Long-term follow-up of limbic leucotomy for self-injurious behavior: Report of 2 cases.

Abstract

Introduction Severe self-injurious behavior (SIB) is a potentially life-threatening condition that is often treatment refractory, particularly in patients with severe psychiatric illness. Limbic leucotomy, which combines anterior cingulotomy and subcaudate tractotomy, has shown benefit in select patients with severe, treatment-refractory SIB as an intervention of last resort. However, long-term outcome data beyond a few years is essentially absent from present literature. We report the longest follow-up to date in two patients after limbic leucotomy for severe refractory SIB. Case Presentations Two chronically institutionalized female patients (ages 23 and 31 at surgery) with longstanding, refractory SIB underwent MRI-guided stereotactic limbic leucotomy at Massachusetts General Hospital. In one patient, the procedure was staged (anterior cingulotomy followed 13 months later by subcaudate tractotomy), and in the other patient the limbic leucotomy was performed in a single procedure. Both had extensive prior treatment including pharmacotherapy, psychotherapy, and electroconvulsive therapy, without sustained benefit. Outcomes were assessed longitudinally by an independent psychiatrist using validated measures, including the Clinical Global Impression (CGI), Current Global Psychiatric-Social Status (CGPS), Global Assessment of Functioning (GAF), Beck Depression Inventory (BDI), and neuropsychological testing through 47 months in one patient and 11 years in the other patient. Both patients demonstrated marked and sustained reductions in SIB and overall psychiatric symptom burden following surgery. Improvements were gradual and continued over extended follow-up. Functional outcomes improved substantially, with significant increases in GAF scores. Last follow-up exceeded 18 years for both patients (18 and 23 years) which were descriptive and did not include validated instruments. However, both patients transitioned from long-term institutionalization to independent living, pursued higher education, and obtained employment. No long-term adverse effects attributable to surgery were observed. Conclusions We present two cases of sustained clinical and functional improvement of 18 and 23 years after limbic leucotomy, the longest follow-up reported to date.