Neurosurgery in the Treatment of Alcohol Use Disorder: A Systematic Literature Review

 

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Abstract

Alcohol abuse has impacts on public health worldwide. Conservative treatment to achieve abstinence consists of detoxification combined with psychotherapy and the use of drugs, but it is estimated that only half of the individuals achieve long-term abstinence with the available treatments. In this sense, neurosurgery appears as a therapeutic proposal. The present study aimed to gather information about the circuitry related to alcohol use disorder (AUD), to describe possible surgical targets, and to establish whether a surgical approach could be a safe and effective treatment option. A systematic review of the literature was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. The 14 selected articles analyze ablative operations, deep brain stimulation (DBS), and a new procedure in which the patient is first submitted to repetitive transcranial magnetic stimulation to evaluate their response, and later an implant is surgically positioned on the evaluated target to obtain more lasting results. The most relevant outcomes were found when the anterior cingulate cortex (ACC) and the nucleus accumbens (NAcc) were used as targets, demonstrating a large reduction in alcohol intake and even its cessation. However, important side effects were observed, such as psychotic symptoms, right frontal venous infarction, seizures after implantation in the ACC and a hypomanic period after DBS in the NAcc, which could be reversed. Due to the lack of studies involving the surgical treatment of AUD, more clinical trials are needed to compare targets, to assess surgical techniques, and to estimate the safety of these techniques.

Resumo

O abuso de álcool tem impacto na saúde pública em todo o mundo. O tratamento conservador para alcançar a abstinência consiste na desintoxicação combinada com psicoterapia e uso de drogas, mas estima-se que apenas metade dos indivíduos alcance a abstinência de longo prazo com os tratamentos disponíveis. Nesse sentido, a neurocirurgia surge como proposta terapêutica. O presente estudo teve como objetivo reunir informações sobre a neurocircuitaria relacionada ao transtorno por uso de álcool, descrever possíveis alvos cirúrgicos e estabelecer se a abordagem cirúrgica pode ser uma opção de tratamento segura e eficaz. Foi realizada uma revisão sistemática da literatura de acordo com a declaração Principais Itens para Relatar Revisões sistemáticas e Metanálises (PRISMA, na sigla em inglês). Os 14 artigos selecionados analisam técnicas ablativas, estimulação cerebral profunda (ECP) e um novo procedimento no qual o paciente é primeiramente submetido à estimulação magnética transcraniana repetitiva para avaliar sua resposta e, posteriormente, um implante é posicionado cirurgicamente no alvo avaliado para obter resultados mais duradouros. Os desfechos mais relevantes foram encontrados quando o córtex cingulado anterior (CCA) e o núcleo accumbens (NAcc) foram usados como alvos, demonstrando uma grande redução na ingestão de álcool e até mesmo sua cessação. No entanto, foram observados efeitos colaterais importantes, como sintomas psicóticos, infarto venoso frontal direito e convulsões após implantação no CCA e período hipomaníaco após ECP no NAcc, que podem ser revertidos. Devido à falta de estudos envolvendo o tratamento cirúrgico do transtorno por uso de álcool, mais ensaios clínicos são necessários para comparar alvos, avaliar técnicas cirúrgicas e estimar a segurança dessas técnicas.

Publication History

Received: 21 October 2020

Accepted: 09 March 2021

Article published online:
16 February 2022

© 2022. Sociedade Brasileira de Neurocirurgia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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