RESUMO
INTRODUCTION: Aggressiveness is part of the behavioural manifestations associated with some mental disorders; it is a symptom that is difficult to manage and is often resistant to pharmacological measures. Surgery for behavioural disorders emerges as a therapeutic alternative. This procedure consists in performing interventions on different structures of the limbic system in order to correct the alteration of the circuit involved in producing the symptoms. AIM: To describe the clinical outcomes of a posterior hypothalamotomy with gamma knife to control aggressiveness in 20 patients resistant to treatment, who underwent surgery at the Imbanaco Medical Centre between 2013 and 2018. PATIENTS AND METHODS: The severity of the aggressiveness was quantified using the Overt Aggression Scale (OAS) and the Clinical Global Impression Scale (CGI-SI), and its functional impact is evaluated using the Global Assessment of Functioning scale (GAF). RESULTS: Control over aggressiveness was observed in all patients treated by posterior hypothalamotomy with gamma knife, evidenced by a decrease in the scores on the OAS and CGI-SI and an improvement in the GAF. CONCLUSIONS: Posterior hypothalamotomy gives rise to few complications, is a safe procedure and offers good results, suggesting that it could be a good alternative treatment in cases of treatment-resistant aggressiveness where it seems that all the possible pharmacological and therapeutic measures have failed.
TITLE: Hipotalamotomía en pacientes con agresividad refractaria: resultados funcionales.Introducción. La agresividad forma parte de las manifestaciones comportamentales asociadas a algunos trastornos mentales, es un síntoma de difícil manejo y, con frecuencia, es refractaria a las medidas farmacológicas. La cirugía de los trastornos del comportamiento surge como una alternativa terapéutica. Este procedimiento consiste en realizar intervenciones sobre distintas estructuras del sistema límbico, con el fin de corregir la alteración del circuito que estaría implicado en la producción de los síntomas. Objetivo. Describir los resultados clínicos de la hipotalamotomía posterior con gamma knife en el control de la agresividad en 20 pacientes refractarios al tratamiento, intervenidos en el Centro Médico Imbanaco entre 2013 y 2018. Pacientes y métodos. La gravedad de la agresividad se cuantificó mediante la escala de agresividad manifiesta (OAS) y la escala de impresión clínica global (CGI-SI), y su impacto funcional, a través de la escala de evaluación de la actividad global (EEAG). Resultados. El control de la agresividad se observó en todos los pacientes tratados con hipotalamotomía posterior con gamma knife, evidenciado por la disminución en las puntuaciones de la OAS y la CGI-SI y la mejoría en la EEAG. Conclusiones. La hipotalamotomía posterior muestra bajas complicaciones, seguridad en el procedimiento y buenos resultados, lo cual sugiere que podría ser una buena alternativa de tratamiento en los casos de agresividad refractaria donde las medidas farmacológicas y terapéuticas parecen agotarse.
Assuntos
Agressão , Hipotálamo Posterior/cirurgia , Psicocirurgia/métodos , Radiocirurgia/métodos , Adolescente , Adulto , Transtorno Autístico/complicações , Criança , Terapia Combinada , Resistência a Medicamentos , Feminino , Humanos , Hiperfagia/etiologia , Deficiência Intelectual/complicações , Imageamento por Ressonância Magnética , Masculino , Neuroimagem , Equipe de Assistência ao Paciente , Psicocirurgia/efeitos adversos , Psicotrópicos/uso terapêutico , Radiocirurgia/efeitos adversos , Índice de Gravidade de Doença , Distúrbios do Início e da Manutenção do Sono/etiologia , Resultado do Tratamento , Adulto JovemRESUMO
Schizophrenia is a chronic and disabling psychiatric disease that can be refractory to conventional treatment. The present study aims to gather information about the circuitry related to schizophrenia to describe possible surgical targets, and to establish whether psychosurgery can be a safe and effective treatment option for refractory schizophrenia. A systematic review of the literature was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. An electronic search was performed in the Pubmed and BVSalud databases using medical subject headings (MeSH) combined with Boolean operators. Out of the 724 studies retrieved, 13 were included in the review. Regarding leucotomy without a stereotactic approach, we found side effects such as irritability, nervous excitement, cases of disinhibition, and compromised normal social control. In other stereotactic procedures, there was some improvement, mainly regarding aggressiveness and positive symptoms; an anterior capsulotomy had an efficacy rate of 74% according to the Clinical Global Impression (CGI) rating scales. The only deep brain stimulation (DBS) case report found in our study described a significant improvement in the positive and negative symptoms. The use of a stereotactic approach enables psychosurgery to be a safe and effective treatment option in cases of refractory schizophrenia, improving the quality of life and the symptoms. Cognitive and negative symptoms remain a challenge in the treatment of schizophrenia, revealing that more targets in the circuitrymust be surgically explored. Furthermore,more clinical trials are needed to compare these many surgical techniques and targets, using a standard evaluation parameter. The results show that DBS has a promising future in the treatment of refractory schizophrenia.
