Stereotactic ablation surgery for treatment-resistant obsessive-compulsive disorder: Technical evolution, clinical application, and future prospects.

To the Editor: We read with admiration the manuscript “Laser Interstitial Thermal Therapy for First-Line Treatment of Surgically Accessible Recurrent Glioblastoma: Outcomes Compared With a Surgical Cohort” by Fadel et al.1 This study's objective—to compare outcomes between laser interstitial thermal therapy (LITT) and surgical resection—is impactful because it influences surgical decision-making and patient prognosis. Further exploring the applicability of LITT to treat unifocal, lobar, first-time recurrent glioblastoma (rGBM) begins the conversation regarding not restricting LITT to poor surgical candidates and reducing the risk of surgical complications. The authors demonstrated similar survival outcomes between LITT and craniotomy groups, with significantly shorter length of hospital stay for patients treated with LITT. We agree with and recognize the value of the authors' initiative to investigate the applicability of LITT as a first-line treatment for rGBM, though we believe further investigation into the baseline characteristics of patient's satisfying the inclusion criteria would enable a more holistic understanding of the impact of LITT on outcomes. Although the authors did compare baseline differences between the cohorts, we would have appreciated more details regarding the initial management of patients before intervention because this may affect the effectiveness of thermal therapy and shed light on possible indications or contraindications for using LITT to manage rGBM. Considerations include whether patients were initially treated with radiosurgery, surgical resection, targeted therapies, or immunotherapy. This may be helpful to explore, for example, to better understand if there is any increased efficacy for LITT in patients who have received prior radiotherapy or immunotherapy. Such considerations warrant further investigation considering the findings by Hong et al on the comparison between craniotomy and LITT for recurrence in patients with brain metastases previously treated with stereotactic radiosurgery.2 The authors found no difference between the 2 treatment groups for survival metrics, as well as postoperative neurological outcomes and steroid dependence. We also believe that it would be helpful to know how many patients required adjuvant chemotherapy or salvage radiotherapy because this can affect decision-making for both patients and surgeons given the patient age and clinical status. In addition, although preoperative Karnofsky Performance Scale was evidenced to be statistically insignificant between both cohorts in this study, future studies can further explore preoperative symptomatology including neurological deficits and postoperative symptom relief. Multiple studies have demonstrated significantly improved symptom relief after craniotomy, and this is another factor associated with quality of life that can affect the surgical approach.2,3 Despite methodological limitations and a lack of robust data comparing LITT with resection for both surgically accessible and inoperable GBM, this study provides an avenue for future research exploring a broadened approach to the use of LITT. LITT as a primary treatment is valuable in conserving hospital resources without compromising patient outcomes and in providing patients with a minimally invasive and more cost-effective option than surgical resection for rGBM.4

INTRODUCTION: Laser interstitial thermal therapy (LITT) is used to treat radiographically progressive brain metastases following stereotactic radiosurgery (SRS), while resection has been reserved for large, symptomatic lesions in the upfront setting. Resection-associated morbidity in eloquently-located metastases may hinder definitive management. METHODS: Patients receiving resection or LITT for brain metastases associated with the primary motor cortex (PMC) from 2015-2023 were retrospectively reviewed. Clinicodemographic and survival data were collected, with patient Karnofsky Performance Status (KPS) or modified Rankin Scale (mRS) scores assessed out to 1-year by independent raters. RESULTS: Forty-one patients underwent resection and 30 underwent LITT to a PMC-associated lesion during the study period. Median age was 67 (range 38 – 80) years for resections versus 65 (44 – 80) for LITT; median pre-operative KPS (70 vs 80, P = 0.1) or mRS (2 vs 2, P = 0.66) did not differ between groups. Resected lesions were of larger median diameter than LITT treated lesions, 2.8 vs 1.9, P = 0.0001. Length of stay was longer for resections versus LITT, median 2 vs 1 day, P =0.0002, and the ICU was more frequently used (75.6% versus 20.0%, P < 0.0001). At 1 month from surgery, 66.7% of resection patients and 51.7% of LITT patients had stable or improved symptoms from pre-op, P = 0.21. This gap closed at 3 months, where 65.7% and 62.9% of patients in either cohort demonstrated symptom stability or improvement. Further, there was no significant decrement in KPS or mRS score out to a year for both LITT and resection. Overall survival was 11.5 vs 7.5 months for resections versus LITT, respectively, P = 0.99. CONCLUSIONS: LITT in the motor cortex may result in short-term motor deficits which ultimately recover in the long-term. Patients should be counseled accordingly.

