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Herrera-Pino J, Benedetti-Isaac J, Ripoll-Córdoba D, Camargo L, Castillo-Tamara EE, Morales-Asencio B, Perea-Castro E, Torres Zambrano M, Ducassou A, Flórez Y, Porto MF, Gargiulo PA, Zurita-Cueva B, Caldichoury N, Coronado JC, Castellanos C, Ramírez-Penso C, López N. Effectiveness of deep brain stimulation on refractory aggression in pediatric patients with autism and severe intellectual disability: meta-analytic review. BMC Pediatr 2024; 24:487. [PMID: 39080575 PMCID: PMC11290060 DOI: 10.1186/s12887-024-04920-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 07/01/2024] [Indexed: 08/02/2024] Open
Abstract
Some patients with autism and severe intellectual disability may experience uncontrolled aggression, causing serious injury or harm to others, and the therapeutic ineffectiveness of traditional pharmacological and behavioral treatment may aggravate symptoms. Deep brain stimulation (DBS) has been tested in patients with little evidence in children and adolescents. Therefore, we analyzed the efficacy and safety of DBS in refractory aggression in pediatric subjects with autism (ASD) and severe intelligence deficit (ID).Methods A meta-analytic review of Web of Science (WOS) and Scopus articles, following Prisma criteria. A total of 555 articles were identified, but after applying the inclusion criteria, only 18 were analyzed. The review of the registries and the extraction of information was performed by 2 independent groups, to reduce the evaluator's bias. For the description of the results, pediatric patients with ASD or ID present in each registry, with an application of specialized scales (Overt aggression scale, OAS, and THE modified version of the OAS, MOAS) pre and post-DBS, with a clinical follow-up of at least 12 months, were considered valid. Clinical improvement was calculated using tests of aggressiveness. In each registry with available data and then pooling the means of all patients in the OAS and MOAS, the effect size of DBS (overall and per study) was estimated. Finally, the adapted NOS scale was applied to rate the studies' quality and level of bias.Results In the studies analyzed, 65/100 were pediatric patients, with a mean age of 16.8 years. Most of the studies were conducted in South America and Europe. In all teams, aggressive behavior was intractable, but only 9 groups (53/65) applied specialized scales to measure aggressiveness, and of these, only 51 subjects had a follow-up of at least 12 months. Thus, in 48/51 a clinical improvement of patients was estimated (94.2%), with a considerable overall effect size (OAS: d = 4.32; MOAS: d = 1.46). However, adverse effects and complications were found in 13/65 subjects undergoing DBS. The brain target with the most evidence and the fewest side effects was the posteromedial hypothalamic nuclei (pHypN). Finally, applying the adapted NOS scale, quality, and bias, only 9 studies show the best indicators.Conclusion An optimal level of efficacy was found in only half of the publications. This is mainly due to design errors and irrelevant information in the reports. We believe that DBS in intractable aggressiveness in children and adolescents with ASD and severe ID can be safe and effective if working groups apply rigorous criteria for patient selection, interdisciplinary assessments, objective scales for aggressiveness, and known surgical targets.
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Affiliation(s)
- Jorge Herrera-Pino
- College of Medicine, Florida International University, 11200 SW 8Th St, Miami, FL, 33199, USA
| | - Juancarlos Benedetti-Isaac
- Clinica Neurocardiovascular, Neurodinamia, Tv. 54 #21a-75, Cartagena, Colombia
- Misericordia International Clinic, Cra. 74 #76-105, Barranquilla, 080001, Colombia
| | - Daniela Ripoll-Córdoba
- Departamento de Ciencias Sociales, Universidad de La Costa, Cl. 58 #55 - 66, Barranquilla, 080002, Colombia
| | - Loida Camargo
- Facultad de Medicina, Universidad de Cartagena, Campus Zaragocilla, Cartagena de Indias, Bolívar, 130014, Colombia
| | - Edgard E Castillo-Tamara
- Facultad de Medicina, Universidad del Sinú, Provincia de Cartagena, Calle 30 #20-71, Cartagena de Indias, Bolívar, 130001, Colombia
| | - Breiner Morales-Asencio
- Departamento de Ciencias Sociales, Universidad de La Costa, Cl. 58 #55 - 66, Barranquilla, 080002, Colombia
| | - Esther Perea-Castro
- Clinica Neurocardiovascular, Neurodinamia, Tv. 54 #21a-75, Cartagena, Colombia
| | | | | | - Yuliana Flórez
- Departamento de Ciencias Sociales, Universidad de La Costa, Cl. 58 #55 - 66, Barranquilla, 080002, Colombia
| | - María F Porto
- Department of Cognition, Development and Educational Psychology, Universitat de Barcelona and Bellvitge Institute for Biomedical Research (IDIBELL), Carrer de La Feixa Llarga, L'Hospitalet de Llobregat, Barcelona, 08907, Spain
| | - Pascual A Gargiulo
- Laboratorio de Neurociencias y Psicología Experimental (CONICET), Departamento de Patología, Facultad de Ciencias Médicas, Universidad Nacional de Cuyo. Parque General San Martín, Mendoza, M5502JMA, Argentina
| | - Boris Zurita-Cueva
- Departamento de Neurocirugía, Omni Hospital, Avenida abel Romeo Castillo y ave. Tanca Marengo., Guayaquil, 090513, Ecuador
| | - Nicole Caldichoury
- Departamento de Ciencias Sociales, Universidad de Los Lagos, Av Alberto-Hertha Fuchslocher 1305, Osorno, Los Lagos, Chile
| | - Juan-Carlos Coronado
- Facultad de Salud, Universidad Católica de Temuco, Montt 56, Temuco, Araucanía, 4780000, Chile
| | - Cesar Castellanos
- Instituto Dominicano para el Estudio de la Salud Integral y la Psicología Aplicada (IDESIP), C. Eugenio Deschamps No.5, Santo Domingo, 10014, República Dominicana
| | - Cleto Ramírez-Penso
- Departamento de Neurocirugía, Director general del Centro Cardio-Neuro-Oftalmológico y Trasplante (CECANOT), C/ Federico Velázquez #1, Sector Maria Auxiliadora, Santo Domingo, República Dominicana
- Sociedad Dominicana de Neurología y Neurocirugía (Pax- President), F38M+CHM, Santo Domingo, 10106, República Dominicana
| | - Norman López
- Departamento de Ciencias Sociales, Universidad de La Costa, Cl. 58 #55 - 66, Barranquilla, 080002, Colombia.
- Escuela de Kinesiología, Facultad de Salud, Universidad Santo Tomás, Manuel Rodríguez 060, Temuco, 4790870, Chile.