Assuntos
Psicocirurgia/tendências , Estimulação Encefálica Profunda/efeitos adversos , Esquizofrenia Resistente ao Tratamento/cirurgia , Neurocirurgia/tendências , Psicocirurgia/efeitos adversos , Técnicas Estereotáxicas , Complicações Cognitivas Pós-Operatórias , Esquizofrenia Resistente ao Tratamento/diagnósticoRESUMO
OBJECTIVE: To give validity to the claim that Eva Perón underwent a prefrontal lobotomy and/or another neurosurgical procedure. METHODS: 1) Press interviews given by Dr. George Udvarhelyi, who passed away in 2010, were read and his statements were crosschecked with excerpts of his memoirs; 2) Searched for other oral and written evidence in Argentina; 3) Reviewed radiological evidence and recent revelations about her illness and death; and 4) Carried out historic review of prefrontal lobotomy as an accepted and established surgical treatment during the relevant time period and place. RESULTS: Udvarhelyi's assertion in a press interview that a prefrontal lobotomy was performed on Eva Perón is consistent with the history he penned in his memoirs. Interviews with individuals close to Eva conducted by historians, revealed a clinical picture compatible with side effects from such an operation. Comments from surgeon Dr. Ricardo Finochietto, leader of the group of physicians involved in Eva's medical care, provide further support that a neurosurgical procedure was performed. President Perón's orders and instructions to the medical team also support this allegation. Review of skull radiographs show findings compatible with burr holes. Photographs of the patient at the end of her illness show indentation at the coronal level. The alleged procedure was cutting edge of surgery in 1952. The Argentine neurosurgical establishment was up to par in psychosurgical developments and there were neurosurgeons close to Perón that could have performed the procedure in those circumstances. CONCLUSIONS: Evidence was found that gives validity to Dr. George Udvarhelyi's claim that Eva Perón underwent a neurosurgical prefrontal lobotomy in Buenos Aires, Argentina. This was done for treatment of pain, anxiety, and agitation secondary to uterine metastatic cancer before her death in 1952. Neurosurgeon Dr. James L. Poppen appears to have been involved in the case.
Assuntos
Neurocirurgia/história , Psicocirurgia/história , Ansiedade/psicologia , Argentina , Biópsia , Pessoas Famosas , Feminino , História do Século XX , Humanos , Pessoa de Meia-Idade , Manejo da Dor , Agitação Psicomotora/psicologia , Psicocirurgia/efeitos adversos , Radiografia , Crânio/diagnóstico por imagem , Neoplasias Uterinas/complicações , Neoplasias Uterinas/radioterapiaRESUMO
Present study represents a case follow up for seven years. A case of Epilepsy Partialis Continua (EPC) in a fifteen year old girl was studied with CT, MRI, cerebral SPECT and constantly EEG procedures: The SPECT study showed in right frontal lobe and right temporal lobe hypoperfusion (reduction of regional cerebral blood flow [rCBF]) cerebral zone in the interictal period and hyperperfusion (increase rCBF) in the ictal period in the same hemisphere. The EEG showed abnormal activity consisting in sharp wave and polyphasic sharp wave in frontal and temporal regions. The medical treatment was refractory at all kind of anticonvulsant drugs. In order to improve the refractory epilepsy the team decided an epilepsy surgery with right temporal lobotomy and right frontal corticetomy. This procedure were done at the eight year old and the results were satisfactory immediately after the surgery with absolute control and normal cognitive performance two weeks later the surgery. This patient was follow up for seven years with EEG constantly with normal activity, SPECT and MRI, all studies showed functional hemispherectomy, total absence in the structure and cerebral blood flow in right hemisphere with normal perfusion and structure in left hemisphere. The late control of neuropsychology assessment showed some deficits in the I.Q. cognitive performance, evaluated by the Weschler scale and Machover tests. These findings would be able to demonstrate a phenomenon of brain plasticity and neuronal restoration in the left cerebral hemisphere after to remove the abnormal cerebral epilepsy focus. This procedure might permits the restoration of inadequate neuronal environment and normalization of neural physiological stability. The postulated mechanisms of reorganization of function are unmasking, nonsynaptic diffusion neurotransmission and receptor plasticity, trophic factors, synapsins and neurotransmitters. The neuropsychological mechanism to preserve the functions would be involving in a cortical reorganization with axonal and dendritic development beside sprouting and synaptogenesis. This patient is a good example of neuronal plasticity in epilepsy surgery.