BACKGROUND For brain metastases (BM), resection remains a mainstay for the upfront management of large, symptomatic lesions, while laser interstitial thermal therapy (LITT) has become a key treatment for radiographically progressive BM following stereotactic radiosurgery (SRS). Compared to LITT, resection-associated morbidity may delay systemic therapies. We evaluated functional outcomes for resection versus LITT to primary motor cortex (PMC)-associated metastases. METHODS Patients receiving resection or LITT for BM radiographically associated with the PMC from 2015-2023 were retrospectively reviewed. Demographic and survival data were collected, with patient Karnofsky Performance Status (KPS) or modified Rankin Scale (mRS) scores assessed out to 1-year by independent raters. RESULTS Forty-one patients underwent resection and 30 underwent LITT to a PMC-associated lesion. Median age was 67 (range 38 – 80) vs 65 (44 – 80) for resection vs LITT; median pre-operative KPS (70 vs 80, P = 0.1) or mRS (2 vs 2, P = 0.66) did not differ between groups. Lung was the most common primary (56.1% resections vs 56.7% LITTs). Resected lesions were of larger median diameter than LITT, 2.8 vs 1.9 cm, P = 0.0001. For resections, length of stay was longer, median 2 vs 1 day, P = 0.0002, and ICU use more frequent (75.6% versus 20.0%, P < 0.0001). At 1-month post-op, 66.7% of resection patients and 51.7% of LITT patients had stable or improved symptoms from pre-op, P = 0.21, with parity at 3-months (65.7% vs 62.9%) and therafter. Further, there was no significant decrement in KPS or mRS score out to a year for either intervention. CONCLUSIONS While there is a short-term increased risk of post-operative neurologic worsening due to LITT-associated edema, our data shows that, relative to resection, this is a transient and clinically limited phenomenon. With careful patient selection, LITT to lesions involving the PMC is feasible.

Subependymal giant cell astrocytomas (SEGAs) are WHO grade 1 tumors associated with tuberous sclerosis that classically arise from the ventricular wall near the caudate groove and foramen of Monro. Laser interstitial thermal therapy (LITT) is a minimally invasive surgical technique, which works by heating a stereotactically placed laser fiber to ablative temperatures under MRI thermometry monitoring. In this paper, the authors present LITT as a surgical alternative to open resection of SEGAs. Twelve patients with SEGAs who underwent 16 procedures between 2007 and 2022 at a single institution were retrospectively reviewed. These patients underwent either open resection or LITT. Clinical data, imaging, recurrence rate, further treatments, and related complications were analyzed. Among the 16 procedures, 9 were open resection and 7 were LITT. An external ventricular drain was placed in 66% (6/9) of open procedures and 57.1% (4/7) of LITT cases. A septostomy was performed in 56% (5/9) of open procedures and 29% (2/7) of LITT cases. Complication rates were higher in open cases than in LITT procedures (44% vs 0%, p < 0.05). Complications included hydrocephalus, transient venous ischemia, wound infection, and bone flap migration. The median length of hospital stay was 4 days (IQR 3.3-5.5 days) for open cases and 4 days (IQR 3.0-7.0 days) for LITT procedures. Recurrence or progression occurred after 3 open cases and 2 LITT cases (33% vs 33%, p = 0.803). For the recurrences, 2 open cases underwent stereotactic radiosurgery, 1 open case underwent LITT, and 1 LITT case underwent repeat LITT. Among the LITT cases, only the patients with no decrease in tumor size by 6 months experienced tumor progression afterward. The 2 LITT cases with progression were the only ones with calcification present on preoperative imaging. The median follow-up times for cases assessed for progression were 8.4 years (IQR 3.8-14.4 years) for open resection and 3.9 years (IQR 3.4-5.1 years) for LITT. The small size of this case series limits generalizability or adequate comparison of safety. However, this series adds to the literature supporting LITT as a less invasive surgical alternative to open resection of SEGAs and demonstrates that LITT has similar recurrence and/or progression rates to open resection. Additional studies with more data are necessary for comprehensive comparisons between open resection and LITT for treating SEGA.

