Bilateral Cingulotomy Surgery for OCD and Depression

Limbic System Surgery for Refractory Obsessive Compulsive Disorder

Doctor looking at brain scans
How does a bilateral cingulotomy (brain surgery) work for OCD and what are the possible risks?. Getty Images/Image Source

Bilateral cingulotomy is brain surgery considered a last treatment resort for people with obsessive-compulsive disorder (OCD) major depression and sometimes chronic pain who haven't found relief from other forms of therapy. It's been suggested as a treatment for bipolar disorder, but it hasn't been well studied for that condition, and so is not recommended.

This surgery targets the region of the brain called the cingulate gyrus, which is a small area in the brain connecting the limbic system.

The limbic system is involved with many emotions. The surgery also targets the frontal lobes, whose functions include reasoning, impulse control and judgment.

Surgical procedures in psychiatry are controversial, and most doctors will not perform bilateral cingulotomy unless all other avenues of treatment for the patient's condition already have been tried. In some cases, neurosurgeons will seek consent for the surgery from both the patient and a close family member.

Rationale for Bilateral Cingulotomy

The brain's cingulate gyrus helps to regulate emotions and pain, including emotional responses to pain. It's also thought to regulate aggressive behavior. This region of the brain directly controls a person's response to bad experiences, and in turn, it helps the person avoid repeated bad experiences. This is an important part of learning and memory.

There's evidence that the limbic system plays a major role in obsessive-compulsive disorder and in other psychiatric conditions.

Therefore, psychiatrists and neurosurgeons believe that certain forms of brain surgery might help these conditions.

The Bilateral Cingulotomy Procedure

To perform a bilateral cingulotomy, an electrode or gamma knife (which focuses beams of radiation) is guided to the target area of the brain by means of a process known as stereotactic magnetic resonance imaging.

A small lesion is created there—about a 1/2 inch cut or burn. The idea is that this lesion will disrupt the circuits in the brain that lead to OCD-type behaviors or to depression.

Surgery Results

Bilateral cingulotomy appears to help some patients, but it's not a cure-all for these difficult-to-treat psychiatric conditions.

In a 2002 study conducted by Harvard Medical School researchers, 44 patients with obsessive-compulsive disorder underwent the surgical procedure over the course of more than two decades. Those 44 people had not responded to medication or to behavioral treatments for their condition. The researchers found that 32 percent to 45 percent of those treated with bilateral cingulotomy responded at least partially to the treatment.

In another small 2013 trial conducted in China, researchers treated seven patients with obsessive-compulsive disorder with bilateral cingulotomy and bilateral capsulotomy, which is another form of brain surgery to treat OCD. In this study, five out of seven patients responded well to the surgery.

In this study, it appeared that the effectiveness of surgery rose significantly during the 12 month period following surgery, demonstrating a long term benefit to the treatment.

A 2016 review looked at studies to date and compared dorsal anterior cingulotomy to anterior capsulotomy with regard to effectiveness as well as short term and serious adverse effects. Overall, a complete response was seen in 41 percent of those having a cingulotomy and 54 percent of those who had a capsulotomy. Short term adverse effects occurred in 14 percent of those who received a cingulotomy compared with 56 percent of those who had a capsulotomy. Serious adverse effects occurred in five percent of the cingulotomy patients and 21 percent of the capsulotomy patients.

When Cingulotomy May Not Be Effective

As noted in these studies, many people with refractory obsessive compulsive disorder did very well following cingulotomy surgery with a relatively low rate of adverse events. Further studies, however, have found a few groups of people for whom the surgery is less likely to be effective. This appears to be the case for people who exhibited hoarding behaviors. Those who had problems with "forbidden thoughts" also did worse, but this was felt to be due to underlying hoarding.

Possible Complications

Bilateral cingulotomy doesn't carry with it very many side effects. Some patients experience nausea and vomiting in the days following the surgery, and they may also experience headaches. The surgery may also trigger seizures in some people, although it's possible that those experiencing seizures following the surgery may have had a history of seizures before the surgery as well.

Following the surgery, some people complained of apathy, while others complained of memory lapses. However, these weren't common side effects of the procedure.

Unfortunately, bilateral cingulotomy doesn't eliminate the need for treatment of the mental condition—most people require ongoing treatment following the surgery, and some surgical teams require patients to remain in treatment. However, it does offer one option for people who haven't responded to other forms of treatment.

Sources:

Brown, L., Mikell, C., Youngerman, B. et al. Dorsal Anterior Cingulotomy and Anterior Capsulotomy for Severe, Refractory Obsessive-Compulsive Disorder: A Systematic Review of Observational Studies. Journal of Neurosurgery. 2016. 124(1):77-89.

Dougherty, D., Baer, L., Cosgrove, G. et al. Prospective Long-Term Follow-up of 44 Patients who Received Cingulotomy for Treatment-Refractory Obsessive-Compulsive Disorder. American Journal of Psychiatry. 2002 Feb;159(2):269-75.

Shah, D., Pesiridou, A., Baltuch, G. et al. Functional Neurosurgery in the Treatment of Severe Obsessive Compulsive Disorder and Major Depression: Overview of Disease Circuits and Therapeutic Targeting for the Clinician. Psychiatry (Edgmont). 2008. 5(9):24-33.

Gentil, A., Lopes, A., Dougherty, D. et al. Hoarding Symptoms and Prediction of Poor Response to Limbic System Surgery for Treatment-Refractory Obsessive-Compulsive Disorder. Journal of Neurosurgery. 2014. 121(1):123-30.

Zhang, Q., Wang, W., and X. Wei. Long-Term Efficacy of Stereotactic Bilateral Anterior Cingulotomy and Bilateral Anterior Capsulotomy as a Treatment for Refractory Obsessive-Compulsive Disorder. Stereotactic and Functional Neurosurgery. 2013. 91(4):258-61.

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