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Bilateral Anterior Capsulotomy (BAC) for Treatment-Resistant Depression & OCD (2023 Case Reports)

In the relentless pursuit of effective treatments for mental disorders, neurosurgery offers a glimmer of hope where traditional methods falter.

Bilateral anterior capsulotomy (BAC), a neurosurgical procedure, emerges as an option for patients with treatment-resistant depression (TRD) and obsessive-compulsive disorder (OCD), offering substantial relief with minimal side effects.


  • Bilateral Anterior Capsulotomy (BAC) is a neurosurgical procedure targeting the anterior limb of the internal capsule, showing promise for patients with treatment-resistant depression and obsessive-compulsive disorder.
  • Precision & Tailoring: The procedure’s efficacy hinges on targeting specific fiber tracts within the ventral aspect of the anterior limb of the internal capsule, guided by pre-surgical diffusion tensor MRI.
  • Safety & Efficacy: Recent cases demonstrate significant symptom relief in TRD and TROCD patients without notable side effects, including the preservation of executive functions.
  • The Future of Treatment: With advancements in neuroimaging and surgical techniques, BAC’s use may expand, especially with the integration of magnetic resonance-guided focused ultrasound.

Source: Journal of Affective Disorders (2023)

Bilateral Anterior Capsulotomy (BAC) Procedure (How It Works)

Bilateral Anterior Capsulotomy (BAC) is a neurosurgical procedure that targets the anterior limb of the internal capsule (ALIC) in the brain.

This area is known to be involved in the regulation of mood and emotion, making it a focal point for treating certain psychiatric disorders.

Historical Evolution

From Frontal Leukotomy to BAC: The evolution of BAC is marked by a transition from the highly controversial and non-specific frontal leukotomy of the mid-20th century to the more refined and targeted approach of modern neurosurgery. Frontal leukotomy, often referred to as lobotomy, involved extensive and non-specific cutting of brain tissue in the prefrontal cortex, leading to significant and often debilitating cognitive and emotional side effects. In contrast, BAC represents a significant advancement, offering a more focused approach with reduced risk of such adverse outcomes.

Refinement in Targeting the ALIC: The shift to targeting the ALIC for BAC stems from an improved understanding of its role in mood and behavior regulation. The ALIC, part of the brain’s white matter, connects the frontal lobes to deeper brain structures. Early capsulotomies often involved creating extensive lesions in this area, but with time, the focus has shifted to minimizing damage to the dorsal part of the ALIC to preserve cognitive functions.

Technological Advancements in Surgery

Role of Diffusion Tensor Imaging (DTI): DTI, a type of MRI, has revolutionized the planning of BAC. This imaging technique allows for the mapping of neural tracts in the brain, enabling surgeons to visualize and precisely target the fiber tracts within the ALIC. This level of precision was not possible with earlier imaging technologies, leading to a significant reduction in collateral damage to surrounding brain tissue.

Customized Surgical Planning: DTI allows for individualized surgical planning, tailoring the procedure to each patient’s unique brain anatomy. This customization is crucial in avoiding unnecessary damage and maximizing the therapeutic impact of the lesions.

The Science Behind Capsulotomy’s Success

Disruption of Pathological Circuits: The efficacy of BAC in treating TRD and TROCD is attributed to its disruption of maladaptive neural circuits. Specifically, by targeting the ventral portion of the ALIC, BAC interrupts pathways like the thalamocorticolimbic and mesocorticolimbic radiations. These pathways are implicated in the emotional and cognitive dysfunctions characteristic of TRD and TROCD.

Selective Targeting: The focus on ventral ALIC avoids disrupting the dorsal ALIC fibers, which are crucial for maintaining connectivity with the dorsolateral prefrontal cortex, a key area involved in executive functions. Preserving these fibers helps avoid the frontal lobe syndromes that were a significant risk with older forms of psychosurgery.

The Role of Magnetic Resonance-Guided Focused Ultrasound (MRgFUS)

Non-Invasive Approach: MRgFUS represents a leap forward in the field of neurosurgery by providing a non-invasive method to perform capsulotomy. Using focused ultrasound waves, guided by MRI, surgeons can create precise lesions in targeted brain areas without the need for incisions or traditional surgical intervention.

Safety & Accessibility: This technique reduces the risks associated with conventional neurosurgery, such as infection and bleeding. It also potentially makes the procedure accessible to a broader range of patients, including those for whom traditional surgery might be too risky.

Future of Neurosurgical Treatments: The integration of MRgFUS in BAC procedures points towards a future where neurosurgical treatments for mental disorders are less invasive, more precise, and come with fewer risks and side effects, making them a more viable option for a larger patient population.

