Ablative brain surgery

Ablative brain surgery
Ablative brain surgery
Other names	Brain lesioning
Specialty	neurology
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Last updated October 20, 2024

Ablative brain surgery (also known as brain lesioning) is the surgical ablation by various methods of brain tissue to treat neurological or psychological disorders. The word "Ablation" stems from the Latin word Ablatus meaning "carried away". In most cases, however, ablative brain surgery does not involve removing brain tissue, but rather destroying tissue and leaving it in place.^[1] The lesions it causes are irreversible. There are some target nuclei for ablative surgery and deep brain stimulation. Those nuclei are the motor thalamus, the globus pallidus, and the subthalamic nucleus.^[2]

Ablative brain surgery was first introduced by Pierre Flourens (1794–1867), a French physiologist. He removed different parts of the nervous system from animals and observed what effects were caused by the removal of certain parts. For example, if an animal could not move its arm after a certain part was removed, it was assumed that the region would control arm movements. The method of removal of part of the brain was termed "experimental ablation". With the use of experimental ablation, Flourens claimed to find the area of the brain that controlled heart rate and breathing.^[3]

Ablative brain surgery is also often used as a research tool in neurobiology. For example, by ablating specific brain regions and observing differences in animals subjected to behavioral tests, the functions of all the removed areas may be inferred.

Experimental ablation is used in research on animals. Such research is considered unethical on humans due to the irreversible effects and damages caused by the lesion and by the ablation of brain tissues. However, the effects of brain lesions (caused by accidents or diseases) on behavior can be observed to draw conclusions on the functions of different parts of the brain.^[4]

Uses

Parkinson's disease

An implanted neurostimulator, sometimes called a 'brain pacemaker, in an adult male as part of ablative brain surgery. Neurostimulator.jpg — An implanted neurostimulator, sometimes called a 'brain pacemaker, in an adult male as part of ablative brain surgery.

Parkinson's disease (PD) is a progressive degenerative disease of the basal ganglia, characterized by the loss of dopaminergic cells of the substantia nigra, pars compacta (SNc).^[2] Surgical ablation has been used to treat Parkinson's disease. In the 1990s, the pallidum was a common surgical target. Unilateral pallidotomy improves tremor and dyskinesia on one side of the body (opposite the side of the brain surgery), but bilateral pallidotomy was found to cause irreversible deterioration in speech and cognition.^{[ citation needed ]}

Two other rapidly evolving or potential surgical approaches to Parkinson's disease are deep brain stimulation (DBS) and restorative therapies.^[2]

Deep brain stimulation is a surgical treatment involving the implantation of a neurostimulator medical device, sometimes called a 'brain pacemaker', which sends electrical impulses to specific parts of the brain. Generally, deep brain stimulation surgery is considered preferable to ablation because it has the same effect and is adjustable and reversible.^[5]

The advent of deep brain stimulation has been an important advance in the treatment of Parkinson's disease. DBS may be employed in the management of medication-refractory tremor or treatment-related motor complications, and may benefit between 4.5% and 20% of patients at some stage of their disease course. DBS at high frequency often has behavioral effects that are similar to those of lesioning.

In Australia, patients with PD are reviewed by specialized DBS teams who assess the likely benefits and risks associated with DBS for each individual.^[2] The aim of these guidelines is to assist neurologists and general physicians identify patients who may benefit from referral to a DBS team. Common indications for referral are motor fluctuations and/or dyskinesias that are not adequately controlled with optimised medical therapy, medication-refractory tremor, and intolerance to medical therapy. Early referral for consideration of DBS is recommended as soon as optimised medical therapy fails to offer satisfactory motor control.^[6]