Assuntos
Encefalite/complicações , Epilepsia Parcial Contínua/fisiopatologia , Plasticidade Neuronal , Psicocirurgia , Fatores Etários , Anticonvulsivantes/uso terapêutico , Criança , Transtornos Cognitivos/etiologia , Transtornos Cognitivos/fisiopatologia , Terapia Combinada , Eletroencefalografia , Epilepsia Parcial Contínua/diagnóstico por imagem , Epilepsia Parcial Contínua/tratamento farmacológico , Epilepsia Parcial Contínua/etiologia , Epilepsia Parcial Contínua/cirurgia , Feminino , Seguimentos , Lobo Frontal/diagnóstico por imagem , Lobo Frontal/fisiopatologia , Lobo Frontal/cirurgia , Humanos , Imageamento por Ressonância Magnética , Testes Neuropsicológicos , Psicocirurgia/efeitos adversos , Lobo Temporal/diagnóstico por imagem , Lobo Temporal/fisiopatologia , Lobo Temporal/cirurgia , Tomografia Computadorizada de Emissão de Fóton Único , Tomografia Computadorizada por Raios XRESUMO
Con motivo de la publicación de un caso en el cual la risa involuntaria e inmotivada constituye la única manifestación clínica de Epilepsia en la edad adulta, se hace una revisión histórica del problema, se discute la fisiología de la risa normal, se enmarca la Epilepsia Gelástica en el contexto de la risa patológica y se comentan múltiples etiologías, diversas localizaciones lesionales y un espectro de patrones clínicos y electroencefalográficos en relación con Epilepsia Gelástica
Assuntos
Epilepsia/etiologia , Riso , Epilepsia/diagnóstico , Epilepsia/fisiopatologia , Doenças de Niemann-Pick/complicações , Neoplasias Encefálicas/complicações , Psicocirurgia/efeitos adversos , Lobo Temporal/lesõesRESUMO
Con motivo de la publicación de un caso en el cual la risa involuntaria e inmotivada constituye la única manifestación clínica de Epilepsia en la edad adulta, se hace una revisión histórica del problema, se discute la fisiología de la risa normal, se enmarca la Epilepsia Gelástica en el contexto de la risa patológica y se comentan múltiples etiologías, diversas localizaciones lesionales y un espectro de patrones clínicos y electroencefalográficos en relación con Epilepsia Gelástica
Assuntos
Epilepsia/etiologia , Riso , Neoplasias Encefálicas/complicações , Doenças de Niemann-Pick/complicações , Epilepsia/diagnóstico , Epilepsia/fisiopatologia , Lobo Temporal/lesões , Psicocirurgia/efeitos adversosRESUMO
Two cases of partial Klüver-Bucy syndrome developed after probable herpes simplex meningoencephalitis are reported. Clinical, pathological, diagnostic and therapeutic aspects of herpes simplex encephalitis and Klüver-Bucy syndrome are discussed.
Assuntos
Comportamento , Epilepsia do Lobo Temporal/etiologia , Comportamento Alimentar , Herpes Simples/complicações , Meningoencefalite/complicações , Psicocirurgia/efeitos adversos , Comportamento Sexual , Adolescente , Feminino , Humanos , Masculino , Síndrome , Lobo TemporalRESUMO
Säo apresentados dois casos de meningoencefalite viral, de provável etiologia herpetica, que desenvolveram síndrome de Klüver-Bucy parcial. Aspectos clinicopatológicos, diagnósticos e terapêuticos da meningoencefalite herpética säo discutidos revisando-se também conceitos acerca da síndrome de Klüver-Bucy