Lesion analysis for cingulotomy and limbic leucotomy: comparison and correlation with clinical outcomes.
OBJECTIVE
Cingulotomy and limbic leucotomy are lesioning surgeries with demonstrated benefit for medically intractable psychiatric illnesses. They represent significant refinements of the prefrontal lobotomy used from the 1930s through the 1950s. However, the associations between anatomical characterization of these lesions and outcome data are not well understood. To elucidate these procedures and associations, the authors sought to define and compare the neuroanatomy of cingulotomy and limbic leucotomy and to test a method that uses neuroanatomical data and voxel-based lesion-symptom mapping (VLSM) to reveal potential refinements to modern psychiatric neurosurgical procedures.


METHODS
T1-weighted MR images of patients who had undergone cingulotomy and limbic leucotomy were segmented and registered onto the Montreal Neurological Institute T1-weighted template brain MNI152. Using an atlas-based approach, the authors calculated, by case, the percentage of each anatomical structure affected by the lesion. Because of the infrequency of modern lesion procedures and the requirement for higher-resolution clinical imaging, the sample size was small. The pilot study correlated cingulotomy and limbic leucotomy lesion characteristics with clinical outcomes for patients with obsessive-compulsive disorder. For this study, preoperative and postoperative Yale-Brown Obsessive Compulsive Scale scores for 11 cingulotomy patients and 8 limbic leucotomy patients were obtained, and lesion masks were defined and compared anatomically by using an atlas-based method. Statistically significant voxels were additionally calculated by using VLSM techniques that correlated lesion characteristics with postoperative scores.


RESULTS
Mean lesion volumes were 13.3 ml for cingulotomy and 11.8 ml for limbic leucotomy. As expected, cingulotomy was isolated to the anterior cingulum. The subcaudate tractotomy portion of limbic leucotomy additionally affected Brodmann area 25, the medial orbitofrontal cortex, and the nucleus accumbens. Initial results indicated that the dorsolateral regions of the cingulotomy lesion and the posteroventral regions of the subcaudate tractotomy lesion were associated with improved postoperative Yale-Brown Obsessive Compulsive Scale scores.


CONCLUSIONS
Cingulotomy and limbic leucotomy are lesioning surgeries that target pathological circuits implicated in psychiatric disease. Lesion analysis and VLSM contextualize outcome data and have the potential to be useful for improving lesioning neurosurgical procedures.
Department of Neurosurgery, Center for Morphometric Analysis, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, Massachusetts.|Harvard Medical School, Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Boston, Massachusetts.
Jimmy C
JC
Yang
Department of Imaging, Center for Morphometric Analysis, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, Massachusetts.
Daniel T
DT
Ginat
Department of Psychiatry, Center for Morphometric Analysis, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, Massachusetts.|Harvard Medical School, Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Boston, Massachusetts.
Darin D
DD
Dougherty
Department of Neurology and Psychiatry, Center for Morphometric Analysis, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, Massachusetts.|Harvard Medical School, Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Boston, Massachusetts.|Department of Psychiatry, Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Boston, Massachusetts.
Nikos
N
Makris
Department of Neurosurgery, Center for Morphometric Analysis, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, Massachusetts.|Harvard Medical School, Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Boston, Massachusetts.
Emad N
EN
Eskandar
D000328:Adult; D005260:Female; D006179:Gyrus Cinguli / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008032:Limbic System / Q000473:pathology / Q000601:surgery*; D008279:Magnetic Resonance Imaging; D008297:Male; D009771:Obsessive-Compulsive Disorder / Q000473:pathology / Q000601:surgery*; D011184:Postoperative Period; D011612:Psychosurgery / Q000379:methods*; D016896:Treatment Outcome