Abstract

Objective: This study evaluates the clinical efficacy of a novel psychosurgical technique for patients with complex multipsychiatric disorders (having more than two disorders)   resistant to medication with suicide risk This approach involves a single stereotactic (mini) craniotomy targeting five specific brain regions bilaterally, aiming to yield better clinical outcomes in complex multipsychiatric disorders  than conventional surgical methods.

Background: Psychosurgery remains a critical treatment modality for severe psychiatric disorders that do not respond to standard pharmacotherapy,electro or magnetic stimulation and behavioral therapies and have suicide risk. Cingulate gyrus,anterior capsula and subcaudate tractus are the targets mostly known and used bilaterally.Lesioning bilaterally the cingulate gyrus (cingulotomy) and subcaudate region (subcaudate tractotomy) together is also known as limbic leucotomy. Limbic leucotomy can be used alone or with capsulotomy (lesioning of anterior capsula).But there are two more targets; genu of the corpus callosum and stria terminalis which may be not be suitable for stereotactic lesioning and as these targets are aligned at the same plane with different dephts we decided to reach these targets from a single stereotactic craniotomy.As drug-resistant  psychiatric cases, have more than two disorders which make them complex, in this instance intervention of more targets seem to be more logic to increase the success rate of the surgery. Conventional techniques typically involve one or two bilateral brain regions, which may be inadequate for addressing the intricate neural networks implicated in complex multipsychiatric pathologies. 

Methods: A retrospective analysis was conducted on eleven patients who underwent this  psychosurgical procedure from 2016 to 2023. These patients had shown no response to pharmacotherapy psychotherapy and electroconvulsive therapy for durations of 5 to 15 years with a risk of suicide. Follow-ups were conducted at 1, 3, 6, and 12 months post-procedure.  All patients exhibited Generalized Anxiety Disorder with various combinations of; Major Depressive Disorder, Obsessive-Compulsive Disorder, Panic Attack, Impulsive Aggresive Behavior due to Impulse Control Disorder, Bipolar Disorder, Fobic Disorder and Psychotic Depression which were resistant to multiple treatment modalities. The procedure encompassed a precoronal parasagittal craniotomy suitable for an anterior interhemispheric approach, followed by bilateral cingulotomy, anterior callosotomy (especially the genu region), bilateral subcaudate tractotomy, bilateral anterior capsulotomy and cutting of the stria terminalis bilaterally.

Results: Remarkable clinical improvements were evident following the surgical intervention. The Beck Depression Inventory (BDI) scores decreased considerably from preoperative scores of 28–45 to postoperative scores of 4–12. Average BDI scores decreased from a preoperative mean of 37.9 to a postoperative mean of 7.7, indicating a significant reduction in depressive symptoms. By the first month post-surgery, 73% of the patients were able to reduce and at the third month to discontinue psychiatric medications. Only three patients (%27) maintained on a single medication until to the six-month follow-up which was ceased by our psychiatrist. Postoperative controls were done by the same chief neurosurgery and psychiatry doctors in a double-blind manner.

Conclusion: This micropsychosurgical  technique offers a promising advancement in treating combined multipsychiatric disorders which are therefore  refractory to medical treatment. The high rate of remission observed in this study suggests it may be an alternative to conventional methods. These preliminary findings necessitate further research to confirm the results and optimize treatment outcomes.