Many publications report laser-interstitial thermal therapy (LITT) as a viable alternative treatment to craniotomy for radiation necrosis (RN) and re-growing tumor occurring after stereotactic radiosurgery (SRS) for brain metastases. No studies to-date have compared the two options. The aim of this study was to retrospectively compare outcomes after LITT versus craniotomy for regrowing lesions in patients previously treated with SRS for brain metastases. Data were collected from a single-institution chart review of patients treated with LITT or craniotomy for previously irradiated brain metastasis. Of 75 patients, 42 had recurrent tumor (56%) and 33 (44%) had RN. Of patients with tumor, 26 underwent craniotomy and 16 LITT. For RN, 15 had craniotomy and 18 LITT. There was no significant difference between LITT and craniotomy in ability to taper off steroids or neurological outcomes. Progression-free survival (PFS) and overall survival (OS) were similar for LITT versus craniotomy, respectively: %PFS-survival at 1-year = 72.2% versus 61.1%, %PFS-survival at 2-years = 60.0% versus 61.1%, p = 0.72; %OS-survival at 1-year = 69.0% versus 69.3%, %OS-survival at 2-years = 56.6% versus 49.5%, p = 0.90. Craniotomy resulted in higher rates of pre-operative deficit improvement than LITT (p < 0.01). On subgroup analysis, the single factor most significantly associated with OS and PFS was pathology of the lesion. About 40% of tumor lesions needed post-operative salvage with radiation after both craniotomy and LITT. LITT was as efficacious as craniotomy in achieving local control of recurrent irradiated brain metastases and facilitating steroid taper, regardless of pathology. Craniotomy appears to be more advantageous for providing symptom relief in those with pre-operative symptoms.

Obsessive-compulsive disorder (OCD) is characterized by obsessions and compulsions that significantly impair functioning. Obsessive-compulsive personality disorder (OCPD) co-occurs in 17-45% of OCD patients, worsening outcomes across multiple domains. Therefore, we aimed to study the impact of OCPD in more detail by analyzing selected comorbidities, emotional aspects, and sociodemographic data. This study assessed 78 OCD patients (average age 44.9 years, 34.61% OCPD), using Y-BOCS, BABS, BPAQ, BIS-11, YMRS, HDRS-17, and ASEX. Patients with comorbid OCPD had significantly worse outcomes in symptom severity (Y-BOCS = 0.0006), treatment duration (p = 0.0127), insight (BABS, p = 0.0185), aggression (p = 0.0266), impulsivity (p = 0.0469), depression (HDRS, p = 0.0178), mania (YMRS, p = 0.0003), and sexual dysfunction (ASEX, p = 0.008). OCPD was more prevalent in unemployed individuals (p = 0.046) and older patients (p = 0.009). No significant differences were found regarding gender, education, or relationship status. Obsessions and compulsions, such as contamination (p = 0.025), somatic (p = 0.018), ruminations (p = 0.003), and obsessional slowness (p = 0.007), were more common in the OCPD group. In the group with OCPD, aggression and OCD severity were correlated with increased levels of depression, which can be considered potential correlates of bipolarity in the relationship between OCD and OCPD. In conclusion, OCPD significantly worsens clinical outcomes in OCD across emotional, behavioral, and functional dimensions.

