title: Anterior cingulotomy for major depression: clinical outcome and relationship to lesion characteristics.
abstract: BACKGROUND
  Anterior cingulotomy (ACING) is a neurosurgical treatment for chronic refractory depression, pain, and obsessive-compulsive disorder. Anterior cingulotomy involves the placement of bilateral lesions in the anterior cingulate under stereotactic guidance. Although a long-established therapeutic intervention, the optimal location and volume of lesions are not known, but it is generally believed that efficacious lesions interrupt the fibers of the cingulum bundle.
  
  
  METHODS
  Using T2-weighted magnetic resonance imaging, we tested the hypothesis that lesions placed more anteriorly would be associated with a better clinical response. We also tested a secondary hypothesis that a superior clinical response would be associated with larger lesion volumes.
  
  
  RESULTS
  When assessed 12 months following surgery, a superior clinical response was associated with more anterior lesions but, unexpectedly, with smaller lesion volumes. Specifically, the best clinical response was associated with total (right plus left hemisphere) lesion volumes of 1000 to 2000 mm(3) centered at Montreal Neurological Institute (MNI) coordinates (+/- 9,19,30).
  
  
  CONCLUSIONS
  There is considerable evidence from neuroimaging studies that more rostral areas within the anterior cingulate cortex are functionally and structurally abnormal in patients with major depressive disorder. Anteriorly placed ACING lesions would target and modify function within such regions. It should not be assumed that larger lesions are associated with a better response. These findings of relationships between lesion characteristics and clinical response argue against the suggestion that ACING represents a placebo treatment.
authors.affiliation: Department of Mental Health, University of Aberdeen, Royal Cornhill Hospital, Aberdeen, United Kingdom. d.steele@abdn.ac.uk
authors.forename: J Douglas
authors.initials: JD
authors.lastname: Steele
authors.forename: David
authors.initials: D
authors.lastname: Christmas
authors.forename: M Sam
authors.initials: MS
authors.lastname: Eljamel
authors.forename: Keith
authors.initials: K
authors.lastname: Matthews
mesh_terms: D000328:Adult; D003865:Major Depressive Disorder / Q000175:diagnosis / Q000473:pathology* / Q000601:surgery*; D005260:Female; D006179:Gyrus Cinguli / Q000473:pathology* / Q000601:surgery*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D019635:Neurosurgical Procedures / Q000379:methods; D011795:Surveys and Questionnaires