The Perils of Ablative Stereotactic Radiosurgery for the Nucleus Accumbens: A Historical Perspective Urging Caution

Over the past decade, interest in lesion-based neuromodulation has experienced a resurgence fueled in large part by the noninvasive nature of new technologies, especially high-intensity focused ultrasound (HIFU). The noninvasiveness and relatively low cost of these outpatient methods are key attributes contributing to growing acceptance. A recent resurgent embrace of stereotactic radiosurgery (SRS) for brain lesioning, especially in the treatment of tremor via thalamotomy, builds on this new trend. While we believe this development for treating well-established movement (tremor) and behavioral (obsessive-compulsive) disorders is warranted and perhaps even applauded, we are worried that enthusiasm for lesioning using SRS may now be getting ahead of itself. This concern stems from the exuberance for using SRS to treat additional behavioral diseases, as showcased during the recent American Society for Radiation Oncology (ASTRO) 2025 meeting. The near giddiness observed in San Francisco regarding the use of SRS to treat patients with psychiatric disorders prompts us to write the present cautionary editorial. The aim of this editorial is to caution against premature clinical enthusiasm for using ablative SRS to target the nucleus accumbens (NAc) for psychiatric disorders. Our objectives are to (1) contextualize this proposal within the troubling history of psychosurgical overreach, (2) summarize the substantial neuroscientific and clinical risks inherent to NAc ablation, and (3) advocate for a strict, evidence-based, and ethically grounded approach that prioritizes reversible neuromodulation over irreversible lesioning.