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

Journal Section:
Editor's choice
Keywords:
Aggression, Deep brain stimulation, Posteromedial hypothalamus, Nucleus accumbens
1.
Sano K, Mayanagi Y, Sekino H, Ogashiwa M, Ishijima B: Results of stimulation and destruction of the posterior hypothalamus in man. J Neurosurg 1970;33:689-707.
[PubMed]
https://doi.org/10.3171/jns.1970.33.6.0689
2.
Sano K, Mayanagi Y: Posteromedial hypothalamotomy in the treatment of violent, aggressive behaviour. Acta Neurochir Suppl (Wien) 1988;44:145-151.
[PubMed]
https://doi.org/10.1007/978-3-7091-9005-0_28
3.
Franzini A, Marras C, Ferroli P, Bugiani O, Broggi G: Stimulation of the posterior hypothalamus for medically intractable impulsive and violent behavior. Stereotact Funct Neurosurg 2005;83:63-66.
[PubMed]
https://doi.org/10.1159/000086675
4.
Torres CV, Sola RG, Pastor J, Pedrosa M, Navas M, Garcia-Navarette E, Ezquiaga E, Garcia-Camba E: Long-term results of posteromedial hypothalamic deep brain stimulation for patients with resistant aggressiveness. J Neurosurg 2013;119:277-287.
[PubMed]
https://doi.org/10.3171/2013.4.JNS121639
5.
Tomycz ND, Whiting DM, Oh MY: Deep brain stimulation for obesity - from theoretical foundations to designing the first human pilot study. Acta Neurochir (Wien) 2011;153:2293-2306.
[PubMed]
https://doi.org/10.1007/s10143-011-0359-9
6.
Benabid AL, Torres N: New targets for DBS. Parkinsonism Relat Disord 2012;18(suppl 1):S21-S23.
[PubMed]
https://doi.org/10.1016/S1353-8020(11)70009-8
7.
Halpern CH, Torres N, Hurtig HI, Wolf JA, Stephen J, Oh MY, Williams NN, Dichter MA, Jaggi JL, Caplan AL, Kampman KM, Wadden TA, Whiting DM, Baltuch GH: Expanding applications of deep brain stimulation: a potential therapeutic role in obesity and addiction management. Acta Neurochir (Wien) 2011;153:2293-2306.
[PubMed]
https://doi.org/10.1007/s00701-011-1166-3
8.
Mantione M, van de Brink W, Schuurman PR, Denys D: Smoking cessation and weight loss after chronic deep brain stimulation of the nucleus accumbens: therapeutic and research implications - case report. Neurosurgery 2010;66:E218.
[PubMed]
https://doi.org/10.1227/01.NEU.0000360570.40339.64
9.
Halpern CH, Wolf JA, Bale TL, Stunkard AJ, Danish SF, Grossman M, Jaggi JL, Grady MS, Baltuch GH: Deep brain stimulation in the treatment of obesity. J Neurosurg 2008;109:625-634.
[PubMed]
https://doi.org/10.3171/JNS/2008/109/10/0625
10.
Halpern CH, Torres N, Hurtig HI, Wolf JA, Stephen J, Oh MY, Williams NN, Dichter MA, Jaggi JL, Caplan AL, Kampman KM, Wadden TA, Whiting DM, Baltuch GH: Expanding applications of deep brain stimulation: a potential therapeutic role in obesity and addiction management. Acta Neurochir (Wien) 2011;153:2293-2306.
[PubMed]
https://doi.org/10.1007/s00701-011-1166-3
11.
Sun B, Li D, Lin G, Zhan S, Zhang XX: Grading refractory anorexia nervosa for surgical treatment. Stereotact Funct Neurosurg 2012;90(suppl 1):99.
12.
Taghva A, Corrigan JD, Rezai AR: Obesity and brain addiction circuitry: implications for deep brain stimulation. Neurosurgery 2012;71:224-238.
[PubMed]
https://doi.org/10.1227/NEU.0b013e31825972ab
13.
Volkov ND, Wang GJ, Fowler JS, Telang F: Overlapping neuronal circuits in addiction and obesity: evidence of systems pathology. Philos Trans R Soc Lond B Biol Sci 2008;393:3191-3200.
[PubMed]
https://doi.org/10.1098/rstb.2008.0107
14.
Stoeckel LE, Kim J, Weller RE, Cox JE, Cook EW 3rd, Horwitz B: Effective connectivity of a reward network in obese women. Brain Res Bull 2009;79:388-395.
[PubMed]
https://doi.org/10.1016/j.brainresbull.2009.05.016
15.
Goncalves-Ferreira A, Simoes Do Cuto F, Rainha Campos A, Lucas Neto L, Salgado L, Lauterbach M, Goncalves-Ferreira D, Teixeira J, Rueff MC, Raposo H, Sequeira R: Deep brain stimulation for the treatment of refractory cocaine dependence. Stereotact Funct Neurosurg 2012;90(suppl 1):90.
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