Table 3.
Hypothalamic Surgery for Aggressive Behavior
| Ref. and year | No.GenderAge | Population | Behavior disturbance | Surgical target and laterality | Imaging guidance | Electro physiological recordings | Surgical technique | Associated surgery | Improvement and form of evaluation | Side effects | Follow-up (mo) |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 121/1972 | N: 11N/GN/A | CI; ID; psychopathic personality; schizophrenia | Hetero and auto-aggressiveness, violent and destructive behavior | Posteromedial hypothalamusBilateral: 10Unilateral: 1 | PEG | Electrical stimulation of the target | Thermal coagulation | Not reported | 90%Clinical observations | 18% Transient hypersomnia9% Transient tachycardia | Up to 48 |
| 86/1966 | N: 49N/GN/A | CI; schizophrenia | Aggression, violent and destructive behavior; low rage threshold; self-mutilation | Hypothalamus nucleus not specifiedBilateral: 21Unilateral: 28 | Not reported | DR and electrical stimulation of the target | Thermal coagulation; surgical wax | Previous amygdalotomy (33) | 75%Grading scale developed by the authors | 4% Transient diabetes insipidus2% Ballistic movement4.1% Mortality | Up to 108 |
| 83/1988 | N: 122N/GN/A | CI, ID | Refractory physical aggression, hyperkinesis, wandering tendency, destructive and self-destructive tendencies | Posteromedial hypothalamusLaterality not reported | PCV | Electrical stimulation of the target | Thermal coagulation | Amygdalotomy | 60%Clinical observations | No side effects reported | Up to 36 |
| 125/2008 | N: 60M: 44F: 16N/A | CI; ID | Refractory aggressive behavior, rage attacks, restless behavior | Posteromedial hypothalamusLaterality not reported | Ventriculo-graphy | EEG; electrical stimulation of the target | Thermal coagulation | Not reported | 78%Clinical observations | No side effects reported | Up to 300 |
| 126/2008 | 1 Male18 yr | Hypothalamic hamartoma | Refractory aggressive behavior | Hypothalamus: hamartomaUnilateral | Brain MRI; stereotactic head CT scan; Schaltenbrand digital brain atlas | EEG; DR en route and at target; electrical stimulation of target | Thermal coagulation | No other surgery | 100%Clinical observations | No surgical complications, no side effects reported | 24 |
| SummaryLesionsTotal: 5 | N: 243M:45F: 16N/G:182N/A | CI: 5ID: 3Psychopathic personality: 1 Schizophrenia: 2 | Refractory: 5With seizures:5 | Posteromedial hypothalamusBilateral: 31Unilateral: 30 | <2000: PEG; PCV; ventriculography>2000: brain MRI; stereotactic head CT scan; brain atlas | DR en route: 1DR target: 1Electrical stimulation of target: 5 | Thermal coagulation: 5Surgical wax: 1 | No other surgery: 3Associated surgery: 2 | Total: 80.6% | No side effects: 3Transient: 2Permanent: 1 | 0-24: 125-36: 155-48: 1>49: 2 |
| 127/2008 | 1 Male22 yr | ID | Drug-resistant aggressiveness | Posteromedial hypothalamusBilateral | Brain MRI; ventriculography | Scalp EEG; DR, and electrical stimulation of the target | DBSInitial parameters: left 0.4 V, right 0.1 V, 450 μs, 15 Hz | No other surgery | 100%ICAP | No surgical complications, worsening of unilateral headaches | 18 |
| 128/2010 | 1 Female22 yr | CI; ID | Drug-resistant self-mutilating behavior | Posterior hypothalamusBilateral | Not reported | Not reported | DBSInitial parameters: 1.5 V, 90 μs, 130 Hz | No other surgery | 100%Clinical observations | No surgical complications, no side effects of stimulation | 4 |
| 129/2013 | 1 Female19 yr | IED; ID | Severe violent attacks against family | Orbitofrontal projections to the hypothalamusUnilateral | Brain MRI; stereotactic head CT scan; Schaltenbrand-Wahren atlas | Not reported | DBSInitial parameters: 2.5 V, 360 μs,40 Hz, 1 min “on”/1 min “off” | No other surgery | 100%Clinical observations | No surgical complications, no side effects of stimulation | 24 |
| 130/2013 | N: 7M: 6F: 120-68 yr | CI; ID | Refractory aggressive behavior | Posterior hypothalamusAll bilateral | Brain MRI; stereotactic head CT scan Framelink 4 software | Scalp EEG; DR en route and at target; electrical stimulation of target | DBSInitial parameters:1-3 V, 60-90 μs, 185 Hz | No other surgery | 85%OAS | No surgical complications, no side effects of stimulation | Up to 118 |
| 131/2015 | N: 6M:4F: 217-488 yr | CI; ID | Uncontrollable refractory aggressiveness | Posteromedial hypothalamusLaterality not reported | Brain MRI; stereotactic head CT scan; BrainLAB wokstation. | Scalp EEG; DR and electrical stimulation of the target | DBSInitial parameters: 0.1-0.9 V, 15-60 Hz, 180-450 μs | 1 patient lesionST, AC, ICPMH, DmTN, IlTN | 83%ICAP | No surgical complications, worsening of unilateral headaches in 1 patient | Up to 82 |
| 124/1988 | N: 5M: 4F: 116-33 yr | ID | Intractable aggressive behavior | Posteromedial hypothalamusAll bilateral | Brain MRI; stereotactic head CT scan; Praezis 3.1 workstation | DR en route and at target | DBSInitial parameters: 2.4-3 V, 185 Hz, 90 μs1 min “on”/5 min “off” | No other surgery | 80%OAS | No surgical complications | Up to 48 |
| SummaryDBSTotal: 6 | N: 21M:15F: 616-68 yr | CI: 3ID: 6IED: 1 | Refractory: 6With seizures: 4 | Posteromedial: 3Posterior: 2Other: 1Bilateral: 31Unilateral: 30 | Brain MRI; stereotactic head CT scan; surgical planning workstations; brain atlas | EEG: 3DR en route: 2DR target: 4Electrical stimulation of target: 4 | DBS Parameters: 0.1-3 V, 60-450 μs, 15-185 Hz | No other surgery: 5Associated surgery: 1 | Total: 91.3% | No side effects: 4Permanent: 2 | 0-24: 325-48: 1>49: 2 |
AC = anterior cingulum, CI = cerebral Insults; CT = computed tomography; DBS = deep brain stimulation; DmTN = dorsomedial thalamic nuclei, DR = depth recording; EEG = electroencephalogram; F = female; IC = internal capsule; ICAP = Inventory for Client and Agency Planning; ID = intellectual disabilities; IED = intermittent explosive disorder; IlTN = intralaminar thalamic nuclei; M = male; MRI = magnetic resonance imaging; N/A = no age specified in the article; N/G = no gender specified in the article; OAS = Overt Aggression Scale; PCV = positive contrast ventriculography; PEG = pneumoencephalography; PMH = postermedial hypothalamus; ST = stria terminalis.