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Background and importance Obsessive-compulsive disorder (OCD) is a disabling psychiatric disorder, mainly treated with psychotherapy and pharmacotherapy. Surgical intervention may be appropriate for patients with treatment-refractory OCD. Deep brain stimulation (DBS) is an alternative for previously common ablative surgical procedures. Tractography has been proposed as a method for individualizing DBS treatment and may have the potential to improve efficacy. Clinical presentation We present a patient with treatment-refractory OCD previously treated with bilateral leucotomies, who underwent DBS surgery with targeting informed by tractography. Preoperative tractography to identify suitable DBS targets was undertaken. Structural images were also utilized for standard stereotactic surgical planning. The anteromedial globus pallidus internus (amGPi) was chosen as the target bilaterally after consideration of white matter projections to frontal cortical regions and neurosurgical approach. Bilateral amGPi DBS surgery was undertaken without adverse events. At 16-mo follow-up, there was a 48.5% reduction in OCD symptom severity as measured by the Yale-Brown Obsessive Compulsive Scale. Conclusion The amGPi can be a successful DBS target for OCD. This is the first known case to report on DBS surgery postleucotomies for OCD and highlights the utility of tractography for surgical planning in OCD.

OBJECTIVE: To determine the frequency and nature of potentially epileptogenic lesions on MRI in adults with new-onset seizures. METHODS: We prospectively studied a consecutive series of 993 patients (597 males [61%]; mean [SD] age: 42.2 [18.8] years, range 14.3-94.3 years) who presented to an adult First Seizure Clinic over a 10-year period. The MRI scans, performed clinically on 3- and 1.5-tesla scanners, were reviewed for their diagnostic yield, nature of abnormalities, and their association with abnormal electrical activity on EEG. RESULTS: MRI scans were acquired in 764 patients (77%); potentially epileptogenic lesions were detected in 177 (23%). The frequency of potentially epileptogenic lesions was higher in patients who were diagnosed as having an epileptic seizure (28%) than in those with a nonepileptic event (8%) (p < 0.001), and highest in those who had focal-onset seizures (53%) (p < 0.001). The most common lesion type in patients with focal seizures was gliosis or encephalomalacia (49%). Other common lesion types were tumors (15%), cavernomas (9%), and mesial temporal sclerosis (9%). Abnormal MRI and EEG were concordant in 18% of patients, with EEG being normal in 55% of patients with epileptogenic lesions. CONCLUSIONS: MRI reveals potentially epileptogenic lesions in a minority of patients with a newly diagnosed seizure disorder. Lesions are most common in patients who have experienced focal seizures. The presence of a potentially epileptogenic MRI lesion did not influence the chance of having an abnormal EEG.

A 73-year-old man with a history of previous coronary artery bypass surgery (left internal mammary artery [LIMA]–to–first obtuse marginal artery graft, right internal mammary artery–to–left anterior descending artery graft, and venous graft to second obtuse marginal branch) and previously treated melanoma and gastric carcinoma was referred for evaluation of an enlarging lung mass adjacent to a vascular graft on computed tomography (CT). CT coronary angiography confirmed that the suspicious left upper lobe lung mass was encasing the LIMA graft (Figure 1). 18F-fluorodeoxyglucose positron emission tomography/CT study confirmed isolated, intense metabolic activity within the lesion consistent with malignancy (Figure 2). Echocardiography confirmed normal left ventricular systolic function. A decision for surgical resection was made, with the need for further evaluation of the coronary circulation to assess the implications of potential sacrifice of the LIMA graft. At the time of coronary angiography (Figure 3), 76 MBq 99mTc-sestamibi was injected directly into the LIMA graft to establish the area of viable myocardium perfused by this vessel. Single photon emission CT/CT imaging performed 1 hour later (Figure 4) demonstrated that, at most, sacrifice of the LIMA graft would result in only a small infarct of the lateral wall. Subtraction of these images from …