KISEP Special Articles 14 2 2003 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. Schematic drawings of methods for prefrontal lobotomy by Freeman and Watts. - - - - - - - Korean J Psychopharmacol 2003;14(2):99-107
- - - 2. Psychosurgery의해부및생리학 - - - - 3. 환자의선택 Parahippocampal gyrus Thalamus Fornix Hippocampus Figure 2. Papez circuits. Cerebral cortex (cingulate gyrus) Internal capsule Mammillothalamic Fornix Tract Septal Area Hypothalamus - 101
Table 1. Indications of psychosurgery for intractable obsessive compulsive disorders 1.. 2. 3. 3. 3 4.. 5. 6. 7. 4. 외과적치료 102-1) Subcaudate tractotomy - 우울증, 강박신경증, 불안신경증 - - 2) Anterior cingulotomy - Korean J Psychopharmacol 2003;14(2):99-107
- 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 34.94.01 means.d. 24.37.43* 21.56.61* CGI-S mean 06.9 04.83* 04.24* CGI 24 21 HAM-D 10.05.98* 27.511.75 16.210.62* means.d. HAM-A 16.17.88 means.d. 09.27.12* 06.35.41* 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
- 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) - - 104 Korean J Psychopharmacol 2003;14(2):99-107
A B Figure 5. Postop skull lateral A and brain CT scanning B findings of deep brain stimulation. 6) 심부뇌자극술 (Deep brain stimulation) - - - - 105
5. Psychosurgery의예후 - 106 - - 결론 Korean J Psychopharmacol 2003;14(2):99-107
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