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Casula A, Milazzo BM, Martino G, Sergi A, Lucifora C, Tomaiuolo F, Quartarone A, Nitsche MA, Vicario CM. Non-Invasive Brain Stimulation for the Modulation of Aggressive Behavior-A Systematic Review of Randomized Sham-Controlled Studies. Life (Basel) 2023; 13:life13051220. [PMID: 37240865 DOI: 10.3390/life13051220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/10/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
INTRO Aggressive behavior represents a significant public health issue, with relevant social, political, and security implications. Non-invasive brain stimulation (NIBS) techniques may modulate aggressive behavior through stimulation of the prefrontal cortex. AIMS To review research on the effectiveness of NIBS to alter aggression, discuss the main findings and potential limitations, consider the specifics of the techniques and protocols employed, and discuss clinical implications. METHODS A systematic review of the literature available in the PubMed database was carried out, and 17 randomized sham-controlled studies investigating the effectiveness of NIBS techniques on aggression were included. Exclusion criteria included reviews, meta-analyses, and articles not referring to the subject of interest or not addressing cognitive and emotional modulation aims. CONCLUSIONS The reviewed data provide promising evidence for the beneficial effects of tDCS, conventional rTMS, and cTBS on aggression in healthy adults, forensic, and clinical samples. The specific stimulation target is a key factor for the success of stimulation on aggression modulation. rTMS and cTBS showed opposite effects on aggression compared with tDCS. However, due to the heterogeneity of stimulation protocols, experimental designs, and samples, we cannot exclude other factors that may play a confounding role.
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Affiliation(s)
- Antony Casula
- Dipartimento di Scienze Cognitive, Psicologiche, Pedagogiche e Degli Studi Culturali, Università di Messina, 98121 Messina, Italy
| | - Bianca M Milazzo
- Dipartimento di Scienze Cognitive, Psicologiche, Pedagogiche e Degli Studi Culturali, Università di Messina, 98121 Messina, Italy
| | - Gabriella Martino
- Dipartimento di Medicina e Clinica Sperimentale, Università degli Studi di Messina, A.O.U. "G. Martino", Via Consolare Valeria, 98125 Messina, Italy
| | - Alessandro Sergi
- Dipartimento di Scienze Matematiche e Informatiche, Scienze Fisiche e Scienze della Terra, Università degli Studi di Messina, Viale F. Stagno d'Alcontres 31, 98166 Messina, Italy
| | - Chiara Lucifora
- Dipartimento di Filosofia e Comunicazione, Università di Bologna, 40131 Bologna, Italy
| | - Francesco Tomaiuolo
- Dipartimento di Medicina e Clinica Sperimentale, Università degli Studi di Messina, A.O.U. "G. Martino", Via Consolare Valeria, 98125 Messina, Italy
| | | | - Michael A Nitsche
- Department of Psychology and Neurosciences, Leibniz Research Centre for Working Environment and Human Factors, 44139 Dortmund, Germany
- University Clinic of Psychiatry and Psychotherapy and University Clinic of Child and Adolescent Psychiatry and Psychotherapy, Protestant Hospital of Bethel Foundation, University Hospital OWL, Bielefeld University, 33615 Bielefeld, Germany
| | - Carmelo M Vicario
- Dipartimento di Scienze Cognitive, Psicologiche, Pedagogiche e Degli Studi Culturali, Università di Messina, 98121 Messina, Italy
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Lara F. Neurorehabilitation of Offenders, Consent and Consequentialist Ethics. NEUROETHICS-NETH 2023. [DOI: 10.1007/s12152-022-09510-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
The new biotechnology raises expectations for modifying human behaviour through its use. This article focuses on the ethical analysis of the not so remote possibility of rehabilitating criminals by means of neurotechnological techniques. The analysis is carried out from a synthetic position of, on the one hand, the consequentialist conception of what is right and, on the other hand, the emphasis on individual liberties. As a result, firstly, the ethical appropriateness of adopting a general predisposition for allowing the neurorehabilitation of prisoners only if it is safe and if they give their consent will be defended. But, at the same time, reasons will be given for requiring, in certain circumstances, the exceptional use of neurotechnology to rehabilitate severely psychopathic prisoners, even against their will, from the same ethical perspective.
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Benedetti-Isaac JC, Camargo L, Torres Zambrano M, Perea-Castro E, Castillo-Tamara E, Caldichoury N, Herrera-Pino J, Flórez Y, Porto M, López N. Deep brain stimulation may be a viable option for resistant to treatment aggression in children with intellectual disability. CNS Neurosci Ther 2023. [PMID: 36890650 DOI: 10.1111/cns.14156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 02/11/2023] [Accepted: 02/22/2023] [Indexed: 03/10/2023] Open
Abstract
INTRODUCTION Deep brain stimulation (DBS) is a surgical technique used to manage aggression in patients who do not improve despite the use of appropriate drug treatment. OBJECTIVE The objective of this study is to assess the impact of DBS on aggressive behavior refractory to the pharmacological and behavioral treatment of patients with Intellectual Disabilities (ID). METHODS A follow-up was conducted on a cohort of 12 patients with severe ID, undergoing DBS in posteromedial hypothalamic nuclei; evaluated with the Overt Aggression Scale (OAS), before the intervention, at 6, 12, and 18 months of medical follow-up. RESULTS After the surgical procedure, there was a significant reduction in the aggressiveness of patients in the follow-up medical evaluation at 6 months (t = 10.14; p < 0.01), 12 months (t = 14.06; p < 0.01), and 18 months (t = 15.34; p < 0.01), respect to the initial measurement; with a very large effect size (6 months: d = 2.71; 12 months: d = 3.75; 18 months: d = 4.10). From 12 months onward, emotional control stabilized and is sustained at 18 months (t = 1.24; p > 0.05). CONCLUSION DBS in posteromedial hypothalamic nuclei may be an effective treatment for the management of aggression in patients with ID refractory to pharmacological treatment.
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Affiliation(s)
| | - Loida Camargo
- Facultad de Medicina, Universidad de Cartagena, Cartagena, Colombia
| | | | | | | | | | | | | | - María Porto
- Department of Cognition, Development and Educational Psychology, University of Barcelona, Barcelona, Spain
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4
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Temiz G, Atkinson-Clement C, Lau B, Czernecki V, Bardinet E, Francois C, Worbe Y, Karachi C. Structural hyperconnectivity of the subthalamic area with limbic cortices underpins anxiety and impulsivity in Tourette syndrome. Cereb Cortex 2022; 33:5181-5191. [PMID: 36310093 DOI: 10.1093/cercor/bhac408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
Tourette syndrome (TS) is a neurodevelopmental disorder characterized by motor and vocal tics, which is often associated with psychiatric comorbidities. Dysfunction of basal ganglia pathways might account for the wide spectrum of symptoms in TS patients. Although psychiatric symptoms may be related to limbic networks, the specific contribution of different limbic structures remains unclear. We used tractography to investigate cortical connectivity with the striatal area (caudate, putamen, core and shell of the nucleus accumbens), the subthalamic nucleus (STN), and the adjacent medial subthalamic region (MSR) in 58 TS patients and 35 healthy volunteers. 82% of TS patients showed psychiatric comorbidities, with significantly higher levels of anxiety and impulsivity compared to controls. Tractography analysis revealed significantly increased limbic cortical connectivity of the left MSR with the entorhinal (BA34), insular (BA48), and temporal (BA38) cortices in TS patients compared to controls. Furthermore, we found that left insular-STN connectivity was positively correlated with impulsivity scores for all subjects and with anxiety scores for all subjects, particularly for TS. Our study highlights a heterogenous modification of limbic structure connectivity in TS, with specific abnormalities found for the subthalamic area. Abnormal connectivity with the insular cortex might underpin the higher level of impulsivity and anxiety observed in TS.
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Affiliation(s)
- Gizem Temiz
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute- ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière , 75013 Paris, France
| | - Cyril Atkinson-Clement
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute- ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière , 75013 Paris, France
| | - Brian Lau
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute- ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière , 75013 Paris, France
| | - Virginie Czernecki
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute- ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière , 75013 Paris, France
- Department of Neurology, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris , 75013 Paris, France
| | - Eric Bardinet
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute- ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière , 75013 Paris, France
| | - Chantal Francois
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute- ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière , 75013 Paris, France
| | - Yulia Worbe
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute- ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière , 75013 Paris, France
- Department of Neurophysiology, Saint Antoine Hospital, Assistance Publique-Hôpitaux de Paris , 75012 Paris, France
| | - Carine Karachi
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute- ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière , 75013 Paris, France
- Department of Neurosurgery, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris , 75013 Paris, France
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5
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Yan H, Elkaim LM, Venetucci Gouveia F, Huber JF, Germann J, Loh A, Benedetti-Isaac JC, Doshi PK, Torres CV, Segar DJ, Elias GJB, Boutet A, Cosgrove GR, Fasano A, Lozano AM, Kulkarni AV, Ibrahim GM. Deep brain stimulation for extreme behaviors associated with autism spectrum disorder converges on a common pathway: a systematic review and connectomic analysis. J Neurosurg 2022; 137:699-708. [PMID: 35061980 DOI: 10.3171/2021.11.jns21928] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 11/16/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Individuals with autism spectrum disorder (ASD) may display extreme behaviors such as self-injury or aggression that often become refractory to psychopharmacology or behavioral intervention. Deep brain stimulation (DBS) is a surgical alternative that modulates brain circuits that have yet to be clearly elucidated. In the current study the authors performed a connectomic analysis to identify brain circuitry engaged by DBS for extreme behaviors associated with ASD. METHODS A systematic review was performed to identify prior reports of DBS as a treatment for extreme behaviors in patients with ASD. Individual patients' perioperative imaging was collected from corresponding authors. DBS electrode localization and volume of tissue activated modeling were performed. Volumes of tissue activated were used as seed points in high-resolution normative functional and structural imaging templates. The resulting individual functional and structural connectivity maps were pooled to identify networks and pathways that are commonly engaged by all targets. RESULTS Nine patients with ASD who were receiving DBS for symptoms of aggression or self-injurious behavior were identified. All patients had some clinical improvement with DBS. Connectomic analysis of 8 patients (from the systematic review and unpublished clinical data) demonstrated a common anatomical area of shared circuitry within the anterior limb of the internal capsule. Functional analysis of 4 patients identified a common network of distant brain areas including the amygdala, insula, and anterior cingulate engaged by DBS. CONCLUSIONS This study presents a comprehensive synopsis of the evidence for DBS in the treatment of extreme behaviors associated with ASD. Using network mapping, the authors identified key circuitry common to DBS targets.