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Baizabal-Carvallo JF, Cavanna AE, Jankovic J. Tics emergencies and malignant tourette syndrome: Assessment and management. Neurosci Biobehav Rev 2024; 159:105609. [PMID: 38447821 DOI: 10.1016/j.neubiorev.2024.105609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/29/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
Tourette syndrome (TS) is a complex neurodevelopmental disorder characterized by the presence of tics, frequently accompanied by a variety of neuropsychiatric comorbidities. A subset of patients with TS present with severe and disabling symptoms, requiring prompt therapeutic intervention. Some of these manifestations may result in medical emergencies when severe motor or phonic tics lead to damage of anatomical structures closely related to the tic. Examples include myelopathy or radiculopathy following severe neck ("whiplash") jerks or a variety of self-inflicted injuries. In addition to self-aggression or, less commonly, allo-aggression, some patients exhibit highly inappropriate behavior, suicidal tendencies, and rage attacks which increase the burden of the disease and are important components of "malignant TS". This subset of TS is frequently associated with comorbid obsessive-compulsive disorder. Therapeutic measures include intensive behavioral therapy, optimization of oral pharmacotherapy, botulinum toxin injections, and deep brain stimulation.
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Affiliation(s)
- José Fidel Baizabal-Carvallo
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA; Department of Sciences and Engineering, University of Guanajuato, León, Mexico.
| | - Andrea E Cavanna
- Department of Neuropsychiatry, BSMHFT and University of Birmingham, Birmingham, United Kingdom; Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology and University College London, London, United Kingdom; School of Health and Life Sciences, Aston Institute of Health and Neurodevelopment, Aston University, Birmingham, United Kingdom; School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
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Santin MDN, Tempier N, Belaid H, Zenoni M, Dumas S, Wallén-Mackenzie Å, Bardinet E, Destrieux C, François C, Karachi C. Anatomical characterisation of three different psychosurgical targets in the subthalamic area: from the basal ganglia to the limbic system. Brain Struct Funct 2023; 228:1977-1992. [PMID: 37668733 DOI: 10.1007/s00429-023-02691-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 07/24/2023] [Indexed: 09/06/2023]
Abstract
Effective neural stimulation for the treatment of severe psychiatric disorders needs accurate characterisation of surgical targets. This is especially true for the medial subthalamic region (MSR) which contains three targets: the anteromedial STN for obsessive compulsive disorder (OCD), the medial forebrain bundle (MFB) for depression and OCD, and the "Sano triangle" for pathological aggressiveness. Blocks containing the subthalamic area were obtained from two human brains. After obtaining 11.7-Tesla MRI, blocks were cut in regular sections for immunohistochemistry. Fluorescent in situ hybridisation was performed on the macaque MSR. Electron microscopic observation for synaptic specialisation was performed on human and macaque subthalamic fresh samples. Images of human brain sections were reconstructed in a cryoblock which was registered on the MRI and histological slices were then registered. The STN contains glutamatergic and fewer GABAergic neurons and has no strict boundary with the adjacent MSR. The anteromedial STN has abundant dopaminergic and serotoninergic innervation with very sparse dopaminergic neurons. The MFB is composed of dense anterior dopaminergic and posterior serotoninergic fibres, and fewer cholinergic and glutamatergic fibres. Medially, the Sano triangle presumably contains orexinergic terminals from the hypothalamus, and neurons with strong nuclear oestrogen receptor-alpha staining with a decreased anteroposterior and mediolateral gradient of staining. These findings provide new insight regarding MSR cells and their fibre specialisation, forming a transition zone between the basal ganglia and the limbic systems. Our 3D reconstruction enabled us to visualize the main histological features of the three targets which should enable better targeting and understanding of neuromodulatory stimulation results in severe psychiatric conditions.
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Affiliation(s)
- Marie des Neiges Santin
- Sorbonne Université, Institut du Cerveau-Paris Brain Institute- ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière, 75013, Paris, France
| | - Nicolas Tempier
- Sorbonne Université, Institut du Cerveau-Paris Brain Institute- ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière, 75013, Paris, France
| | - Hayat Belaid
- Service de Neurochirurgie, Hôpital Fondation Adolphe de Rothschild, 29 rue Manin, Paris, France
| | - Matthieu Zenoni
- Sorbonne Université, Institut du Cerveau-Paris Brain Institute- ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière, 75013, Paris, France
| | | | - Åsa Wallén-Mackenzie
- Department of Organismal Biology, Unit of Comparative Physiology, Uppsala University, S-756 32, Uppsala, Sweden
| | - Eric Bardinet
- Sorbonne Université, Institut du Cerveau-Paris Brain Institute- ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière, 75013, Paris, France
| | - Christophe Destrieux
- UMR Inserm U1253, IBrain, Université de Tours, Tours, France
- Laboratoire d'Anatomie, Faculté de Médecine, Université François Rabelais, Tours, France
| | - Chantal François
- Sorbonne Université, Institut du Cerveau-Paris Brain Institute- ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière, 75013, Paris, France
| | - Carine Karachi
- Sorbonne Université, Institut du Cerveau-Paris Brain Institute- ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière, 75013, Paris, France.
- AP-HP, Hôpital de la Pitié-Salpêtrière, Service de Neurochirurgie, Paris, France.
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Vega-Zelaya L, Pastor J. The Network Systems Underlying Emotions: The Rational Foundation of Deep Brain Stimulation Psychosurgery. Brain Sci 2023; 13:943. [PMID: 37371421 DOI: 10.3390/brainsci13060943] [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: 05/02/2023] [Revised: 06/08/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Science and philosophy have tried to understand the origin of emotions for centuries. However, only in the last 150 years have we started to try to understand them in a neuroscientific scope. Emotions include physiological changes involving different systems, such as the endocrine or the musculoskeletal, but they also cause a conscious experience of those changes that are embedded in memory. In addition to the cortico-striato-thalamo-cortical circuit, which is the most important of the basal ganglia, the limbic system and prefrontal circuit are primarily involved in the process of emotion perceptions, thoughts, and memories. The purpose of this review is to describe the anatomy and physiology of the different brain structures involved in circuits that underlie emotions and behaviour, underlying the symptoms of certain psychiatric pathologies. These circuits are targeted during deep brain stimulation (DBS) and knowledge of them is mandatory to understand the clinical-physiological implications for the treatment. We summarize the main outcomes of DBS treatment in several psychiatric illness such as obsessive compulsive disorder, refractory depression, erethism and other conditions, aiming to understand the rationale for selecting these neural systems as targets for DBS.
