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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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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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Mithani K, Davison B, Meng Y, Lipsman N. The anterior limb of the internal capsule: Anatomy, function, and dysfunction. Behav Brain Res 2020; 387:112588. [PMID: 32179062 DOI: 10.1016/j.bbr.2020.112588] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 12/22/2019] [Accepted: 02/28/2020] [Indexed: 12/22/2022]
Abstract
The last two decades have seen a re-emergence of neurosurgery for severe, refractory psychiatric diseases, largely due to the advent of more precise and safe operative techniques. Nevertheless, the optimal targets for these surgeries remain a matter of debate, and are often grandfathered from experiences in the late 20th century. To better explore the rationale for one target in particular - the anterior limb of the internal capsule (ALIC) - we comprehensively reviewed all available literature on its role in the pathophysiology and treatment of mental illness. We first provide an overview of its functional anatomy, followed by a discussion on its role in several prevalent psychiatric diseases. Given its structural integration into the limbic system and involvement in a number of cognitive and emotional processes, the ALIC is a robust target for surgical treatment of refractory psychiatric diseases. The advent of novel neuroimaging techniques, coupled with image-guided therapeutics and neuromodulatory treatments, will continue to enable study on the ALIC in mental illness.
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Affiliation(s)
- Karim Mithani
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Ying Meng
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Nir Lipsman
- Sunnybrook Research Institute, Toronto, Ontario, Canada.
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Ems R, Garg A, Ostergard TA, Miller JP. Potential Deep Brain Stimulation Targets for the Management of Refractory Hypertension. Front Neurosci 2019; 13:93. [PMID: 30858796 PMCID: PMC6397890 DOI: 10.3389/fnins.2019.00093] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 01/25/2019] [Indexed: 11/13/2022] Open
Abstract
Hypertension is the single greatest contributor to human disease and mortality affecting over 75 million people in the United States alone. Hypertension is defined according to the American College of Cardiology as systolic blood pressure (SBP) greater than 120 mm Hg and diastolic blood pressure (DBP) above 80 mm Hg measured on two separate occasions. While there are multiple medication classes available for blood pressure control, fewer than 50% of hypertensive patients maintain appropriate control. In fact, 0.5% of patients are refractory to medical treatment which is defined as uncontrolled blood pressure despite treatment with five classes of antihypertensive agents. With new guidelines to define hypertension that will increase the incidence of hypertension world-wide, the prevalence of refractory hypertension is expected to increase. Thus, investigation into alternative methods of blood pressure control will be crucial to reduce comorbidities such as higher risk of myocardial infarction, cardiovascular accident, aneurysm formation, heart failure, coronary artery disease, end stage renal disease, arrhythmia, left ventricular hypertrophy, intracerebral hemorrhage, hypertensive enchaphelopathy, hypertensive retinopathy, glomerulosclerosis, limb loss due to arterial occlusion, and sudden death. Recently, studies demonstrated efficacious treatment of neurological diseases with deep brain stimulation (DBS) for Tourette's, depression, intermittent explosive disorder, epilepsy, chronic pain, and headache as these diseases have defined neurophysiology with anatomical targets. Currently, clinical applications of DBS is limited to neurological conditions as such conditions have well-defined neurophysiology and anatomy. However, rapidly expanding knowledge about neuroanatomical controls of systemic conditions such as hypertension are expanding the possibilities for DBS neuromodulation. Within the central autonomic network (CAN), multiple regions play a role in homeostasis and blood pressure control that could be DBS targets. While the best defined autonomic target is the ventrolateral periaqueductal gray matter, other targets including the subcallosal neocortex, subthalamic nucleus (STN), posterior hypothalamus, rostrocaudal cingulate gyrus, orbitofrontal gyrus, and insular cortex are being further characterized as potential targets. This review aims to summarize the current knowledge regarding neurologic contribution to the pathophysiology of hypertension, delineate the complex interactions between neuroanatomic structures involved in blood pressure homeostasis, and then discuss the potential for using DBS as a treatment for refractory hypertension.
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Affiliation(s)
- Raleigh Ems
- Department of Neurological Surgery, Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Anisha Garg
- Department of Neurological Surgery, Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Thomas A Ostergard
- Department of Neurological Surgery, Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Jonathan P Miller
- Department of Neurological Surgery, Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
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Di Nuzzo C, Ferrucci R, Gianoli E, Reitano M, Tedino D, Ruggiero F, Priori A. How Brain Stimulation Techniques Can Affect Moral and Social Behaviour. JOURNAL OF COGNITIVE ENHANCEMENT 2018. [DOI: 10.1007/s41465-018-0116-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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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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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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