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Affiliation(s)
- Han Yan
- 1Division of Neurosurgery, Department of Surgery, University of Toronto
- 2Division of Neurosurgery, The Hospital for Sick Children, Toronto
- 3Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario
| | - Lior M Elkaim
- 4Division of Neurosurgery, McGill University, Montreal, Quebec
| | | | - Joelene F Huber
- 6Divisions of Paediatric Medicine and Developmental Paediatrics, Department of Paediatrics, The Hospital for Sick Children, Toronto
| | | | - Aaron Loh
- 7University Health Network, Toronto, Ontario, Canada
| | - Juan Carlos Benedetti-Isaac
- 8Stereotactic and Functional Neurosurgery Division, International Misericordia Clinic, Barranquilla, Colombia
| | - Paresh K Doshi
- 9Department of Stereotactic and Functional Neurosurgery, Jaslok Hospital and Research Centre, Mumbai, India
| | - Cristina V Torres
- 10Department of Neurosurgery, University Hospital La Princesa, Madrid, Spain
| | - David J Segar
- 11Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Alexandre Boutet
- 7University Health Network, Toronto, Ontario, Canada
- 12Joint Department of Medical Imaging, University of Toronto
| | - G Rees Cosgrove
- 11Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alfonso Fasano
- 13Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Toronto
- 14Division of Neurology, University of Toronto
- 15Krembil Brain Institute, Toronto
| | - Andres M Lozano
- 7University Health Network, Toronto, Ontario, Canada
- 12Joint Department of Medical Imaging, University of Toronto
| | - Abhaya V Kulkarni
- 1Division of Neurosurgery, Department of Surgery, University of Toronto
- 2Division of Neurosurgery, The Hospital for Sick Children, Toronto
- 3Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario
| | - George M Ibrahim
- 1Division of Neurosurgery, Department of Surgery, University of Toronto
- 2Division of Neurosurgery, The Hospital for Sick Children, Toronto
- 16Institute of Biomedical Engineering, University of Toronto; and
- 17Institute of Medical Science, University of Toronto, Ontario, Canada
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6
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Heiden P, Weigel DT, Loução R, Hamisch C, Gündüz EM, Ruge MI, Kuhn J, Visser-Vandewalle V, Andrade P. Connectivity in deep brain stimulation for self-injurious behavior: multiple targets for a common network? Front Hum Neurosci 2022; 16:958247. [PMID: 36092644 PMCID: PMC9448926 DOI: 10.3389/fnhum.2022.958247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
Self-injurious behavior (SIB) is associated with diverse psychiatric conditions. Sometimes (e.g., in patients with autism spectrum disorder or acquired brain injuries), SIB is the most dominant symptom, severely restricting the psychosocial functioning and quality of life of the patients and inhibiting appropriate patient care. In severe cases, it can lead to permanent physical injuries or even death. Primary therapy consists of medical treatment and if implementable, behavioral therapy. For patients with severe SIB refractory to conventional therapy, neuromodulation can be considered as a last recourse. In scientific literature, several successful lesioning and deep brain stimulation targets have been described that can indicate a common underlying neuronal pathway. The objectives of this study were to evaluate the short- and long-term clinical outcome of patients with severe, therapy refractory SIB who underwent DBS with diverse underlying psychiatric disorders and to correlate these outcomes with the activated connectivity networks. We retrospectively analyzed 10 patients with SIB who underwent DBS surgery with diverse psychiatric conditions including autism spectrum disorder, organic personality disorder after hypoxic or traumatic brain injury or Tourette syndrome. DBS targets were chosen according to the underlying disorder, patients were either stimulated in the nucleus accumbens, amygdala, posterior hypothalamus, medial thalamus or ventrolateral thalamus. Clinical outcome was measured 6 months after surgery and at long-term follow-up after 10 or more years using the Early Rehabilitation Barthel index (ERBI) and time of restraint. Connectivity patterns were analyzed using normative connectome. Based on previous literature the orbitofrontal cortex, superior frontal gyrus, the anterior cingulate cortex, the amygdala and the hippocampus were chosen as regions of interest. This analysis showed a significant improvement in the functionality of the patients with DBS in the short- and long-term follow-up. Good clinical outcome correlated with higher connectivity to the amygdala and hippocampus. These findings may suggest a common pathway, which can be relevant when planning a surgical procedure in patients with SIB.
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Affiliation(s)
- Petra Heiden
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Department of Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Daniel Tim Weigel
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ricardo Loução
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Department of Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christina Hamisch
- Department of Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Enes M. Gündüz
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Maximilian I. Ruge
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jens Kuhn
- Department of Psychiatry and Psychotherapy, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- Department of Psychiatry, Psychotherapy and Psychosomatic, Johanniter Hospital Oberhausen, Oberhausen, Germany
| | - Veerle Visser-Vandewalle
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Pablo Andrade
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- *Correspondence: Pablo Andrade
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Neurophysiological Characterization of Posteromedial Hypothalamus in Anaesthetized Patients. Brain Sci 2021; 12:brainsci12010043. [PMID: 35053786 PMCID: PMC8773588 DOI: 10.3390/brainsci12010043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 12/25/2021] [Accepted: 12/27/2021] [Indexed: 11/23/2022] Open
Abstract
Deep brain stimulation (DBS) requires a precise localization, which is especially difficult at the hypothalamus, because it is usually performed in anesthetized patients. We aimed to characterize the neurophysiological properties posteromedial hypothalamus (PMH), identified by the best neurophysiological response to electrical stimulation. We obtained microelectrode recordings from four patients with intractable aggressivity operated under general anesthesia. We pooled data from 1.5 mm at PMH, 1.5 mm upper (uPMH) and 1.5 mm lower (lPMH). We analyzed 178 units, characterized by the mean action potential (mAP). Only 11% were negative. We identified the next types of units: P1N1 (30.9%), N1P1N2 (29.8%), P1P2N1 (16.3%), N1P1 and N1N2P1 (6.2%) and P1N1P2 (5.0%). Besides, atypical action potentials (amAP) were recorded in 11.8%. PMH was highly different in cell composition from uPMH and lPMH, exhibiting also a higher percentage of amAP. Different kinds of cells shared similar features for the three hypothalamic regions. Although features for discharge pattern did not show region specificity, the probability mass function of inter-spike interval were different for all the three regions. Comparison of the same kind of mAP with thalamic neurons previously published demonstrate that most of cells are different for derivatives, amplitude and/or duration of repolarization and depolarization phases and also for the first phase, demonstrating a highly specificity for both brain centers. Therefore, the different properties described for PMH can be used to positively refine targeting, even under general anesthesia. Besides, we describe by first time the presence of atypical extracellular action potentials.
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8
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Harat M, Kiec M, Rudaś M, Birski M, Furtak J. Treating Aggression and Self-destructive Behaviors by Stimulating the Nucleus Accumbens: A Case Series. Front Neurol 2021; 12:706166. [PMID: 34707553 PMCID: PMC8542713 DOI: 10.3389/fneur.2021.706166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/08/2021] [Indexed: 12/14/2022] Open
Abstract
Self-destructive and aggressive behaviors can have a significant impact on the quality of life of affected individuals and their carrers. While deep brain stimulation (DBS) has been applied to the treatment of self-destructive and aggressive behaviors in isolated cases, clinical data on this treatment modality are still lacking. We therefore assessed responses to treatment with bilateral DBS of the nucleus accumbens in six patients with severe self-destructive and aggressive behaviors. Three patients had Tourette syndrome and three had other underlying predispositions including obsessive compulsive disorder, cerebral palsy, encephalitis, and epilepsy. Patients were followed up for between 2 and 7 years, and patients were assessed using the Modified Overt Aggression Scale (six patients) and the Buss-Perry Aggression Questionnaire (three patients able to complete the questionnaire on their own). DBS reduced self-destructive and aggressive behaviors by 30–100% and by an average of 74.5%. Patients with Tourette syndrome responded better to DBS and improved by 27.3% according to the Buss-Perry Aggression Questionnaire. These results suggest that nuclei accumbens stimulation may be an effective treatment for aggressive and self-destructive behaviors regardless of etiology.
