Narrative review proposes connectomic-guided psychosurgery framework for treatment-refractory patients

$Narrative review proposes connectomic-guided psychosurgery framework for treatment-refractory patien…$

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Frontiers in Medicine Published April 23, 2026 Medically reviewed April 24, 2026 DOI ↗ By Dr. Ji-eun Park, MD · Brain, Mind & Pain

Key Takeaway

Consider the proposed connectomic framework as a conceptual guide for refractory cases, not as evidence of efficacy.

This narrative critical review examines contemporary psychosurgery for treatment-refractory psychiatric disorders, including obsessive-compulsive disorder, treatment-resistant major depression, eating disorders, addictions, Tourette syndrome, aggression, schizophrenia, and post-traumatic stress disorder. The authors describe ablative approaches (radiofrequency, radiosurgery, laser ablation, focused ultrasound) and stimulation-based interventions (deep brain stimulation, vagus nerve stimulation, cortical stimulation, transcranial magnetic stimulation) and propose a connectomic-guided, circuit-based framework to select carefully selected subgroups of treatment-refractory patients based on symptom dimensions rather than diagnosis.

The review synthesizes conceptual arguments for targeting specific neural circuits associated with clinical outcomes and candidate profiles. It does not report quantitative synthesis, pooled effect sizes, or meta-analysis of outcomes. No specific study-level data, sample sizes, or effect sizes are extracted for individual conditions, and comparative effectiveness between modalities is not assessed.

Key limitations include the narrative critical review design, absence of formal systematic methods, and lack of primary trial data. The authors acknowledge gaps in evidence and do not report adverse events, follow-up duration, or safety outcomes. Practice relevance is limited to a proposed framework for patient selection and procedural planning, with no causal claims or recommendations for specific interventions.

Study Details

Study typeSystematic review

EvidenceLevel 1

PublishedApr 2026

View Original Abstract ↓

Contemporary psychosurgery is increasingly regarded less as an invasive surgical discipline and more as a circuit-based medicine. This narrative critical review traces the evolution from the extensive frontal lesions of the early twentieth century to contemporary techniques, in which focal ablation and reversible neuromodulation form part of a shared therapeutic armamentarium. Building on the classical history—from trephinations and lobotomies to stereotaxy—we outline a functional neuroanatomical framework that integrates thelimbic system, basal ganglia, prefrontal cortex, and monoaminergic systems, conceptualized as networks in which emotional and cognitive symptoms are generated and maintained. We then introduce the foundations of connectomics (diffusion tensor imaging, functional MRI, and graph-theoretical models) and their contributions to redefining targets not as isolated points but as nodes within fronto-limbic networks implicated in psychopathology. On this substrate, we review the main contemporary techniques: ablative approaches (radiofrequency, radiosurgery, laser ablation, focused ultrasound) and stimulation-based interventions (deep brain stimulation, vagus nerve stimulation, cortical stimulation, and transcranial magnetic stimulation), emphasizing their mechanisms, advantages, and limitations. The core of the article is an indication and circuit-based synthesis of evidence in obsessive- compulsive disorder, treatment-resistant major depression, and other selected conditions (eating disorders, addictions, Tourette syndrome, aggression, schizophrenia, and post-traumatic stress disorder), with particular attention to candidate profiles, clinical outcomes, and integration with psychotherapeutic and pharmacological strategies. We subsequently explore how these developments may converge into a model of precision psychiatry built around symptom dimensions, connectomic-guided targeting, biomarker-informed decision-making, and adaptive stimulation, while also considering the major ethical and organizational issues they raise. Overall, we propose understanding contemporary psychosurgery as a network-based, gradual, and multimodal intervention intended for carefully selected subgroups of treatment- refractory patients whose core symptom clusters might be linked to potentially modifiable white-matter hubs.