Case Report
The legal guardian of a 30-year-old female, with a pathological history of acute bacterial
meningitis, previously healthy and with no comorbidities until she developed ischemic
stroke at 15 years old, looked for medical assistance in 2019 because of her aggressive
behavior. After the diagnosis of bacterial meningitis and the appropriate treatment,
the patient presented with dysarthria, left upper limb hemiparesis with loss of movement
at light touch, mental retardation, episodes of pathological aggressive behavior manifested
as verbal aggression (screaming with anger, temper tantrums), property damage (slamming
doors, throwing objects on the floor), self- injury (hitting herself and hitting her
fists on the wall), and hetero-aggression (making threatening gestures, hitting and
pushing others, even causing minor injuries). She scored 47 points on the Modified
Overt Aggression Scale (MOAS)[11] and also presented with intense sexual impulse, motor tic (clapping), vocal tic
(recurrent sounds), and binge eating disorder.
The legal guardian claimed to have made use of grills and restraints on household
utensils and objects to protect the patient, belongings, and property. Additionally,
the family had to adopt social distancing due to embarrassment, conflicts, and compromised
coexistence.
The magnetic resonance imaging (MRI) performed in 2019 ([Figs. 1] and [2]), prior to the stereotactic NPD to control aggressiveness, shows most of the following
injuries caused by the evolution of the bacterial meningitis and the stroke: 1) extensive
area of encephalomalacia and gliosis, affecting the temporal lobes bilaterally, including
the amygdala, the uncus, and the hippocampus, the insular lobes bilaterally, the frontobasal
region, the right anterior cingulate gyrus, and the genu, trunk, and splenium of the
corpus callosum; 2) areas of encephalomalacia/gliosis in the lower part of the cerebellar
hemispheres; 3) relative preservation of the occipital lobe and of the nucleus-capsular
region. In the same year, stereotactic NPD was indicated to control her aggressive
behavior, respecting the protocol of the Federal Council of Medicine and with the
consent of the family and of the legal guardian. Using software planning and the stereotactic
technique, the NAcc, the hypothalamus, the cingulate, and the anterior limb of the
internal capsule, all of them to the left, underwent thermocoagulation at 80°C for
80 seconds. The range of the NAcc coordinate values was between 5 and 6 mm under the
line joining the anterior and posterior commissure, 17 mm anterior to the brain midpoint,
and 5 mm lateral to the brain midline; the anterior cingulotomy involved lesions 20 mm
posterior to the anterior extent of the frontal horn of the lateral ventricles, between
5 and 7 mm off the midline, and 5 mm above the corpus callosum; the lesions in the
anterior capsule were performed in the middle of the anterior limb of the internal
capsule, ∼ 4 mm above the level of the midcommissural plane. The hypothalamus was
located by macrostimulation, using a 2-mm exposed tip electrode, with frequency between
5 Hz and 100 Hz and voltage ranging from 1 V to 10 V. As an electrophysiological response,
the patient presented autonomic signs, including mydriasis, increase in mean arterial
pressure and heart rate, and ipsilateral eyeball inversion. The target point chosen
was 2 mm laterally, 2 mm posteriorly, and 2 mm inferiorly from the midpoint of the
intercommissural line. No complications occurred during the surgical procedure or
in the postsurgical period.
Fig. 1 Magnetic resonance imaging performed prior to the stereotactic neurosurgery for psychiatric
disorder showing injuries caused by bacterial meningitis and stroke. T1 axial section:
extensive area of encephalomalacia and gliosis in the right insular lobe, the genu
of the corpus callosum, the temporal lobes, and the frontobasal region bilaterally,
with predominance on the right; relative preservation of the occipital lobe and of
the nucleus-capsular region.
Fig. 2 Magnetic resonance imaging performed prior to the stereotactic neurosurgery for psychiatric
disorder showing injuries caused by bacterial meningitis and stroke. T1 inversion
recovery coronal section: encephalomalacia and gliosis affecting the right insular
lobe, the right frontobasal region, and the temporal lobes bilaterally, with predominance
on the right.
