Anterior capsulotomy improves persistent developmental stuttering with a psychiatric disorder: a case report and literature review
A 28-year-old male first presented with stuttering at the age of 7 years. No management was carried out at that time because his symptoms were mild. By the age of 20 years, he was being ridiculed and humiliated by his college classmates. He became more introverted and did not want to communicate with others. Since then, his stuttering had worsened. He experienced multiple blocks in expressing words, including sound and syllable repetitions, circumlocutions, and monosyllabic repetitions, that made it difficult to conduct the interview.\nIn addition to deterioration of his PDS, he developed depression and anxiety and was afraid to communicate with others. He also had physical concomitants of involuntary jerking of his head and upper extremities and muscle spasm of his neck and lower jaw while stuttering. He was diagnosed with depression and anxiety disorder by the psychiatrists at the age of 24 years. He was managed medically with multiple antipsychotics in conjunction with cognitive behavioral therapy. Significant improvement in his psychiatric disorder but not his PDS was achieved at that time.\nOne year earlier, because of his local culture, he had refused to take any medicine, which led to a relapse of his psychiatric symptoms. Subsequent antipsychotics and cognitive behavioral therapy were of limited help in alleviating his psychiatric symptoms. We carefully addressed his treatment options, which included further medical treatment, deep brain stimulation, or capsulotomy. Both the patient and his family opted for capsulotomy for financial reasons and in the hope of being able to avoid using antipsychotics. The surgery was approved by the ethics committee at our hospital.\nPreoperative magnetic resonance imaging was done to rule out an intracranial tumor, hemorrhage, infarction, and infection. No family history of a speech disorder was reported. The preoperative neuropsychological evaluations were carried out using the 24-item Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, the Mini-Mental State Examination, the similarities and block design subtests of the Wechsler Adult Intelligence scale, the logical memory and visual reproduction subtests of the Wechsler Memory Scale, and the Wisconsin Card Sorting Test-Simplified (WCST-S). Both the logical memory and visual reproduction tests were carried out immediately and after a 30-minute delay. The WCST-S included 48 cards, and his performance was assessed by the number of correct answers, number of errors, number of perseverative errors, number of nonperseverative errors, and number of categories completed. Neuropsychological and PDS evaluations were done before surgery and at 6-month follow-up by the same psychiatrist and speech therapist, who were both aware that the patient had undergone neurosurgery.\nTo better identify the magnetic resonance images without fixation of the head frame were obtained the day before surgery. A 3 T Trio Unite magnetic resonance imaging system (Siemens AG, Muenchen, Germany) was used with T1-weighted and T2-weighted spin-echo sequences in the axial and coronal planes. The slice thickness was 2 mm with an interval gap of 0.02 mm. The preplanning procedure was completed using the Surgi-plan workstation (version 2.1; Elekta Instruments AB, Stockholm, Sweden). On the day of surgery, a Leksell model G head frame (Elekta Instruments AB) was positioned on the skull parallel to the anterior commissure–posterior commissure line under local anesthesia. A repeat magnetic resonance scan with the same parameters as the preplanning scanning was performed using a 1.5 T Sonata Unite magnetic resonance imaging system (Siemens AG). With the help of the Surgi-plan workstation, the prescanned images were then coregistered with the images using location markers. The coordinates of the target and the angles of electrode penetration were calculated. The lesion targets were located 14 mm anterior and 18 mm lateral to the anterior commissure and 5 mm below the anterior commissure–posterior commissure plane. Under the guidance of the Leksell multifunctional stereotactic operation system (Elekta Instruments AB), the lesion electrode was then inserted into the lesion target according to the calculated coordinates. A test stimulation generated by the Elekta neurostimulator at both high frequency (130 Hz) and low frequency (5 Hz) was then carried out to verify the target of the electrode. Next, multiple lesions were produced using the Elekta neurostimulator at 75°C for 70 seconds each. The length of the lesions on both sides was 14 mm ( and ).