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Affiliation(s)
- Marek Harat
- Department of Neurosurgery and Neurology, Collegium Medicum of the Nicolaus Copernicus University, Toruń, Poland.,Neurosurgery Clinic, 10th Military Research Hospital, Bydgoszcz, Poland
| | - Michał Kiec
- Neurosurgery Clinic, 10th Military Research Hospital, Bydgoszcz, Poland
| | - Marcin Rudaś
- Neurosurgery Clinic, 10th Military Research Hospital, Bydgoszcz, Poland.,Clinic of Neurosurgery and Neurology, The Department of Neurosurgery and Neurotraumatology with the Treatment Improvement Sub-unit, Jan Biziel University Hospital No. 2, Bydgoszcz, Poland
| | - Marcin Birski
- Neurosurgery Clinic, 10th Military Research Hospital, Bydgoszcz, Poland
| | - Jacek Furtak
- Neurosurgery Clinic, 10th Military Research Hospital, Bydgoszcz, Poland
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9
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Contreras López WO, Navarro PA, Crispín S. Effectiveness of Deep Brain Stimulation in Reducing Body Mass Index and Weight: A Systematic Review. Stereotact Funct Neurosurg 2021; 100:75-85. [PMID: 34583359 DOI: 10.1159/000519158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/18/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Obesity has become a major public health concern worldwide, with current behavioral, pharmacological, and surgical treatments offering varying rates of success and adverse effects. Neurosurgical approaches to treatment of refractory obesity include deep brain stimulation (DBS) on either specific hypothalamic or reward circuitry nuclei, which might contribute to weight reduction through different mechanisms. We aimed to determine the safety and clinical effect of DBS in medical refractory obesity. SUMMARY Adhering to PRISMA guidelines, we performed a systematic review to identify all original studies - observational and experimental - in which DBS was performed to treat refractory obesity. From database inception to April 2021, we conducted our search in PubMed, Scopus, and LILACS databases using the following MeSH terms: "Obesity" OR "Prader-Willi Syndrome" AND "Deep Brain Stimulation." The main outcomes were safety and weight loss measured with the body mass index (BMI). The Grading of Recommendations Assessment, Development, and Evaluation methods were applied to evaluate the quality of evidence. This study protocol was registered with PROSPERO ID: CRD42019132929. Seven studies involving 12 patients met the inclusion criteria; the DBS target was the nucleus accumbens in four (57.1%), the lateral hypothalamic area in two (29.6%), and the ventral hypothalamus in one (14.3%). Further, 33% of participants had obesity secondary to Prader-Willi syndrome (PWS) and 66.6% had primary obesity. The global BMI average at baseline was 46.7 (SD: 9.6, range: 32.2-59.1), and after DBS, 42.8 (SD: 8.8, range: 25-53.9), with a mean difference of 3.9; however, the delta in PWS patients was -2.3 and 10 in those with primary obesity. The incidence of moderate side effects was 33% and included manic symptoms (N = 2), electrode fracture (N = 1), and seizure (N = 1); mild complications (41.6%) included skin infection (N = 2), difficulties falling asleep (N = 1), nausea (N = 1), and anxiety (N = 1). Key Messages: Despite available small case series and case reports reporting a benefit in the treatment of refractory obesity with DBS, this study emphasizes the need for prospective studies with longer follow-ups in order to further address the efficacy and indications.
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Affiliation(s)
- William Omar Contreras López
- División de Neurocirugía Funcional, Departamento de Neurocirugía, Clínica FOSCAL, Bucaramanga, Colombia.,Semillero de Investigación NEMOD, Universidad Autónoma de Bucaramanga, Bucaramanga, Colombia
| | - Paula Alejandra Navarro
- División de Neurocirugía Funcional, Departamento de Neurocirugía, Clínica FOSCAL, Bucaramanga, Colombia.,Departamento de Epidemiología, Universidad de Los Andes, Bogotá, Colombia
| | - Santiago Crispín
- Semillero de Investigación NEMOD, Universidad Autónoma de Bucaramanga, Bucaramanga, Colombia
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10
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Benedetti-Isaac JC, Camargo L, Gargiulo P, López N. Deep Brain Stimulation in the Posteromedial Hypothalamic Nuclei in Refractory Aggressiveness: Post-Surgical Results of 19 Cases. Int J Neuropsychopharmacol 2021; 24:977-978. [PMID: 34448852 PMCID: PMC8653869 DOI: 10.1093/ijnp/pyab059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/25/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Loida Camargo
- Universidad del Sinú, Medical School, Cartagena de Indias, Colombia
| | - Pascual Gargiulo
- Laboratorio de Neurociencias y Psicología Experimental, CONICET, Departamento de Patología, Facultad de Ciencias Médicas, Universidad Nacional de Cuyo, Mendoza, Argentina
| | - Norman López
- Universidad de La Costa, Barranquilla, Colombia,Correspondence: Prof. Norman López, PhD, Universidad de La Costa, S.58 # 55 – 66, Barranquilla, Colombia ()
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11
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Contreras Lopez WO, Navarro PA, Gouveia FV, Fonoff ET, Lebrun I, Auada AVV, Lopes Alho EJ, Martinez RCR. Directional Deep Brain Stimulation of the Posteromedial Hypothalamus for Refractory Intermittent Explosive Disorder: A Case Series Using a Novel Neurostimulation Device and Intraoperative Microdialysis. World Neurosurg 2021; 155:e19-e33. [PMID: 34325026 DOI: 10.1016/j.wneu.2021.07.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/17/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Intermittent explosive disorder (IED) is a psychiatric disorder characterized by recurrent outbursts of aggressive behavior. Deep brain stimulation (DBS) in the posteromedial nucleus of the hypothalamus (pHyp) is an alternative therapy for extreme cases and shows promising results. Intraoperative microdialysis can help elucidate the neurobiological mechanism of pHyp-DBS. We sought to evaluate efficacy and safety of pHyp-DBS using 8-contact directional leads in patients with refractory IED (rIED) and the accompanying changes in neurotransmitters. METHODS This was a prospective study in which patients with a diagnosis of rIED were treated with pHyp-DBS for symptom alleviation. Bilateral pHyp-DBS was performed with 8-contact directional electrodes. Follow-up was performed at 3, 6, and 12 months after surgery. RESULTS Four patients (3 men, mean age 27 ± 2.8 years) were included. All patients were diagnosed with rIED and severe intellectual disability. Two patients had congenital rubella, one had a co-diagnosis of infantile autism, and the fourth presented with drug-resistant epilepsy. There was a marked increase in the levels of gamma-aminobutyric acid and glycine during intraoperative stimulation. The average improvement in aggressive behavior in the last follow-up was 6 points (Δ: 50%, P = 0.003) while also documenting an important improvement of the Short Form Health Survey in all domains except bodily pain. No adverse events associated with pHyp-DBS were observed. CONCLUSIONS This is the first study to show the safety and beneficial effect of directional lead pHyp-DBS in patients with rIED and to demonstrate the corresponding mechanism of action through increases in gamma-aminobutyric acid and glycine concentration in the pHyp.
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Affiliation(s)
- William Omar Contreras Lopez
- Nemod Research Group, Universidad Autónoma de Bucaramanga, Bucaramanga, Colombia; Division of Functional Neurosurgery, Department of Neurosurgery, FOSCAL Clinic, Bucaramanga, Colombia.
| | - Paula Alejandra Navarro
- Division of Functional Neurosurgery, Department of Neurosurgery, FOSCAL Clinic, Bucaramanga, Colombia; Department of Epidemiology, School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | | | - Erich Talamoni Fonoff
- Department of Neurology, University of São Paulo School of Medicine and Integrated Clinic of Neuroscience, São Paulo, Brazil
| | - Ivo Lebrun
- Biochemistry and Biophysics Laboratory, Butantan Institute, University of Sao Paulo, Sao Paulo, Brazil
| | - Aline V V Auada
- Biochemistry and Biophysics Laboratory, Butantan Institute, University of Sao Paulo, Sao Paulo, Brazil
| | - Eduardo Joaquim Lopes Alho
- Department of Neurology, University of São Paulo School of Medicine and Integrated Clinic of Neuroscience, São Paulo, Brazil
| | - Raquel C R Martinez
- LIM 23, Institute of Psychiatry, University of Sao Paulo, School of Medicine, Sao Paulo, Brazil; Division of Neuroscience, Sírio-Libanês Hospital, São Paulo, Brazil
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Blasco García de Andoain G, Navas García M, González Aduna Ó, Bocos Portillo A, Ezquiaga Terrazas E, Ayuso-Mateos JL, Pastor J, Vega-Zelaya L, Torres CV. Posteromedial Hypothalamic Deep Brain Stimulation for Refractory Aggressiveness in a Patient With Weaver Syndrome: Clinical, Technical Report and Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:165-171. [PMID: 34017998 DOI: 10.1093/ons/opab149] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 03/14/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Deep brain stimulation of the posteromedial hypothalamus (PMH DBS) appears to be an effective treatment for drug-resistant aggressiveness. Weaver syndrome (WS) is a rare genetic disorder in which patients develop some degree of intellectual disability and rarely severe behavioral alterations that may benefit from this procedure. CLINICAL PRESENTATION We present the case of a 26-yr-old man diagnosed with WS presenting with uncontrollable self and heteroaggressiveness and disruptive behavior refractory to pharmacological treatment and under severe physical and mechanical restraining measures. The patient was successfully treated with bilateral PMH DBS resulting in affective improvement, greater tolerance for signs of affection, regularization in his sleep pattern and appetite disturbances at 12-mo follow-up. A detailed description and video of the procedure are presented, and a review of the clinical characteristics of WS and the utility and benefits of PMH DBS for refractory aggressiveness are reviewed. CONCLUSION To our knowledge, this is the first case of refractory aggressiveness described in WS as well as the first patient with WS successfully treated with PMH DBS.