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Affiliation(s)
- Lorena Vega-Zelaya
- Clinical Neurophysiology, Instituto de Investigación Biomédica Hospital, Universitario de La Princesa, C/Diego de León 62, 28006 Madrid, Spain
| | - Jesús Pastor
- Clinical Neurophysiology, Instituto de Investigación Biomédica Hospital, Universitario de La Princesa, C/Diego de León 62, 28006 Madrid, Spain
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Carrillo-Ruiz JD, Carrillo-Márquez JR, Beltrán JQ, Jiménez-Ponce F, García-Muñoz L, Navarro-Olvera JL, Márquez-Franco R, Velasco F. Innovative perspectives in limbic surgery using deep brain stimulation. Front Neurosci 2023; 17:1167244. [PMID: 37274213 PMCID: PMC10233042 DOI: 10.3389/fnins.2023.1167244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/24/2023] [Indexed: 06/06/2023] Open
Abstract
Limbic surgery is one of the most attractive and retaken fields of functional neurosurgery in the last two decades. Psychiatric surgery emerged from the incipient work of Moniz and Lima lesioning the prefrontal cortex in agitated patients. Since the onset of stereotactic and functional neurosurgery with Spiegel and Wycis, the treatment of mental diseases gave attention to refractory illnesses mainly with the use of thalamotomies. Neurosis and some psychotic symptoms were treated by them. Several indications when lesioning the brain were included: obsessive-compulsive disorder, depression, and aggressiveness among others with a diversity of targets. The indiscriminately use of anatomical sites without enough scientific evidence, and uncertainly defined criteria for selecting patients merged with a deficiency in ethical aspects, brought a lack of procedures for a long time: only select clinics allowed this surgery around the world from 1950 to the 1990s. In 1999, Nuttin et al. began a new chapter in limbic surgery with the use of Deep Brain Stimulation, based on the experience of pain, Parkinson's disease, and epilepsy. The efforts were focused on different targets to treat depression and obsessive-compulsive disorders. Nevertheless, other diseases were added to use neuromodulation. The goal of this article is to show the new opportunities to treat neuropsychiatric diseases.
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Affiliation(s)
- José Damián Carrillo-Ruiz
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
- Research Direction, Mexico General Hospital, Mexico City, Mexico
- Neuroscience Coordination, Psychology Faculty, Anahuac University, Mexico City, Mexico
| | - José Rodrigo Carrillo-Márquez
- Faculty of Health Sciences, Anahuac University, Mexico City, Mexico
- Alpha Health Sciences Leadership Program, Anahuac University, Mexico City, Mexico
| | - Jesús Quetzalcóatl Beltrán
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
| | - Fiacro Jiménez-Ponce
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
| | - Luis García-Muñoz
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
| | - José Luis Navarro-Olvera
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
| | - René Márquez-Franco
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
| | - Francisco Velasco
- Stereotactic, Functional & Radiosurgery Unit of Neurosurgery Service, Mexico General Hospital, Mexico City, Mexico
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Fritz M, Soravia SM, Dudeck M, Malli L, Fakhoury M. Neurobiology of Aggression-Review of Recent Findings and Relationship with Alcohol and Trauma. BIOLOGY 2023; 12:biology12030469. [PMID: 36979161 PMCID: PMC10044835 DOI: 10.3390/biology12030469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/14/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023]
Abstract
Aggression can be conceptualized as any behavior, physical or verbal, that involves attacking another person or animal with the intent of causing harm, pain or injury. Because of its high prevalence worldwide, aggression has remained a central clinical and public safety issue. Aggression can be caused by several risk factors, including biological and psychological, such as genetics and mental health disorders, and socioeconomic such as education, employment, financial status, and neighborhood. Research over the past few decades has also proposed a link between alcohol consumption and aggressive behaviors. Alcohol consumption can escalate aggressive behavior in humans, often leading to domestic violence or serious crimes. Converging lines of evidence have also shown that trauma and posttraumatic stress disorder (PTSD) could have a tremendous impact on behavior associated with both alcohol use problems and violence. However, although the link between trauma, alcohol, and aggression is well documented, the underlying neurobiological mechanisms and their impact on behavior have not been properly discussed. This article provides an overview of recent advances in understanding the translational neurobiological basis of aggression and its intricate links to alcoholism and trauma, focusing on behavior. It does so by shedding light from several perspectives, including in vivo imaging, genes, receptors, and neurotransmitters and their influence on human and animal behavior.
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Affiliation(s)
- Michael Fritz
- School of Health and Social Sciences, AKAD University of Applied Sciences, 70191 Stuttgart, Germany
- Department of Forensic Psychiatry and Psychotherapy, Ulm University, BKH Günzburg, Lindenallee 2, 89312 Günzburg, Germany
| | - Sarah-Maria Soravia
- Department of Forensic Psychiatry and Psychotherapy, Ulm University, BKH Günzburg, Lindenallee 2, 89312 Günzburg, Germany
| | - Manuela Dudeck
- Department of Forensic Psychiatry and Psychotherapy, Ulm University, BKH Günzburg, Lindenallee 2, 89312 Günzburg, Germany
| | - Layal Malli
- Department of Natural Sciences, School of Arts and Sciences, Lebanese American University, Beirut P.O. Box 13-5053, Lebanon
| | - Marc Fakhoury
- Department of Natural Sciences, School of Arts and Sciences, Lebanese American University, Beirut P.O. Box 13-5053, Lebanon
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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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Martínez-Álvarez R, Torres-Diaz C. Surgery of autism: Is it possible? PROGRESS IN BRAIN RESEARCH 2022; 272:73-84. [PMID: 35667807 DOI: 10.1016/bs.pbr.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Autism spectrum disorder (ASD) is a developmental disability of the brain that can be associated to severe conductual alterations, such as self or heteroaggression and obsessive and compulsive behavior. Many of these patients do not improve with any pharmacological or behavioral therapy and represent a major social problem. We describe the outcome of patients with ASD, treated with radiofrequency brain lesions combined with Gamma Knife radiosurgery for therapy-resistant aggressiveness, obsessive thoughts, and compulsions. The ASD adapted YBOCS, PCQ and EAE scales assessed the therapeutic effect on symptoms. All patients had a significant reduction of their symptoms (YBOCS:34 and 22 PCQ 42 and 35, EAE 11 and 5.5, respectively), although all needed more than one treatment to maintain this improvement. The treatments resulted very safe for the patients and their neurological status has not change. We conclude that in these patients after surgery, there is a marked improvement in behavior, quality of life and relationship with the environment, with no evidence of secondary damage. Changes in connectivity might mediate the clinical improvement, although it is necessary to confirm these results with further studies.
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Affiliation(s)
- Roberto Martínez-Álvarez
- Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, Madrid, Spain.
| | - Cristina Torres-Diaz
- Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, Madrid, Spain; Department of Neurosurgery, La Princesa Hospital, Madrid, Spain
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Masaki T, Ozeki Y, Yoshida Y, Okamoto M, Miyamoto S, Gotoh K, Shibata H. Glucagon-Like Peptide-1 Receptor Agonist Semaglutide Improves Eating Behavior and Glycemic Control in Japanese Obese Type 2 Diabetic Patients. Metabolites 2022; 12:147. [PMID: 35208221 PMCID: PMC8878247 DOI: 10.3390/metabo12020147] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 01/31/2022] [Accepted: 02/02/2022] [Indexed: 02/04/2023] Open
Abstract
We evaluated time-course changes and the relationship between eating behavior and glycemic profile during the treatment of 34 obese type 2 diabetic patients with the glucagon-like peptide-1 receptor agonist (GLP1-RA) semaglutide. Changes in dietary habits were evaluated using the Japan Society for the Study of Obesity questionnaire. Semaglutide improved body weight and hemoglobin A1C (HbA1c) 3 and 6 months after treatment. In addition, semaglutide led to marked improvements in the total scores for eating behavior items on the questionnaire. In particular, changes in the scores regarding the sensation of hunger, food preference, eating style, regularity of eating habits and emotional eating behavior were significantly improved during semaglutide treatment. By contrast, there were no significant changes in the scores for the recognition of weight and constitution and external eating behavior. Furthermore, changes in the scores regarding the sensation of hunger and food preference were correlated with changes in HbA1c after semaglutide treatment. Multivariable regression analyses showed that the change in the sensation of hunger was related to HbA1c during treatment. In conclusion, the GLP1-RA semaglutide regulates eating behavior, and, in particular, the sensation of hunger is closely related to the improvement in HbA1c by semaglutide in obese patients with type 2 diabetes.
