Deep Brain Stimulation in Pathological Aggression

Abstract

Background: We describe a case of deep brain stimulation in a patient with severe aggression refractory to conservative treatment. The targets of the stimulation were set bilaterally in the posteromedial hypothalamus and - in a second procedure due to its ineffectiveness - in the nucleus accumbens (NAcc) bilaterally. Methods: In the first stage, we implanted electrodes into the posteromedial hypothalamus, after obtaining consent of the Bioethics Committee. In the early postoperative period, we observed significant improvement in the range of 50-90% in terms of quantity and quality of the attacks of aggression. After about 3 weeks, attacks of aggression started to return. Despite changes in the stimulation parameters there was no improvement. For this reason, based on the experience of surgery in patients with obsessive-compulsive disorder, Tourette syndrome and with morbid obesity, we decided to implant electrodes into the NAcc. Results: After 15 months of follow-up, the patient has no aggressive behavior, with no side effects. Conclusions: Although the stimulation of the posterior-medial hypothalamus did not bring long-term benefits, its combination with bilateral stimulation of the NAcc practically freed the patient from aggressive disorders. It significantly improved the patient's quality of life.

Deep Brain Stimulation for the Treatment of Aggressive Behaviour: Considerations on Pathophysiology and Target Choice

“…Giordano et al [1] set the following therapeutic parameters: 2.5 V, 130 Hz, 210 μs, using bilateral 4-contacts monopolar stimulation, with the internal pulse generator (IPG) as the cathode. The other group reporting VC/VS DBS for the treatment of aggressive behaviour used higher stimulation intensities, as generally reported in DBS for OCD [4,5]. So, using less energy-demanding parameters is relevant in this population because of the less frequent episodes of IPG end-of-life issues and surgical replacement necessity.…”

“…Bilateral VC/VS DBS was successfully used after the temporary efficacy of bilateral posterior hypothalamus (pHyp) DBS in another single case of IED [4]. Stimulation of the right “orbitofrontal projections” (VC/VS) has been reported with success in a case of IED [5].…”

Exploring the brain through posterior hypothalamus surgery for aggressive behavior

“…DBS of the VC/VS has been performed successfully in 3 cases of aggressive behavior. 30,34,43 This region is supposed to belong to the "emotional brain," a circuit that includes the anterior cingulate cortex, orbitofrontal cortex, amygdala, and insular cortex (similar to the visceral brain or limbic system described by MacLean…”

Deep Brain Stimulation of the Anterior Limb of the Internal Capsule May Be Efficacious for Explosive Aggressive Behaviour

“…The choice of the VC/VS as target of DBS was made because it was successfully used for lesional procedures in ‘anterior capsulotomy' [13,15,16,17] and because it could have controlled the patient's obsessive and ritualistic behaviour [20,21]; furthermore the same target had already been applied for similar clinical settings [9,23]. …”

“…Deep brain stimulation (DBS) may replace destructive procedures with encouraging results as a validated treatment for movement disorders [18,19] and some psychiatric diseases like obsessive-compulsive disorder (OCD) [20,21] and Tourette's syndrome [22]. Three different DBS targets have been used for IED: the bilateral posteromedial hypothalamus [5,6,7,8,10], unilateral right orbitofrontal projection [9], and more recently a combination of bilateral posteromedial hypothalamus together with bilateral anterior limb of internal capsule/ventral capsule/ventral striatum (VC/VS) and nucleus accumbens [23]. …”