Ablative brain surgery (also known as brain lesioning) is the

surgical Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...

ablation Ablation ( la, ablatio – removal) is removal or destruction of something from an object by vaporization, chipping, erosion, erosive processes or by other means. Examples of ablative materials are described below, and include spacecraft materi ...

by various methods of

brain A brain is an organ that serves as the center of the nervous system in all vertebrate and most invertebrate animals. It is located in the head, usually close to the sensory organs for senses such as vision. It is the most complex organ in a v ...

tissue to treat

neurological Neurology (from el, νεῦρον (neûron), "string, nerve" and the suffix -logia, "study of") is the branch of medicine dealing with the diagnosis and treatment of all categories of conditions and disease involving the brain, the spinal ...

psychological Psychology is the scientific study of mind and behavior. Psychology includes the study of conscious and unconscious phenomena, including feelings and thoughts. It is an academic discipline of immense scope, crossing the boundaries between t ...

disorders. The word "Ablation" stems from the Latin word ''Ablatus'' meaning "carried away". In most cases, however, ablative brain surgery does not involve removing brain tissue, but rather destroying tissue and leaving it in place. The

lesion A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma. ''Lesion'' is derived from the Latin "injury". Lesions may occur in plants as well as animals. Types There is no designated classifi ...

s it causes are irreversible. There are some target nuclei for ablative surgery and deep brain stimulation. Those nuclei are the motor thalamus, the globus pallidus, and the subthalamic nucleus. Ablative brain surgery was first introduced by

Pierre Flourens Marie Jean Pierre Flourens (13 April 1794 – 6 December 1867), father of Gustave Flourens, was a French physiologist, the founder of experimental brain science, and a pioneer in anesthesia. Biography Flourens was born at Maureilhan, near Bézi ...

(1774–1867), a French physiologist. He removed different parts of the nervous system from animals and observed what effects were caused by the removal of certain parts. For example, if an animal could not move its arm after a certain part was removed, it was assumed that the region would control arm movements. The method of removal of part of the brain was termed "experimental ablation". With the use of experimental ablation, Flourens claimed to find the area of the brain that controlled heart rate and breathing. Ablative brain surgery is also often used as a research tool in

neurobiology Neuroscience is the scientific study of the nervous system (the brain, spinal cord, and peripheral nervous system), its functions and disorders. It is a multidisciplinary science that combines physiology, anatomy, molecular biology, development ...

. For example, by ablating specific brain regions and observing differences in animals subjected to behavioral tests, the functions of all the removed areas may be inferred. Experimental ablation is used in research on animals. Such research is considered unethical on humans due to the irreversible effects and damages caused by the lesion and by the ablation of brain tissues. However, the effects of brain lesions (caused by accidents or diseases) on behavior can be observed to draw conclusions on the functions of different parts of the brain.

Uses

Parkinson's disease

Parkinson's disease Parkinson's disease (PD), or simply Parkinson's, is a long-term degenerative disorder of the central nervous system that mainly affects the motor system. The symptoms usually emerge slowly, and as the disease worsens, non-motor symptoms becom ...

(PD) is a progressive degenerative disease of the basal ganglia, characterized by the loss of dopaminergic cells of the substantia nigra, pars compacta (SNc). Surgical ablation has been used to treat Parkinson's disease. In the 1990s, the

pallidum The globus pallidus (GP), also known as paleostriatum or dorsal pallidum, is a subcortical structure of the brain. It consists of two adjacent segments, one external, known in rodents simply as the globus pallidus, and one internal, known in rod ...

was a common surgical target. Unilateral pallidotomy improves

tremor A tremor is an involuntary, somewhat rhythmic, muscle contraction and relaxation involving oscillations or twitching movements of one or more body parts. It is the most common of all involuntary movements and can affect the hands, arms, eyes, fa ...

and

dyskinesia Dyskinesia refers to a category of movement disorders that are characterized by involuntary muscle movements, including movements similar to tics or chorea and diminished voluntary movements. Dyskinesia can be anything from a slight tremor of t ...

on one side of the body (opposite the side of the brain surgery), but bilateral pallidotomy was found to cause irreversible deterioration in

speech Speech is a human vocal communication using language. Each language uses Phonetics, phonetic combinations of vowel and consonant sounds that form the sound of its words (that is, all English words sound different from all French words, even if ...

and

cognition Cognition refers to "the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses". It encompasses all aspects of intellectual functions and processes such as: perception, attention, thought, ...

. Two other rapidly evolving or potential surgical approaches to Parkinson's disease are

deep brain stimulation Deep brain stimulation (DBS) is a neurosurgical procedure involving the placement of a medical device called a neurostimulator, which sends electrical impulses, through implanted electrodes, to specific targets in the brain (the brain nucleu ...