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Affiliation(s)
- Takayuki Masaki
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Yufu City 879-5593, Japan; (Y.O.); (Y.Y.); (M.O.); (S.M.); (K.G.); (H.S.)
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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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Kelly R, Pearce J, Sani S. Commentary: 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:E454-E456. [PMID: 34467982 PMCID: PMC8510845 DOI: 10.1093/ons/opab293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 07/06/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- Ryan Kelly
- Rush University Medical Center, Department of Neurosurgery, Rush University, Chicago, Illinois, USA
| | - John Pearce
- Rush University Medical Center, Department of Neurosurgery, Rush University, Chicago, Illinois, USA
| | - Sepher Sani
- Rush University Medical Center, Department of Neurosurgery, Rush University, Chicago, Illinois, USA
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12
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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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Ashkan K, Mirza AB, Tambirajoo K, Furlanetti L. Deep brain stimulation in the management of paediatric neuropsychiatric conditions: Current evidence and future directions. Eur J Paediatr Neurol 2021; 33:146-158. [PMID: 33092983 DOI: 10.1016/j.ejpn.2020.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/21/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Neurosurgery has provided an alternative option for patients with refractory psychiatric indications. Lesion procedures were the initial techniques used, but deep brain stimulation (DBS) has the advantage of relative reversibility and adjustability. This review sets out to delineate the current evidence for DBS use in psychiatric conditions, with an emphasis on the paediatric population, highlighting pitfalls and opportunities. METHODS A systematic review of the literature was conducted on studies reporting the use of DBS in the management of psychiatric disorders. The PRISMA guidelines were employed to structure the review of the literature. Data was discussed focusing on the indications for DBS management of psychiatric conditions in the paediatric age group. RESULTS A total of seventy-three full-text papers reported the use of DBS surgery for the management of psychiatric conditions matching the inclusion criteria. The main indications were Tourette Syndrome (GTS) (15 studies), Obsessive Compulsive Disorder (OCD) (20), Treatment Resistant Depression (TRD) (27), Eating Disorders (ED) (7) and Aggressive Behaviour and self-harm (AB) (4). Out of these, only 11 studies included patients in the paediatric age group (≤18 years-old). Among the paediatric patients, the indications for surgery included GTS, AB and ED. CONCLUSIONS The application of deep brain stimulation for psychiatric indications has progressed at a steady pace in the adult population and at a much slower pace in the paediatric population. Future studies in children should be done in a trial setting with strict and robust criteria. A move towards personalising DBS therapy with new stimulation paradigms will provide new frontiers and possibilities in this growing field.
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Affiliation(s)
- Keyoumars Ashkan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK; King's Health Partners Academic Health Sciences Centre, London, UK
| | - Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK; King's Health Partners Academic Health Sciences Centre, London, UK
| | - Kantharuby Tambirajoo
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK; King's Health Partners Academic Health Sciences Centre, London, UK
| | - Luciano Furlanetti
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK; King's Health Partners Academic Health Sciences Centre, London, UK.
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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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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 2021; 134:366-375. [PMID: 32032944 DOI: 10.3171/2019.11.jns192608] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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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16
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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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Gabery S, Salinas CG, Paulsen SJ, Ahnfelt-Rønne J, Alanentalo T, Baquero AF, Buckley ST, Farkas E, Fekete C, Frederiksen KS, Helms HCC, Jeppesen JF, John LM, Pyke C, Nøhr J, Lu TT, Polex-Wolf J, Prevot V, Raun K, Simonsen L, Sun G, Szilvásy-Szabó A, Willenbrock H, Secher A, Knudsen LB, Hogendorf WFJ. Semaglutide lowers body weight in rodents via distributed neural pathways. JCI Insight 2020; 5:133429. [PMID: 32213703 DOI: 10.1172/jci.insight.133429] [Citation(s) in RCA: 256] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 02/26/2020] [Indexed: 12/16/2022] Open
Abstract
Semaglutide, a glucagon-like peptide 1 (GLP-1) analog, induces weight loss, lowers glucose levels, and reduces cardiovascular risk in patients with diabetes. Mechanistic preclinical studies suggest weight loss is mediated through GLP-1 receptors (GLP-1Rs) in the brain. The findings presented here show that semaglutide modulated food preference, reduced food intake, and caused weight loss without decreasing energy expenditure. Semaglutide directly accessed the brainstem, septal nucleus, and hypothalamus but did not cross the blood-brain barrier; it interacted with the brain through the circumventricular organs and several select sites adjacent to the ventricles. Semaglutide induced central c-Fos activation in 10 brain areas, including hindbrain areas directly targeted by semaglutide, and secondary areas without direct GLP-1R interaction, such as the lateral parabrachial nucleus. Automated analysis of semaglutide access, c-Fos activity, GLP-1R distribution, and brain connectivity revealed that activation may involve meal termination controlled by neurons in the lateral parabrachial nucleus. Transcriptomic analysis of microdissected brain areas from semaglutide-treated rats showed upregulation of prolactin-releasing hormone and tyrosine hydroxylase in the area postrema. We suggest semaglutide lowers body weight by direct interaction with diverse GLP-1R populations and by directly and indirectly affecting the activity of neural pathways involved in food intake, reward, and energy expenditure.
