Neurosurgery. 2026;99(2):265–276.
Severe obsessive-compulsive disorder can remain profoundly disabling despite optimized pharmacological and behavioral treatment. Stereotactic radiosurgical capsulotomy offers a nonincisional ablative option for a highly selected refractory population. This systematic review and meta-analysis summarizes symptom response, remission and adverse events in 254 patients. Approximately half achieved remission and more than half met the threshold for complete response. The accompanying practice guidelines support careful multidisciplinary selection while emphasizing the limitations of predominantly observational evidence.
Objective
To evaluate the efficacy and safety of stereotactic radiosurgery capsulotomy for severe, treatment-refractory obsessive-compulsive disorder and develop evidence-based practice recommendations.
Methods
PubMed, Embase, Web of Science and Scopus were searched for studies including at least three patients, OCD-specific outcomes and a minimum follow-up of 6 months. Primary outcomes were change in the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), remission defined as Y-BOCS 16 or lower and complete response defined as a reduction of at least 35%.
Secondary outcomes included partial response, adverse events, depression and global functioning. Seventeen studies involving 254 patients were included. Mean age was 37 years and mean baseline Y-BOCS score was 32.78.
Main results
At final follow-up, Y-BOCS scores decreased by 46.52% (95% CI 36.72–56.32). Complete response was achieved by 56.48% of patients and remission by 49.30%. Global functioning improved significantly, whereas depression scores changed little.
Female sex, longer disease duration and older age were associated with greater response. The most frequent adverse events were weight change (36.13%), headache (6.67%) and transient mood disturbance. Serious complications were uncommon: necrosis occurred in 0.92% and radiation-induced changes in 2.96%.
Interpretation
Radiosurgical capsulotomy may provide clinically meaningful improvement in carefully selected adults with otherwise intractable OCD. The delayed biological effect and irreversible nature of lesioning require rigorous confirmation of treatment resistance, realistic counseling and long-term psychiatric, neuropsychological and imaging follow-up.
Limitations
The evidence was derived largely from small, uncontrolled and heterogeneous series. Target definition, dose, technique, follow-up and response reporting varied across studies. Selection and publication bias are possible, and pooled prognostic associations cannot establish causality. Long-term cognitive, behavioral and radiation-related outcomes remain incompletely characterized.
Clinical takeaway
Stereotactic radiosurgery capsulotomy should be reserved for severe OCD that remains disabling after comprehensive evidence-based treatment. Candidacy should be determined by an experienced multidisciplinary team, with explicit discussion of delayed response, irreversibility, weight change and the small but important risk of radiation injury.