Treating Depression & OCD via Bilateral Anterior Capsulotomy (Mechanisms of Action)

1. Targeting of Neural Circuits

  • Targeting Hyperactive Pathways: In TRD and OCD, it’s hypothesized that certain neural circuits, particularly those involving the anterior limb of the internal capsule (ALIC), become hyperactive or function aberrantly. This dysregulation is thought to contribute significantly to the symptomatology of these disorders.
  • Resetting Neural Communication: BAC strategically creates lesions within these specific areas of the ALIC. This intervention disrupts the abnormal neural traffic and connectivity, effectively ‘resetting’ these circuits. This disruption can reduce the pathological hyperactivity, potentially bringing the neural networks back to a more normal state of functioning.

2. Modulation of Emotional Regulation

  • Modulating Limbic System Connectivity: The ALIC is a crucial conduit for neural fibers connecting the frontal lobes – areas crucial for higher cognitive functions – to the limbic system, which is central to emotional processing. By lesioning parts of the ALIC, BAC modulates this connection.
  • Regulation of Emotional Responses: This modulation has a direct impact on the brain’s emotional regulation mechanisms. It may dampen the intensity of pervasive negative emotions in TRD and mitigate the relentless intrusive thoughts in OCD, thereby offering symptom relief.

3. Neurochemical Changes

  • Altering Neurotransmitter Levels: The creation of lesions in the brain, as seen in BAC, can have profound effects on neurochemical signaling. This includes altering levels of critical neurotransmitters like serotonin and dopamine, which are deeply involved in mood regulation, anxiety, and compulsive behaviors.
  • Indirect Effects on Neurotransmitter Systems: These neurochemical changes are not just localized but can have broader, network-wide effects. Altering the activity in one part of the brain can lead to compensatory changes in other areas, potentially leading to a more balanced and functional neurotransmitter system overall.

Mechanisms combined (integrative perspective)

BAC’s multifaceted mechanism of action – encompassing the disruption of dysfunctional neural circuits, modulation of emotional regulation pathways, and alteration of neurochemical balances – offers a comprehensive approach to treating the complex pathophysiology underlying TRD and OCD.

By intervening directly within the brain’s physical structure, BAC addresses these disorders at a foundational level, which is often unreachable by pharmacological or psychotherapeutic means alone.

This direct approach is what potentially makes BAC a viable option for treatment-resistant cases, where other methods have failed to adequately recalibrate the intricate neural networks and chemical balances involved in these mental health conditions.

How effective is BAC for Refractory Depression & OCD?


Studies evaluating BAC for treatment-resistant depression (TRD) typically report response rates ranging from 50-60%.

This indicates that a significant proportion of patients experience a notable reduction in depressive symptoms following the procedure.

It’s important to note that these response rates represent a substantial improvement for a patient group that has not responded to conventional treatments, including medications and psychotherapy.


For obsessive-compulsive disorder (OCD), the reported response rates to BAC are in a similar range or slightly higher, often reaching up to 60-70% in some studies.

This suggests that BAC can be particularly effective in alleviating the symptoms of OCD, such as intrusive thoughts and compulsive behaviors, which are typically persistent and resistant to other forms of treatment.

Comparative Efficacy

  • Against Other Resistant Interventions: When compared to other interventions for treatment-resistant conditions, such as deep brain stimulation (DBS) or transcranial magnetic stimulation (TMS), BAC often shows comparable or even favorable efficacy. This is particularly significant in patients who have exhausted other treatment avenues.
  • Long-term Efficacy: While the immediate response rates are promising, the long-term efficacy of BAC is an important consideration. Some studies indicate that the benefits of BAC can be sustained over time, although ongoing monitoring and, in some cases, additional treatment may be necessary to maintain symptom relief.
  • Quality of Life Improvement: Beyond the reduction of specific symptoms, BAC has been shown to improve overall quality of life for many patients, facilitating better social functioning and general well-being, which are often severely impacted by TRD and OCD.

Factors Influencing Efficacy

  • Lesion Location & Size: The effectiveness of BAC is highly dependent on the precision of the lesion placement within the ALIC. Both the size and the specific location of the lesions play a crucial role in determining the outcome. Optimal targeting is designed to disrupt the dysfunctional neural circuits implicated in TRD and OCD without impacting other crucial brain functions.
  • Severity & Duration of Illness: The patient’s history of the illness, including its severity and how long they have been experiencing symptoms, can influence the efficacy of BAC. Generally, patients with a long-standing history of severe symptoms might have varying responses to the surgery.
  • Individual Brain Anatomy & Pathology: Variations in individual brain structures and the specific nature of the neural dysfunction involved in each case of TRD or OCD can affect the response to BAC. This highlights the importance of personalized surgical planning based on detailed neuroimaging.

