5.3\ Neurodegenerative,

Neuropsychiatric,

and Epilepsy Surgery

5.3.1\ Prefrontal Lobotomy

5.3.1.1\ Discussion

Prefrontal lobotomy (leucotomy) is a now obsolete procedure that was introduced in 1935 as a treatment option for psychiatric illnesses, such as schizophrenia. The procedure essentially consists of ablating the frontal lobe white matter tracts using a probe-like device known

as the leukotome via a transorbital or transcranial approach. This produces the appearance of band-like cavitary lesions in the frontal lobe white matter (Fig. 5.31). On MRI, FLAIR sequences show a hyperintense rim of gliosis surrounding the cavitary­ defects. Focal atrophy of the frontal lobe and corpus callosum is common and often pronounced. High-attenuation foci on CT and susceptibility effects on MRI can be observed along the lobotomy margins, which correspond to residual Pantopaque used for visualization of the lobotomy plane during the operation.

Fig. 5.31  Bilateral prefrontal lobotomy. The patient has a history of schizophrenia treated with bifrontal lobotomy many years before. Axial (a) and coronal (b) CT images show low-attenuation defects in the bilateral frontal lobe white matter. There are scattered punctate hyperattenuating foci in the surgical defects bilaterally, consistent with Pantopaque. There is also disproportionate enlargement of

the bilateral frontal lobe sulci. Axial FLAIR (c), axial T1-weighted (d), and sagittal T1-weighted (e) MR images demonstrate linear cystic defects in the bilateral frontal lobes with surrounding white matter signal abnormality, consistent with gliosis. Axial GRE (f) shows small foci of susceptibility, which correspond to residual deposits of Pantopaque (arrows)