CC BY-NC-ND 4.0 · Arquivos Brasileiros de Neurocirurgia: Brazilian Neurosurgery 2020; 39(02): 108-115
DOI: 10.1055/s-0040-1702978
Review Article | Artigo de Revisão
Thieme Revinter Publicações Ltda Rio de Janeiro, Brazil

Neurosurgery for Refractory Schizophrenia: A Systematic Literature Review

Neurocirurgia para esquizofrenia refratária: Uma revisão sistemática da literatura
1   Departament of Medicine, Escola de Ciências Médicas, Farmacêuticas e Biomédicas, Pontifícia Universidade Católica de Goiás, Goiânia, Goiás, Brazil
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1   Departament of Medicine, Escola de Ciências Médicas, Farmacêuticas e Biomédicas, Pontifícia Universidade Católica de Goiás, Goiânia, Goiás, Brazil
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1   Departament of Medicine, Escola de Ciências Médicas, Farmacêuticas e Biomédicas, Pontifícia Universidade Católica de Goiás, Goiânia, Goiás, Brazil
› Author Affiliations
Further Information

Publication History

10 June 2019

11 December 2019

Publication Date:
06 April 2020 (online)

Abstract

Schizophrenia is a chronic and disabling psychiatric disease that can be refractory to conventional treatment. The present study aims to gather information about the circuitry related to schizophrenia to describe possible surgical targets, and to establish whether psychosurgery can be a safe and effective treatment option for refractory schizophrenia. A systematic review of the literature was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. An electronic search was performed in the Pubmed and BVSalud databases using medical subject headings (MeSH) combined with Boolean operators. Out of the 724 studies retrieved, 13 were included in the review. Regarding leucotomy without a stereotactic approach, we found side effects such as irritability, nervous excitement, cases of disinhibition, and compromised normal social control. In other stereotactic procedures, there was some improvement, mainly regarding aggressiveness and positive symptoms; an anterior capsulotomy had an efficacy rate of 74% according to the Clinical Global Impression (CGI) rating scales. The only deep brain stimulation (DBS) case report found in our study described a significant improvement in the positive and negative symptoms. The use of a stereotactic approach enables psychosurgery to be a safe and effective treatment option in cases of refractory schizophrenia, improving the quality of life and the symptoms. Cognitive and negative symptoms remain a challenge in the treatment of schizophrenia, revealing that more targets in the circuitry must be surgically explored. Furthermore, more clinical trials are needed to compare these many surgical techniques and targets, using a standard evaluation parameter. The results show that DBS has a promising future in the treatment of refractory schizophrenia.

Resumo

A esquizofrenia é uma doença psiquiátrica crônica e incapacitante, que pode ser refratária ao tratamento convencional Este estudo tem como objetivo coletar informações sobre a circuitaria relacionada à esquizofrenia, descrever possíveis alvos cirúrgicos, e estabelecer se a psicocirurgia pode ser uma opção de tratamento segura e eficaz para a esquizofrenia refratária. Uma revisão sistemática da literatura foi realizada de acordo com a recomendação Itens Preferidos para Relatar Revisões Sistemáticas e Meta-análises (Preferred Reporting Items for Systematic Reviews and Meta-Analyses, PRISMA, em inglês). Uma busca eletrônica foi realizada nas bases de dados Pubmed e BVSalud, e, de 724 estudos coletados, 13 foram incluídos na revisão. Com relação à leucotomia sem abordagem estereotáxica, foram encontrados efeitos colaterais como irritabilidade, excitação nervosa, e casos de desinibição e comprometimento do controle social normal. Em outros procedimentos estereotáxicos, houve alguma melhora, principalmente na agressividade e nos sintomas positivos. A capsulotomia anterior apresentou taxa de eficácia de 74% de acordo com as escalas de Impressão Clínica Global (Clinical Global Impression, CGI, em inglês). No único relato de caso de estimulação cerebral profunda (ECP) encontrado em nosso estudo os autores descreveram uma melhora significativa nos sintomas positivos e negativos. O uso da abordagem estereotáxica permite que a psicocirurgia seja uma opção de tratamento segura e eficaz para a esquizofrenia refratária. Os sintomas cognitivos e negativos permanecem um desafio no tratamento da esquizofrenia, revelando que mais alvos devem ser explorados cirurgicamente. Além disso, mais ensaios clínicos são necessários para comparar essas várias técnicas e alvos cirúrgicos, segundo parâmetro comum de avaliação. Os resultados mostram que a ECP tem um futuro promissor no tratamento da esquizofrenia refratária.