The prescribed medication, quetiapine hemifumarate and clonazepam, was discontinued
without medical advice shortly after the surgery, because the family considered that
the patient had achieved a stable condition with no return of symptoms. One year after
the surgery, the patient still showed no postsurgical complications, with improvement
in her aggressive condition, with a decrease in verbal aggression and property damage,
a partial decrease in sex drive, and absence of self-harm and heteroaggression (MOAS
score 5).
The present study was approved by the Ethics Committee of the Pontifícia Universidade
Católica de Goiás (CAAE: 29424920.0.0000.0037). It was conducted according to the
Helsinki Declaration, and the written consent was signed by the legal guardian of
the patient.
Discussion
Meningitis and its Neurological Complications
Bacterial meningitis is a group of diseases characterized by the inflammatory process
of the subarachnoid space and of the leptomeningeal membranes (arachnoid and pia mater),
the protective covering for the brain and the spinal cord.[12] It is a serious and life-threatening condition and remains a major public health
challenge. The main microorganisms involved are Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis.[13]
After invading the nasopharynx mucosa, these bacteria overcome the defense barriers
of the central nervous system and penetrate the subarachnoid space, which lacks mechanisms
capable of controlling bacterial replication. Pathogens release active subcapsular
components such as lipopolysaccharide or peptidoglycan and teichoic acid, compounds
that stimulate astrocytes and microglia cells to produce cytokines such as tumor necrosis
factor and interleukin-1, which, in turn, trigger the meningeal inflammatory response,
with neutrophil adhesion to endothelial cells and their passage to the subarachnoid
space.[1]
[14]
[15]
The inflammatory response causes endothelial damage, increases the permeability of
the blood-brain barrier, and allows the entry of serum proteins into the subarachnoid
space, generating vasogenic edema.[16] Bacteria and neutrophils release toxic substances and produce inflammatory exudates
that alter cerebrospinal fluid dynamics, resulting in interstitial edema. Both forms
of edema are responsible for the increase in intracranial pressure, causing a decrease
in cerebral perfusion, hypoxemia, and anaerobic metabolism, which determines the consumption
of glucose and hypoglycorrhachia, leading to brain damage.[1]
[14]
[17]
Strokes are a particular complication of bacterial meningitis. Among the mechanisms
that cause cerebral ischemia, the increase in cerebral blood flow velocity, vasculopathies,
and intravascular thrombosis result from inflammation. The progression of the infection
to sepsis affects the vascular self-regulation of the central nervous system, making
the cerebral blood flow dependent on systemic pressure. In cases of systemic hypotension,
a reduction in brain irrigation and tissue ischemia occur.[3]
The interaction and synergy of the events described above can cause focal or diffuse
irreversible damage to the brain. It has been long believed that diffuse brain lesions
result in psychic changes.[18]
The patient that has a stroke in a certain cerebral hemisphere can have hemiplegia
on the opposite side of the lesion due to the crossing of the motor pathways in the
brainstem.[19]
[20] Other symptoms associated with a stroke are dysphagia, hemianopsia, and urinary
and fecal incontinence. The most common psychological consequences reported are anxiety,
depression, as well as sleep, sexual, motor, sensory, cognitive, and communication
disorders.[21]
Brain Injury and Etiology of Behavioral Changes
Lesions to the frontal lobe as well as to both temporal lobes can trigger aggressive
behavior. The association of orbitofrontal cortex lesions with inappropriate behaviors
such as impulsivity, anger, little expression of happiness, and personality disorders
has been reported.[21] The frontal cortex and the ventromedial frontal cortex are involved in the inhibition
and control of emotions, whereas the orbitofrontal cortex plays a role in anger and
pathological aggressive behavior, is directly involved in the modulation of reactive
aggression, and regulates the calculation of consequences and punishments to aggressive
responses.[22]
[23]
Aggressive and impulsive patients have shown decreasing activation of inhibitory regions
in the left anteromedial cortex when compared with control subjects. These patients
also presented deactivation of the anterior cingulate gyrus and activation of the
posterior cingulate gyrus.[22] The cingulate gyrus is the structure involved in evaluating the approach of stimuli
capable of triggering the aggressive response. However, different patterns of brain
activation can occur in individuals with an impulsive and aggressive personality.[22]
[24]
The effects caused by the lesion of the midtemporal lobe, which includes subcortical
