KISEP Special Articles 정신질환에대한새로운기능외과적치료 ABSTRACT 하윤 1 김찬형 2 장종희 1 박용구 1 정상섭 1 장진우 1 연세대학교의과대학신경외과학교실, 뇌연구소, 1 정신과학교실 2 Functional Neurosurg

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1 KISEP Special Articles 정신질환에대한새로운기능외과적치료 ABSTRACT 하윤 1 김찬형 2 장종희 1 박용구 1 정상섭 1 장진우 1 연세대학교의과대학신경외과학교실, 뇌연구소, 1 정신과학교실 2 Functional Neurosurgery for Psychiatric Disease Yoon Ha, MD, PhD, 1 Chan Hyung Kim, MD, PhD, 2 Jong Hee Chang, MD, 1 Yong Gou Park, MD, PhD, 1 Sang Sup Chung, MD, PhD, 1 and Jin Woo Chang, MD, PhD 1 1 Department of Neurosurgery, 2 Psychiatry, Institute for Brain Research, Yonsei University College of Medicine, Seoul, Korea Despite a long and controversial history, psychosurgery has persisted as a modern treatment option for some severe, medically intractable psychiatric disorders. The empirical basis of psychosurgery is weak because of the lack of well-designed investigations. Several carefully conducted studies in which independent evaluation has been made, however, show convincingly that highly selective stereotactic operations on the brain can benefit some carefully selected, chronically ill psychiatric patients with a low rate of unwanted side effects. The goal of this article is to review the current state of psychosurgery. In this review, the definition of psychosurgery, patient selection criteria, and anatomical and physiological rationales for anterior cingulotomy, subcaudate tractotomy, anterior capsulotomy, limbic leukotomy, vagus nerve stimulation and deep brain stimulation are discussed. (Korean J Psychopharmacol 2003;14(2):99-107) KEY WORDS:Psychosurgery Cingulotomy Subcaudate tractotomy Anterior capsulotomy Limbic leukotomy Vagus nerve stimulation Deep brain stimulation. 서 - 교신저자 론 99

본론 1. Psychosurgery의역사 - - - 100 Figure 1.

2 본론 1. Psychosurgery의역사 Figure 1. Schematic drawings of methods for prefrontal lobotomy by Freeman and Watts Korean J Psychopharmacol 2003;14(2):99-107

3 Psychosurgery의해부및생리학 환자의선택 Parahippocampal gyrus Thalamus Fornix Hippocampus Figure 2. Papez circuits. Cerebral cortex (cingulate gyrus) Internal capsule Mammillothalamic Fornix Tract Septal Area Hypothalamus - 101

4 Table 1. Indications of psychosurgery for intractable obsessive compulsive disorders 외과적치료 102-1) Subcaudate tractotomy - 우울증, 강박신경증, 불안신경증 - - 2) Anterior cingulotomy - Korean J Psychopharmacol 2003;14(2):99-107

5 - Table 2. Postoperative changes in scales for evaluation of obsessive compulsive disorders Evaluation Post-op 6 Post-op 12 Pre-op method month month Y-BOCS means.d * * CGI-S mean * 04.24* CGI HAM-D * * means.d. HAM-A means.d * * Y-BOCYale-Brown Obsessive Compulsive Scale, HAM- DHamilton Depression Scale. HAM-AHamilton Anxiety Scale, CGI-SClinical Global Improvement of Severity, CGIClinical Global Improvement, Wilcoxon-Sign Rank Test, p0.01 3) Limbic leukotomy - - 4) Anterior capsulotomy - 103

This diagram shows the known connections of the nucleus tractus solitarius to the parabrachial nucleus and the locus ceruleus LC.

6 - A Figure 3. postoperative MRI findings of stereotactic anterior cingulotomy for intractable obsessive compulsive disorder. Cingulate gyrus Orbito-frontal cortex Hyothalamus amygdala Parabrachial nucleus Pons Nucleus (PB) locus coeruleus Vagus nerve B Thalamus Nucleus Track solitaris Cerebellum Spinal cord Figure 4. This diagram shows the known connections of the nucleus tractus solitarius to the parabrachial nucleus and the locus ceruleus LC. Lesioning the LC in rats eliminates the antiepileptic properties of vagus nerve stimulation. The LC is the site of many norepinephrinecontaining neurons that have important connections to the amygdala, hypothalamus, insula, thalamus, orbitofrontal cortex, and other limbic regions linked to mood and anxiety regulation. 5) 미주신경자극술 (Vagus nerve stimulation) Korean J Psychopharmacol 2003;14(2):99-107