 
  • References

  • 1 Agarwal P, Sarris CE, Herschman Y, Agarwal N, Mammis A. Schizophrenia and neurosurgery: A dark past with hope of a brighter future. J Clin Neurosci 2016; 34: 53-58
  • 2 Perez SM, Lodge DJ. New approaches to the management of schizophrenia: focus on aberrant hippocampal drive of dopamine pathways. Drug Des Devel Ther 2014; 8: 887-896
  • 3 Gault JM, Davis R, Cascella NG. , et al. Approaches to neuromodulation for schizophrenia. J Neurol Neurosurg Psychiatry 2018; 89 (07) 777-787
  • 4 Liu W, Hao Q, Zhan S. , et al. Long-term follow-up of mri-guided bilateral anterior capsulotomy in patients with refractory schizophrenia. Stereotact Funct Neurosurg 2014; 92 (03) 145-152
  • 5 Lorr M, Jenkins RL, Holsopple JQ. Factors descriptive of chronic schizophrenics selected for the operation of prefrontal lobotomy. J Consult Psychol 1954; 18 (04) 293-296
  • 6 Kim JS, Shin KS, Jung WH, Kim SN, Kwon JS, Chung CK. Power spectral aspects of the default mode network in schizophrenia: an MEG study. BMC Neurosci 2014; 15: 104
  • 7 Ewing SG, Winter C. The ventral portion of the CA1 region of the hippocampus and the prefrontal cortex as candidate regions for neuromodulation in schizophrenia. Med Hypotheses 2013; 80 (06) 827-832
  • 8 Gillespie AL, Samanaite R, Mill J, Egerton A, MacCabe JH. Is treatment-resistant schizophrenia categorically distinct from treatment-responsive schizophrenia? a systematic review. BMC Psychiatry 2017; 17 (01) 12
  • 9 Moeller S, Kalkwarf N, Lücke C. , et al. Achieving stable remission with maintenance electroconvulsive therapy in a patient with treatment-resistant schizophrenia: A case report. Medicine (Baltimore) 2017; 96 (48) e8813
  • 10 Faria Jr MA. Violence, mental illness, and the brain - A brief history of psychosurgery: Part 2 - From the limbic system and cingulotomy to deep brain stimulation. Surg Neurol Int 2013; 4: 75-75
  • 11 Mikell CB, Sinha S, Sheth SA. Neurosurgery for schizophrenia: an update on pathophysiology and a novel therapeutic target. J Neurosurg 2016; 124 (04) 917-928
  • 12 Mikell CB, McKhann GM, Segal S, McGovern RA, Wallenstein MB, Moore H. The hippocampus and nucleus accumbens as potential therapeutic targets for neurosurgical intervention in schizophrenia. Stereotact Funct Neurosurg 2009; 87 (04) 256-265
  • 13 Schvarcz JR, Driollet R, Rios E, Betti O. Stereotactic hypothalamotomy for behaviour disorders. J Neurol Neurosurg Psychiatry 1972; 35 (03) 356-359
  • 14 Barbosa DAN, de Oliveira-Souza R, Monte Santo F, de Oliveira Faria AC, Gorgulho AA, De Salles AAF. The hypothalamus at the crossroads of psychopathology and neurosurgery. Neurosurg Focus 2017; 43 (03) E15-E15
  • 15 Benson DF, Stuss DT, Naeser MA, Weir WS, Kaplan EF, Levine HL. The long-term effects of prefrontal leukotomy. Arch Neurol 1981; 38 (03) 165-169
  • 16 Kelly D, Walter CJ, Mitchell-Heggs N, Sargant W. Modified leucotomy assessed clinically, physiologically and psychologically at six weeks and eighteen months. Br J Psychiatry 1972; 120 (554) 19-29
  • 17 McKenzie KG, Kaczanowski G. Prefrontal leucotomy: a five-year controlled study. Can Med Assoc J 1964; 91: 1193-1196
  • 18 Hirose S. Orbito-ventromedial undercutting 1957-1963; Follow-up study of 77 cases. Am J Psychiatry 1965; 121: 1194-1202
  • 19 Ström-Olsen R, Carlisle S. Bi-frontal stereotactic tractotomy. A follow-up study of its effects on 210 patients. Br J Psychiatry 1971; 118 (543) 141-154
  • 20 Göktepe EO, Young LB, Bridges PK. A further review of the results of sterotactic subcaudate tractotomy. Br J Psychiatry 1975; 126: 270-280
  • 21 Kelly D, Richardson A, Mitchell-Heggs N, Greenup J, Chen C, Hafner RJ. Stereotactic limbic leucotomy: a preliminary report on forty patients. Br J Psychiatry 1973; 123 (573) 141-148
  • 22 Mitchell-Heggs N, Kelly D, Richardson A. Stereotactic limbic leucotomy--a follow-up at 16 months. Br J Psychiatry 1976; 128: 226-240
  • 23 Parhad MB. Bilateral cingulo-tractotomy. J Neurosurg 1953; 10 (05) 483-489
  • 24 Ballantine Jr HT, Bouckoms AJ, Thomas EK, Giriunas IE. Treatment of psychiatric illness by stereotactic cingulotomy. Biol Psychiatry 1987; 22 (07) 807-819