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Affiliation(s)
| | - Marta Navas García
- Department of Neurosurgery, La Princesa University Hospital, Madrid, Spain
| | | | | | | | | | - Jesús Pastor
- Department of Clinical Neurophysiology, La Princesa University Hospital, Madrid, Spain
| | - Lorena Vega-Zelaya
- Department of Clinical Neurophysiology, La Princesa University Hospital, Madrid, Spain
| | - Cristina V Torres
- Department of Neurosurgery, La Princesa University Hospital, Madrid, Spain
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Rizzi M, Gambini O, Marras CE. Posterior hypothalamus as a target in the treatment of aggression: From lesioning to deep brain stimulation. HANDBOOK OF CLINICAL NEUROLOGY 2021; 182:95-106. [PMID: 34266615 DOI: 10.1016/b978-0-12-819973-2.00007-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Intermittent explosive disorder can be described as a severe "affective aggression" condition, for which drugs and other supportive therapies are not fully effective. In the first half of the 19th century, experimental studies progressively increased knowledge of aggressive disorders. A neurobiologic approach revealed the posterior hypothalamic region as a key structure for the modulation of aggression. In the 1960s, patients with severe aggressive disorder, frequently associated with intellectual disability, were treated by bilateral stereotactic lesioning of the posterior hypothalamic area, with efficacy. This therapy was later abandoned because of issues related to the misuse of psychosurgery. In the last 2 decades, however, the same diencephalic target has been selected for the reversible treatment by deep brain stimulation, with success. This chapter presents a comprehensive approach to posterior hypothalamic surgery for the treatment of severely aggressive patients and discusses the experimental steps that allowed this surgical target to be selected. Surgical experiences are reported, together with considerations on target features and related encephalic circuits.
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Affiliation(s)
- Michele Rizzi
- "C.Munari" Epilepsy Surgery Center, Department of Neuroscience, ASST GOM Niguarda, Milan, Italy.
| | - Orsola Gambini
- Department of Health of Sciences, University of Milan, Milan, Italy; CRC "Aldo Ravelli" for Neurotechnology and Experimental Brain Therapeutics, University of Milan Medical School, Milan, Italy
| | - Carlo Efisio Marras
- Neurosurgery Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Torres CV, Blasco G, Navas García M, Ezquiaga E, Pastor J, Vega-Zelaya L, Pulido Rivas P, Pérez Rodrigo S, Manzanares R. Deep brain stimulation for aggressiveness: long-term follow-up and tractography study of the stimulated brain areas. J Neurosurg 2020; 134:366-375. [PMID: 32032944 DOI: 10.3171/2019.11.jns192608] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 11/26/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Initial studies applying deep brain stimulation (DBS) of the posteromedial hypothalamus (PMH) to patients with pathological aggressiveness have yielded encouraging results. However, the anatomical structures involved in its therapeutic effect have not been precisely identified. The authors' objective was to describe the long-term outcome in their 7-patient series, and the tractography analysis of the volumes of tissue activated in 2 of the responders. METHODS This was a retrospective study of 7 subjects with pathological aggressiveness. The findings on MRI with diffusion tensor imaging (DTI) in 2 of the responders were analyzed. The authors generated volumes of tissue activated according to the parameters used, and selected those volumes as regions of interest to delineate the tracts affected by stimulation. RESULTS The series consisted of 5 men and 2 women. Of the 7 patients, 5 significantly improved with stimulation. The PMH, ventral tegmental area, dorsal longitudinal fasciculus, and medial forebrain bundle seem to be involved in the stimulation field. CONCLUSIONS In this series, 5 of 7 medication-resistant patients with severe aggressiveness who were treated with bilateral PMH DBS showed a significant long-lasting improvement. The PMH, ventral tegmental area, dorsal longitudinal fasciculus, and medial forebrain bundle seem to be in the stimulation field and might be responsible for the therapeutic effect of DBS.
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Affiliation(s)
| | | | | | - Elena Ezquiaga
- 5Department of Psychiatry, University Hospital La Princesa, Madrid, Spain
| | - Jesús Pastor
- 3Clinical Neurophysiology, University Hospital La Princesa, Madrid
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Barbosa DAN, de Oliveira-Souza R, Monte Santo F, de Oliveira Faria AC, Gorgulho AA, De Salles AAF. The hypothalamus at the crossroads of psychopathology and neurosurgery. Neurosurg Focus 2017; 43:E15. [DOI: 10.3171/2017.6.focus17256] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The neurosurgical endeavor to treat psychiatric patients may have been part of human history since its beginning. The modern era of psychosurgery can be traced to the heroic attempts of Gottlieb Burckhardt and Egas Moniz to alleviate mental symptoms through the ablation of restricted areas of the frontal lobes in patients with disabling psychiatric illnesses. Thanks to the adaptation of the stereotactic frame to human patients, the ablation of large volumes of brain tissue has been practically abandoned in favor of controlled interventions with discrete targets.Consonant with the role of the hypothalamus in the mediation of the most fundamental approach-avoidance behaviors, some hypothalamic nuclei and regions, in particular, have been selected as targets for the treatment of aggressiveness (posterior hypothalamus), pathological obesity (lateral or ventromedial nuclei), sexual deviations (ventromedial nucleus), and drug dependence (ventromedial nucleus). Some recent improvements in outcomes may have been due to the use of stereotactically guided deep brain stimulation and the change of therapeutic focus from categorical diagnoses (such as schizophrenia) to dimensional symptoms (such as aggressiveness), which are nonspecific in terms of formal diagnosis. However, agreement has never been reached on 2 related issues: 1) the choice of target, based on individual diagnoses; and 2) reliable prediction of outcomes related to individual targets. Despite the lingering controversies on such critical aspects, the experience of the past decades should pave the way for advances in the field. The current failure of pharmacological treatments in a considerable proportion of patients with chronic disabling mental disorders is reminiscent of the state of affairs that prevailed in the years before the early psychosurgical attempts.This article reviews the functional organization of the hypothalamus, the effects of ablation and stimulation of discrete hypothalamic regions, and the stereotactic targets that have most often been used in the treatment of psychopathological and behavioral symptoms; finally, the implications of current and past experience are presented from the perspective of how this fund of knowledge may usefully contribute to the future of hypothalamic psychosurgery.
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Affiliation(s)
- Daniel A. N. Barbosa
- 1Department of Clinical Neuroscience, D’Or Institute for Research and Education
- 2Division of Neurosurgery and
| | - Ricardo de Oliveira-Souza
- 1Department of Clinical Neuroscience, D’Or Institute for Research and Education
- 3Department of Neurology and Psychiatry, Gaffrée e Guinle University Hospital, Federal University of the State of Rio de Janeiro
| | - Felipe Monte Santo
- 1Department of Clinical Neuroscience, D’Or Institute for Research and Education
- 4Intensive Care Unit, Icaraí Hospital, Niteroi, RJ
| | - Ana Carolina de Oliveira Faria
- 1Department of Clinical Neuroscience, D’Or Institute for Research and Education
- 3Department of Neurology and Psychiatry, Gaffrée e Guinle University Hospital, Federal University of the State of Rio de Janeiro
| | - Alessandra A. Gorgulho
- 5HCor Neuroscience, São Paulo, Brazil; and
- 6Department of Neurosurgery and Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Antonio A. F. De Salles
- 5HCor Neuroscience, São Paulo, Brazil; and
- 6Department of Neurosurgery and Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, California
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Rizzi M, Trezza A, Messina G, De Benedictis A, Franzini A, Marras CE. Exploring the brain through posterior hypothalamus surgery for aggressive behavior. Neurosurg Focus 2017; 43:E14. [DOI: 10.3171/2017.6.focus17231] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Neurological surgery offers an opportunity to study brain functions, through either resection or implanted neuromodulation devices. Pathological aggressive behavior in patients with intellectual disability is a frequent condition that is difficult to treat using either supportive care or pharmacological therapy. The bulk of the laboratory studies performed throughout the 19th century enabled the formulation of hypotheses on brain circuits involved in the generation of emotions. Aggressive behavior was also studied extensively. Lesional radiofrequency surgery of the posterior hypothalamus, which peaked in the 1970s, was shown to be an effective therapy in many reported series. As with other surgical procedures for the treatment of psychiatric disorders, however, this therapy was abandoned for many reasons, including the risk of its misuse. Deep brain stimulation (DBS) offers the possibility of treating neurological and psychoaffective disorders through relatively reversible and adaptable therapy. Deep brain stimulation of the posterior hypothalamus was proposed and performed successfully in 2005 as a treatment for aggressive behavior. Other groups reported positive outcomes using target and parameter settings similar to those of the original study. Both the lesional and DBS approaches enabled researchers to explore the role of the posterior hypothalamus (or posterior hypothalamic area) in the autonomic and emotional systems.
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Affiliation(s)
- Michele Rizzi
- 1Functional Neurosurgery Unit, Department of Neurosurgery, IRCCS Foundation “Istituto Neurologico Carlo Besta,” Milan
- 3“Claudio Munari” Center for Epilepsy Surgery, Niguarda Hospital, Milan
| | - Andrea Trezza
- 4Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, IRCCS Bambino Gesù Children’s Hospital, Rome; and
- 5Division of Neurosurgery, Department of Surgery and Translational Medicine, Milan Center for Neuroscience, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Giuseppe Messina
- 1Functional Neurosurgery Unit, Department of Neurosurgery, IRCCS Foundation “Istituto Neurologico Carlo Besta,” Milan
| | - Alessandro De Benedictis
- 4Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, IRCCS Bambino Gesù Children’s Hospital, Rome; and
| | - Angelo Franzini
- 1Functional Neurosurgery Unit, Department of Neurosurgery, IRCCS Foundation “Istituto Neurologico Carlo Besta,” Milan
| | - Carlo Efisio Marras
- 4Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, IRCCS Bambino Gesù Children’s Hospital, Rome; and
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Micieli R, Rios ALL, Aguilar RP, Posada LFB, Hutchison WD. Single-unit analysis of the human posterior hypothalamus and red nucleus during deep brain stimulation for aggressivity. J Neurosurg 2017; 126:1158-1164. [DOI: 10.3171/2016.4.jns141704] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Deep brain stimulation (DBS) of the posterior hypothalamus (PH) has been reported to be effective for aggressive behavior in a number of isolated cases. Few of these case studies have analyzed single-unit recordings in the human PH and none have quantitatively analyzed single units in the red nucleus (RN). The authors report on the properties of ongoing neuronal discharges in bilateral trajectories targeting the PH and the effectiveness of DBS of the PH as a treatment for aggressive behavior.