Laser interstitial thermal therapy (LITT) is a minimally invasive treatment option for patients with intracranial lesions. The success of LITT is dependent on accurate placement of the laser probe in target tissue. Placement can be facilitated by various stereotactic methods, including the Robotic Surgical Assistant (ROSA) ONE Brain robotic platform. The aim of this study is to examine the accuracy of stereotactic probe placement utilizing the ROSA robot. Primary outcomes were entry distance, target distance, and entry angle error. Accuracy differences between two major LITT platforms, the Neuroblate (Monteris Medical) and Visualase Systems, were compared. A prospective institutional database was used to identify all patients who underwent LITT for intracranial tumors utilizing the ROSA robot between 2013-2023. The sign test was used to compare error values to test their difference from a null value of 0. Spearman correlation was used to assess the relationship between angle of error and trajectory length. Kuskal-Wallis test was used to compare errors and trajectory length between the two companies. Of the 105 patients who underwent LITT during the study period, 337 probes were placed. For Visualase probes, median entry distance (1.1mm, IQR=0.4-2.0), target distance (1.6mm, IQR =0.9-2.4), and entry angle error (1.5°, IQR=0.9-2.5), were significantly different than zero (p=&amp;lt;.0001). For Neuroblate probes, median entry distance (1.5mm, IQR=1.0-2.1), target distance (1.8mm, IQR=1.1-2.4), and entry angle error (1.8°, IQR=1.1-2.5) were significantly different than zero (p=&amp;lt;.0001). When comparing laser systems, there was a significant difference in median entry distance error with Neuroblate having a higher error (1.5mm, IQR=1.0-2.1) than Visualase (1.1mm IQR=0.4-2.0, p=0.0041). Stereotactic placement of LITT probes utilizing the ROSA robotic system was not able to achieve perfect alignment with the planned trajectory. When comparing the systems, Visualase probes were placed more accurately at the entry point than Neuroblate probes.

Background: For 30% of anorexia nervosa (AN) patients, conventional treatments are unsuccessful; this is termed intractable AN. Objectives: This study investigates whether ablation of the nucleus accumbens (NAc) using stereotactic surgery can arouse the physiological drive to eat in intractable AN patients. Methods: Eight patients with intractable AN were included: 6 patients underwent bilateral stereotactic radio frequency ablation in the NAc and 2 patients received bilateral NAc deep brain stimulation (DBS). Observations were made for basic vital signs, body mass index (BMI), menstruation, depression, anxiety, obsessive-compulsive disorder, personality, intelligence, memory, quality of life, social functioning, as well as complications and adverse events associated with the treatment. Results: Basic vital signs, BMI and menstruation had recovered 1 year after the operation. Depression, anxiety and obsessive-compulsive disorder were improved 1 year postoperatively. There were changes in personality scores for psychoticism, neuroticism and lie tendencies that seemed to be helpful to the recovery from AN. Intelligence and memory improved after 6 months postoperatively. Quality of life and social functioning were dramatically improved at 1 year postoperatively. Conclusions: The results of this study reveal that ablation of the NAc can increase the AN patients' physiological drive to eat. Furthermore, there were no severe and/or life-influencing complications associated with the treatment.

Inpatient hospital admissions for people with obsessive-compulsive disorder (OCD). A position statement by the international college of obsessive-compulsive spectrum disorders.

Obsessive-compulsive personality disorder (OCPD) is an early-onset disorder characterized by perfectionism, need for control, and cognitive rigidity. Its nosological status is currently under review. Historically, OCPD has been conceptualized as bearing a close relationship with obsessive-compulsive disorder (OCD). In this article, we discuss the diagnosis of OCPD in anticipation of its review for the ICD-11, from the perspective of clinical utility, global applicability, and research planning. Considering the recent establishment of an obsessive-compulsive and related disorders (OCRD) category in DSM-5, we focus on the relationship between OCPD and the disorders that are currently thought to bear a close relationship with OCD, including DSM-5 OCRD, and other compulsive disorders such as eating disorder and autistic spectrum disorder (that were not included in the DSM-5 OCRD category), as well as with the personality disorders, focusing on nosological determinants such as phenomenology, course of illness, heritability, environmental risk factors, comorbidity, neurocognitive endophenotypes, and treatment response. Based on this analysis, we attempt to draw conclusions as to its optimal placement in diagnostic systems and draw attention to key research questions that could be explored in field trials.