(DBS) and restorative therapies.(Starr, Philip A. MD, PhD; Vitek, Jerrold L. MD, PhD; Bakay, Roy A.E. MD. 1998. Departments of Neurosurgery (PAS, RAEB) and Neurology (JLV), Emory University, Atlanta, Georgia. Ablative Surgery and Deep Brain Stimulation for Parkinson's Disease. 43(5):989-1013)) Deep brain stimulation is a surgical treatment involving the implantation of a

neurostimulator Neurostimulation is the purposeful modulation of the nervous system's activity using invasive (e.g. microelectrodes) or non-invasive means (e.g. transcranial magnetic stimulation or transcranial electric stimulation, tES, such as tDCS or transcr ...

medical device, sometimes called a 'brain pacemaker', which sends electrical impulses to specific parts of the brain. Generally, deep brain stimulation surgery is considered preferable to ablation because it has the same effect and is adjustable and reversible. The advent of deep brain stimulation has been an important advance in the treatment of Parkinson's disease. DBS may be employed in the management of medication-refractory tremor or treatment-related motor complications, and may benefit between 4.5% and 20% of patients at some stage of their disease course. DBS at high frequency often has behavioral effects that are similar to those of lesioning. In Australia, patients with PD are reviewed by specialized DBS teams who assess the likely benefits and risks associated with DBS for each individual. The aim of these guidelines is to assist neurologists and general physicians identify patients who may benefit from referral to a DBS team. Common indications for referral are motor fluctuations and/or dyskinesias that are not adequately controlled with optimised medical therapy, medication-refractory tremor, and intolerance to medical therapy. Early referral for consideration of DBS is recommended as soon as optimised medical therapy fails to offer satisfactory motor control. The

thalamus The thalamus (from Greek θάλαμος, "chamber") is a large mass of gray matter located in the dorsal part of the diencephalon (a division of the forebrain). Nerve fibers project out of the thalamus to the cerebral cortex in all directions, ...

is another potential target for treating a tremor; in some countries, so is the

subthalamic nucleus The subthalamic nucleus (STN) is a small lens-shaped nucleus in the brain where it is, from a functional point of view, part of the basal ganglia system. In terms of anatomy, it is the major part of the subthalamus. As suggested by its name, the ...

, although not in the

United States The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country primarily located in North America. It consists of 50 states, a federal district, five major unincorporated territorie ...

due to its severe side effects. Stimulation of portions of the thalamus or lesioning has been used for various psychiatric and neurological conditions, and when practiced for movement disorders the target is in the motor nuclei of the thalamus. Thalamotomy is another surgical option in the treatment of Parkinson's disease. However, rigidity is not fully controlled after successful thalamotomy, it is replaced by hypotonia. Furthermore, significant complications can occur, for example, left ventral-lateral thalamotomy in a right-handed patient results in verbal deterioration while right thalamotomy causes visual-spatial defects. However, for patients for whom DBS is not feasible, ablation of the subthalamic nucleus has been shown to be safe and effective. DBS is not suitable for certain patients. Patients with immunodeficiencies are an example of a situation in which DBS is not a suitable procedure. However, a major reason as to why DBS is not often performed is the cost. Because of its high cost, DBS cannot be performed in regions of the world that are not wealthy. In the case of such circumstances, a permanent lesion in the subthalamic nucleus (STN) is created as it is a more favourable surgical procedure. The surgical procedure is going to be done on the non-dominant side of the brain; a lesion might be favored to evade numerous pacemaker replacements. More so, patients who gain relief from stimulation devoid of any side effects and need a pacemaker change may have a lesion performed on them in the same position. The stimulation parameters act as a guide for the preferred size of the lesion. In order to identify the part of the brain that is to be destroyed, new techniques such as micro electrode mapping have been developed.

Cluster headaches

Cluster headache Cluster headache (CH) is a neurological disorder characterized by recurrent severe headaches on one side of the head, typically around the eye(s). There is often accompanying eye watering, nasal congestion, or swelling around the eye on the a ...

s occur in cyclical patterns or clusters—which gives the condition of its name. Cluster headache is one of the most painful types of headache. Cluster headache is sometimes called the "alarm clock headache" because it commonly awakens you in the middle of the night with intense pain in or around the eye on one side of your head. The bouts of frequent attacks may last from weeks to months. When drug treatment fails, an invasive nerve stimulation procedure shows promise.

s have been treated by ablation of the

trigeminal nerve In neuroanatomy, the trigeminal nerve ( lit. ''triplet'' nerve), also known as the fifth cranial nerve, cranial nerve V, or simply CN V, is a cranial nerve responsible for sensation in the face and motor functions such as biting and chewin ...

, but have not been very effective. Other surgical treatments for cluster headaches are under investigation.