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Affiliation(s)
| | | | | | | | | | - Arian F Baquero
- Institute of Experimental Medicine Hungarian Academy of Sciences, Budapest, Hungary
| | - Stephen T Buckley
- Global Research Technologies, Novo Nordisk A/S, Måløv, Denmark, and Seattle, Washington, USA
| | - Erzsébet Farkas
- Institute of Experimental Medicine Hungarian Academy of Sciences, Budapest, Hungary
| | - Csaba Fekete
- Institute of Experimental Medicine Hungarian Academy of Sciences, Budapest, Hungary
| | | | - Hans Christian C Helms
- Global Research Technologies, Novo Nordisk A/S, Måløv, Denmark, and Seattle, Washington, USA
| | | | | | | | | | | | | | - Vincent Prevot
- Inserm, Laboratory of Development and Plasticity of the Neuroendocrine Brain, Jean-Pierre Aubert Research Centre, Lille, France
| | | | | | - Gao Sun
- Global Research Technologies, Novo Nordisk A/S, Måløv, Denmark, and Seattle, Washington, USA
| | - Anett Szilvásy-Szabó
- Institute of Experimental Medicine Hungarian Academy of Sciences, Budapest, Hungary
| | - Hanni Willenbrock
- Global Research Technologies, Novo Nordisk A/S, Måløv, Denmark, and Seattle, Washington, USA
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Gouveia FV, Hamani C, Fonoff ET, Brentani H, Alho EJL, de Morais RMCB, de Souza AL, Rigonatti SP, Martinez RCR. Amygdala and Hypothalamus: Historical Overview With Focus on Aggression. Neurosurgery 2019; 85:11-30. [PMID: 30690521 PMCID: PMC6565484 DOI: 10.1093/neuros/nyy635] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 01/08/2019] [Indexed: 12/29/2022] Open
Abstract
Aggressiveness has a high prevalence in psychiatric patients and is a major health problem. Two brain areas involved in the neural network of aggressive behavior are the amygdala and the hypothalamus. While pharmacological treatments are effective in most patients, some do not properly respond to conventional therapies and are considered medically refractory. In this population, surgical procedures (ie, stereotactic lesions and deep brain stimulation) have been performed in an attempt to improve symptomatology and quality of life. Clinical results obtained after surgery are difficult to interpret, and the mechanisms responsible for postoperative reductions in aggressive behavior are unknown. We review the rationale and neurobiological characteristics that may help to explain why functional neurosurgery has been proposed to control aggressive behavior.
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Affiliation(s)
| | - Clement Hamani
- Department of Neurology, Division of Functional Neurosurgery of the Institute of Psychiatry, University of Sao Paulo School, Medicine School, Sao Paulo, Brazil
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Erich Talamoni Fonoff
- Department of Neurology, Division of Functional Neurosurgery of the Institute of Psychiatry, University of Sao Paulo School, Medicine School, Sao Paulo, Brazil
| | - Helena Brentani
- Department of Psychiatry, University of Sao Paulo, Medical School, Sao Paulo, Brazil
- National Institute of Developmental Psychiatry for Children and Adolescents, CNPq, Sao Paulo, Brazil
| | - Eduardo Joaquim Lopes Alho
- Department of Neurology, Division of Functional Neurosurgery of the Institute of Psychiatry, University of Sao Paulo School, Medicine School, Sao Paulo, Brazil
| | | | - Aline Luz de Souza
- Department of Neurology, Division of Functional Neurosurgery of the Institute of Psychiatry, University of Sao Paulo School, Medicine School, Sao Paulo, Brazil
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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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20
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Hernández Salazar M, Zarate Méndez A, Meneses Luna O, Ledesma Torres L, Paniagua Sierra R, Sánchez Moreno MC, Serrato Avila JL. Ablative stereotactic neurosurgery for irreducible neuroaggressive disorder in pediatric patients. Neurocirugia (Astur) 2018; 29:296-303. [PMID: 29914842 DOI: 10.1016/j.neucir.2018.05.003] [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: 01/04/2018] [Revised: 05/07/2018] [Accepted: 05/10/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND OBJECTIVES The irreducible neuroaggressive disorder (IND) is a well-described entity known to be associated with impulsive and aggressive behavior. While various studies have assessed available pharmacological and non-pharmacological treatment regimens, patients with IND continue to pose a major threat to themselves and society. While targeted stereotactic therapy for IND has gained traction in recent years, there is a paucity of information describing comparative effectiveness of different validated anatomic regions. In this paper, we discuss the surgical results for patients with IND following targeted lesional therapy with a special focus on selection criteria and operative methods. The objective is to analyze the efficacy and safety of the different described targets for this disorder in pediatric patients. MATERIALS AND METHODS Eight pediatric patients met strict criteria for IND and were enrolled in this study. Electroencephalography (EEG), video electroencephalography (VEEG) and magnetic resonance imaging (MRI) were performed in all patients prior to surgery. Irreducible neuroagressive symptom was approached by lesional therapy based on most described targets for this disorder and assessed by The Overt Agressive Scale (OAS) pre-operatively and 6 months following surgery, using Wilcoxon test for statistical analysis. RESULTS AND CONCLUSIONS The average patient age was 13 years 2 months. 7 of the 8 patients enrolled had intellectual disabilities, 1 patient suffered neurologic sequelae referable to Dandy Walker syndrome and 7 patients had no preoperative anatomical alterations. Following surgery, patients with IND noted improvement in their OAS. On average, the OAS improved by 39.29% (P=.0156), a figure similar in comparison to studies assessing treatment of IND in adult patients. The most satisfactory results were achieved in patients whose ablative therapy involved the Amygdala in their targets. There were no deaths or permanent neurological deficits attributable to procedure. To the author's knowledge, this is the largest series described in the literature for pediatric patients with IND treated with lesional stereotactic therapy.
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Affiliation(s)
| | | | | | | | - Ramón Paniagua Sierra
- Centro Médico Nacional Siglo XXI, Hospital de Especialidades, Ciudad de México, México
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De Salles AAF, Barbosa DAN, Fernandes F, Abucham J, Nazato DM, Oliveira JD, Cury A, Biasi A, Rossi R, Lasagno C, Bueno PT, Santos RHN, Damiani LP, Gorgulho AA. An Open-Label Clinical Trial of Hypothalamic Deep Brain Stimulation for Human Morbid Obesity: BLESS Study Protocol. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Human morbid obesity is increasing worldwide in an alarming way. The hypothalamus is known to mediate its mechanisms. Deep brain stimulation (DBS) of the ventromedial hypothalamus (VMH) may be an alternative to treat patients refractory to standard medical and surgical therapies.
OBJECTIVE
To assess the safety, identify possible side effects, and to optimize stimulation parameters of continuous VMH-DBS. Additionally, this study aims to determine if continuous VMH-DBS will lead to weight loss by causing changes in body composition, basal metabolism, or food intake control.
METHODS
The BLESS study is a feasibility study, single-center open-label trial. Six patients (body mass index > 40) will undergo low-frequency VMH-DBS. Data concerning timing, duration, frequency, severity, causal relationships, and associated electrical stimulation patterns regarding side effects or weight changes will be recorded.
EXPECTED OUTCOMES
We expect to demonstrate the safety, identify possible side effects, and to optimize electrophysiological parameters related to VMH-DBS. No clinical or behavioral adverse changes are expected. Weight loss ≥ 3% of the basal weight after 3 mo of electrical stimulation will be considered adequate. Changes in body composition and increase in basal metabolism are expected. The amount of food intake is likely to remain unchanged.
DISCUSSION
The design of this study protocol is to define the safety of the procedure, the surgical parameters important for target localization, and additionally the safety of long-term stimulation of the VMH in morbidly obese patients. Novel neurosurgical approaches to treat metabolic and autonomic diseases can be developed based on the data made available by this investigation.
