Ernest. Feigenbaum (Author)

References

1)

Sheth SA, Neal J, Tangherlini F, Mian MK, Gentil A, Cosgrove GR, Eskandar EN, Dougherty DD. Limbic system surgery for treatment-refractory obsessive-compulsive disorder: a prospective long-term follow-up of 64 patients. J Neurosurg. 2013 Mar;118(3):491-7. doi: 10.3171/2012.11.JNS12389. Epub 2012 Dec 14. PubMed PMID: 23240700.
2)

Banks GP, Mikell CB, Youngerman BE, Henriques B, Kelly KM, Chan AK, Herrera D, Dougherty DD, Eskandar EN, Sheth SA. Neuroanatomical Characteristics Associated With Response to Dorsal Anterior Cingulotomy for Obsessive-Compulsive Disorder. JAMA Psychiatry. 2014 Dec 23. doi: 10.1001/jamapsychiatry.2014.2216. [Epub ahead of print] PubMed PMID: 25536384.
3)

Deng Z, Pan Y, Li D, Zhang C, Jin H, Wang T, Zhan S, Sun B. Effect of Bilateral Anterior Cingulotomy on Chronic Neuropathic Pain with Severe Depression. World Neurosurg. 2019 Jan;121:196-200. doi: 10.1016/j.wneu.2018.10.008. Epub 2018 Oct 10. PubMed PMID: 30315971.
4)

Strauss I, Berger A, Ben Moshe S, Arad M, Hochberg U, Gonen T, Tellem R. Double Anterior Stereotactic Cingulotomy for Intractable Oncological Pain. Stereotact Funct Neurosurg. 2018 Jan 10;95(6):400-408. doi: 10.1159/000484613. [Epub ahead of print] PubMed PMID: 29316566.
5)

Patel NV, Agarwal N, Mammis A, Danish SF. Frameless stereotactic magnetic resonance imaging-guided laser interstitial thermal therapy to perform bilateral anterior cingulotomy for intractable pain: feasibility, technical aspects, and initial experience in 3 patients. Neurosurgery. 2015 Mar;11 Suppl 2:17-25; discussion 25. doi: 10.1227/NEU.0000000000000581. PubMed PMID: 25584953.
6)

Zhang QJ, Wang WH, Wei XP. Long-term efficacy of stereotactic bilateral anterior cingulotomy and bilateral anterior capsulotomy as a treatment for refractory obsessive-compulsive disorder. Stereotact Funct Neurosurg. 2013;91(4):258-61. doi: 10.1159/000348275. Epub 2013 May 7. PubMed PMID: 23652367.
7)

Pillay PK, Hassenbusch SJ. Bilateral MRI-guided stereotactic cingulotomy for intractable pain. Stereotact Funct Neurosurg. 1992;59(1-4):33-8. PubMed PMID: 1295044.
8)

Bernad PG, Ballantine HT. Computed tomographic analysis of bilateral cingulotomy for intractable mood disturbance and chronic pain. Comput Radiol. 1987 May-Jun;11(3):117-23. PubMed PMID: 3301189.
9)

Huotarinen A, Kivisaari R, Hariz M. Laitinen’s Subgenual Cingulotomy: Anatomical Location and Case Report. Stereotact Funct Neurosurg. 2018;96(5):342-346. doi: 10.1159/000492058. Epub 2018 Oct 2. PubMed PMID: 30278436.
10)

Pereira EA, Paranathala M, Hyam JA, Green AL, Aziz TZ. Anterior cingulotomy improves malignant mesothelioma pain and dyspnoea. Br J Neurosurg. 2014 Aug;28(4):471-4. doi: 10.3109/02688697.2013.857006. Epub 2013 Nov 7. PubMed PMID: 24199940.

Superciliary keyhole approach

Superciliary keyhole approach

In the modern era of neurosurgery, the use of the operative microscope, rigid rod-lens endoscope, and neuronavigation has helped to overcome some of the previous limitations of surgery due to poor lighting and anatomic localization available to the surgeon. Over the last thirty years, the supraorbital craniotomy and subfrontal approach through an eyebrow skin incision have been developed and refined to play a legitimate role in the armamentarium of the modern skull base neurosurgeon. With careful patient selection, the supraorbital “keyhole” approach offers a less invasive but still efficacious approach to a number of lesions along the subfrontal corridor. In 2013 over 1000 cases have been reported in the literature utilizing this approach establishing its safety and efficacy 1).