  • 25 Corripio I, Sarró S, McKenna PJ. , et al. Clinical improvement in a treatment-resistant patient with schizophrenia treated with deep brain stimulation. Biol Psychiatry 2016; 80 (08) e69-e70
  • 26 Anderson CA, Arciniegas DB. Neurosurgical interventions for neuropsychiatric syndromes. Curr Psychiatry Rep 2004; 6 (05) 355-363
  • 27 Hoffman JL. Clinical observations concerning schizophrenic patients treated by prefrontal leukotomy. N Engl J Med 1949; 241 (06) 233-236
  • 28 Bartlett J, Bridges P, Kelly D. Contemporary indications for psychosurgery. Br J Psychiatry 1981; 138: 507-511
  • 29 Stone JL. Dr. Gottlieb Burckhardt--the pioneer of psychosurgery. J Hist Neurosci 2001; 10 (01) 79-92
  • 30 Friedman S, Moore BE, Ranger CO, Russman C. A progress study of lobotomized and control patients. Am J Psychiatry 1951; 108 (01) 10-18
  • 31 Jenkins RL, Holsopple JQ, Lorr M. Effects of prefrontal lobotomy on patients with severe chronic schizophrenia. Am J Psychiatry 1954; 111 (02) 84-90
  • 32 Freyhan FA. Prefrontal lobotomy and transorbital leucotomy: a comparative study of 175 patients. Am J Psychiatry 1954; 111 (01) 22-32
  • 33 Hoch PH, Pool JL, Ransohoff J, Cattell JP, Pennes HH. The psychosurgical treatment of pseudoneurotic schizophrenia. Am J Psychiatry 1955; 111 (09) 653-658
  • 34 Lorr M, Holsopple JQ, Jenkins RL, O'Connor JP. Factors of change in lobotomized chronic schizophrenic patients. J Consult Psychol 1955; 19 (01) 39-43
  • 35 Hanlon TE, Sheets CS, Kurland AA. Spontaneous fluctuations in the severity of illness of hospitalized lobotomized patients. J Clin Psychol 1958; 14 (01) 6-10
  • 36 Smith A, Kinder EF. Changes in psychological test performances of brain-operated schizophrenics after 8 years. Science 1959; 129 (3342): 149-150
  • 37 Hamlin RM, Kinder EF. Vocabulary deficit in brain operated schizophrenics. J Consult Psychol 1961; 25: 239-244
  • 38 Oltman JE, Friedman S. Long-term results of frontal lobotomy in schizophrenic patients. Am J Psychiatry 1961; 118: 70-71
  • 39 De Mille R. An incidental observation of epilepsy in catatonic schizophrenics after prefrontal lobotomy. J Nerv Ment Dis 1962; 134: 182-183
  • 40 De Mille R. Intellectual effects of transorbital versus prefrontal lobotomy in schizophrenia: a follow-up study. J Clin Psychol 1962; 18: 61-62
  • 41 Sykes MK, Tredgold RF. Restricted orbital undercutting; a study of its effects on 350 patients over the ten years 1951-1960. Br J Psychiatry 1964; 110: 609-640
  • 42 Hamlin RM. Intellectual function 14 years after frontal lobe surgery. Cortex 1970; 6 (03) 299-307
  • 43 Freeman W. Frontal lobotomy in early schizophrenia. Long follow-up in 415 cases. Br J Psychiatry 1971; 119 (553) 621-624
  • 44 Wehler R, Hoffmann H. Intellectual functioning in lobotomized and non-lobotomized long term chronic schizophrenic patients. J Clin Psychol 1978; 34 (02) 449-451
  • 45 Hussain ES, Freeman H, Jones RA. A cohort study of psychosurgery cases from a defined population. J Neurol Neurosurg Psychiatry 1988; 51 (03) 345-352
  • 46 Kucharski A. History of frontal lobotomy in the United States, 1935-1955. Neurosurgery 1984; 14 (06) 765-772
  • 47 Knight G. Stereotactic tractotomy in the surgical treatment of mental illness. J Neurol Neurosurg Psychiatry 1965; 28: 304-310
  • 48 Berstein IC, Callahan WA, Jaranson JM. Lobotomy in private practice. Arch Gen Psychiatry 1975; 32 (08) 1041-1047
  • 49 Nicolaidis S. Neurosurgery of the future: Deep brain stimulations and manipulations. Metabolism 2017; 69S: S16-S20
  • 50 Toga AW, Clark KA, Thompson PM, Shattuck DW, Van Horn JD. Mapping the human connectome. Neurosurgery 2012; 71 (01) 1-5
  • 51 Bourdillon P, Apra C, Lévêque M, Vinckier F. Neuroplasticity and the brain connectome: what can Jean Talairach's reflections bring to modern psychosurgery?. Neurosurg Focus 2017; 43 (03) E11-E11
  • 52 Gasquoine PG. Localization of function in anterior cingulate cortex: from psychosurgery to functional neuroimaging. Neurosci Biobehav Rev 2013; 37 (03) 340-348
  • 53 Leiphart JW, Valone III FH. Stereotactic lesions for the treatment of psychiatric disorders. J Neurosurg 2010; 113 (06) 1204-1211