From lesion to circuit modulation: A narrative review of psychosurgery in refractory obsessive–compulsive disorder, treatment-resistant depression, and pathological aggression
Héctor Aceituno, Juan José Valero, Juan Ignacio López Urdaneta, René Mena-González, Eugenio Cerezo-Prado, José Vásconez-Fabre, José Villamediana-Rodríguez, Anthuan Hazkour, Francisco Rico-Fernández, Jennifer Vela-Poveda, Luisana Maldonado-De SantiagoBackground:
To synthesize the available clinical evidence on psychoneurosurgical techniques in refractory obsessive – compulsive disorder (OCD), treatment-resistant depression (TRD), and refractory pathological aggression.
Methods:
A structured narrative review of prospective studies published between 1999 and 2026, identified in PubMed/MEDLINE, Web of Science, and Scopus, with a complementary search in Google Scholar. Randomized controlled trials, quasi-experimental studies with a control group, and prospective cohorts with a minimum 6-month follow-up, standardized outcome measures, and a minimum sample size of 10 patients were prioritized; for refractory pathological aggression, given the scarcity of trials, selected prospective and retrospective series were additionally included.
Results:
Both stereotactic ablative techniques (capsulotomy, cingulotomy, gamma radiosurgery, focused ultrasound) and deep brain stimulation (DBS) constitute therapeutic options for refractory patients. DBS of the anterior ventral limb of the internal capsule (vALIC) and gamma ventral capsulotomy (GVC) achieve response rates of 50–62% in refractory OCD. In TRD, DBS of the subcallosal cingulate and the vALIC shows response rates of 40–55% in long-term open phases, although sham-controlled trials have yielded predominantly null results in their blind phases. For pathological aggression, DBS of the posteromedial hypothalamus reports improvements of 63–91%, although on a largely uncontrolled evidence base. These figures should be interpreted with caution given the heterogeneity of designs, response thresholds, and follow-up duration.
Conclusion:
Contemporary psychoneurosurgical techniques constitute reasonable therapeutic options for patients with severe refractory psychiatric disorders, with moderate efficacy profiles and acceptable safety in specialized centers, although the strength of the evidence is unequal across conditions and is weaker in aggression. Multicenter controlled trials and prolonged prospective follow-up are required.