Pain on mastication was the most commonly reported approach-related complication of the minipterional craniotomy, and occurred in 7.5% of cases. Temporary palsy of the frontal branch of the facial nerve and temporary supraorbital hypesthesia were associated with the supraorbital craniotomy (SOC) eyebrow variant, and occurred in 6.5%, respectively in 3.6% of cases. Transient postoperative periorbital edema and transient ophthalmoparesis occurred in 36.8% and 17.4% of cases, respectively, when the SOC was performed via an eyelid skin incision. The risk of occurrence of the latter 2 complications was related to the removal of the orbital rim, which is an obligatory part of the SOC approach through the eyelid but optional with the SOC eyebrow variant.

Each of the 3 keyhole approaches has a specific set and incidence of approach-related complications. It is essential to be aware of these complications to make the safest individual choice.


A superciliary approach can be a reasonable alternative to a pterional approach for small (<15 mm) UIAs arising at the supraclinoid ICA, A1, ACoA, and M1 segment including the MCA bifurcation 2).

For unruptured anterior circulation aneurysms, a superciliary keyhole approach using a supraorbital minicraniotomy, rather than a pterional approach, is invariably limited due to the small cranial opening.

Most anterior circulation aneurysms can still be clipped safely, rapidly, and less invasively using a superciliary approach based on appropriate indications and refined surgical technique 3) 4) 5) 6) 7) 8) 9) 10) 11) 12)


Patients who underwent an ipsilateral superciliary keyhole approach and a contralateral pterional approach for bilateral intracranial aneurysms during an 11-year period were contacted and asked to complete a patient satisfaction questionnaire. The questionnaire covered 5 complaint areas related to the surgical approaches: craniotomy-related pain, sensory symptoms in the head, cosmetic complaints, palpable cranial irregularities, and limited mouth opening. The patients were asked to rate the 5 complaint areas on a scale from 0 (asymptomatic or very pleasant) to 4 (severely symptomatic or very unpleasant). Finally, the patients were asked to rate the level of overall satisfaction related to each surgical procedure on a visual analog scale (VAS) from 0 (most unsatisfactory) to 100 (most satisfactory).

A total of 21 patients completed the patient satisfaction questionnaire during a follow-up clinic visit. For the superciliary procedures, no craniotomy-related pain, palpable irregularities, or limited mouth opening was reported, and only minor sensory symptoms (numbness in the forehead) and cosmetic complaints (short linear operative scar) were reported (score = 1) by 1 (4.8%) and 3 patients (14.3%), respectively. Compared with the pterional approach, the superciliary approach showed better outcomes regarding the incidence of craniotomy-related pain, cosmetic complaints, and palpable irregularities, with a significant between-approach difference (p < 0.05). Furthermore, the VAS score for patient satisfaction was significantly higher for the superciliary approach (mean 95.2 ± 6.0 [SD], range 80-100) than for the pterional approach (mean 71.4 ± 10.6, range 50-90). Moreover, for the pterional approach, a multiple linear regression analysis indicated that the crucial factors decreasing the level of patient satisfaction were cosmetic complaints, craniotomy-related pain, and sensory symptoms, in order of importance (p < 0.05).

In successful cases in which the primary surgical goal of complete aneurysm clipping without postoperative complications is achieved, a superciliary keyhole approach provides a much higher level of patient satisfaction than a pterional approach, despite a facial wound. For a pterional approach, the patient satisfaction level is affected by the cosmetic results, craniotomy-related pain, and numbness behind the hairline, in order of importance 13).

References

1)

Ormond DR, Hadjipanayis CG. The Supraorbital Keyhole Craniotomy through an Eyebrow Incision: Its Origins and Evolution. Minim Invasive Surg. 2013;2013:296469. doi: 10.1155/2013/296469. Epub 2013 Jul 10. PubMed PMID: 23936644; PubMed Central PMCID: PMC3723243.
2) , 8)

Park J, Woo H, Kang DH, Sung JK, Kim Y. Superciliary keyhole approach for small unruptured aneurysms in anterior cerebral circulation. Neurosurgery. 2011 Jun;68(2 Suppl Operative):300-9; discussion 309. doi: 10.1227/NEU.0b013e3182124810. PubMed PMID: 21346651.
3)