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Affiliation(s)
- Antonio A F De Salles
- Neuroscience Institute—Heart Hospital (HCor Neuro), University of São Paulo (USP), São Paulo, Brazil
- Research Institute—Heart Hospital (HCor IEP), University of São Paulo (USP), São Paulo, Brazil
| | - Daniel A N Barbosa
- Neuroscience Institute—Heart Hospital (HCor Neuro), University of São Paulo (USP), São Paulo, Brazil
| | - Fernando Fernandes
- Neuroscience Institute—Heart Hospital (HCor Neuro), University of São Paulo (USP), São Paulo, Brazil
- Department of Psychiatry, University of São Paulo (USP), São Paulo, Brazil
| | - Julio Abucham
- Department of Medicine, University Federal of São Paulo (UNIFESP), São Paulo, Brazil
| | - Debora M Nazato
- Department of Medicine, University Federal of São Paulo (UNIFESP), São Paulo, Brazil
| | - Juliana D Oliveira
- Research Institute—Heart Hospital (HCor IEP), University of São Paulo (USP), São Paulo, Brazil
| | - Abrão Cury
- Department of Medicine, University Federal of São Paulo (UNIFESP), São Paulo, Brazil
| | - Alexandre Biasi
- Neuroscience Institute—Heart Hospital (HCor Neuro), University of São Paulo (USP), São Paulo, Brazil
| | - Ronaldo Rossi
- Research Institute—Heart Hospital (HCor IEP), University of São Paulo (USP), São Paulo, Brazil
| | - Camila Lasagno
- Research Institute—Heart Hospital (HCor IEP), University of São Paulo (USP), São Paulo, Brazil
| | - Priscila T Bueno
- Research Institute—Heart Hospital (HCor IEP), University of São Paulo (USP), São Paulo, Brazil
| | - Renato H N Santos
- Research Institute—Heart Hospital (HCor IEP), University of São Paulo (USP), São Paulo, Brazil
| | - Lucas P Damiani
- Research Institute—Heart Hospital (HCor IEP), University of São Paulo (USP), São Paulo, Brazil
| | - Alessandra A Gorgulho
- Neuroscience Institute—Heart Hospital (HCor Neuro), University of São Paulo (USP), São Paulo, Brazil
- Research Institute—Heart Hospital (HCor IEP), University of São Paulo (USP), São Paulo, Brazil
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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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Abstract
BACKGROUND Despite optimal medical treatment, including epilepsy surgery, many epilepsy patients have uncontrolled seizures. Since the 1970s interest has grown in invasive intracranial neurostimulation as a treatment for these patients. Intracranial stimulation includes both deep brain stimulation (DBS) (stimulation through depth electrodes) and cortical stimulation (subdural electrodes). This is an updated version of a previous Cochrane review published in 2014. OBJECTIVES To assess the efficacy, safety and tolerability of DBS and cortical stimulation for refractory epilepsy based on randomized controlled trials (RCTs). SEARCH METHODS We searched the Cochrane Epilepsy Group Specialized Register on 29 September 2015, but it was not necessary to update this search, because records in the Specialized Register are included in CENTRAL. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 11, 5 November 2016), PubMed (5 November 2016), ClinicalTrials.gov (5 November 2016), the WHO International Clinical Trials Registry Platform ICTRP (5 November 2016) and reference lists of retrieved articles. We also contacted device manufacturers and other researchers in the field. No language restrictions were imposed. SELECTION CRITERIA RCTs comparing deep brain or cortical stimulation versus sham stimulation, resective surgery, further treatment with antiepileptic drugs or other neurostimulation treatments (including vagus nerve stimulation). DATA COLLECTION AND ANALYSIS Four review authors independently selected trials for inclusion. Two review authors independently extracted the relevant data and assessed trial quality and overall quality of evidence. The outcomes investigated were seizure freedom, responder rate, percentage seizure frequency reduction, adverse events, neuropsychological outcome and quality of life. If additional data were needed, the study investigators were contacted. Results were analysed and reported separately for different intracranial targets for reasons of clinical heterogeneity. MAIN RESULTS Twelve RCTs were identified, eleven of these compared one to three months of intracranial neurostimulation with sham stimulation. One trial was on anterior thalamic DBS (n = 109; 109 treatment periods); two trials on centromedian thalamic DBS (n = 20; 40 treatment periods), but only one of the trials (n = 7; 14 treatment periods) reported sufficient information for inclusion in the quantitative meta-analysis; three trials on cerebellar stimulation (n = 22; 39 treatment periods); three trials on hippocampal DBS (n = 15; 21 treatment periods); one trial on nucleus accumbens DBS (n = 4; 8 treatment periods); and one trial on responsive ictal onset zone stimulation (n = 191; 191 treatment periods). In addition, one small RCT (n = 6) compared six months of hippocampal DBS versus sham stimulation. Evidence of selective reporting was present in four trials and the possibility of a carryover effect complicating interpretation of the results could not be excluded in five cross-over trials without any or a sufficient washout period. Moderate-quality evidence could not demonstrate statistically or clinically significant changes in the proportion of patients who were seizure-free or experienced a 50% or greater reduction in seizure frequency (primary outcome measures) after one to three months of anterior thalamic DBS in (multi)focal epilepsy, responsive ictal onset zone stimulation in (multi)focal epilepsy patients and hippocampal DBS in (medial) temporal lobe epilepsy. However, a statistically significant reduction in seizure frequency was found for anterior thalamic DBS (mean difference (MD), -17.4% compared to sham stimulation; 95% confidence interval (CI) -31.2 to -1.0; high-quality evidence), responsive ictal onset zone stimulation (MD -24.9%; 95% CI -40.1 to -6.0; high-quality evidence) and hippocampal DBS (MD -28.1%; 95% CI -34.1 to -22.2; moderate-quality evidence). Both anterior thalamic DBS and responsive ictal onset zone stimulation do not have a clinically meaningful impact on quality life after three months of stimulation (high-quality evidence). Electrode implantation resulted in postoperative asymptomatic intracranial haemorrhage in 1.6% to 3.7% of the patients included in the two largest trials and 2.0% to 4.5% had postoperative soft tissue infections (9.4% to 12.7% after five years); no patient reported permanent symptomatic sequelae. Anterior thalamic DBS was associated with fewer epilepsy-associated injuries (7.4 versus 25.5%; P = 0.01) but higher rates of self-reported depression (14.8 versus 1.8%; P = 0.02) and subjective memory impairment (13.8 versus 1.8%; P = 0.03); there were no significant differences in formal neuropsychological testing results between the groups. Responsive ictal-onset zone stimulation seemed to be well-tolerated with few side effects.The limited number of patients preclude firm statements on safety and tolerability of hippocampal DBS. With regards to centromedian thalamic DBS, nucleus accumbens DBS and cerebellar stimulation, no statistically significant effects could be demonstrated but evidence is of only low to very low quality. AUTHORS' CONCLUSIONS Except for one very small RCT, only short-term RCTs on intracranial neurostimulation for epilepsy are available. Compared to sham stimulation, one to three months of anterior thalamic DBS ((multi)focal epilepsy), responsive ictal onset zone stimulation ((multi)focal epilepsy) and hippocampal DBS (temporal lobe epilepsy) moderately reduce seizure frequency in refractory epilepsy patients. Anterior thalamic DBS is associated with higher rates of self-reported depression and subjective memory impairment. There is insufficient evidence to make firm conclusive statements on the efficacy and safety of hippocampal DBS, centromedian thalamic DBS, nucleus accumbens DBS and cerebellar stimulation. There is a need for more, large and well-designed RCTs to validate and optimize the efficacy and safety of invasive intracranial neurostimulation treatments.
