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

Update: Bilateral chronic subdural hematoma

Data on bilateral chronic subdural hematomas (CSHs) are scant 1) , including information on the frequency of symptoms, response to various treatments, and postoperative complications, compared with data on unilateral CSH. Bilateral CSHs constitute a fair portion of CSHs, especially in patients older than 75 years and in those with coagulopathy.

Clinical features

The presenting symptoms are those of raised intracranial pressure and mass effect.
The frequency of focal neurological deficits was found to be lesser in patients with bilateral CSDH, and it may confound the diagnosis and delay treatment 2).

Diagnosis

Computed tomography


Bilateral hematomas may lead to medial compression of both ventricles resulting in a narrow, slit-like elongated ventricle (the anterior horns sharply pointed and approaching one another so called ‘squeezed ventricle,’ ‘hare’s ears sign, or ‘rabbit’s ears’) 3) 4)5) 6).
see also Bilateral isodense chronic subdural hematoma

Magnetic resonance imaging

Magnetic resonance imaging is a more sensitive modality.

Differential diagnosis

If the lesion is placed more anteriorly and medially, hyperdense in intensity and enclosed in thick capsule, it may look biconvex in shape and can mimic extradural hematoma. This location of the lesion will also displace the frontal horns of the lateral ventricles laterally than medially, as in the present case. To avoid this confusion, if available, magnetic resonance imaging (MRI) would be better than CT in identifying these lesions 7) 8) 9) 10) 11).

Treatment

Occasionally patients with bilateral CSDH undergo unilateral surgery because the contralateral hematoma is deemed to be asymptomatic, and in some of these patients the contralateral hematoma may subsequently enlarge, requiring additional surgery.
Treatment of bilateral CSHs presents its own unique set of problems. New hemorrhage on the contralateral side and shift of midline structures are concerns and can be avoided by simultaneous bilateral decompression 12) 13). and significantly lowers the risk of retreatment compared with unilateral intervention and should be considered when choosing a surgical procedure 14).
To prevent neurological deterioration resulting from the thicker hematomas, early surgical decompression for bilateral CSDH should be implemented 15).

Outcome

Mixed high and low intensity in T2WI or low intensity in T1WI is the most predictable factor to show rapid aggravation 16).
Clinicians must be aware of the higher recurrent rate of bilateral CSDH after burr hole craniostomy 17).

Case series

2017

Two hundred ninety-one patients with bCSDH were identified, and 264 of them underwent unilateral (136 patients) or bilateral (128 patients) surgery. The overall retreatment rate was 21.6% (57 of 264 patients). Cases treated with unilateral surgery had twice the risk of retreatment compared with cases undergoing bilateral surgery (28.7% vs 14.1%, respectively, p = 0.002). In accordance with previous studies, the data also showed that a separated hematoma density and the absence of postoperative drainage were independent predictors of retreatment.
In bCSDHs bilateral surgical intervention significantly lowers the risk of retreatment compared with unilateral intervention and should be considered when choosing a surgical procedure 18).


Ninety-three patients with bilateral CSDH who underwent unilateral bur hole surgery at Aizu Chuo Hospital were included in a retrospective analysis. Findings on preoperative MRI, preoperative thickness of the drained hematoma, and the influence of antiplatelet or anticoagulant drugs were considered and evaluated in univariate and multivariate analyses.
The overall growth rate was 19% (18 of 93 hematomas), and a significantly greater percentage of the hematomas that were iso- or hypointense on preoperative T1-weighted imaging showed growth compared with other hematomas (35.4% vs 2.3%, p < 0.001). Multivariate logistic regression analysis showed that findings on preoperative T1-weighted MRI were the sole significant predictor of hematoma growth, and other factors such as antiplatelet or anticoagulant drug use, patient age, patient sex, thickness of the treated hematoma, and T2-weighted MRI findings were not significantly related to hematoma growth. The adjusted odds ratio for hematoma growth in the T1 isointense/hypointense group relative to the T1 hyperintense group was 25.12 (95% CI 3.89-51.58, p < 0.01).
The findings of preoperative MRI, namely T1-weighted sequences, may be useful in predicting the growth of hematomas that did not undergo bur hole surgery in patients with bilateral CSDH 19).

2013

Huang et al., identified 25 of 98 CSDH (25.51%). The patients with bilateral lesions had a lower incidence of hemiparesis than those having unilateral lesions (p = 0.004). Analysis of the neuro-images revealed significant differences in the presence of a midline shift (p = 0.001) and thickness of the hematoma (p < 0.001).
The mean Markwalder grading score at admission was 1.89 ± 0.66 and 1.64 ± 0.49 in the unilateral and bilateral hematoma groups, respectively (p = 0.010). After a minimum follow-up period of 6 months, the mean Glasgow Outcome Scale was not significantly different (p = 0.060). The recurrence rate of up to 28.00% observed for the bilateral disease was found to be higher than 9.59% observed for the unilateral disease (p = 0.042) 20).

Case reports

2017

A 72-year-old man with bilateral chronic subdural hematomas was admitted and treated using a YL-1 type hematoma aspiration needle. The treatment was complicated by hemorrhage of the basal ganglia and brainstem. This patient had no history of hypertension. Chen et al evaluated the relevant literature to analyze the causes of cerebral hemorrhage in similar patients.
This case report illustrates that the stability of the intracranial pressure should be closely monitored during the surgical treatment of chronic subdural hematomas, and large fluctuations in the cerebral perfusion pressure should be avoided during the operation. They also propose improvements in the technical details of the operative treatment of chronic subdural hematomas 21).


