双侧内囊前肢毁损术治疗难治性焦虑症

Bilateral anterior internal capsulotomy for refractory anxiety disorders

目的 分析立体定向下双侧内囊前肢毁损术治疗难治性焦虑症的临床疗效。 方法 收集上海交通大学附属瑞金医院功能神经外科自2009年11月至2012年1月收治的21例难治性焦虑症患者临床资料,所有患者均在MRI计算机工作站上定位双侧内囊前肢靶点,术中用电阻抗及高频电刺激验证靶点,行80℃/60 s射频毁损。术前、术后由精神科医师进行简易精神状态检查（MMSE）、焦虑自评量表（SAS）、汉密尔顿抑郁量表（HAMD）和汉密尔顿焦虑量表（HAMA）评定。结果 21例手术患者中8例治愈,10例得到显著改善,3例未见明显改善或无效。21例患者均无严重手术相关并发症;9例术后1～2周内出现轻度认知障碍及近记忆力障碍,之后消失;4例患者术后出现人格改变,主要表现为动机缺乏、生活及工作懒散、情感淡漠。精神科量表检查中,SAS、HAMD及HAMA量表术后分数较术前均明显下降,差异有统计学意义（P＜0.05）;而手术前后MMSE分值差异无统计学意义（P＞0.05）。 结论 MRI导向下立体定向双侧内囊前肢毁损术定位精确、安全性高,对改善难治性焦虑症患者焦虑及伴随的抑郁症状有明显疗效。

Objective To study the clinical effect of bilateral anterior internal capsulotomy on patients with refractory anxiety disorders.Methods Twenty-one patients with anxiety disorders,failed to pharmacological and cognitive behavior therapies for 5 years and admitted to our hospital from November 2009 to January 2012,were chosen; they received MRI-guided stereotactic bilateral anterior capsulotomy.The coordinates of the lesion target were determined under high resolution MRI directly and confirmed by intra-operative impedance test and high frequency stimulation.The lesions were received radiofrequency at 80 ℃ for 60 seconds.Pre-and post-operative mini-mental state examination （MMSE）,self-rating anxiety scale （SAS）,Hamilton depression rating scale （HAMD） and Hamilton anxiety rating scale （HAMA） were performed by the same psychiatrists.Results In the 21 patients,8 had anxiety-free,10 had significant improvement,and 3 had no significant improvement.No serious surgery-related complications were noted.Nine patients had mild cognitive deficit and transient dysmnesia only at 1-2 weeks after operation.Personality changes,such as lack of motivation,apathy and indolence,appeared in 4 patients.Psychiatric evaluations demonstrated significant decrease of SAS,HAMD and HAMA scores after operation as compared with those before operation （P〈0.05）.However,the difference of MMSE scores between pre-and post-operation was not statistically significant （P〉0.05）.Conclusion MRI guided stereotactic bilateral capsulotomy is precise,safe and much an effective treatment for refractory anxiety disorders,whcih is promising to alleviate the symptoms of anxiety and depression,as well as improving the quality of life.