For patients with surgically accessible solitary metastases or oligometastatic disease, treatment often involves resection followed by postoperative stereotactic radiosurgery (SRS). This strategy has several potential drawbacks, including irregular target delineation for SRS and potential tumor "seeding" away from the resection cavity during surgery. A neoadjuvant (preoperative) approach to radiation therapy avoids these limitations and offers improved patient convenience. This study assessed the efficacy of neoadjuvant SRS as a new treatment paradigm for patients with brain metastases. A retrospective review was performed at a single institution to identify patients who had undergone neoadjuvant SRS (specifically, Gamma Knife radiosurgery) followed by resection of a brain metastasis. Kaplan-Meier survival and log-rank analyses were used to evaluate risks of progression and death. Assessments were made of local recurrence and leptomeningeal spread. Additionally, an analysis of the contemporary literature of postoperative and neoadjuvant SRS for metastatic disease was performed. Twenty-four patients who had undergone neoadjuvant SRS followed by resection of a brain metastasis were identified in the single-institution cohort. The median age was 64 years (range 32-84 years), and the median follow-up time was 16.5 months (range 1 month to 5.7 years). The median radiation dose was 17 Gy prescribed to the 50% isodose. Rates of local disease control were 100% at 6 months, 87.6% at 12 months, and 73.5% at 24 months. In 4 patients who had local treatment failure, salvage therapy included repeat resection, laser interstitial thermal therapy, or repeat SRS. One hundred thirty patients (including the current cohort) were identified in the literature who had been treated with neoadjuvant SRS prior to resection. Overall rates of local control at 1 year after neoadjuvant SRS treatment ranged from 49% to 91%, and rates of leptomeningeal dissemination from 0% to 16%. In comparison, rates of local control 1 year after postoperative SRS ranged from 27% to 91%, with 7% to 28% developing leptomeningeal disease. Neoadjuvant SRS for the treatment of brain metastases is a novel approach that mitigates the shortcomings of postoperative SRS. While additional prospective studies are needed, the current study of 130 patients including the summary of 106 previously published cases supports the safety and potential efficacy of preoperative SRS with potential for improved outcomes compared with postoperative SRS.

The author reviews both the epidemiology and the genetics of obsessive-compulsive disorder (OCD). A relatively common disorder, OCD has an onset in late adolescence or early adulthood. Its gender distribution is nearly equal, although women are slightly more likely to develop the disorder. Usually chronic, OCD fluctuates depending on factors including the presence of depressed mood or stressful life events. OCD is associated with substantial psychiatric comorbidity, it affects quality of life, and it affects health care utilization. Many questions remain unanswered, such as whether its natural history has changed with the advent of effective therapies, and to what extent patients with OCD are disabled.There are no adoption studies of OCD, but reports of twins suggest greater monozygotic than dizygotic concordance. Family study results are not entirely consistent, probably because of differences in study methods, but tend to show that OCD is familial. They also show a genetic relationship to subclinical OCD and Tourette's syndrome. Molecular genetic studies are just getting under way. Important issues remain to be answered, including defining the extent of an OCD spectrum of disorders, and determining what constitutes an OCD phenotype.The author concludes by recommending that further studies on OCD involve samples from the general population rather than clinic- or hospital-based samples, which are inherently biased for severity.The past 15 years have been exciting for psychiatric researchers interested in the epidemiology and genetics of OCD. Combined with ongoing development of effective pharmacologic and behavioral treatments, new research in these areas has affected how physicians think about OCD, as well as how we clinically manage patients. More work needs to be done, as many important questions about both the epidemiology and genetics of OCD remain unanswered.