Psychiatric disorders

Ablative psychosurgery continues to be used in a few centres in various countries.P.S. Sachdev and X. Chen 2009 Neurosurgical treatment of mood disorders: traditional psychosurgery and the advent of deep brain stimulation ''Current Opinion in Psychiatry'' 22(1): 25-31. In the US there are a few centres including

Massachusetts General Hospital Massachusetts General Hospital (Mass General or MGH) is the original and largest teaching hospital of Harvard Medical School located in the West End neighborhood of Boston, Massachusetts. It is the third oldest general hospital in the United Stat ...

that carry out ablative psychosurgical procedures. Belgium, the United Kingdom, and Venezuela are other examples of countries where the technique is still used. In the

People's Republic of China China, officially the People's Republic of China (PRC), is a country in East Asia. It is the world's most populous country, with a population exceeding 1.4 billion, slightly ahead of India. China spans the equivalent of five time zones and ...

, surgical ablation was used to treat psychological and neurological disorders, particularly

schizophrenia Schizophrenia is a mental disorder characterized by continuous or relapsing episodes of psychosis. Major symptoms include hallucinations (typically hearing voices), delusions, and disorganized thinking. Other symptoms include social withdra ...

, but also including

clinical depression Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. Introdu ...

, and obsessive-compulsive disorder. The official

Xinhua News Agency Xinhua News Agency (English pronunciation: )J. C. Wells: Longman Pronunciation Dictionary, 3rd ed., for both British and American English, or New China News Agency, is the official state news agency of the People's Republic of China. Xinhua ...

has since reported that China's Ministry of Health has banned the procedure for schizophrenia and severely restricted the practice for other conditions. In recent studies, Deep Brain Stimulation (DBS) is beginning to replace Ablative Brain Surgery for severe psychiatric conditions that are generally treatment resistant, such as obsessive-compulsive disorder.

Methods

Experimental ablation involves the drilling of holes in the skull of an animal and inserting an electrode or a small tube called a cannula into the brain using a stereotactic apparatus. A brain lesion can be created by conducting electricity through the electrode which damages the targeted area of the brain. likewise, chemicals can be inserted in the cannula which could possibly damages the area of interest. By comparing the prior behavior of the animal to after the lesion, the researcher can predict the function of damaged brain segment. Recently,

laser A laser is a device that emits light through a process of optical amplification based on the stimulated emission of electromagnetic radiation. The word "laser" is an acronym for "light amplification by stimulated emission of radiation". The fir ...

s have been shown to be effective in ablation of both cerebral and

cerebellar The cerebellum (Latin for "little brain") is a major feature of the hindbrain of all vertebrates. Although usually smaller than the cerebrum, in some animals such as the mormyrid fishes it may be as large as or even larger. In humans, the cerebel ...

tissue. A laser technology called

MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio waves ...

-guided laser ablation, for example, allows great precision in location and size of the lesion and the causes little to no thermal damage to adjacent tissue. The

Texas Children's Hospital Texas Children's Hospital is a nationally ranked, freestanding 973-bed, acute care women's and children's hospital located in Houston, Texas. It is the primary pediatric teaching hospital affiliated with Baylor College of Medicine and is located wit ...

is one of the first to use this MRI guided method to destroy and treat brain lesions effectively and precisely. A prime example is a patient at this hospital who now no longer undergoes frequent seizures because of the success of this treatment. MRI-guided laser ablation is also used for ablating brain, prostate and liver tumors. Heating or freezing are also alternative methods to ablative brain surgery.

Sham lesions

A sham lesion is a way for researchers to give a placebo lesion to animals involved in experimental ablation. Whenever a cannula or electrode is placed into brain tissue, unintended additional damage is caused by the instrument itself. A sham lesion is simply the placement of the lesioning instrument into the same spot it would be placed in a regular lesion, only there is no chemical or electrical process. This technique allows researchers to properly compare to an appropriate control group by controlling for the damage done separate from the intended lesion.

Excitotoxic lesions

An excitotoxic lesion is the process of an excitatory amino acid being injected into the brain using a cannula. The amino acid is used to kill neurons by essentially stimulating them to death. Kainic acid is an example of an excitatory amino acid used in this type of lesion. One crucial benefit to this lesion is its specificity. The chemicals are selective in that they do not damage the surrounding axons of nearby neurons, but only the target neurons.

Radio frequency lesions

Radio frequency (RF) lesions are produced by electrodes placed in the brain tissue. RF current is an alternating current of very high frequency. The process during which the current passes through tissue produces heat that kills cells in the surrounding area. Unlike excitotoxic lesions, RF lesions destroy everything in the nearby vicinity of the electrode tip. The use of ablative brain surgery on the nucleus accumbens is the wrong method to treat addictions according to Dr. Charles O'Brien. Dr. John Adler, however, believes ablation can provide valuable information about how the nucleus accumbens works.