structures such as the amygdala and the hippocampus, are still controversial. The
amygdala is responsible for detecting, generating, and maintaining emotions related
to fear, as well as for coordinating appropriate responses to threat and danger. Thus,
injuries to the amygdala in humans reduce the expression of emotions and the ability
to recognize fear. Some studies have indicated that, in apes, bilateral lesions in
the temporal lobe, which reach the contralateral amygdala, cause loss of fear, adoption
of docile posture, extreme curiosity, quick forgetfulness, tendency to put objects
in the mouth, and intense sexual impulse.[25] Humans with damage to both temporal lobes (Klüver-Bucy syndrome) react in a similar
way, with apathy, lethargy, emotional insensitivity, hypersexuality, psychic blindness
or visual agnosia, strong oral tendencies, and hypermetamorphosis.[25]
[26]
Other studies have demonstrated a correlation between temporal lobe abnormalities,
such as reduced tissue volume and/or activity, and exacerbated aggressive behavior.[27] New functional and structural neuroimaging techniques for examining abnormalities
of the temporal lobe have revealed temporal irregularities, including asymmetric gyratory
patterns in the parietal-temporal region, decreases in the volume of the anterior-inferior
temporal lobe (encompassing the amygdala-hippocampus region or adjacent areas), increases
in the volume of the left temporal lobe, and specific pathologies of the amygdala.[28]
In patients with borderline personality syndrome, the glucose metabolism is increased
in the anterior cingulate, bilaterally in the upper frontal gyrus, in the lower right
frontal gyrus, and in the operculum of the precentral gyrus, and is decreased in the
left hippocampus and in the cuneus. The hippocampus is involved in fear responses
and stressful situations, participating in the regulation of emotions. Dysfunctions
in this region, therefore, can generate symptoms of anxiety and impulsivity. Glucose
hypometabolism has also been found in the ipsilateral cuneus, even though the interconnections
between the hippocampus and the cuneus are not fully known.[29]
Damage to the frontal lobe has been associated with exacerbated and targeted aggressive
responses, while temporal lobe dysfunction generates bursts of misdirected anger.[30] Neuropathologies that occur in both areas can increase the risk of exacerbated aggressive
behavior compared with those that affect only one or the other area.[27]
Prefrontal and insular regions are also implicated in eating disorders such as obesity,
with a gray matter volume reduction in the medial prefrontal cortex, the anterior
cingulate, the frontal pole, the caudate nucleus, and the uncus, as well as a white
matter volume decrease in the anterior limb of the internal capsule, adjacent to the
caudate nucleus. These regions are involved in the decision, motivation, and reward
processes, which suggests a relationship between the anatomical structures described,
atypical behaviors, and polyphagia.[31]
The corpus callosum can be anatomically subdivided into the rostrum, the genu, the
anterior body, the anterior middle body, the posterior middle body, the isthmus, and
the splenium.[32] Among the major psychiatric diseases associated with morphological changes in the
corpus callosum are those originating from injuries to the splenium or to the posterior
middle body. Splenial lesion is associated with depression, a syndrome characterized
by loss of pleasure in daily activities, with cognitive and sleep alterations, loss
of appetite and of sexual interest. Injury to the posterior trunk of the corpus callosum
is associated with Tourette syndrome.[32]
[33] This chronic tic disorder is manifested by fluctuating motor and vocal tics (emission
of sounds with differing degrees of intensity and frequency, or sudden, repetitive,
involuntary, rapid movements, rhythmless and stereotyped, with unpredictable durations).
They usually occur as attacks, are reduced by sleep, and may cause social and occupational
limitations.[33]
[34]
It has been recognized that the cerebellum, in addition to its motor functions, also
acts in several cognitive processes. Cerebellar damage may be associated with dysfunctions
in executive tasks, learning, procedural and declarative memory, language processing,
visual and spatial functions, as well as with dysfunctions in personality, affection,
and cognition.[12] In 1998, a new concept related to the cerebellum was created: “dysmetria of thought”
or “cognitive dysmetria.” According to this concept, the cerebellum would be responsible
for the chronology of reasoning and of ideas, and it would be altered in several diseases
such as schizophrenia, autism, dyslexia, and bipolar mood depression.[35] The cerebellum has the capacity to regulate the mood via the nuclei. Emotional control
is achieved through its influences on the prefrontal cortex and on the hypothalamus.
