In our MRgFUS-capsulotomy series, w

In our MRgFUS-capsulotomy series, we have not employed theventral-dorsal “lesion-stacking” approach that has been reportedin the RF and radiosurgery literatures.15,36 As experience withMRgFUS capsulotomy continues to increase, this strategy will nodoubt be tested for safety and clinical efficacy. Given that skullheating throughout the procedures may be responsible for dimin-ishing treatment efficiency, such an approach may be most appro-priately used in patients who do not achieve a clinical responseand elect to undergo re-treatment.Current MRgFUS technology does not allow for lesioningof the anterior cingulate, or other targets that are moreremote from the geometric center of the brain. One of thereasons for this is the increased skull heating associated withmore peripheral targets, which could reach either unsafe orintolerably painful levels. We anticipate that this technicalhurdle will soon be overcome, allowing for the possibility ofchoosing between AC and Cing based on clinical or radio-graphic features, as well as surgeon experience and preference.For instance, it may be possible to increase the focal gain (ie,ratio of heating at target to skull heating) during MRgFUSablation procedures via systemic administration of contrast agentmicrobubbles.37CONCLUSIONWith this study, we outline the clinical, procedural, andtechnical considerations of performing bilateral MRgFUS capsu-lotomy, an emerging incisionless surgical technique that shouldbe added to the functional neurosurgery toolkit for psychiatricsurgery.