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Affiliation(s)
- Mathieu Sprengers
- Ghent University HospitalDepartment of Neurology1K12, 185 De PintelaanGhentBelgiumB‐9000
| | - Kristl Vonck
- Ghent University HospitalDepartment of Neurology1K12, 185 De PintelaanGhentBelgiumB‐9000
| | - Evelien Carrette
- Ghent University HospitalDepartment of Neurology1K12, 185 De PintelaanGhentBelgiumB‐9000
| | - Anthony G Marson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
| | - Paul Boon
- Ghent University HospitalDepartment of Neurology1K12, 185 De PintelaanGhentBelgiumB‐9000
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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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Zhang S, Zhou P, Jiang S, Li P, Wang W. Bilateral anterior capsulotomy and amygdalotomy for mental retardation with psychiatric symptoms and aggression: A case report. Medicine (Baltimore) 2017; 96:e5840. [PMID: 28072743 PMCID: PMC5228703 DOI: 10.1097/md.0000000000005840] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Mental retardation (MR) is a chronic condition that often has no readily identifiable cause or treatment. Aggression and psychiatric symptoms are prevalent in children with MR. Surgical treatment of aggression and psychiatric symptoms of MR is seldom investigated and studies are limited. PATIENT CONCERNS We encountered a 19-year-old female who had MR with aggression and psychiatric symptoms. DIAGNOSES She was diagnosed with mild MR with aggressiveness and psychiatric symptoms. INTERVENTIONS Because the patient was refractory to conservative treatment, bilateral anterior capsulotomy and amygdaloid neurosurgery were performed for her psychiatric symptoms and aggression. The benefits and side effects of the surgery were analyzed. OUTCOMES After surgery, the patient showed significant alleviation of her psychiatric symptoms and aggression with no observed side effects. LESSONS Bilateral anterior capsulotomy in combination with amygdaloid neurosurgery may resolve both psychiatric and aggressive symptoms. Future investigations of control studies with large patient cohorts are needed.
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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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Bayless DW, Shah NM. Genetic dissection of neural circuits underlying sexually dimorphic social behaviours. Philos Trans R Soc Lond B Biol Sci 2016; 371:20150109. [PMID: 26833830 DOI: 10.1098/rstb.2015.0109] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2015] [Indexed: 11/12/2022] Open
Abstract
The unique hormonal, genetic and epigenetic environments of males and females during development and adulthood shape the neural circuitry of the brain. These differences in neural circuitry result in sex-typical displays of social behaviours such as mating and aggression. Like other neural circuits, those underlying sex-typical social behaviours weave through complex brain regions that control a variety of diverse behaviours. For this reason, the functional dissection of neural circuits underlying sex-typical social behaviours has proved to be difficult. However, molecularly discrete neuronal subpopulations can be identified in the heterogeneous brain regions that control sex-typical social behaviours. In addition, the actions of oestrogens and androgens produce sex differences in gene expression within these brain regions, thereby highlighting the neuronal subpopulations most likely to control sexually dimorphic social behaviours. These conditions permit the implementation of innovative genetic approaches that, in mammals, are most highly advanced in the laboratory mouse. Such approaches have greatly advanced our understanding of the functional significance of sexually dimorphic neural circuits in the brain. In this review, we discuss the neural circuitry of sex-typical social behaviours in mice while highlighting the genetic technical innovations that have advanced the field.
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Affiliation(s)
- Daniel W Bayless
- Department of Anatomy, University of California San Francisco, San Francisco, CA 94158, USA
| | - Nirao M Shah
- Department of Anatomy, University of California San Francisco, San Francisco, CA 94158, USA
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Youngerman BE, Chan AK, Mikell CB, McKhann GM, Sheth SA. A decade of emerging indications: deep brain stimulation in the United States. J Neurosurg 2016; 125:461-71. [PMID: 26722851 DOI: 10.3171/2015.7.jns142599] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) is an emerging treatment option for an expanding set of neurological and psychiatric diseases. Despite growing enthusiasm, the patterns and implications of this rapid adoption are largely unknown. National trends in DBS surgery performed for all indications between 2002 and 2011 are reported. METHODS Using a national database of hospital discharges, admissions for DBS for 14 indications were identified and categorized as either FDA approved, humanitarian device exempt (HDE), or emerging. Trends over time were examined, differences were analyzed by univariate analyses, and outcomes were analyzed by hierarchical regression analyses. RESULTS Between 2002 and 2011, there were an estimated 30,490 discharges following DBS for approved indications, 1647 for HDE indications, and 2014 for emerging indications. The volume for HDE and emerging indications grew at 36.1% annually in comparison with 7.0% for approved indications. DBS for emerging indications occurred at hospitals with more neurosurgeons and neurologists locally, but not necessarily at those with the highest DBS caseloads. Patients treated for HDE and emerging indications were younger with lower comorbidity scores. HDE and emerging indications were associated with greater rates of reported complications, longer lengths of stay, and greater total costs. CONCLUSIONS DBS for HDE and emerging indications underwent rapid growth in the last decade, and it is not exclusively the most experienced DBS practitioners leading the charge to treat the newest indications. Surgeons may be selecting younger and healthier patients for their early experiences. Differences in reported complication rates warrant further attention and additional costs should be anticipated as surgeons gain experience with new patient populations and targets.
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Affiliation(s)
- Brett E Youngerman
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York; and
| | - Andrew K Chan
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Charles B Mikell
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York; and
| | - Guy M McKhann
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York; and
| | - Sameer A Sheth
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York; and
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Fuss J, Auer MK, Biedermann SV, Briken P, Hacke W. Deep brain stimulation to reduce sexual drive. J Psychiatry Neurosci 2015; 40:429-31. [PMID: 26057198 PMCID: PMC4622642 DOI: 10.1503/jpn.150003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
To date there are few treatment options to reduce high sexual drive or sexual urges in paraphilic patients with a risk for sexual offending. Pharmacological therapy aims to reduce sexual drive by lowering testosterone at the cost of severe side effects. We hypothesize that high sexual drive could also be reduced with deep brain stimulation (DBS) of circuits that generate sexual drive. This approach would help to avoid systemic side effects of antiandrogenic drug therapies. So far the best investigated target to reduce sexual drive is the ventromedial hypothalamus, which was lesioned unilaterally and bilaterally by stereotaxic interventions in paraphilic patients in the 1970s. Here, we discuss DBS as a treatment strategy in patients with severe paraphilic disorders with a serious risk of sexual offending. There are profound ethical and practical issues associated with DBS treatment of paraphilic patients that must be solved before considering such a treatment approach.
