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First successful case of OCD surgery as per the core group guidelines – Anterior Capsulotomy For Obsessive Compulsive Disorder

Mr. S V, M 62 yrs.
Diagnosis: Intractable Obsessive Compulsive Disorder
Surgery: Bilateral Anterior Capsulotomy
Date of Surgery: 03.08.10 
Date of Discharge: 12.08.10
Centre: Jaslok Hospital and Research centre, Mumbai

History: Mr. V, 62 yrs old Engineer from Karnataka who was an anxious, determined, short tempered, reserved and dominating personality was apparently normal 20 yrs. ago when he developed depression after the demise of his father in 1990. He was treated for the same in Mysore. One year later his symptom progressed to anxiety dominated by obsessive and compulsive symptoms, which were gradually increasing in severity. His obsessive symptoms included insisting on repeated checking and verifying the documents, cheques and money. He had taken voluntary retirement and has not been working since past 15yrs.

He was unable to get the pension also, as he could not sign for himself. His compulsions included repeated washing of the hands (about 80-100 times at the time of admission), spending long time in the toilet (about 3-4hrs), repeatedly asking the same questions and verifying the answers multiple times. Since the last two years he had been confined to home due to the symptoms severely affecting his daily life and also that of the caretakers. He had been on appropriate medications (SSRIs,SDAs) along with behavioural therapy for 15yrs. under the care of psychiatrist without any significant change in his symptoms.

At the time of admission he was on a daily dose of Sizodon 2mg, Quitipin 75mg, Alprzolam .5mg, Nexito 10 mg and fluoxetine 100mg.

On Examination: He was intelligent, anxious, well oriented and had normal memory. He had preseverd insight present, was well kept, co-operative and repetitive. His thought process had occasional tangentiality but can be brought back to rational thinking. He had no other focal neurological deficits.

Yale-Brown Obsessive-compulsive scale was 38/40 suggestive of Extreme OCD

Hamilton Depression Scale was 24.

Beck Anxiety Inventory score was 26 suggestive of moderate anxiety.

MMSE was 30.

Dr.Vihang Vahia (Psychiatrist), Dr. H S Venkatesh (Psychiatrist) from Mysore & Dr.Paresh Doshi (Neurosurgeon) confirmed that the patient met the inclusion criteria. Jaslok Hospital Psychosurgery review board of Dr Joy Desai (Neurologist) , Dr.H M Dastur (Neurosurgeon) , Dr.Amit Desai (Psychiatrist) confirmed that patient was appropriate candidate for the surgery.

Options of DBS versus Lesion were thoroughly discussed. There were financial & practical concerns for performing DBS. Patient was living in Mysore where access to DBS programming was not available. He did not have adequate support to make frequent visits to Mumbai for programming. Considering all aspects and the past experiences of lesional procedures, a decision to perform Bilateral Anterior Capsulotomy was made. Patients relative (sisters & wife) were briefed about this and they agreed to give consent for the surgical procedure.

Operative summary: Preoperative MRI was performed a day prior to surgery to locate Nucleus Acumbens at the bottom of the internal capsule. On the day of surgery under local anesthesia, CRW stereo tactic frame was applied on the patient’s head. CT scan was performed and co-ordinates were obtained. This was then fused with the preoperative MRI. Frame Link was used to define trajectory.

Neurophysiological response was noted starting from 20mm above the target to 3mm below the target on right side and 15mm above till 3mm below the target on left side. The response in the form of decrease in anxiety, more calmness and pseudosmile were noted nearer the targets. Radiofrequency lesioning was done bilaterally at 75 degree Celsius for 60seconds.

Post op CT scan confirmed appropriate target. (Fig. 1) He had good improvement in his OCD symptoms but had severe confusion and disorientation in the initial three postoperative days. He was also having high-grade fever and hyponatremia, for which no identifiable apparent cause. Reduction in the dosage of anti-psychiatric medications was done on consultation with the Psychiatrist. At the time of discharge he had very good relief of his OCD symptoms.

Y-BOCS was 9/40

Hamilton depression scale – 6.

Fig. Showing Bilateral ant. Capsulotomy lesions like two tiger eyes

He had mild memory lapses and apathy. He was able to write and sign his name after a long duration of 15years.

On discharge his medications were Sizoden 1 mg., Quitipin 25 mg. and Alprazolam 0.5mg.