Approaches and landmarks for nucleus accumbens area: a review of the literature and review-based suggestions for nucleus accumbens surgery

Discussion The well established approach to the NA through the internal capsule could be used for strereotactic biopsy or aspiration. A transorbital, transnasal or an endoscopic approach through the lateral ventricle could be applied to the NA. More invasively, an inferior frontal or an approach through the frontal horn of the lateral ventricle could be applied. Stereotactic radiosurgery and inferior frontal approach could be useful for stereotactic ablation of the NA. Based on its anatomical location and relations, new potential landmarks useful in non-stereotactic surgery of this nucleus are also presented. Conclusion Apart from the approaches and land-marks that are used nowadays for approaching the NA area, there are some other potential approaches and landmarks for reaching this crucial area of the human brain. Introduction Surgery of the human nucleus accumbens (NA) is a neurosurgical achievement of the 21st century. Deep brain stimulation (DBS) of the NA was first reported in 2003 by Sturm et al. for the treatment of obsessive–compulsive and anxiety disorders1. Also, in 2003, stereotactic ablation of the NA was first reported by Gao et al. for alleviating opiate drug psychological dependence2. During the last few years, the number of reports of NA DBS has been geometrically increasing, and the number of countries reporting this procedure has also been increasing (mainly in Europe). DBS is the main surgical procedure that is nowadays applied to the NA in some carefully selected patients suffering from refractory major depression, obsessive– compulsive disorder and Tourette’s syndrome3–5. There are also other reports for NA ablation in opiate addicts6 and alcoholics7. Moreover, the NA has been discussed in the literature as a potential target for neurosurgical intervention in treating obesity8 and schizophrenia9. The expanding dynamics of the NA DBS is promising. The well established benefits of DBS have set this minimally invasive procedure as the surgical intervention of choice in NA surgery, with only one reported alternative intervention, namely the ablation. They are both based on similar standard surgical procedures, following specific reported approaches to reach the NA through the anterior limb of the internal capsule (ALIC). There are several stereotactic or even non-stereotactic (endoscopic or non-endoscopic) NA surgery. Further, we believe that there are also some other anatomical landmarks potentially useful in NA surgery. Our purpose was to explore the existing neurosurgical techniques from an anatomical point of view and suggest new approaches and relative landmarks. We reviewed the literature regarding neurosurgical approaches (more or less invasive) to the posterior-medial part of the anterior cranial fossa (where NA is located) and anatomical landmarks that have been reported for NA surgery (always stereotactic). We also reviewed the literature about the existing use (other than NA surgery) of other approaches potentially applicable to the NA.