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This study shows that the continuing presence of activity similar to normal sleep in the EEG in conjunction with the EEG polygraph (EEGP) can be used to determine the severity of brain damage after head injury. Recordings were taken within seven days of head injury from 154 unselected patients after resuscitation and emergency surgery. Sixteen patients with ongoing seizures were excluded. In the remaining 138 patients the presence of activity in the EEG, EEGP, or both, which can also be recognised in normal alertness and sleep, was noted. Particular attention was paid to the presence or absence of arousal related phasic activity involving EEG, motor, and autonomic changes. The traces were allocated to one of five groups: group 1, wakeful traces with normal alpha in at least one hemisphere; group 2, sleep-like traces with K complexes responsive to stimulation; group 3, traces with phasic activity related to abnormal spontaneous arousal including EEG changes; group 4, traces with abnormal spontaneous arousal activity without EEG changes; group 5, traces with no spontaneous arousal activity. The mean follow up was 21.5 months. Groups 2 and 3 were significantly associated with a good outcome and group 5 with death or a vegetative state. Comparison between the EEG/EEGP findings and the Glasgow coma scale at the time of the recording showed the EEG/EEGP to be the better predictor of outcome, particularly for individual patients.

BackgroundStereotactic subcaudate tractotomy (SST) is the only type of psychosurgery performed at the Geoffrey Knight Unit, London, where nearly 1300 operations have been done since 1961. Statistically reliable data are not available to prove the effectiveness of SST. A detailed statement about contemporary psychosurgery is given.MethodRelevant publications from the Unit and via Medline are discussed. The outcome figures are reviewed. The outcome is assessed at the Unit in global and clinical terms, associated with results of self-completed questionnaires.ResultsST allows 40–60% of patients to live normal or near-normal lives, perhaps with continuation of medication. A reduction in suicide rate to 1% postoperatively, from 15% in cases of uncontrolled affective disorders is seen.ConclusionAs a treatment of last resort, no controlled trial against a comparable treatment is possible. It appears reasonable to offer SST to patients with suicidal and deluded depression or with frequently swinging moods, not responding to other treatments.

Aspartic acid, 5-hydroxyindoleacetic acid, glutamic acid, homovanillic acid and 3-methoxy-4-hydroxyphenylethylene glycol was determined in samples of ventricular fluid from 82 subjects. Laminar distribution of the total number (Bmax value) of serotonin 1A receptors was determined on seven neurosurgical samples of neocortex. Apart from an association in a small subgroup of subjects between homovanillate concentration and corticosteroid medication, no complicating influences of treatment preceding operation were found. The content of the serotonin metabolite alone was significantly reduced in intractable depressive illness (bipolar and major depressive disorders) compared with neurological conditions subdivided into Alzheimer's disease, other dementias and other conditions. There was no other significant difference between these groups for the compounds measured. The total number of serotonin 1A receptors was highest in the superficial layers, being considerably higher than in the rat, irrespective of cortical layer. This part of the study indicated that these receptors are important for regulating activity of human corticocortical glutamatergic neurons. The results are discussed in relation to treating depression with serotonergic agents and targeting corticocortical glutamatergic neurons as well as acetylcholine in Alzheimer's disease.

Samples of ventricular CSF were taken from 52 consecutive patients admitted for psychosurgery for intractable depression. Concentrations of asparagine, aspartate, glutamine, glutamic acid, and serine were determined. Glutamate and aspartate concentrations, implicated in excitotoxic brain damage, were not affected by various types of psychotropic drug treatment. Serine, a modulator of glutamate responses, was significantly elevated in samples from subjects receiving antidepressants. These subjects responded poorly to the operation. Psychotropic drugs are unlikely to be neurotoxic. Nevertheless, antidepressants may influence excitatory neurotransmission.

The relationship between neurotransmitter metabolite concentrations and measurements of ventricular size on CAT scans and pneumoencephalographs was investigated in 15 patients with severe affective disorder. An association was identified between reduced levels of plasma free tryptophan and ventricular enlargement and also between raised ventricular CSF levels of 5 HIAA and ventricular enlargement.

The initial period of enthusiasm for the surgical treatment of certain psychiatric illnesses, has later given way to increasing rejection of this mode of therapy. But more recently there has been a reappraisal of the therapeutic possibilities of the modern refined operations, which are now receiving more objective assessment.

Plasma, cerebrospinal fluid and brain tissue amino acid levels were measured in 14 patients with affective illness and generally confirm previous findings. There was no correlation between these values and age, sex, family history and levels of anxiety. GABA levels measured in cortex tissue were negatively correlated with depressive mood (P less than 0.05), supporting a possible involvement of GABA in depressive illness.