Findings from Case Reports of BAC in Depression & OCD (2023)

Hurwitz et al. presented case reports showcasing the efficacy and safety of Bilateral Anterior Capsulotomy (BAC) in treating treatment-resistant depression (TRD) and treatment-resistant obsessive-compulsive disorder (TROCD).

Surgical Intervention & Targeting

  • Targeting & Lesion Size: The precision in targeting the ventral aspect of the anterior limb of the internal capsule (ALIC) is central to the procedure’s success. The lesions created were of varying sizes between 20 and 229 mm³, with the average size being 95 mm³. This demonstrates a tailored approach, adjusted for each individual’s unique brain structure and pathology.
  • Diffusion Tensor MRI Guidance: The use of pre-surgical diffusion tensor MRI was crucial in identifying the individual fiber tracts within the ALIC. This advanced imaging technique allowed for a highly targeted surgical intervention, minimizing unnecessary damage to surrounding brain tissue and preserving key cognitive functions.

Patient Outcomes & Response to Treatment

  • Symptom Relief: Both patients in the study, suffering from TRD and TROCD, responded positively to the treatment. This was characterized by a significant alleviation of symptoms associated with their respective conditions.
  • Preservation of Cognitive Functions: Notably, neither patient experienced significant adverse effects, especially concerning executive functions. This preservation of cognitive abilities is a critical advancement, considering the historical context of neurosurgical treatments for mental disorders where such side effects were common.

2 Case Studies (Specifics)

Case 1

A patient with severe TRD underwent BAC, resulting in a notable decrease in depressive symptoms.

The capsulotomy had a calculated lesion volume of 229 mm³ on the right and 71 mm³ on the left.

This reduction in depressive symptoms was achieved without inducing any significant decline in cognitive or executive functions.

Case 2

Involving a patient with both TR-OCD and TRD, the surgical intervention led to a substantial improvement in both obsessive-compulsive and depressive symptoms.

The capsulotomy in this case had a smaller calculated lesion volume of 59 mm³ on the right and 20 mm³ on the left.

Again, this was achieved without detrimental effects on cognitive functions.

Advanced Insights on Capsulotomy Length

  • Optimal Capsulotomy Length: The report suggests that the length of the capsulotomy is a critical factor in its efficacy. An optimal length of around 10mm, as visualized in the coronal plane, appears to be most effective. This length is sufficient to disrupt the pathological circuits involved in TRD and TROCD while avoiding unnecessary damage to the dorsal ALIC, which could lead to cognitive impairments.

Bilateral Anterior Capsulotomy (BAC) for Depression & OCD (2023 Review)

Researchers presented 2 case reports of BAC surgery at their medical center/clinic in patients with treatment-resistant cases of depression and OCD.


  • Patients were selected due to their diagnosis of TRD and TROCD, and their previous non-responsiveness to traditional treatments.
  • Pre-surgical diffusion tensor Magnetic Resonance Imaging (MRI) was employed to identify individual fiber tracts within the ventral ALIC, guiding the surgical intervention.
  • Radiofrequency-induced thermal lesions were then created at the identified targets, with lesion volumes ranging between 20 and 229 mm^3.


  • The findings indicated that both patients were responders to the treatment, exhibiting significant symptom relief without experiencing significant side effects, including compromised executive functions.
  • This success suggests that BAC, when individually tailored to target the ventral aspect of the ALIC, can be both effective and safe for treating TRD and TROCD.


  • The paper acknowledges several limitations, chiefly the generalizability of its findings due to the outcome being based on only two subjects.
  • This small sample size significantly restricts the ability to draw broad conclusions from the results.
  • Furthermore, the study’s design as a case report limits the strength of the evidence provided, necessitating further research with larger sample sizes and more rigorous study designs to validate these preliminary findings.

Risks & Potential Long-Term Effects of Bilateral Anterior Capsulotomy for MDD & OCD

Bilateral Anterior Capsulotomy (BAC) is a significant intervention for treatment-resistant depression and OCD, offering potential relief where other treatments have failed.

However, like all surgical procedures, especially those involving the brain, BAC carries risks and potential long-term effects that need careful consideration.

