Long-term results of posteromedial hypothalamic deep brain stimulation for patients with resistant aggressiveness

Clinical article

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Erethism describes severe cases of unprovoked aggressive behavior, usually associated with some degree of mental impairment and gross brain damage. The etiology can be epileptic, postencephalitic, or posttraumatic, or the condition can be caused by brain malformations or perinatal insults. Erethism is often refractory to medication, and patients must often be interned in institutions, where they are managed with major restraining measures. The hypothalamus is a crucial group of nuclei that coordinate behavioral and autonomic responses and play a central role in the control of aggressive behavior. Deep brain stimulation (DBS) of the posteromedial hypothalamus (PMH) has been proposed as a treatment for resistant erethism, although experience with this treatment around the world is scarce. The objective of this study was to examine the long-term outcome of PMH DBS in 6 patients with severe erethism treated at the authors' institution.


Medical records of 6 patients treated with PMH DBS for intractable aggressiveness were reviewed. The therapeutic effect on behavior was assessed by the Inventory for Client and Agency Planning preoperatively and at the last follow-up visit.


Two patients died during the follow-up period due to causes unrelated to the neurosurgical treatment. Five of 6 patients experienced a significant reduction in aggressiveness (the mean Inventory for Client and Agency Planning general aggressiveness score was −47 at baseline and −25 at the last follow-up; mean follow-up 3.5 years). Similar responses were obtained with low- and high-frequency stimulation. In 4 cases, the patients' sleep patterns became more regular, and in 1 case, binge eating and polydipsia ceased. One of the 3 patients who had epilepsy noticed a 30% reduction in seizure frequency. Another patient experienced a marked sympathetic response with high-frequency stimulation during the first stimulation trial, but this subsided when stimulation was set at low frequency. A worsening of a previous headache was noted by 1 patient. There were no other side effects.


In this case series, 5 of 6 patients with pathological aggressiveness had a reduction of their outbursts of violence after PMH DBS, without significant adverse effects. Prospective controlled studies with a larger number of patients are needed to confirm these results.

Abbreviations used in this paper:AVM = arteriovenous malformation; DBS = deep brain stimulation; EEG = electroencephalography; ICAP = Inventory for Client and Agency Planning; OCD = obsessive-compulsive disorder; PMH = posteromedial hypothalamus.

Article Information

Address correspondence to: Cristina V. Torres Díaz, M.D., Ph.D., Department of Neurosurgery, University Hospital La Princesa, C/Diego de León 32, 28006 Madrid, Spain. email: cristinatorresdiaz@yahoo.es.

Please include this information when citing this paper: published online June 7, 2013; DOI: 10.3171/2013.4.JNS121639.

© AANS, except where prohibited by US copyright law.



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    Flow chart showing the evaluation process for patients with intractable aggressiveness referred to our program. VEEG = video EEG.

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    Microrecordings superimposed on a schematic of a parasagittal section through the hypothalamus (2 mm lateral to the midcommisural point) obtained using a digital version of the Schaltenbrand-Wahren brain atlas. The blue stars correspond to areas where stimulation elicited sympathetic responses. The open red star indicates a spot where stimulation was not followed by any response. s = seconds.

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    Axial T1-weighted MR image showing the distal end of the electrode lead, placed in the PMH in a patient with severe intractable aggressiveness.

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    Postoperative changes in the scores for self-aggression (A), outward aggression (heteroagressiveness, B), asocial behavior (C), and general aggression (D). Values shown in red indicate the mean ± SEM for the entire group. * p < 0.05, paired Student t-test. Pat = patient (case number).



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