7 A B Figure 5. Postop skull lateral A and brain CT scanning B findings of deep brain stimulation. 6) 심부뇌자극술 (Deep brain stimulation)

8 5. Psychosurgery의예후 결론 Korean J Psychopharmacol 2003;14(2):99-107

9 참고문헌 1) Burckhardt G. Uber Rindenexcisionen. als Beitrag zur operativen Therapie der Psychosen. Z psychiatr 1891;47: ) Hollander B. The Mental Symptoms of Brain Disease. New York, Rabman Co, Vol9-13;1910. p ) Fulton JF, Jacobsen CF. Fonctions des lobes frontaux; etude comparee chez I homme et les singes chimpanzes. In Proceedings of the International Neurological Congress, London;1935. p ) Moniz E. Prefrontal leucotomy in the treatment of mental disorders. Am J Psychiatry 1937;92: ) Freeman W, Watts JW. Prefrontal lobotomy in the treatment of mental disorders. South Med J 1937;30: ) Freeman W, Watts JW. Psychosurgery: Intelligence, emotion and social behavior following prefrontal lobotomy for mental disorders. Springfield, Charles C Thomas; ) Tooth JC, Newton MP. Leucotomy in England and Wales Reports on public health and medical subjects No London, Her Majesty s Stationary Office; ) Freeman W. Transorbital leucotomy. Lancet 1948;2: ) Foltz EL, White LE Jr. Pain relief by frontal cingulotomy. J Neurosurg 1962;19: ) Knight GC. The orbital cortex as an objective in the surgical treatment of mental illness. The development of the stereotactic approach. Br J Surgery 1964;51: ) Bingley T, Leksell L, Meyerson BA. Long-term results of stereotactic capsulotomy in chronic obsess-sive compulsive neurosis. In Sweet WH, Obrador S, Martin-Rodriguez JG (eds): Neurosurgical Treatment in Psychiatry, Pain and Epilepsy. Baltimore, University Park Press;1977. p ) Papez JW. A proposed mechanism of emotion. Arch Neurol Psychiatry 1937;38: ) McLean PD. Some Psychoatric implications of physiologic studies on the frontotemporal portion of limbic system. Electroenceph Clin Neurophysiol 1952;4: ) Knight GC. Bifrontal stereotacitc tractotomy: An atraumatic operation of value in the treatment of value in the treatment of psychoneurosis. Br J Psychiatry 1969;115: ) Goktepe EO, Young LB, Bridges PK. A further review of the results of stereotactic subcaudate tractotomy. Br J Psychiat 1975;126: ) Fulton JE. frontal Lobotomy and Affective Behavior: A Neurophysiological Analysis. New York, WW Norton; ) Ballantine HT Jr, Bouckoms AJ, Thomas EK, Giriunas IE. Treatment of psychiatric illness by stereotactic cingulotomy. Biol psychiatry1987;22: ) Kelley D, Richardson A, Mitchell-Heggs N. Stereotactic limbic leucotomy: Neurophysiologic aspects and operative technique. Br J Psychiatry 1973;123: ) Mitchell-Heggs N, Kelley D, Richardson A. Stereotactic limbic leucotomy-a follow-up at 16 months. Br J Psychiatry 1976;128: ) Talairach J, Hecaen H, David M. Lobotomie prefrontale limitee par electrocoagulation des fibres thalamo-frontalis a leur emergence du bras anterior de la capsule interne. Proceedings of the 4th Congress Neurologique Internationale. Paris, Masson;1949. p ) Mindus P, Nyman H. Normalization of personality characteristics in patients with incapacitating anxiety disorders after capsulotomy. Acta Psychiatr Scand 1991;83: ) Nuttin B, Cosyns P, Demeulemeester H, Gybels J, Meyerson B. Electrical stimulation in anterior limbs of internal capsules in patients with obsessive-compulsive disorder. Lancet 1999;354: ) Abbott A. Brain implants show promise against obsessive disorder. Nature 2002;419(6908): ) Benabid AL, Pollak P, Louveau A, Henry S, de Rougemont J. Combined(thalamotomy and stimulation) stereotactic surgery of the VIM thalamic nucleus for bilateral Parkinson s disease. Appl Neurophsiol 1987; 50:

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