Immediate & Short-term Risks

  • Surgical Complications: As with any surgical procedure, there are risks associated with anesthesia, infection, and bleeding. Given that BAC is an intracranial procedure, these risks, while rare, can be particularly serious.
  • Neurological Effects: Temporary or, in rare cases, permanent neurological deficits can occur, depending on the precise location and extent of the lesions. These might include weakness, problems with coordination, or sensory deficits.
  • Psychiatric Fluctuations: Some patients may experience an initial exacerbation of psychiatric symptoms or the emergence of new symptoms such as anxiety, irritability, or mood swings.

Potential Long-term Effects

  • Cognitive Impairment: While BAC aims to minimize cognitive side effects by precise targeting, there’s still a risk of impairing functions such as memory, attention, or executive functions. This risk can vary depending on individual factors and the specifics of the surgical procedure.
  • Personality Changes: Changes in personality or social behavior have been reported, though these are less common with modern, targeted BAC compared to historical procedures like lobotomy. Patients might experience apathy, reduced initiative, or changes in their emotional responsiveness.
  • Frontal Lobe Syndromes: Although rare with the current targeted approach, there’s a possibility of developing frontal lobe syndromes characterized by impairments in planning, decision-making, and social behavior.
  • Dependence on Medication or Continued Therapy: Post-surgery, patients may still require medication or ongoing psychological therapy to manage their symptoms effectively.
  • Relapse or Incomplete Resolution of Symptoms: There’s always a possibility that the surgery might not completely alleviate the symptoms of depression or OCD, or that symptoms may recur over time.
  • Psychosocial Effects: The psychological impact of undergoing brain surgery and the changes in symptoms can have significant psychosocial implications, including effects on relationships, employment, and overall quality of life.

Ideal Candidates for Bilateral Anterior Capsulotomy (BAC)

Bilateral Anterior Capsulotomy (BAC) is a specialized neurosurgical procedure primarily considered for individuals with specific mental health conditions that have proven resistant to conventional treatments.

  • Diagnosis of TRD or TR-OCD: The primary candidates for this surgery are those diagnosed with treatment-resistant depression (TRD) or treatment-resistant obsessive-compulsive disorder (TROCD). These are individuals for whom traditional therapies, including various psychotherapies, pharmacotherapies, and other interventions like transcranial magnetic stimulation or deep brain stimulation, have failed.
  • Severity & Duration of Condition: Candidates typically have a long history of severe symptoms that significantly impair their daily functioning and quality of life. The decision to proceed with BAC is often made when these conditions persistently resist standard treatment methods over an extended period.
  • Comprehensive Psychological Evaluation: Ideal patients for BAC should undergo thorough psychological assessments to ensure that their symptoms are not attributable to other treatable mental health conditions and that they have the cognitive and emotional resilience to undergo such an invasive procedure.
  • Physical Health Considerations: Given the invasive nature of the surgery, candidates should be in good physical health to minimize surgical risks and promote effective recovery.

BAC Neurosurgery: Considerations & Process

  • Consultation & Evaluation: The process typically begins with a detailed consultation with a psychiatrist and neurosurgeon who specialize in this treatment. This includes a comprehensive review of the patient’s medical history, psychiatric evaluations, and treatment responses.
  • Neuroimaging & Surgical Planning: Advanced neuroimaging, such as diffusion tensor MRI, is essential to map the brain’s structure accurately and plan the surgery. This step is crucial for targeting specific fiber tracts within the ALIC.
  • Understanding Risks & Expectations: Patients must be informed about the potential risks and benefits of the procedure. A clear understanding of what the surgery can and cannot achieve is vital for setting realistic expectations.
  • Legal & Ethical Considerations: Given the complexity and ethical implications of neurosurgery for mental disorders, obtaining informed consent is a critical step. This may involve legal counsel and a review by an ethics committee.
  • Postoperative Care & Follow-up: Planning for postoperative care, including rehabilitation and long-term follow-up with mental health professionals, is an integral part of the treatment process.

Takeaways: Bilateral Anterior Capsulotomy for Depression & OCD

The study on Bilateral Anterior Capsulotomy offers promising insights into treating treatment-resistant depression and obsessive-compulsive disorder.

It underscores the potential of tailored neurosurgical interventions in cases where traditional treatments have failed.

The precision in targeting specific brain areas, guided by advanced neuroimaging techniques, marks a significant advancement in ensuring the safety and efficacy of the procedure.

The findings, based on detailed case studies, highlight the importance of patient selection and individualized surgical planning.

While the results are encouraging, the limited sample size and the inherent risks associated with neurosurgery necessitate cautious optimism.

Future research, focused on larger cohorts and longer follow-up periods, will be crucial in validating the effectiveness of BAC as a viable treatment option for these complex mental health conditions.


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