The thalamus is another potential target for treating a tremor; in some countries, so is the subthalamic nucleus, although not in the United States due to its severe side effects. Stimulation of portions of the thalamus or lesioning has been used for various psychiatric and neurological conditions, and when practiced for movement disorders the target is in the motor nuclei of the thalamus.^[2] Thalamotomy is another surgical option in the treatment of Parkinson's disease. However, rigidity is not fully controlled after successful thalamotomy, it is replaced by hypotonia. Furthermore, significant complications can occur, for example, left ventral-lateral thalamotomy in a right-handed patient results in verbal deterioration while right thalamotomy causes visual-spatial defects.^[7] However, for patients for whom DBS is not feasible, ablation of the subthalamic nucleus has been shown to be safe and effective.^[8] DBS is not suitable for certain patients. Patients with immunodeficiencies are an example of a situation in which DBS is not a suitable procedure. However, a major reason as to why DBS is not often performed is the cost. Because of its high cost, DBS cannot be performed in regions of the world that are not wealthy. In the case of such circumstances, a permanent lesion in the subthalamic nucleus (STN) is created as it is a more favourable surgical procedure.^[9] The surgical procedure is going to be done on the non-dominant side of the brain; a lesion might be favored to evade numerous pacemaker replacements. More so, patients who gain relief from stimulation devoid of any side effects and need a pacemaker change may have a lesion performed on them in the same position. The stimulation parameters act as a guide for the preferred size of the lesion.^[10] In order to identify the part of the brain that is to be destroyed, new techniques such as micro electrode mapping have been developed.^[11]

Cluster headaches

Cluster headaches occur in cyclical patterns or clusters—which gives the condition of its name. Cluster headache is one of the most painful types of headache.^[12] Bouts of frequent cluster headaches may last from weeks to months.^[13] Attempts have been made to treat cluster headaches via ablation of the trigeminal nerve, but have not been very effective. Other surgical treatments for cluster headaches are currently under investigation.^[14]

Psychiatric disorders

Ablative psychosurgery continues to be used in a few centres in various countries.^[15] In the US there are a few centres including Massachusetts General Hospital that carry out ablative psychosurgical procedures.^[16] Belgium,^[15] the United Kingdom,^[17] and Venezuela^[18] are other examples of countries where the technique is still used. In the People's Republic of China, surgical ablation was used to treat psychological and neurological disorders, particularly schizophrenia, but also including clinical depression, and obsessive-compulsive disorder.^[19] The official Xinhua News Agency has since reported that China's Ministry of Health has banned the procedure for schizophrenia and severely restricted the practice for other conditions.^[20] In recent studies, Deep Brain Stimulation (DBS) is beginning to replace Ablative Brain Surgery for severe psychiatric conditions that are generally treatment resistant, such as obsessive-compulsive disorder.^[21]

Methods

Experimental ablation involves the drilling of holes in the skull of an animal and inserting an electrode or a small tube called a cannula into the brain using a stereotactic apparatus. A brain lesion can be created by conducting electricity through the electrode which damages the targeted area of the brain. likewise, chemicals can be inserted in the cannula which could possibly damages the area of interest. By comparing the prior behavior of the animal to after the lesion, the researcher can predict the function of damaged brain segment.^[22] Recently, lasers have been shown to be effective in ablation of both cerebral and cerebellar tissue. A laser technology called MRI-guided laser ablation,^[23] for example, allows great precision in location and size of the lesion and the causes little to no thermal damage to adjacent tissue. The Texas Children's Hospital is one of the first to use this MRI guided method to destroy and treat brain lesions effectively and precisely. A prime example is a patient at this hospital who now no longer undergoes frequent seizures because of the success of this treatment.^[24] MRI-guided laser ablation is also used for ablating brain, prostate and liver tumors. Heating or freezing are also alternative methods to ablative brain surgery.^[25]

Sham lesions

A sham lesion is a way for researchers to give a placebo lesion to animals involved in experimental ablation. Whenever a cannula or electrode is placed into brain tissue, unintended additional damage is caused by the instrument itself. A sham lesion is simply the placement of the lesioning instrument into the same spot it would be placed in a regular lesion, only there is no chemical or electrical process. This technique allows researchers to properly compare to an appropriate control group by controlling for the damage done separate from the intended lesion.^[26]

Excitotoxic lesions

An excitotoxic lesion is the process of an excitatory amino acid being injected into the brain using a cannula. The amino acid is used to kill neurons by essentially stimulating them to death. Kainic acid is an example of an excitatory amino acid used in this type of lesion. One crucial benefit to this lesion is its specificity. The chemicals are selective in that they do not damage the surrounding axons of nearby neurons, but only the target neurons.^[1]