METHODS
DBS electrodes were surgically implanted in the PH of 1 awake patient with Sotos syndrome and 3 other anesthetized patients with treatment-resistant aggressivity. Intraoperative extracellular recordings were obtained from the ventral thalamus, PH, and RN and analyzed offline to discriminate single units and measure firing rates and firing patterns. Target location was based on the stereotactic coordinates used by Sano et al. in their 1970 study and the location of the dorsal border of the RN.
RESULTS
A total of 138 units were analyzed from the 4 patients. Most of the PH units had a slow, irregular discharge (mean [± SD] 4.5 ± 2.7 Hz, n = 68) but some units also had a higher discharge rate (16.7 ± 4.7 Hz, n = 15). Two populations of neurons were observed in the ventral thalamic region as well, one with a high firing rate (mean 16.5 ± 6.5 Hz, n = 5) and one with a low firing rate (mean 4.6 ± 2.8 Hz, n = 6). RN units had a regular firing rate with a mean of 20.4 ± 9.9 Hz and displayed periods of oscillatory activity in the beta range. PH units displayed a prolonged period of inhibition following microstimulation compared with RN units that were not inhibited. Patients under anesthesia showed a trend for lower firing rates in the PH but not in the RN. All 4 patients displayed a reduction in their aggressive behavior after surgery.
CONCLUSIONS
During PH DBS, microelectrode recordings can provide an additional mechanism to help identify the PH target and surrounding structures to be avoided such as the RN. PH units can be distinguished from ventral thalamic units based on their response to focal microstimulation. The RN has a characteristic higher firing rate and a pattern of beta oscillations in the spike trains. The effect of the anesthetic administered should be considered when using microelectrode recordings. The results of this study, along with previous reports, suggest that PH DBS may be an effective treatment for aggression.
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Affiliation(s)
- Robert Micieli
- Departments of 1Physiology and
- 3Krembil Research Institute, Toronto, Ontario, Canada; and
| | - Adriana Lucia Lopez Rios
- 4Centros Especializados de Hospital Universitario San Vicente Fundacion, Medellin-Rionegro, Colombia
| | - Ricardo Plata Aguilar
- 4Centros Especializados de Hospital Universitario San Vicente Fundacion, Medellin-Rionegro, Colombia
| | | | - William D. Hutchison
- Departments of 1Physiology and
- 2Surgery, University of Toronto
- 3Krembil Research Institute, Toronto, Ontario, Canada; and
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Rizzi M, Marras CE. Deep Brain Stimulation for the Treatment of Aggressive Behaviour: Considerations on Pathophysiology and Target Choice. Stereotact Funct Neurosurg 2017; 95:114-116. [DOI: 10.1159/000460260] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 02/01/2017] [Indexed: 11/19/2022]
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Neumaier F, Paterno M, Alpdogan S, Tevoufouet EE, Schneider T, Hescheler J, Albanna W. Surgical Approaches in Psychiatry: A Survey of the World Literature on Psychosurgery. World Neurosurg 2017; 97:603-634.e8. [DOI: 10.1016/j.wneu.2016.10.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 09/29/2016] [Accepted: 10/01/2016] [Indexed: 12/11/2022]
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Giordano F, Cavallo M, Spacca B, Pallanti S, Tomaiuolo F, Pieraccini F, Fagiolini A, Grandoni M, Melani F, Zicca A, Sestini S, Genitori L. Deep Brain Stimulation of the Anterior Limb of the Internal Capsule May Be Efficacious for Explosive Aggressive Behaviour. Stereotact Funct Neurosurg 2016; 94:371-378. [DOI: 10.1159/000449171] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 08/16/2016] [Indexed: 11/19/2022]
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Gonçalves-Ferreira A, do Couto FS, Rainha Campos A, Lucas Neto LP, Gonçalves-Ferreira D, Teixeira J. Deep Brain Stimulation for Refractory Cocaine Dependence. Biol Psychiatry 2016; 79:e87-9. [PMID: 26235303 DOI: 10.1016/j.biopsych.2015.06.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 06/18/2015] [Accepted: 06/19/2015] [Indexed: 10/23/2022]
Affiliation(s)
| | | | | | | | | | - Joana Teixeira
- Centro Hospitalar Psiquiátrico de Lisboa, Lisbon, Portugal
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Harat M, Rudaś M, Zieliński P, Birska J, Sokal P. Deep Brain Stimulation in Pathological Aggression. Stereotact Funct Neurosurg 2015; 93:310-5. [DOI: 10.1159/000431373] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 05/15/2015] [Indexed: 11/19/2022]
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Cleary DR, Ozpinar A, Raslan AM, Ko AL. Deep brain stimulation for psychiatric disorders: where we are now. Neurosurg Focus 2015; 38:E2. [DOI: 10.3171/2015.3.focus1546] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Fossil records showing trephination in the Stone Age provide evidence that humans have sought to influence the mind through physical means since before the historical record. Attempts to treat psychiatric disease via neurosurgical means in the 20th century provided some intriguing initial results. However, the indiscriminate application of these treatments, lack of rigorous evaluation of the results, and the side effects of ablative, irreversible procedures resulted in a backlash against brain surgery for psychiatric disorders that continues to this day. With the advent of psychotropic medications, interest in invasive procedures for organic brain disease waned.
Diagnosis and classification of psychiatric diseases has improved, due to a better understanding of psychiatric patho-physiology and the development of disease and treatment biomarkers. Meanwhile, a significant percentage of patients remain refractory to multiple modes of treatment, and psychiatric disease remains the number one cause of disability in the world. These data, along with the safe and efficacious application of deep brain stimulation (DBS) for movement disorders, in principle a reversible process, is rekindling interest in the surgical treatment of psychiatric disorders with stimulation of deep brain sites involved in emotional and behavioral circuitry.
This review presents a brief history of psychosurgery and summarizes the development of DBS for psychiatric disease, reviewing the available evidence for the current application of DBS for disorders of the mind.
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Affiliation(s)
- Daniel R. Cleary
- 1Department of Neurology, Yale Medical School, New Haven, Connecticut
| | - Alp Ozpinar
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Ahmed M. Raslan
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Andrew L. Ko
- 3Department of Neurological Surgery, University of Washington, Seattle, Washington
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Yampolsky C, Bendersky D. [Surgery for behavioral disorders: the state of the art]. Surg Neurol Int 2014; 5:S211-31. [PMID: 25165612 PMCID: PMC4138826 DOI: 10.4103/2152-7806.137936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 08/15/2013] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Surgery for behavioral disorders (SBD) is becoming a more common treatment since the development of neuromodulation techniques. METHODS This article is a non-systematic review of the history, current indications, techniques and surgical targets of SBD. We divide its history into 3 eras: the first era starts in the beginning of psychosurgery and finishes with the development of stereotactic techniques, when the second one starts. It is characterized by the realization of stereotactic lesions. We are traveling through the third era, which begins when deep brain stimulation (DBS) starts to be used for SBD. RESULTS In spite of the serious mistakes committed in the past, nowadays, SBD is reawakening. The psychiatric disorders which are most frequently treated by surgery are: treatment-resistant depression, obsessive-compulsive disorder and Tourette syndrome. Furthermore, some patients with abnormal aggression were surgically treated. There are several stereotactic targets described for these disorders. Vagus nerve stimulation may be also used for depression. CONCLUSION The results of DBS in these disorders seem to be encouraging. However, more randomized trials are needed in order to establish the effectiveness of SBD. It must be taken in mind that a proper patient selection will help us to perform a safer procedure as well as to achieve better surgical results, leading SBD to be more accepted by psychiatrists, patients and their families. Further research is needed in several topics such as: physiopathology of behavioral disorders, indications of SBD and new surgical targets.
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Affiliation(s)
- Claudio Yampolsky
- Servicio de Neurocirugía, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Damián Bendersky
- Servicio de Neurocirugía, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
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Posterior hypothalamic deep brain stimulation. The impact on cluster headache control and other indications. World Neurosurg 2014; 82:68-9. [PMID: 24793979 DOI: 10.1016/j.wneu.2013.02.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 02/22/2013] [Indexed: 11/24/2022]
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Franzini A, Cordella R, Rizzi M, Marras CE, Messina G, Zorzi G, Caldiroli D. Deep brain stimulation in critical care conditions. J Neural Transm (Vienna) 2013; 121:391-8. [PMID: 24292857 DOI: 10.1007/s00702-013-1122-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 11/15/2013] [Indexed: 11/26/2022]
Abstract
Some neurological conditions require admission to an intensive care unit (ICU) where deep sedation and mechanical ventilation are administered to improve the patient's condition. Nevertheless, these treatments are not always helpful in disease control. At this stage, deep brain stimulation (DBS) could become a viable alternative in the treatment of critical neurological conditions with long-lasting clinical benefit. The value of deep brain stimulation has been investigated in the treatment of patients who had undergone surgical electrode implants as an emergency procedure to treat acute life-threatening conditions requiring admission to neurological ICU (NICU). A before-and-after perspective study was examined of seven patients who were treated with DBS for status dystonicus (SD) and post-stroke severe hemiballismus. Bilateral globus pallidus internus (GPi) DBS was performed in five SD patients and unilateral ventralis oralis anterior and posterior (Voa/Vop) nucleus of the thalamus DBS in two post-stroke hemiballismus patients. Bilateral GPi-DBS allowed SD resolution in a time lapse varying from 1 week to 3 months. No clear improvements compared to the baseline clinical condition were observed. Unilateral Voa/Vop-DBS intervention controlled hemiballismus after 10 h, and the patient was discharged in 2 days. The other patient was transferred from the NICU to the neurosurgery ward after 13 days. No surgical complications were observed in any of the above procedures. Neurostimulation procedures could represent a valuable choice in critical care conditions, when involuntary movements are continuous, life-threatening and refractory to intensive care procedures. DBS is feasible, safe and effective in selected cases.
