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Table of Contents

    Topic review

    Psychiatric Disorders

    Subjects: Clinical Neurology
    View times: 38


    Psychiatric disorders refer to the behavior or psychological pattern that can lead to significant distress or functional impairment.

    1. Introduction

    Psychosurgery was developed from the need to manage patients affected by untreatable mental pathologies. The history of neurosurgical treatment for psychiatric disorders started in 1935, when Antonio Moniz, a Portuguese neurologist, proposed the prefrontal leucotomy to section the white matter connections between the prefrontal cortex and the thalamus. For such research, he received the Nobel Prize in 1949[1]. Then, Freeman and Watts modified the Moniz’s procedure, developing a faster surgical technique called “trans-orbital leucotomy”[2]. Since then, the number of procedures performed to treat psychiatric disorders has rapidly grown, reaching its apex in the 50s[3]. Nonetheless, the primary surgical treatment of psychiatric diseases was represented by “disconnection” procedures to separate white matter tracts from the prefrontal lobes. However, the need for reducing the serious adverse effects, cognitive alterations, and personality changes associated with such treatments led to a progressive reduction of such procedures. Finally, the advent of pharmacotherapy appeared to determine an irreversible stop to psychosurgery. However, over the last years, a better understanding of overall cerebral functions, along with the enormous technological advances in neurosurgery, has led to reconsidering the role of neurosurgical procedures in treating some psychiatric disorders, in a multidisciplinary approach that makes these procedures more effective, suitable, and more consistent in terms of results.

    Functional surgery based on deep-brain stimulation (DBS) was first tried, in patients with psychiatric disorders, more than sixty years ago[4]. As it happened for movement disorders, DBS has almost totally replaced ablative neurosurgical procedures in psychiatric neurosurgery. More recently, the adjunct of radiotherapy procedures as cyber-knife or gamma-knife (GK), and the introduction of Magnetic Resonance–guided Focus Ultrasound procedures (MRgFUS), opened new therapeutic fields for selected psychiatric patients who are unresponsive to psychotherapy and pharmacotherapy. 

    Table 1. Overview of the techniques currently used.

    Technique Step 1 Step 2 Step 3 Treatment
    GK Positioning of a stereotactic frame to the patient’s head (for the target’s coordinates) Acquisition of stereotactic MRI images for localizing the target; setup of the target’s coordinates The patient and the sterotactic frame are fixed into a hemispherical helmet connected to the Main unit of the GK apparatus The radiation sources are up to 201 γ radiation-emittingCobalt units connected to 4 or 8 mm collimators; the target is drawn on MRI images, and the total radiation dosage and radiation duration are decided for appropriate target lesioning (usually, single 4-mm isocenter with a maximum dose of 140–160 Gy
    RF Positioning of a stereotactic frame to the patient’s head (for the target’s coordinates) Acquisition of stereotactic MRI images for localizing the target; setup of the target’s coordinates The patient is led to the operating room; target’s coordinates are brought into the sterile stereotactic apparatus Two burr holes are made 3 cm in front of the coronal suture and 2.5 cm lateral to the midline; the thermoelectrode is inserted to the target and a thermic lesion is made
    DBS Positioning of a stereotactic frame to the patient’s head (for the target’s coordinates) Acquisition of stereotactic MRI images for localizing the target; setup of the target’s coordinates The patient is led to the operating room; target’s coordinates are brought into the sterile stereotactic apparatus Two burr holes are made 3 cm in front of the coronal suture and 2.5 cm lateral to the midline; the stimulating electrode is brought to the target structure and then fixed to the skull and connected to a subcutaneous internal pulse generator
    MRgFUS Positioning of a stereotactic frame to the patient’s head (for the target’s coordinates) Acquisition of stereotactic MRI images for localizing the target; setup of the target’s coordinates The patient and the frame are fixed to the MRI FUS suite, which contains up to 1096 Ultrasound beams’ sources The target is drawn on stereotactic MRI images; multiple and gradual sessions of US administration are performed, to reach lesional temperatures (at least 53 °C) with a variable amount of energy requirement (20.000–40.000 J)

    This entry is adapted from 10.3390/psychiatryint2010001


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