Radio frequency lesions

Radio frequency (RF) lesions are produced by electrodes placed in the brain tissue. RF current is an alternating current of very high frequency. The process during which the current passes through tissue produces heat that kills cells in the surrounding area. Unlike excitotoxic lesions, RF lesions destroy everything in the nearby vicinity of the electrode tip.^[1]

The use of ablative brain surgery on the nucleus accumbens is the wrong method to treat addictions according to Dr. Charles O'Brien. Dr. John Adler, however, believes ablation can provide valuable information about how the nucleus accumbens works.^[27]

Related Research Articles

Neurosurgery or neurological surgery, known in common parlance as brain surgery, is the medical specialty concerned with the surgical treatment of disorders which affect any portion of the nervous system including the brain, spinal cord and peripheral nervous system.

Psychosurgery, also called neurosurgery for mental disorder (NMD), is the neurosurgical treatment of mental disorders. Psychosurgery has always been a controversial medical field. The modern history of psychosurgery begins in the 1880s under the Swiss psychiatrist Gottlieb Burckhardt. The first significant foray into psychosurgery in the 20th century was conducted by the Portuguese neurologist Egas Moniz who, during the mid-1930s, developed the operation known as leucotomy. The practice was enthusiastically taken up in the United States by the neuropsychiatrist Walter Freeman and the neurosurgeon James W. Watts who devised what became the standard prefrontal procedure and named their operative technique lobotomy, although the operation was called leucotomy in the United Kingdom. In spite of the award of the Nobel prize to Moniz in 1949, the use of psychosurgery declined during the 1950s. By the 1970s the standard Freeman-Watts type of operation was very rare, but other forms of psychosurgery, although used on a much smaller scale, survived. Some countries have abandoned psychosurgery altogether; in others, for example the US and the UK, it is only used in a few centres on small numbers of people with depression or obsessive-compulsive disorder (OCD). In some countries it is also used in the treatment of schizophrenia and other disorders.

Deep brain stimulation (DBS) is a surgical procedure that implants a neurostimulator and electrodes which sends electrical impulses to specified targets in the brain responsible for movement control. The treatment is designed for a range of movement disorders such as Parkinson's disease, essential tremor, and dystonia, as well as for certain neuropsychiatric conditions like obsessive-compulsive disorder (OCD) and epilepsy. The exact mechanisms of DBS are complex and not entirely clear, but it is known to modify brain activity in a structured way.

Lars Leksell was a Swedish physician and professor of Neurosurgery at the Karolinska Institute in Stockholm, Sweden. He was the inventor of radiosurgery.

Radiosurgery is surgery using radiation, that is, the destruction of precisely selected areas of tissue using ionizing radiation rather than excision with a blade. Like other forms of radiation therapy, it is usually used to treat cancer. Radiosurgery was originally defined by the Swedish neurosurgeon Lars Leksell as "a single high dose fraction of radiation, stereotactically directed to an intracranial region of interest".

Stereotactic surgery is a minimally invasive form of surgical intervention that makes use of a three-dimensional coordinate system to locate small targets inside the body and to perform on them some action such as ablation, biopsy, lesion, injection, stimulation, implantation, radiosurgery (SRS), etc.

The subthalamic nucleus (STN) is a small lens-shaped nucleus in the brain where it is, from a functional point of view, part of the basal ganglia system. In terms of anatomy, it is the major part of the subthalamus. As suggested by its name, the subthalamic nucleus is located ventral to the thalamus. It is also dorsal to the substantia nigra and medial to the internal capsule. It was first described by Jules Bernard Luys in 1865, and the term corpus Luysi or Luys' body is still sometimes used.

<span class="mw-page-title-main">Thalamotomy</span> Surgical procedure

Thalamotomy is a surgical procedure in which a functional lesion is made into the thalamus to improve the overall brain function in patients. First introduced in the 1950s, it is primarily effective for tremors such as those associated with Parkinson's disease, where a selected portion of the thalamus is surgically destroyed (ablated). Neurosurgeons use specialized equipment to precisely locate an area of the thalamus, usually choosing to work on only one side. Bilateral procedures are poorly tolerated because of increased complications and risk, including vision and speech problems. The positive effects on tremors are immediate. Other less destructive procedures are sometimes preferred, such as subthalamic deep brain stimulation, since this procedure can also improve tremors and other symptoms of PD.