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Affiliation(s)
- Angelo Franzini
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico "C. Besta", Via Celoria 11, 20133, Milan, Italy
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Hariz M, Blomstedt P, Zrinzo L. Future of brain stimulation: new targets, new indications, new technology. Mov Disord 2013; 28:1784-92. [PMID: 24123327 DOI: 10.1002/mds.25665] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 06/27/2013] [Accepted: 08/09/2013] [Indexed: 01/15/2023] Open
Abstract
In the last quarter of a century, DBS has become an established neurosurgical treatment for Parkinson's disease (PD), dystonia, and tremors. Improved understanding of brain circuitries and their involvement in various neurological and psychiatric illnesses, coupled with the safety of DBS and its exquisite role as a tool for ethical study of the human brain, have unlocked new opportunities for this technology, both for future therapies and in research. Serendipitous discoveries and advances in structural and functional imaging are providing abundant "new" brain targets for an ever-increasing number of pathologies, leading to investigations of DBS in diverse neurological, psychiatric, behavioral, and cognitive conditions. Trials and "proof of concept" studies of DBS are underway in pain, epilepsy, tinnitus, OCD, depression, and Gilles de la Tourette syndrome, as well as in eating disorders, addiction, cognitive decline, consciousness, and autonomic states. In parallel, ongoing technological development will provide pulse generators with longer battery longevity, segmental electrode designs allowing a current steering, and the possibility to deliver "on-demand" stimulation based on closed-loop concepts. The future of brain stimulation is certainly promising, especially for movement disorders-that will remain the main indication for DBS for the foreseeable future-and probably for some psychiatric disorders. However, brain stimulation as a technique may be at risk of gliding down a slippery slope: Some reports indicate a disturbing trend with suggestions that future DBS may be proposed for enhancement of memory in healthy people, or as a tool for "treatment" of "antisocial behavior" and for improving "morality."
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Affiliation(s)
- Marwan Hariz
- Unit of Functional Neurosurgery, UCL Institute of Neurology, London, UK; Department of Clinical Neuroscience, Umeå University, Umeå, Sweden
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Torres CV, Sola RG, Pastor J, Pedrosa M, Navas M, García-Navarrete E, Ezquiaga E, García-Camba E. Long-term results of posteromedial hypothalamic deep brain stimulation for patients with resistant aggressiveness. J Neurosurg 2013; 119:277-87. [PMID: 23746102 DOI: 10.3171/2013.4.jns121639] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Erethism describes severe cases of unprovoked aggressive behavior, usually associated with some degree of mental impairment and gross brain damage. The etiology can be epileptic, postencephalitic, or posttraumatic, or the condition can be caused by brain malformations or perinatal insults. Erethism is often refractory to medication, and patients must often be interned in institutions, where they are managed with major restraining measures. The hypothalamus is a crucial group of nuclei that coordinate behavioral and autonomic responses and play a central role in the control of aggressive behavior. Deep brain stimulation (DBS) of the posteromedial hypothalamus (PMH) has been proposed as a treatment for resistant erethism, although experience with this treatment around the world is scarce. The objective of this study was to examine the long-term outcome of PMH DBS in 6 patients with severe erethism treated at the authors' institution. METHODS Medical records of 6 patients treated with PMH DBS for intractable aggressiveness were reviewed. The therapeutic effect on behavior was assessed by the Inventory for Client and Agency Planning preoperatively and at the last follow-up visit. RESULTS Two patients died during the follow-up period due to causes unrelated to the neurosurgical treatment. Five of 6 patients experienced a significant reduction in aggressiveness (the mean Inventory for Client and Agency Planning general aggressiveness score was -47 at baseline and -25 at the last follow-up; mean follow-up 3.5 years). Similar responses were obtained with low- and high-frequency stimulation. In 4 cases, the patients' sleep patterns became more regular, and in 1 case, binge eating and polydipsia ceased. One of the 3 patients who had epilepsy noticed a 30% reduction in seizure frequency. Another patient experienced a marked sympathetic response with high-frequency stimulation during the first stimulation trial, but this subsided when stimulation was set at low frequency. A worsening of a previous headache was noted by 1 patient. There were no other side effects. CONCLUSIONS In this case series, 5 of 6 patients with pathological aggressiveness had a reduction of their outbursts of violence after PMH DBS, without significant adverse effects. Prospective controlled studies with a larger number of patients are needed to confirm these results.
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Affiliation(s)
- Cristina V Torres
- Department of Neurosurgery, University Hospital La Princesa, UAM, Madrid, Spain
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Haller J. The neurobiology of abnormal manifestations of aggression--a review of hypothalamic mechanisms in cats, rodents, and humans. Brain Res Bull 2012; 93:97-109. [PMID: 23085544 DOI: 10.1016/j.brainresbull.2012.10.003] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 10/08/2012] [Accepted: 10/09/2012] [Indexed: 01/01/2023]
Abstract
Aggression research was for long dominated by the assumption that aggression-related psychopathologies result from the excessive activation of aggression-promoting brain mechanisms. This assumption was recently challenged by findings with models of aggression that mimic etiological factors of aggression-related psychopathologies. Subjects submitted to such procedures show abnormal attack features (mismatch between provocation and response, disregard of species-specific rules, and insensitivity toward the social signals of opponents). We review here 12 such laboratory models and the available human findings on the neural background of abnormal aggression. We focus on the hypothalamus, a region tightly involved in the execution of attacks. Data show that the hypothalamic mechanisms controlling attacks (general activation levels, local serotonin, vasopressin, substance P, glutamate, GABA, and dopamine neurotransmission) undergo etiological factor-dependent changes. Findings suggest that the emotional component of attacks differentiates two basic types of hypothalamic mechanisms. Aggression associated with increased arousal (emotional/reactive aggression) is paralleled by increased mediobasal hypothalamic activation, increased hypothalamic vasopressinergic, but diminished hypothalamic serotonergic neurotransmission. In aggression models associated with low arousal (unemotional/proactive aggression), the lateral but not the mediobasal hypothalamus is over-activated. In addition, the anti-aggressive effect of serotonergic neurotransmission is lost and paradoxical changes were noticed in vasopressinergic neurotransmission. We conclude that there is no single 'neurobiological road' to abnormal aggression: the neural background shows qualitative, etiological factor-dependent differences. Findings obtained with different models should be viewed as alternative mechanisms rather than conflicting data. The relevance of these findings for understanding and treating of aggression-related psychopathologies is discussed. This article is part of a Special Issue entitled 'Extrasynaptic ionotropic receptors'.
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Affiliation(s)
- Jozsef Haller
- Department of Behavioral Neurobiology, Hungarian Academy of Sciences, Institute of Experimental Medicine, H-1083 Budapest, Szigony utca 43, Hungary.
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Deep-brain stimulation for aggressive and disruptive behavior. World Neurosurg 2012; 80:S29.e11-4. [PMID: 22743202 DOI: 10.1016/j.wneu.2012.06.038] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 05/31/2012] [Accepted: 06/21/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To describe our institutional experience with deep-brain stimulation (DBS) used in the treatment of aggressive and disruptive behavior refractory to conservative treatment. METHODS With stereotactic methodology and under general anesthesia, seven patients (from 2002 to 2010) were given DBS in the posterior hypothalamic region, bilaterally, and with the aid of intraoperative microrecording. RESULTS Six of seven patients presented a clear reduction in the aggression and disruptive bouts, with subsequent simplification of familiar management. CONCLUSIONS DBS of the posterior hypothalamic region could be an effective treatment for patients affected by mental retardation in whom disruptive and drug-refractory aggressive behavior coexists. Although several experimental data are available on this target, further studies are necessary to confirm the long-term efficacy and safety of this procedure.
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Luerding R, Henkel K, Gaul C, Dresler T, Lindwurm A, Paelecke-Habermann Y, Leinisch E, Jürgens TP. Aggressiveness in different presentations of cluster headache: Results from a controlled multicentric study. Cephalalgia 2012; 32:528-36. [DOI: 10.1177/0333102412443336] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background: The hypothalamus has been discussed as a pivotal structure for both cluster headache (CH) and aggressiveness, but little is known about the extent of self-reported aggressiveness in patients with CH. Patients and methods: Twenty-six patients with chronic, 25 with active episodic and 22 with episodic CH outside the active period were examined interictally with a validated questionnaire quantifying factors of aggression and compared with 24 migraine patients and 31 headache-free volunteers. Results: The ANOVA was significant for the subscale ‘self-aggression/depression’ ( F4, 123 = 5.771, p < 0.001) with significant differences between chronic and episodic CH and healthy volunteers. No significant changes were found for other subscales and the sum scale ( F4, 123 < 1.421, p > 0.230). Especially in the clinically most affected group of patients (chronic CH and active episodic CH), high levels of “self-aggression/depression” correlate with higher prevalence of depressive symptoms and higher impairment measured on an emotional and functional level. Discussion: Self-aggressive and depressive cognitions with highest scores in chronic CH seem to be reactive as they correlate with depressive symptoms and impairment. They should be considered as an important therapeutic target since they impair the patient’s life significantly.
