Deep Brain Stimulation for Severe and Intractable Aggressive Behavior

Abstract

Aggressive behavior in patients with intellectual disability can be resistant to pharmacological treatment and have detrimental consequences to themselves, family members, and caregivers. Hypothalamic deep brain stimulation (DBS) has been used to improve this type of behavior in severe and refractory cases. Here, we present the description and analysis of DBS of the posteromedial hypothalamus (PMH) and its long-term impact as treatment to improve severe and refractory aggressive behaviors, even with previous bilateral hypothalamotomy without improvement in patients with intellectual disability. Eleven patients underwent bilateral DBS of the PMH. Their medical records were reviewed, and the impact on behavior was measured using preoperative and postoperative Modified Overt Aggression Scale (MOAS) during the last follow-up medical visit. Nine of 11 patients presented a significant decrease in the severity of aggressive behavior, with a preoperative and postoperative MOAS average value of 50.5 and 18.7, respectively. An overall improvement of 63% was seen with a mean follow-up time of 4 years. A patient who previously underwent a bilateral hypothalamotomy via radiofrequency was included in this group. During follow-up, 3 patients presented deterioration of symptoms subsequent to pulse generator depletion but made a full clinical recovery after battery replacement. We posit that DBS of the PMH may be a safe and effective in improving severe and refractory aggressive behavior in patients with long-term intellectual disability.

Posterior Hypothalamic Region Deep Brain Stimulation for the Treatment of Aggression Disorders in Patients with Intellectual Disability: A Systematic Review

“…Therefore, 33 studies were eligible for full-text screening. After exclusion of 23 studies (4 included overlapping populations, 13 had insufficient data, 2 dealt with irrelevant topics, 4 resulted in conference abstract), a total of 10 studies met the inclusion criteria and were included in our study [12][13][14][15][16][17][18][19][20][21]. All 10 studies were retrospective case series or case reports and published between 2008 and 2022 (Table 1).…”

“…Etiology was not exhaustively reported in all studies with 34 patients (56.7%) that we defined as "criptogenetic" [12,13,15,20,21] since a biological putative cause of ID and aggressive attitude can be hypothesized but not determined (28 of these patients presented a generical brain atrophy). Autistic spectrum disorder and schizophrenia were respectively diagnosed in 6 [16,18,19,21] and in 1 patient, together with ID [18]. Other causes or concomitant diseases, such as syndromes and perinatal accidents, were reported [12][13][14][15][16][17][18]21] (Table 1).…”

“…Targeting and Implantation Strategies DBS system implantation was performed with a stereotactic frame, following a software-based targeting with the use of stereotactic CT scan fused with preoperative MR. Three studies reported PHyp coordinates [14,20,21] described by Franzini et al [22], while one study proposed a more anterior and ventral target [18].…”

Posterior Hypothalamic Region Deep Brain Stimulation for Aggressive Disorder: Hints from a Series with 15 Years of Follow-Up

“…In particular, after surgery patients were followed up in psychiatry territorial units far from our institution and telephone contacts resulted ineffective in 2 patients. Our experience highlights the need to an advanced integration between functional neurosurgeons and psychiatrists, so that, as suggested by Escobar Vidarte et al [1], pHyp DBS “may be included in a strong therapeutic treatment strategy for this group of patients, typically isolated to mental institutions to allow them to reintegrate into society.”…”

“…Dear Editor, The experience of Escobar Vidarte et al [1] contributes significantly to foster the application of posterior hypothalamic region (pHyp) deep brain stimulation (DBS) for the treatment of patients with aggressive attitude and intellectual disability due to the reported efficacy in a large sample size with congruous follow-up up to 10 years. A recent revision of our experience of 7 patients treated by pHyp DBS for aggressive disorder and intellectual disability, operated on between 2002 and 2010 [2], allowed moving some consideration with a longer followup period.…”