The existing literature indicates that psychotherapeutic treatment, especially exposure and response prevention (ERP) is efficacious in treating obsessive-compulsive disorder (OCD). The coronavirus disease 2019 pandemic adversely impacted many patients with OCD and disrupted their usual treatment. Moreover, the pandemic forced a global switch to telemental health (TMH) services to maintain the standards and continuity of care. Consequently, clinicians are increasingly using TMH-based psychotherapeutic treatments to treat OCD. However, several challenges have made it difficult for them to implement these treatments in the changed circumstances imposed by the pandemic. To describe the formulation, implementation, feasibility, and usefulness of videoconferencing-based ERP (VC-ERP) treatment for OCD during the coronavirus disease 2019 pandemic. This prospective, observational study was conducted in the psychiatric unit of a multi-specialty hospital in north India over 12 mo (July 2020-June 2021). All patients with OCD were assessed using the home-based TMH services of the department. The VC-ERP protocol for OCD was the outcome of weekly Zoom meetings with a group of clinicians involved in administering the treatment. After a systematic evaluation of the available treatment options, an initial protocol for delivering VC-ERP was developed. Guidelines for clinicians and educational materials for patients and their families were prepared. The protocol was implemented among patients with OCD attending the TMH services, and their progress was monitored. The weekly meetings were used to upgrade the protocol to meet the needs of all stakeholders. Feasibility and efficacy outcomes were examined. All patients were diagnosed with OCD as a primary or a comorbid condition according to the International Classification of Diseases, 10th version criteria. Out of 115 patients who attended the services during the study period, 37 were excluded from the final analysis. Of the remaining 78 patients, VC-ERP was initiated in 43 patients. Six patients dropped out, and three were hospitalized for inpatient ERP. Eleven patients have completed the full VC-ERP treatment. One patient completed the psychoeducation part of the protocol. VC-ERP is ongoing in 22 patients. The protocol for VC-ERP treatment was developed and upgraded online. A large proportion of the eligible patients (n = 34/43; 79%) actively engaged in the VC-ERP treatment. Drop-out rates were low (n = 6/43; 14%). Satisfaction with the treatment was adequate among patients, caregivers, and clinicians. Apart from hospitalization in 3 patients, there were no other adverse events. Hybrid care and stepped care approaches could be incorporated into the VC-ERP protocol. Therefore, the feasibility of VC-ERP treatment in terms of operational viability, service utilization, service engagement, need for additional in-person services, frequency of adverse events, and user satisfaction was adequate. The VC-ERP treatment was found to be efficacious in the 11 patients who had completed the full treatment. Significant reductions in symptoms and maintenance of treatment gains on follow-up were observed. This study provided preliminary evidence for the feasibility and usefulness of VC-ERP in the treatment of OCD. The results suggest that VC-ERP can be a useful option in resource-constrained settings.

Obsessive-compulsive disorder (OCD) is characterized by recurrent, distressing obsessions and repetitive compulsive behaviors or mental rituals frequently performed to reduce the distress associated with the obsessions. This paper reviews maladaptive and adaptive coping responses used by individuals with OCD, including compulsions as an avoidant coping response, psychotherapeutic and pharmacological treatments, social and family support, lifestyle changes, and stress management. Although several gaps in the extant literature on coping with OCD were identified, a considerable body of research supports the use of cognitive-behavioral therapy (CBT) with exposure and response prevention (E/RP) as an effective therapeutic technique for teaching long-lasting coping skills. Increased research is needed in the role of social support, exercise and dietary changes, and stress management skills on daily functioning in individuals with OCD. Implications and recommendations for future research are discussed. Keywords: Obsessive-compulsive disorder, OCD, SSRI, CBT, exposure, coping, anxiety

Satzer et al 1 report on 18 patients with severe obsessive–compulsive disorder (OCD) who underwent anterior capsulotomy using MRI-guided laser interstitial thermal therapy (LITT). At a mean of 6 months...