Calcified chronic subdural hematomas are an occurrence rarely seen in neurosurgical clinical practice. And when they occur bilaterally, the radiologic image they present is fascinating, as is the clinical presentation, but their management may be challenging. They have been reported to present with a multitude of neurologic deficits but never with diabetes insipidus, which is described by Siddiqui et al.
Due to the rarity of this pathology, the management protocol is not well defined, though there have been quite a few papers on this condition. This review article gathers information published over the years on this rare entity to suggest a treatment protocol 22).

2006

An 81-year-old man suffered blunt trauma to his chest resulting from a road traffic accident. On admission a chest X-ray showed multiple rib fractures but a computerized tomography scan of the head ruled out any post-traumatic lesion. He had a background diagnosis of mild Alzheimer’s dementia for which he was being treated with galantamine. He lived a reasonably independent life with his wife and was driving the car himself when the accident occurred. After a fortnight he was discharged from hospital.
Two months later he developed progressive deterioration in mobility. His wife noted an increasing level of forgetfulness and intermittent episodes of confusion. His general practitioner noted a shuffling gait and rigidity affecting lower limbs and made a working diagnosis of parkinsonism. A trial of Madopar (Levodopa and benserazide: 62.5 mg three times a day for 2 weeks) was given by the GP but this failed to improve the situation and he became virtually bed-bound. He was referred back to the hospital for further investigation.
On admission he was confused and marked rigidity affecting upper and lower limbs was detected. No resting tremor was noted but gait could not be tested, as he was unable to get out of bed. In view of the clinical presentation a computerized tomography scan of the head was repeated which showed bilateral fronto-parietal chronic subdural haematoma (Figure 1a,b). He was referred to the regional neurosurgical centre where he underwent bilateral burrhole drainage. Postoperative recovery was unremarkable and on examination there was complete resolution of previous rigidity affecting upper and lower limbs. He was able to converse normally with his wife and began walking with the aid of a stick by third postoperative day. A week later he was discharged from the hospital having regained his previous level of mobility and independence with activities of daily living 23).
1)

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2) , 15) , 17) , 20)

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Kim KS, Hemmati M, Weinberg P. Computed tomography in isodense subdural haematoma. Radiology. 1978;128:71–4.
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Fujisawa H, Nomura S, Kajiwara K, Kato S, Fujii M, Suzuki M. Various magnetic resonance imaging patterns of chronic subdural hematomas: indicators of the pathogenesis? Neurol Med Chir (Tokyo) 2006;46:333–9.
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Kelly AB, Zimmerman RD, Snow RB, Gandy SE, Heier LA, Deck MD. Head trauma: Comparison of MR and CT experience in 100 patients. AJNR Am J Neuroradiol. 1988;9:699–708.
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Guenot M. Chronic subdural haematoma: diagnostic imaging studies. Neurochirurgie. 2001;47:473–8.
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Hosoda K, Tamaki N, Masumura M, Matsumoto S, Maeda F. Magnetic resonance images of chronic subdural hematomas. J Neurosurg. 1987;67:677–83.
11)

Agrawal A. Bilateral biconvex frontal chronic subdural hematoma mimicking extradural hematoma. J Surg Tech Case Rep. 2010 Jul;2(2):90-1. doi: 10.4103/2006-8808.73625. PubMed PMID: 22091345; PubMed Central PMCID: PMC3214288.
12)

Sadrolhefazi A, Bloomfield SM. Interhemispheric and bilateral chronic subdural hematoma. Neurosurg Clin N Am. 2000 Jul;11(3):455-63. Review. PubMed PMID: 10918015.
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Kurokawa Y, Ishizaki E, Inaba K. Bilateral chronic subdural hematoma cases showing rapid and progressive aggravation. Surg Neurol. 2005 Nov;64(5):444-9; discussion 449. PubMed PMID: 16253697.
14) , 18)

Andersen-Ranberg NC, Poulsen FR, Bergholt B, Hundsholt T, Fugleholm K. Bilateral chronic subdural hematoma: unilateral or bilateral drainage? J Neurosurg. 2017 Jun;126(6):1905-1911. doi: 10.3171/2016.4.JNS152642. Epub 2016 Jul 8. PubMed PMID: 27392267.
19)

Fujitani S, Ishikawa O, Miura K, Takeda Y, Goto H, Maeda K. Factors predicting contralateral hematoma growth after unilateral drainage of bilateral chronic subdural hematoma. J Neurosurg. 2017 Mar;126(3):755-759. doi: 10.3171/2016.1.JNS152655. PubMed PMID: 27081904.
21)

Chen L, Dong L, Wang XD, Zhang HZ, Wei M, She L. Bilateral Chronic Subdural Hematoma Treated by YL-1 Type Hematoma Aspiration Needle Complicated by Hemorrhage of the Basal Ganglia and Brainstem. World Neurosurg. 2017 Jan;97:761.e11-761.e13. doi: 10.1016/j.wneu.2016.09.074. PubMed PMID: 27702707.
22)

Siddiqui SA, Singh PK, Sawarkar D, Singh M, Sharma BS. Bilateral Ossified Chronic Subdural Hematoma Presenting as Diabetes Insipidus-Case Report and Literature Review. World Neurosurg. 2017 Feb;98:520-524. doi: 10.1016/j.wneu.2016.11.031. Review. PubMed PMID: 27867130.
23)

Suman S, Meenakshisundaram S, Woodhouse P. Bilateral chronic subdural haematoma: a reversible cause of parkinsonism. J R Soc Med. 2006 Feb;99(2):91-2. PubMed PMID: 16449784; PubMed Central PMCID: PMC1360497.
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