Yijie Lai, MD*; Tao Wang, MD*; Chencheng Zhang, MD, PhD; Guozhen Lin, MD; Valerie Voon, MD, PhD; Jinwoo Chang, MD, PhD; Bomin Sun, MD, PhD
Background: Several neuroablative procedures are available for severe and treatment-resistant obsessive–compulsive disorder (OCD), but limited knowledge about their relative clinical advantages and disadvantages poses obstacles for treatment decision-making.
Methods: We searched PubMed, Embase, Scopus, Web of Knowledge and the Cochrane Library for reports up to February 2019. We reviewed the literature on the effectiveness (assessed using the Yale–Brown Obsessive Compulsive Scale [Y-BOCS]) and safety of various neuroablative interventions for severe and treatment-resistant OCD.
Results: We included 23 studies involving 487 patients in the systematic review; 21 studies with 459 patients were included in the meta-analysis. Overall, neuroablation achieved a response rate (proportion of patients with ≥ 35% reduction in Y-BOCS) of 55%. Most of the adverse events (88.4%) were mild and transient. The top 3 adverse events were headache (14.9%), cognitive deficits (9.1%) and behaviour problems (8.1%). Severe or permanent adverse events included personality changes (2.3%) and brain edema or brain cyst (1.5%). The response rates associated with capsulotomy, limbic leucotomy and cingulotomy were 59% (95% confidence interval [CI] 54–65), 47% (95% CI 23–72) and 36% (95% CI 23–50), respectively. Interventions with different coverages of the dorsal part of the internal capsule were associated with different adverse-event profiles but were unlikely to modify clinical effectiveness.
Limitations: The level of evidence of most included studies was relatively low.
Conclusion: Ablative surgeries are safe and effective for a large proportion of patients with severe and treatment-resistant OCD. Among the available procedures, capsulotomy seemed to be the most effective. Further research is needed to improve clinical effectiveness and minimize risks.
*These authors contributed equally to this work.
Submitted Apr. 14, 2019; Revised Aug. 5, 2019; Revised Oct. 25, 2019; Revised Dec. 24, 2019; Accepted Jan. 16, 2020; Published online June 17, 2020
Acknowledgements: The authors appreciated the critical comments from Dianyou Li, Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, and Haiyan Jin, Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, in preparation of the manuscript.
Affiliations: From the Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lai, Wang, Zhang, Sun); the Department of Psychiatry, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China (Lin); the Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); and the Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea (Chang).
Funding: B. Sun is supported by a Natural Science Foundation of China Grant (81771482) and a Shanghai Science and Technology Commission International Cooperation Project (STCSM, NO:18410710400). V. Voon is supported by a Medical Research Council Senior Clinical Fellowship (MR/P008747/1).
Competing interests: None declared.
Contributors: Y.J. Lai, C. Zhang, V. Voon, J. Chang and B. Sun designed the study. Y.J. Lai, T. Wang and C. Zhang acquired the data, which Y.J. Lai, C. Zhang, G. Lin, J. Chang and B. Sun analyzed. Y.J. Lai and C. Zhang wrote the article, which all authors reviewed. All authors approved the final version to be published and can certify that no other individuals not listed as authors have made substantial contributions to the paper.
Correspondence to: C. Zhang, Department of Functional Neurosurgery, Ruijin Hospital, No. 197, Second Ruijin Rd., Shanghai, 200025, China; firstname.lastname@example.org