Hemiballismus or hemiballism is a basal ganglia syndrome resulting from damage to the subthalamic nucleus in the basal ganglia. It is a rare hyperkinetic movement disorder, that is characterized by pronounced involuntary limb movements on one side of the body and can cause significant disability. Rarely it affects both sides of the body. Symptoms can decrease during sleep.

<span class="mw-page-title-main">Hypokinesia</span> Decreased movement due to basal ganglia dysfunction

Hypokinesia is one of the classifications of movement disorders, and refers to decreased bodily movement. Hypokinesia is characterized by a partial or complete loss of muscle movement due to a disruption in the basal ganglia. Hypokinesia is a symptom of Parkinson's disease shown as muscle rigidity and an inability to produce movement. It is also associated with mental health disorders and prolonged inactivity due to illness, amongst other diseases.

Pallidotomy is a neurosurgical procedure. It is used to treat Parkinson's disease and some other conditions, often as an alternative to deep brain stimulation. It involves placing a tiny electrical probe in the globus pallidus, one of the basal ganglia of the brain, to damage it. Unilateral pallidotomy can cause side effects including problems with language learning, visuospatial constructional ability, and executive functions. Bilateral pallidotomy is not effective, with many severe side effects.

In the management of Parkinson's disease, due to the chronic nature of Parkinson's disease (PD), a broad-based program is needed that includes patient and family education, support-group services, general wellness maintenance, exercise, and nutrition. At present, no cure for the disease is known, but medications or surgery can provide relief from the symptoms.

Neuromodulation is "the alteration of nerve activity through targeted delivery of a stimulus, such as electrical stimulation or chemical agents, to specific neurological sites in the body". It is carried out to normalize – or modulate – nervous tissue function. Neuromodulation is an evolving therapy that can involve a range of electromagnetic stimuli such as a magnetic field (rTMS), an electric current, or a drug instilled directly in the subdural space. Emerging applications involve targeted introduction of genes or gene regulators and light (optogenetics), and by 2014, these had been at minimum demonstrated in mammalian models, or first-in-human data had been acquired. The most clinical experience has been with electrical stimulation.

Alim Louis Benabid is a French-Algerian emeritus professor, neurosurgeon and member of the French Academy of Sciences, who has had a global impact in the development of deep brain stimulation (DBS) for Parkinson's disease and other movement disorders. He became emeritus professor of biophysics at the Joseph Fourier University in Grenoble in September 2007, and chairman of the board of the Edmond J. Safra Biomedical Research Center in 2009 at Clinatec, a multidisciplinary institute he co-founded in Grenoble that applies nanotechnologies to neurosciences.

Ali R. Rezai is an Iranian-born American neurosurgeon and neuroscientist. His work and research has focused on neuromodulation treatments for patients with neurological and mental health conditions, including neuromodulation techniques such as deep brain stimulation (DBS) through brain chip implants to treat Parkinson's disease tremors, obsessive–compulsive disorder, Alzheimer's disease, traumatic brain injury, spinal cord injury, and addiction. Recent research since 2020 has focused on deep brain stimulation for addiction treatment, as well as focused ultrasound to treat tremor, addiction and Alzheimer's disease.

Amygdalotomy, also known as amygdalectomy, is a form of psychosurgery which involves the surgical removal or destruction of the amygdala, or parts of the amygdala. It is usually a last-resort treatment for severe aggressive behavioral disorders and similar behaviors including hyperexcitability, violent outbursts, and self-mutilation. The practice of medical amygdalotomy typically involves the administration of general anesthesia and is achieved through the application of cranial stereotactic surgery to target regions of the amygdala for surgical destruction. While some studies have found stereotactic amygdalotomy in humans to be an effective treatment for severe cases of intractable aggressive behavior that has not responded to standard treatment methods, other studies remain inconclusive. In most cases of amygdalotomy in humans, there is no substantial evidence of impairment in overall cognitive function, including intelligence and working memory, however, deficits in specific areas of memory have been noted pertaining to the recognition and emotional interpretation of facial stimuli. This is because there are specialized cells in the amygdala which attend to facial stimuli.