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Affiliation(s)
| | - Karsten Henkel
- Kiel Headache Center, Germany
- RWTH Aachen University, Germany
| | - Charly Gaul
- University of Halle, Germany
- University of Essen, Germany
| | | | | | | | - Elke Leinisch
- University of Regensburg, Germany
- Helios Klinikum, Erfurt, Germany
| | - Tim P Jürgens
- University Medical Center Hamburg-Eppendorf, Germany
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Gilbert F, Vranic A, Hurst S. Involuntary & Voluntary Invasive Brain Surgery: Ethical Issues Related to Acquired Aggressiveness. NEUROETHICS-NETH 2012. [DOI: 10.1007/s12152-012-9161-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Franzini A, Cordella R, Messina G, Marras CE, Romito LM, Albanese A, Rizzi M, Nardocci N, Zorzi G, Zekaj E, Villani F, Leone M, Gambini O, Broggi G. Targeting the brain: considerations in 332 consecutive patients treated by deep brain stimulation (DBS) for severe neurological diseases. Neurol Sci 2012; 33:1285-303. [PMID: 22271259 DOI: 10.1007/s10072-012-0937-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 12/23/2011] [Indexed: 11/28/2022]
Abstract
Deep brain stimulation (DBS) extends the treatment of some severe neurological diseases beyond pharmacological and conservative therapy. Our experience extends the field of DBS beyond the treatment of Parkinson disease and dystonia, including several other diseases such as cluster headache and disruptive behavior. Since 1993, at the Istituto Nazionale Neurologico "Carlo Besta" in Milan, 580 deep brain electrodes were implanted in 332 patients. The DBS targets include Stn, GPi, Voa, Vop, Vim, CM-pf, pHyp, cZi, Nacc, IC, PPN, and Brodmann areas 24 and 25. Three hundred patients are still available for follow-up and therapeutic considerations. DBS gave a new therapeutic chance to these patients affected by severe neurological diseases and in some cases controlled life-threatening pathological conditions, which would otherwise result in the death of the patient such as in status dystonicus, status epilepticus and post-stroke hemiballismus. The balance of DBS in severe neurological disease is strongly positive even if further investigations and studies are needed to search for new applications and refine the selection criteria for the actual indications.
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Affiliation(s)
- Angelo Franzini
- Fondazione IRCCS Istituto Neurologico "C. Besta", Via Celoria 11, 20133, Milan, Italy
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Potegal M. Temporal and frontal lobe initiation and regulation of the top-down escalation of anger and aggression. Behav Brain Res 2011; 231:386-95. [PMID: 22085875 DOI: 10.1016/j.bbr.2011.10.049] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 10/26/2011] [Accepted: 10/31/2011] [Indexed: 10/15/2022]
Abstract
The widespread, across-species strategy of stagewise escalation of aggression in agonistic encounters can be understood in terms of resource capture and control with least risk and cost. Human anger likely follows similar principles. As an adaptive phenomenon, escalation may involve particular neural circuitry. To advance beyond a standard view that the frontal lobe tonically inhibits subcortical circuits of aggression, a model is proposed which starts with the general rostrally directed flow of information in the brain. Earlier stage processing of visual and auditory input is transmitted from posterior and middle temporal cortices to anterior temporal lobe where rudimentary appraisals of threat and provocation are developed. These directly but diffusely activate cortical/subcortical anger/aggression response systems. At the same time, the anterior temporal loci transmit the modality-specific perceptual information to orbito-frontal cortex where it is integrated with information about, e.g., the opponent's relative dominance/social status and evaluated for likelihood of potential rewards and punishments associated with different modes of responding and so forth. These frontal areas then impose an inhibitory gating or modulation and focusing of activity initiated by the anterior temporal loci through their projections to GABAergic interneurons in the same cortical/subcortical circuits. Escalation occurs as the inhibition imposed by the frontal areas is progressively lifted. Exploration of the implications, applications and hypotheses flowing from this model will improve our understanding of the biologically important and socially significant phenomena of escalation.
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Baroncini M, Jissendi P, Balland E, Besson P, Pruvo JP, Francke JP, Dewailly D, Blond S, Prevot V. MRI atlas of the human hypothalamus. Neuroimage 2011; 59:168-80. [PMID: 21777680 DOI: 10.1016/j.neuroimage.2011.07.013] [Citation(s) in RCA: 136] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2010] [Revised: 06/24/2011] [Accepted: 07/04/2011] [Indexed: 10/18/2022] Open
Abstract
Gaining new insights into the anatomy of the human hypothalamus is crucial for the development of new treatment strategies involving functional stereotactic neurosurgery. Here, using anatomical comparisons between histology and magnetic resonance images of the human hypothalamus in the coronal plane, we show that discrete gray and white hypothalamic structures are consistently identifiable by MRI. Macroscopic and microscopic images were used to precisely annotate the MRI sequences realized in the coronal plane in twenty healthy volunteers. MRI was performed on a 1.5 T scanner, using a protocol including T1-weighted 3D fast field echo, T1-weighted inversion-recovery, turbo spin echo and T2-weighted 2D fast field echo imaging. For each gray matter structure as well as for white matter bundles, the different MRI sequences were analyzed in comparison to each other. The anterior commissure and the fornix were often identifiable, while the mammillothalamic tract was more difficult to spot. Qualitative analyses showed that MRI could also highlight finer structures such as the paraventricular nucleus, the ventromedial nucleus of the hypothalamus and the infundibular (arcuate) nucleus, brain nuclei that play key roles in the regulation of food intake and energy homeostasis. The posterior hypothalamic area, a target for deep brain stimulation in the treatment of cluster headaches, was readily identified, as was the lateral hypothalamic area, which similar to the aforementioned hypothalamic nuclei, could be a putative target for deep brain stimulation in the treatment of obesity. Finally, each of the identified structures was mapped to Montreal Neurological Institute (MNI) space.
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Affiliation(s)
- Marc Baroncini
- Inserm, Jean-Pierre Aubert Research Center, U837, Development and Plasticity of the postnatal Brain, Univ Lille Nord de France, CHRU Lille, Department of Neurosurgery, Lille University Hospital, 59037 Lille cedex, France.
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Lemaire JJ, Frew AJ, McArthur D, Gorgulho AA, Alger JR, Salomon N, Chen C, Behnke EJ, De Salles AAF. White matter connectivity of human hypothalamus. Brain Res 2011; 1371:43-64. [PMID: 21122799 DOI: 10.1016/j.brainres.2010.11.072] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2010] [Revised: 11/02/2010] [Accepted: 11/19/2010] [Indexed: 11/28/2022]
Affiliation(s)
- Jean-Jacques Lemaire
- Univ Clermont 1, UFR Médecine, EA3295, Equipe de Recherche en signal et Imagerie Médicale, Clermont-Ferrand, F-63001, France.
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Clausen J. Ethical brain stimulation - neuroethics of deep brain stimulation in research and clinical practice. Eur J Neurosci 2010; 32:1152-62. [DOI: 10.1111/j.1460-9568.2010.07421.x] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Kameyama S, Masuda H, Murakami H. Ictogenesis and symptomatogenesis of gelastic seizures in hypothalamic hamartomas: An ictal SPECT study. Epilepsia 2010; 51:2270-9. [DOI: 10.1111/j.1528-1167.2010.02739.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Klaming L, Haselager P. Did My Brain Implant Make Me Do It? Questions Raised by DBS Regarding Psychological Continuity, Responsibility for Action and Mental Competence. NEUROETHICS-NETH 2010; 6:527-539. [PMID: 24273622 PMCID: PMC3825573 DOI: 10.1007/s12152-010-9093-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Accepted: 09/07/2010] [Indexed: 11/25/2022]
Abstract
Deep brain stimulation (DBS) is a well-accepted treatment for movement disorders and is currently explored as a treatment option for various neurological and psychiatric disorders. Several case studies suggest that DBS may, in some patients, influence mental states critical to personality to such an extent that it affects an individual's personal identity, i.e. the experience of psychological continuity, of persisting through time as the same person. Without questioning the usefulness of DBS as a treatment option for various serious and treatment refractory conditions, the potential of disruptions of psychological continuity raises a number of ethical and legal questions. An important question is that of legal responsibility if DBS induced changes in a patient's personality result in damage caused by undesirable or even deviant behavior. Disruptions in psychological continuity can in some cases also have an effect on an individual's mental competence. This capacity is necessary in order to obtain informed consent to start, continue or stop treatment, and it is therefore not only important from an ethical point of view but also has legal consequences. Taking the existing literature and the Dutch legal system as a starting point, the present paper discusses the implications of DBS induced disruptions in psychological continuity for a patient's responsibility for action and competence of decision and raises a number of questions that need further research.