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Affiliation(s)
- Johannes Fuss
- Correspondence to: J Fuss., Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany;
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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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Falkner AL, Lin D. Recent advances in understanding the role of the hypothalamic circuit during aggression. Front Syst Neurosci 2014; 8:168. [PMID: 25309351 PMCID: PMC4174750 DOI: 10.3389/fnsys.2014.00168] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 08/29/2014] [Indexed: 12/04/2022] Open
Abstract
The hypothalamus was first implicated in the classic “fight or flight” response nearly a century ago, and since then, many important strides have been made in understanding both the circuitry and the neural dynamics underlying the generation of these behaviors. In this review, we will focus on the role of the hypothalamus in aggression, paying particular attention to recent advances in the field that have allowed for functional identification of relevant hypothalamic subnuclei. Recent progress in this field has been aided by the development of new techniques for functional manipulation including optogenetics and pharmacogenetics, as well as advances in technology used for chronic in vivo recordings during complex social behaviors. We will examine the role of the hypothalamus through the complimentary lenses of (1) loss of function studies, including pharmacology and pharmacogenetics; (2) gain of function studies, including specific comparisons between results from classic electrical stimulation studies and more recent work using optogenetics; and (3) neural activity, including both immediate early gene and awake-behaving recordings. Lastly, we will outline current approaches to identifying the precise role of the hypothalamus in promoting aggressive motivation and aggressive action.
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Affiliation(s)
- Annegret L Falkner
- Neuroscience Institute, New York University School of Medicine New York, NY, USA
| | - Dayu Lin
- Neuroscience Institute, New York University School of Medicine New York, NY, USA ; Department of Psychiatry, New York University School of Medicine New York, NY, USA
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Abstract
Deep brain stimulation (DBS) is a commonly used neurosurgical form of therapeutic brain stimulation that has been demonstrated to be safe, well tolerated, and effective for the treatment of essential tremor, Parkinson's disease, and primary dystonia. These particular uses have been approved by the U.S. Food and Drug Administration (FDA). Investigational studies using DBS have been conducted for refractory epilepsy, obesity, chronic pain, tardive dyskinesia, Tourette syndrome, and other movement disorders, but none of these studies has led to FDA approval for these indications. Although the use of DBS has been approved by the FDA under a Humanitarian Device Exemption for the treatment of treatment-resistant obsessive-compulsive disorder, studies systematically investigating the potential use of DBS for various severe chronic psychiatric disorders are in their earliest stages, and further studies are warranted.
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Widge AS, Moritz CT. Pre-frontal control of closed-loop limbic neurostimulation by rodents using a brain-computer interface. J Neural Eng 2014; 11:024001. [PMID: 24608127 PMCID: PMC4394990 DOI: 10.1088/1741-2560/11/2/024001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE There is great interest in closed-loop neurostimulators that sense and respond to a patient's brain state. Such systems may have value for neurological and psychiatric illnesses where symptoms have high intraday variability. Animal models of closed-loop stimulators would aid preclinical testing. We therefore sought to demonstrate that rodents can directly control a closed-loop limbic neurostimulator via a brain-computer interface (BCI). APPROACH We trained rats to use an auditory BCI controlled by single units in prefrontal cortex (PFC). The BCI controlled electrical stimulation in the medial forebrain bundle, a limbic structure involved in reward-seeking. Rigorous offline analyses were performed to confirm volitional control of the neurostimulator. MAIN RESULTS All animals successfully learned to use the BCI and neurostimulator, with closed-loop control of this challenging task demonstrated at 80% of PFC recording locations. Analysis across sessions and animals confirmed statistically robust BCI control and specific, rapid modulation of PFC activity. SIGNIFICANCE Our results provide a preliminary demonstration of a method for emotion-regulating closed-loop neurostimulation. They further suggest that activity in PFC can be used to control a BCI without pre-training on a predicate task. This offers the potential for BCI-based treatments in refractory neurological and mental illness.
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Affiliation(s)
- Alik S. Widge
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA
- Center for Sensorimotor Neural Engineering, University of Washington, Seattle, WA
| | - Chet T. Moritz
- Center for Sensorimotor Neural Engineering, University of Washington, Seattle, WA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
- Department of Physiology & Biophysics, University of Washington, Seattle, WA
- Department of Graduate Program in Neurobiology and Behavior, University of Washington, Seattle, WA
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Torres CV, Manzanares R, Sola RG. Integrating Diffusion Tensor Imaging-Based Tractography into Deep Brain Stimulation Surgery: A Review of the Literature. Stereotact Funct Neurosurg 2014; 92:282-90. [DOI: 10.1159/000362937] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 04/13/2014] [Indexed: 11/19/2022]
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Karas PJ, Mikell CB, Christian E, Liker MA, Sheth SA. Deep brain stimulation: a mechanistic and clinical update. Neurosurg Focus 2013; 35:E1. [DOI: 10.3171/2013.9.focus13383] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Deep brain stimulation (DBS), the practice of placing electrodes deep into the brain to stimulate subcortical structures with electrical current, has been increasing as a neurosurgical procedure over the past 15 years. Originally a treatment for essential tremor, DBS is now used and under investigation across a wide spectrum of neurological and psychiatric disorders. In addition to applying electrical stimulation for clinical symptomatic relief, the electrodes implanted can also be used to record local electrical activity in the brain, making DBS a useful research tool. Human single-neuron recordings and local field potentials are now often recorded intraoperatively as electrodes are implanted. Thus, the increasing scope of DBS clinical applications is being matched by an increase in investigational use, leading to a rapidly evolving understanding of cortical and subcortical neurocircuitry. In this review, the authors discuss recent innovations in the clinical use of DBS, both in approved indications as well as in indications under investigation. Deep brain stimulation as an investigational tool is also reviewed, paying special attention to evolving models of basal ganglia and cortical function in health and disease. Finally, the authors look to the future across several indications, highlighting gaps in knowledge and possible future directions of DBS treatment.
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Affiliation(s)
- Patrick J. Karas
- 1Department of Neurosurgery, The Neurological Institute, Columbia University Medical Center, New York, New York; and
| | - Charles B. Mikell
- 1Department of Neurosurgery, The Neurological Institute, Columbia University Medical Center, New York, New York; and
| | - Eisha Christian
- 2Department of Neurosurgery, Keck Hospital of the University of Southern California, Los Angeles, California
| | - Mark A. Liker
- 2Department of Neurosurgery, Keck Hospital of the University of Southern California, Los Angeles, California
| | - Sameer A. Sheth
- 1Department of Neurosurgery, The Neurological Institute, Columbia University Medical Center, New York, New York; and
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