Park J. Superciliary keyhole approach for unruptured anterior circulation aneurysms: surgical technique, indications, and contraindications. J Korean Neurosurg Soc. 2014 Nov;56(5):371-4. doi: 10.3340/jkns.2014.56.5.371. Epub 2014 Nov 30. Review. PubMed PMID: 25535512; PubMed Central PMCID: PMC4272993.
4)

Lan Q, Gong Z, Kang D, Zhang H, Qian Z, Chen J, et al. Microsurgical experience with keyhole operations on intracranial aneurysms. Surg Neurol. 2006;66(Suppl 1):S2–S9.
5)

Mitchell P, Vindlacheruvu RR, Mahmood K, Ashpole RD, Grivas A, Mendelow AD. Supraorbital eyebrow minicraniotomy for anterior circulation aneurysms. Surg Neurol. 2005;63:47–51. discussion 51.
6)

Paladino J, Mrak G, Miklić P, Jednacak H, Mihaljević D. The keyhole concept in aneurysm surgery–a comparative study : keyhole versus standard craniotomy. Minim Invasive Neurosurg. 2005;48:251–258.
7)

Park J, Kang DH, Chun BY. Superciliary keyhole surgery for unruptured posterior communicating artery aneurysms with oculomotor nerve palsy : maximizing symptomatic resolution and minimizing surgical invasiveness. J Neurosurg. 2011;115:700–706.
9)

Ramos-Zúñiga R, Velázquez H, Barajas MA, López R, Sánchez E, Trejo S. Trans-supraorbital approach to supratentorial aneurysms. Neurosurgery. 2002;51:125–130. discussion 130-131.
10)

Reisch R, Perneczky A. Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision. Neurosurgery. 2005;57(4 Suppl):242–255. discussion 242-255.
11)

Shin D, Park J. Unruptured supraclinoid internal carotid artery aneurysm surgery : superciliary keyhole approach versus pterional appro-ach. J Korean Neurosurg Soc. 2012;52:306–311.
12)

van Lindert E, Perneczky A, Fries G, Pierangeli E. The supraorbital keyhole approach to supratentorial aneurysms : concept and technique. Surg Neurol. 1998;49:481–489. discussion 489-490.
13)

Park J, Son W, Kwak Y, Ohk B. Pterional versus superciliary keyhole approach: direct comparison of approach-related complaints and satisfaction in the same patient. J Neurosurg. 2018 Mar 2:1-7. doi: 10.3171/2017.8.JNS171167. [Epub ahead of print] PubMed PMID: 29498570.

Effect of trauma center designation in severe traumatic brain injury outcome

Effect of trauma center designation in severe traumatic brain injury outcome

Trauma center designation is significantly associated with functional independence (FI) and independent expression (IE) (defined as a functional independence measure component of 4) after severe traumatic brain injury, but not moderate traumatic brain injuryProspective study is warranted to verify and explore factors contributing to this discrepancy 1).

Patients with severe traumatic brain injury treated in American College of Surgeons (ACS)-designated level 1 trauma centers have better survival rates and outcomes than those treated in ACS-designated level 2 trauma center2).

In 2019 a study showed superior functional outcomes and lower mortality rates in patients undergoing a neurosurgical procedurefor severe traumatic brain injury in level 1 trauma center3).

References

1)

Brown JB, Stassen NA, Cheng JD, Sangosanya AT, Bankey PE, Gestring ML. Trauma center designation correlates with functional independence after severe but not moderate traumatic brain injury. J Trauma. 2010 Aug;69(2):263-9. doi: 10.1097/TA.0b013e3181e5d72e. PubMed PMID: 20699734.
2)

DuBose JJ, Browder T, Inaba K, Teixeira PG, Chan LS, Demetriades D. Effect of trauma center designation on outcome in patients with severe traumatic brain injury. Arch Surg. 2008 Dec;143(12):1213-7; discussion 1217. doi: 10.1001/archsurg.143.12.1213. PubMed PMID: 19075174.
3)

Chalouhi N, Mouchtouris N, Saiegh FA, Starke RM, Theofanis T, Das SO, Jallo J. Comparison of Outcomes in Level I vs Level II Trauma Centers in Patients Undergoing Craniotomy or Craniectomy for Severe Traumatic Brain Injury. Neurosurgery. 2019 Jan 24. doi: 10.1093/neuros/nyy634. [Epub ahead of print] PubMed PMID: 30690608.
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