SummaryThe growth hormone and hypotensive responses to clonidine have been measured in six drug free severely depressed patients before, and at two weeks after, the surgical procedure of stereotactic sub-caudate tractotomy. The responses were unaltered two weeks after operation, by which time a small clinical improvement was evident. These findings are discussed in relation to central a adrenoceptor functions in depression, and the effect upon this of antidepressant treatment.

The Geoffrey Knight Psychosurgical Unit admits patients on a regular basis and thus offers special opportunities for studying severely ill psychiatric cases, all having one particular treatment under relatively controlled conditions. The opportunity has been taken to repeat various metabolic studies previously reported to be abnormal in some psychiatric illnesses. In the present investigation several measures of endocrinological activity were studied, as was plasma tryptophan, both free and bound. None of these data confirmed reports of abnormalities and neither did the values found at operation help to predict clinical outcome 1 year later, which was another possibility. Urinary catecholamines were also measured before and 2 weeks after operation. Male patients, regardless of diagnosis, showed a mean increase in adrenaline output after operation compared with the pre-operative value and this was significantly different from the females, who showed a small mean decrease. The depressed patients showed a significant reduction in noradrenaline excretion after operation compared with before operation and this trend was enhanced in those of good outcome at 1 year, the difference from those who responded poorly being significant. It could be that the ventromedial lesion that is produced alters noradrenaline metabolism or autonomic activity in depression and this possibility merits further study.

Thirty-five patients were studied by EEG with recordings taken the day before, two weeks after, and six months after psychosurgery. Most showed a characteristic frontal slow activity of varying degrees after operation with varying enhancement of background activity. The amount and spread of the frontal slow waves two weeks after operation showed a significant positive correlation with the clinical outcome one year later, which suggests a relatively objective and very early indication of the subsequent clinical response to psychosurgery.

SummaryThe pneumo-encephalographs and computerized axial tomography scans of fifty patients with severe affective disorder were studied. Measures of ventricular size were compared with those reported by other workers. Findings suggested that some patients suffering from severe affective illness showed abnormalities of brain structure as demonstrated by ventricular enlargement.

The results of stereotactic subcaudate tractotomy in nine patients with resistant bipolar affective disorder are presented in the form of a single case study with a summary of the other eight cases. Follow-up studies at 2–4 years showed substantial improvement in five patients and amelioration of symptoms in a further four patients, with a tendency for a greater improvement in the manic than in the depressive episodes. These preliminary results suggest that there is a place for this operation in the management of severe bipolar affective disorders which are not responding to any other treatment, although decisive recovery occurs less often than with unipolar depression.

SynopsisTryptophan and 5-hydroxyindoleacetic acid (precursor and metabolite respectively of 5-hydroxytryptaminę) were determined in ventricular CSF of psychiatric patients undergoing stereotactic subcaudate tractotomy. Tyrosine and homovanillic acid (precursor and metabolite respectively of dopamine) were also determined. Results suggest an association between affective state and the above precursor amino acids with lower concentrations in primary depression and higher ones when anxiety or agitation predominate. This leads to lower 5-hydroxyindoleacetic acid concentrations in depression and higher concentrations in anxiety and agitation.

SummaryThe routine air ventriculograms of 66 psychiatric patients, aged from 22 to 73 years, taken during the psychosurgical operation of stereotactic subcaudate tractotomy, were studied. Ventricular size was unrelated to progressive ageing, but a minority of patients over 60 years had abnormally large ventricles, not invariably associated with cognitive impairment on testing. Enlargement was associated with a clinical diagnosis of schizoaffective illness but not with past ECT.

To assess the possible significance of cerebral ventricular size and the dexamethasone suppression test (DST) in the outcome of severe endogenous depression, 28 patients were followed up and reviewed 1 year after stereotactic subcaudate tractotomy. Neither ventricular size nor the dexamethasone suppression test predicted either a good or poor outcome. There was no relationship between ventricular size and the DST results.

The results of treating 85 patients suffering from craniopharyngioma are reviewed. The recurrence of the tumour after 20 symptom-free years after radical excision is reported. Claims for successful treatment of this illness should be reviewed in this light.

The aim of this study was to investigate whether psychological abnormalities were present in patients still complaining of low back pain after more than one operation. It was found that these patients were more psychiatrically disturbed and socially disabled than a matched control group whose back pain responded to one operation. These results suggest that patients requiring assessment for a possible second laminectomy should also be psychiatrically examined.