Teaching Case

The patient was suspected of having suffered a stroke due to aphasia. Standard unenhanced brain CT was performed.

Brain CT showed no acute changes. However, in the frontal lobes symmetric white matter lesions were present (Fig. 1a-c). The lesions were of low attenuation without calcifications or soft tissue components. Postoperative changes were seen in the frontal bone with implanted metal and signs of previous craniotomy (Fig. 2). The presented imaging findings are consistent with previous open procedure frontal leucotomy. Exploration of the patient's medical records confirmed that a frontal leucotomy was performed at young age due to severe depression.

The frontal leucotomy is a psychosurgical procedure used in the treatment of psychiatric disorders in the era before antypsychotic drugs [1]. Today, the procedure is regarded as absolutely contraindicated due to the associated ethical problems. Furthermore, evidence-based medicine does not provide results in favour of the procedure [2]. It is important to know the imaging findings after frontal leucotomy as elderly patients who had the procedure at young age may undergo imaging today. The present case shows CT findings similar to previous reports [3-5]. The operative technique in frontal leucotomies was a transcranial approach in the early days of this technique. Later the procedure was performed through the orbital roof. Therefore it is possible to find damage to the frontal lobes without evidence of frontal craniotomy. In the presented case, the transcranial operative technique was used.
In conclusion, symmetric hypodense white matter lesions of the frontal lobes may represent sequelae after frontal leucotomy. In most cases the patient's history will provide the answer.