<span class="mw-page-title-main">Konstantin Slavin</span>

Konstantin Slavin is a Professor and Head of the Department of Stereotactic and functional neurosurgery at the University of Illinois College of Medicine. He is a former president of the American Society for Stereotactic and functional neurosurgery and current vice-president of the World Society for Stereotactic and Functional Neurosurgery. His specialties include Aneurysm, Brain surgery, Brain Tumor, Cerebrovascular Disorders, Craniotomy, Dystonia, Essential Tremor, Facial Nerve Pain, Facial Pain, Glioblastoma, Headache disorders, Laminectomy, Lower back pain, Movement Disorders, Multiple Sclerosis, Neck Pain, Neurosurgery, Neurosurgical Procedures, Pain, Parkinson Disease, Spinal Cord Injuries, and Stroke.

Jerrold Lee Vitek is an American neurologist. He is the Head of the Neurology Department, Director of the Neuromodulation Research Program, and Center Director of the University of Minnesota Udall Center of Excellence for Parkinson's Research. Vitek's clinical interests include movement disorders and evaluation for deep brain stimulation (DBS) and his current research activities focus on Parkinson's disease, dystonia, tremor and deep brain stimulation.

Adaptive Deep Brain Stimulation (aDBS), also known as Closed Loop Deep Brain stimulation (clDBS), is a neuro-modulatory technique currently under investigation for the treatment of neurodegenerative diseases.

<span class="mw-page-title-main">Hagai Bergman</span> Israeli neurologist

Hagai Bergman is an Israeli neuroscientist best known for his work on the basal ganglia and their involvement in movement disorders, especially Parkinson's disease. He is currently the Simone and Bernard Guttman Chair in Brain Research and Professor of Physiology in the Edmond and Lily Safra Center for Brain Sciences at the Hebrew University of Jerusalem.