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Affiliation(s)
- Laura Klaming
- Tilburg Institute for Law, Technology, and Society, Tilburg University, P. O. Box 90153, 5000 LE Tilburg, The Netherlands
| | - Pim Haselager
- Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen, Montessorilaan 3, 6525 HR Nijmegen, The Netherlands
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Franzini A, Messina G, Cordella R, Marras C, Broggi G. Deep brain stimulation of the posteromedial hypothalamus: indications, long-term results, and neurophysiological considerations. Neurosurg Focus 2010; 29:E13. [PMID: 20672915 DOI: 10.3171/2010.5.focus1094] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The aim of this study was to review the indications for and results of deep brain stimulation (DBS) of the posterior hypothalamus (pHyp) in the treatment of drug-refractory and severe painful syndromes of the face, disruptive and aggressive behavior associated with epilepsy, and below-average intelligence. The preoperative clinical picture, functional imaging studies, and overall clinical results in the literature are discussed. METHODS All patients underwent stereotactic implantation of deep-brain electrodes within the pHyp. Data from several authors have been collected and reported for each clinical entity, as have clinical results, adverse events, and neurophysiological characteristics of the pHyp. RESULTS The percentage of patients with chronic cluster headache who responded to DBS was 50% in the overall reported series. The response rate was 100% for short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing and for chronic paroxysmal hemicrania, although only 2 patients and 1 patient, respectively, have been described as having these conditions. None of the 4 patients suffering from refractory neuropathic trigeminal pain benefited from the procedure (0% response rate), whereas all 5 patients (100%) affected with refractory trigeminal neuralgia (TN) due to multiple sclerosis (MS) and undergoing pHyp DBS experienced a significant decrease in pain attacks within the first branch of cranial nerve V. Six (75%) of 8 patients presenting with aggressive behavior and mental retardation benefited from pHyp stimulation; 6 patients were part of the authors' series and 2 were reported in the literature. CONCLUSIONS In carefully selected patients, DBS of the pHyp can be considered an effective procedure for the treatment of refractory trigeminal autonomic cephalalgias, aggressive behavior, and MS-related TN in the first trigeminal branch. Only larger and prospective studies along with multidisciplinary approaches (including, by necessity, neuroimaging studies) can lead us to better patient selection that would reduce the rate of nonresponders.
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Affiliation(s)
- Angelo Franzini
- Department of Neurosurgery, Fondazione IRCCS Istituto Nazionale Neurologico Carlo Besta, Milan, Italy.
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Krack P, Hariz MI, Baunez C, Guridi J, Obeso JA. Deep brain stimulation: from neurology to psychiatry? Trends Neurosci 2010; 33:474-84. [PMID: 20832128 DOI: 10.1016/j.tins.2010.07.002] [Citation(s) in RCA: 180] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Revised: 07/14/2010] [Accepted: 07/28/2010] [Indexed: 11/15/2022]
Abstract
Functional stereotaxy was introduced in the late 1940s to reduce the morbidity of lobotomy in psychiatric disease by using more focal lesions. The advent of neuroleptics led to a drastic decline in psychosurgery for several decades. Functional stereotactic neurosurgery has recently been revitalized, starting with treatment of Parkinson's disease, in which deep brain stimulation (DBS) facilitates reversible focal neuromodulation of altered basal ganglia circuits. DBS is now being extended to treatment of neuropsychiatric conditions such as Gilles de la Tourette syndrome, obsessive-compulsive disorder, depression and addiction. In this review, we discuss the concept that dysfunction of motor, limbic and associative cortico-basal ganglia-thalamocortical loops underlies these various disorders, which might now be amenable to DBS treatment.
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Affiliation(s)
- Paul Krack
- Movement Disorders Unit, Department of Psychiatry and Neurology, University Hospital Grenoble, France.
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Maley JH, Alvernia JE, Valle EP, Richardson D. Deep brain stimulation of the orbitofrontal projections for the treatment of intermittent explosive disorder. Neurosurg Focus 2010; 29:E11. [DOI: 10.3171/2010.5.focus10102] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intermittent explosive disorder (IED) is characterized by a dysfunction in the greater limbic system leading an individual to experience sudden aggressive behavior with little or no environmental perturbation. This report describes a procedure for the treatment of IED in a 19-year-old woman with a history of IED, having had episodes of severe violent attacks against family, dating to early childhood. Due to the severity and intractability of the illness, deep brain stimulation was performed, targeting the orbitofrontal projections to the hypothalamus. The patient's history and the procedure, management, and rationale are described in detail.
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Separating hope from hype: some ethical implications of the development of deep brain stimulation in psychiatric research and treatment. CNS Spectr 2010; 15:285-7. [PMID: 20448518 DOI: 10.1017/s1092852900027504] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Major depression is the most common serious brain disorder with a lifetime prevalence of up to 17%. Despite numerous options currently available for the treatment of depression, ~2 million people in the United States may experience an inadequate response to treatment (treatment-resistant depression [TRD]) at some point in their lives. The definition of TRD is variable, ranging from a failure to respond to two or more trials of antidepressant monotherapy to a failure to respond to four or more trials of different antidepressant therapies, including augmentation, combination therapy, and electroconvulsive therapy. It has been reported that as many as one-third of patients experience only a partial response to initial therapy, while nearly one-fifth are considered nonresponders. In addition to the obvious quality of life issues for the patient with TRD, the economic cost of TRD is significant. Annual healthcare costs increase significantly for patients with TRD with each successive change in antidepressant medication. Early in treatment (two medication changes), the annual costs are <$7,000/Year. By the eighth medication change, annual costs double to nearly $14,000/year.There is a well-documented need for better long-term treatments for TRD, as witnessed by multiple efforts to establish treatment algorithms and best treatment steps when first and subsequent treatment measures prove inadequate. The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, which analyzed outcome following several standardized antidepressive treatment steps, reported that 33% of patients did not respond even after four evidence-based treatment steps. A substantial proportion of patients are inadequately treated and some of these will go on to suffer from chronic, debilitating, and life-threatening symptoms.
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Ettrup KS, Sørensen JC, Bjarkam CR. The anatomy of the Göttingen minipig hypothalamus. J Chem Neuroanat 2010; 39:151-65. [DOI: 10.1016/j.jchemneu.2009.12.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Revised: 12/08/2009] [Accepted: 12/17/2009] [Indexed: 10/20/2022]
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Intraoperative microrecordings in the posterior hypothalamus of anaesthetized humans with aggressive behaviour. Neurol Sci 2010; 31:183-8. [DOI: 10.1007/s10072-010-0217-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Accepted: 01/07/2010] [Indexed: 11/26/2022]
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Kameyama S, Murakami H, Masuda H, Sugiyama I. Minimally invasive magnetic resonance imaging-guided stereotactic radiofrequency thermocoagulation for epileptogenic hypothalamic hamartomas. Neurosurgery 2009; 65:438-49; discussion 449. [PMID: 19687687 DOI: 10.1227/01.neu.0000348292.39252.b5] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To validate the safety and efficacy of magnetic resonance imaging (MRI)-guided stereotactic radiofrequency thermocoagulation (SRT) for epileptogenic hypothalamic hamartoma (HH), we evaluated surgical outcomes and revised the MRI classification. METHODS We retrospectively reviewed 25 consecutive patients with HH (age range, 2-36 years; mean age, 14.8 years) with gelastic seizures. Other seizure types were exhibited in 22 patients (88.0%), precocious puberty in 8 (32.0%), behavioral disorder in 10 (40.0%), and mental retardation in 14 (56.0%). We classified HH into 3 subtypes according to coronal MRI: intrahypothalamic, parahypothalamic, and mixed hypothalamic type. Maximum diameter ranged from 8 to 30 mm (mean, 15.3 mm). All patients underwent SRT (74 degrees C, 60 seconds) for HH. RESULTS HH subtype and size were correlated with precocious puberty, mental retardation, and behavioral disorder. Thirty-one SRT procedures were performed, requiring 1 to 8 tracks (mean, 3.8 tracks) and involving 1 to 18 lesions (mean, 7.2 lesions). There were no adaptive limitations, regardless of size or subtype. Mixed-type HHs needed more tracks and more lesions. No permanent complications persisted after SRT, and gelastic seizures disappeared in all but 2 patients. Complete seizure freedom was achieved in 19 patients (76.0%). These patients had not only disappearance of all seizure types and behavioral disorder but also intellectual improvement. CONCLUSION The present SRT procedure has favorable efficacy and invasiveness and has no adaptive limitations. SRT should therefore be considered before adulthood. The new HH classification is useful to understand clinical symptoms and to determine surgical strategies.
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Affiliation(s)
- Shigeki Kameyama
- Department of Functional Neurosurgery, Epilepsy Center, Nishi-Niigata Chuo National Hospital, Niigata, Japan.
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Sani S, Shimamoto S, Turner RS, Levesque N, Starr PA. Microelectrode recording in the posterior hypothalamic region in humans. Neurosurgery 2009; 64:ons161-7; discussion ons167-9. [PMID: 19240565 DOI: 10.1227/01.neu.0000334051.91501.e3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Deep brain stimulation of the posterior hypothalamic region (PHR) is an emerging technique for the treatment of medically intractable cluster headache. Few reports have analyzed single unit neuronal recordings in the human PHR. We report properties of spontaneous neuronal discharge in PHR for 6 patients who underwent DBS for cluster headaches. METHODS Initial target coordinates, determined by magnetic resonance imaging stereotactic localization, were 2 mm lateral, 3 mm posterior, and 5 mm inferior to the midpoint of the anterior commissure-posterior commissure plane. A single microelectrode penetration was performed beginning 10 mm above the anatomic target, without systemic sedation. Single units were discriminated off-line by cluster cutting in principal components space. Discharge rates, interspike intervals, and oscillatory activity were analyzed and compared between ventromedial thalamic and hypothalamic units. RESULTS Six patients and 24 units were evaluated. Units in the PHR had a slow, regular spontaneous discharge with wide, low-amplitude action potentials. The mean discharge rate of hypothalamic neurons was significantly lower (mean +/- standard deviation, 13.2 +/- 12.2) than that of medial thalamic units (28.0 +/- 8.2). Oscillatory activity was not detected. Microelectrode recording in this region caused no morbidity. CONCLUSION The single-unit discharge rate of neurons in the PHR of awake humans was 13.2 Hz and was significantly lower than medial thalamic neurons recorded dorsal to the target. The findings will be of use for microelectrode localization of the cluster headache target and for comparison with animal studies.
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Affiliation(s)
- Sepehr Sani
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
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