References

1 2 3 Carlson, Neil R. (2013). Physiology of Behavior . New Jersey, United States: Pearson Education Inc. p. 132. ISBN 978-0-20523939-9.
1 2 3 4 5 Starr, Philip A.; Vitek, Jerrold L.; Bakay, Roy A.E. (November 1998). "Ablative Surgery and Deep Brain Stimulation for Parkinson's Disease". Neurosurgery. 43 (5): 989–1013. doi:10.1097/00006123-199811000-00001. PMID 9802843.
↑ Carlson, Neil R. (2010). Psychology: The Science of Behaviour. New Jersey, United States: Pearson Education Inc. pp. 13. ISBN 978-0-205-64524-4.
↑ Carlson, N.R. (1999). Foundations of physiological psychology (4th ed.). Boston: Allyn and Bacon.^{[ page needed ]}
↑ Samii, Ali (2002). "Stereotactic Surgery". American Parkinson Disease Association. Archived from the original on 2013-04-16. Retrieved 2008-05-01.
↑ Silberstein, Paul; Bittar, Richard G; Boyle, Richard; Cook, Raymond; Coyne, Terry; O’Sullivan, Dudley; Pell, Malcolm; Peppard, Richard; Rodrigues, Julian; Silburn, Peter; Stell, Rick; Watson, Peter (August 2009). "Deep brain stimulation for Parkinson's disease: Australian referral guidelines". Journal of Clinical Neuroscience. 16 (8): 1001–1008. doi:10.1016/j.jocn.2008.11.026. PMID 19596113. S2CID 45843391.
↑ Laitinen, Laurie V. (November 1998). "Ablative Surgery and Deep Brain Stimulation for Parkinson's Disease". Neurosurgery. 43 (5): 1013–1014. doi: 10.1097/00006123-199811000-00003 .
↑ O. Barlas; H. Hanagasi; M. Emre. "Unilateral Ablative Lesions of the Subthalamic Nucleus in Advanced Parkinson Disease: Long-term Follow-up" (PDF). American Society for Stereotactic and Functional Neurosurgery. Archived from the original (PDF) on 2004-06-28. Retrieved 2008-05-01.
↑ Yates, Darran (May 2009). "Ablative surgery for Parkinson disease". Nature Reviews Neurology. 5 (5): 238. doi:10.1038/nrneurol.2009.44.
↑ Siegfried, Jean (November 1998). "This extensive review by Starr et al. discusses the relative merits of deep brain stimulation (DBS) and lesion making in the treatment of PD". Neurosurgery. 43 (5): 1014–1015. doi:10.1097/00006123-199811000-00004.
↑ Okun, Michael S.; Vitek, Jerrold L. (April 2004). "Lesion therapy for Parkinson's disease and other movement disorders: Update and controversies". Movement Disorders. 19 (4): 375–389. doi:10.1002/mds.20037. PMID 15077235. S2CID 21932675.
↑ Burish MJ, Pearson SM, Shapiro RE, Zhang W, Schor LI. Cluster headache is one of the most intensely painful human conditions: Results from the International Cluster Headache Questionnaire. Headache. 2021 Jan;61(1):117-124. doi: 10.1111/head.14021. Epub 2020 Dec 18. PMID: 33337540; PMCID: PMC7898696.
↑ Kandel, Sharon A.; Mandiga, Pujyitha (2024), "Cluster Headache", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 31334961 , retrieved 2024-10-19
↑ "Stereotactic and Functional Neurosurgery News" (PDF). American Association of Neurological Surgeons. Fall 2007. Retrieved 10 March 2021.
1 2 Sachdev, Perminder S; Chen, Xiaohua (January 2009). "Neurosurgical treatment of mood disorders: traditional psychosurgery and the advent of deep brain stimulation". Current Opinion in Psychiatry. 22 (1): 25–31. doi:10.1097/YCO.0b013e32831c8475. PMID 19122531. S2CID 30892980.
↑ Massachusetts General Hospital Functional and Stereotactic Neurosurgery Center Archived 2010-08-29 at the Wayback Machine .
↑ Matthews, Keith; Eljamel, Muftah S. (May 2003). "Status of neurosurgery for mental disorder in Scotland: Selective literature review and overview of current clinical activity". British Journal of Psychiatry. 182 (5): 404–411. doi:10.1192/bjp.182.5.404.
↑ G. Chiappe 2010 Las Obsesiones se peuden operar. El Universal, 30 March 2010.
↑ Zamiska, Nicholas (November 2, 2007). "In China, Brain Surgery Is Pushed on the Mentally Ill". The Wall Street Journal .
↑ Zamiska, Nicholas (April 28, 2008). "China Bans Irreversible Brain Procedure". The Wall Street Journal .
↑ Goodman, Wayne K.; Alterman, Ron L. (18 February 2012). "Deep Brain Stimulation for Intractable Psychiatric Disorders". Annual Review of Medicine. 63 (1): 511–524. doi:10.1146/annurev-med-052209-100401. PMID 22034866.
↑ Carlson, Neil R. (2010). Psychology: The Science of Behaviour. New Jersey, United States: Pearson Education Inc. pp. 105. ISBN 978-0-205-64524-4.
↑ Stafford, R. Jason; Ahrar, Kamran (2012). "MRI-Guided Thermal Ablation Techniques". Interventional Magnetic Resonance Imaging. Medical Radiology. pp. 253–269. doi:10.1007/174_2012_629. ISBN 978-3-642-20705-1.
↑ "Laser Ablation Surgery for Epilepsy". Texas Children's Hospital. Archived from the original on 10 June 2012. Retrieved 8 October 2016.
↑ Samii, Ali. "Stereotactic Surgery". American Parkingson Disease Association, Washington Chapter. Archived from the original on 16 April 2013. Retrieved 23 March 2012.
↑ Carlson, Neil R. (2013). Physiology of Behavior . New Jersey, United States: Pearson Education Inc. p. 133. ISBN 978-0-205-23939-9.
↑ Szalavitz, Maia (December 13, 2012). "Controversial Surgery for Addiction Burns Away Brain's Pleasure Center". Time– via healthland.time.com.