Anatomically, posterior lobe injuries are associated with cognitive changes, while
lesions in the cerebellar vermis are associated with affective disorders. The anterior
lobe is directly involved in motor functions, showing little correlation with cognitive
and affective symptoms.[36]
In the case reported in the present article, the synergy of the lesions found in the
patient before the stereotactic NPD resulted in the behavioral changes described.
This is a rare and extremely interesting case, since the patient, despite presenting
with bilateral lesions of the amygdala, was not diagnosed with Klüver-Bucy Syndrome,
but with an exacerbation of aggressive behavior as a complication of the stroke. Targets
used in surgical procedures in the right hemisphere can lead to a functional imbalance
between these behavioral structures. Thus, the treatment can be more effective using
a bilateral approach and multiple targets. Other findings about this patient are consistent
with the literature, showing a relationship, even if not yet completely clarified,
between neuroanatomical structures and the human psyche. The role of the cerebellum
in aggressive behavior cannot be ruled out in the present case, and may become a surgical
target in the future, after further studies.
Limbic System
The indication of NPDs is based on scientific evidence that correlates psychiatric
illnesses to the limbic system and the pathophysiology of emotions.[37] Psychiatric disorders considered eligible for NPD are not yet fully understood from
a pathological perspective, since injured brain areas are part of a large neuronal
network, which has only been empirically defined. The smaller and more precise targets
currently used in surgical procedures are the result of nearly a century of improvement
in surgical techniques, neuroanatomy, neurophysiology, and neuropsychiatry.[38]
The term “limbic system” was first used by MacLean in 1955,[39] but Willis and Broca were the first ones to describe the limbic lobe, in 1664 and
1828, respectively.[40] In 1937, Papez was a pioneer who suggested the existence of a circuit of specific
brain structures responsible for human emotion. From the observation that the hypothalamus
played a significant role in the expression of emotions, and that higher cognitive
thoughts arose from activity in the cortical areas (frontal lobes), Papez postulated
that since emotion can be influenced by thought, and thought can be influenced by
emotion, the hypothalamus (emotion) would be connected with other upper cortical areas
(thought). Thus, he proposed a circuit in which the cortex connects to the cingulate
gyrus, which connects to the hippocampus, which in turn connects to the mammillary
bodies (hypothalamus) through the fornix. The mammillary bodies project to the anterior
thalamic nuclei, which connect back to the cingulate gyrus, and then to the cortical
areas. He considered that the cingulate cortex is the cortical region receptive to
emotional impulses.[41]
In 1955, MacLean[39] added other structures to the limbic system, such as the septal area, the NAcc,
the orbitofrontal cortex, the anterior temporal cortex, the dorsomedial thalamic nuclei,
and the amygdala. Later, Goldenberg divided the limbic system into three limbic subcircuits:
1) the medial limbic circuit, including the classic Papez circuit; 2) the basolateral
circuit, including the orbitofrontal cortex, the anterior temporal cortex, the amygdala,
and the magnocellular division of the dorsomedial nucleus of the thalamus (frontothalamic
pathway); and 3) a defense reaction circuit, including portions of the hypothalamus,
the stria terminalis, and the amygdala.[38]
[42] The circular nature of these pathways may explain why surgical injuries performed
at different locations within the same circuit can alleviate the same symptoms, and
why injuries in two or more circuits produce better results than isolated lesions.[38] These pathways and their interactions with the basal ganglia (corticostriatothalamic
pathways) constitute the anatomy of human emotion, and disturbances in these routes
are considered the substrate of behavioral psychiatric illness.[38]
Neuropsychosurgery History and Targets
Most probably, neurosurgery began in the Antiquity era, through the practice of trepanation,
a surgical removal of sections of the cranial vault during life,[43] performed with the aid of a cylindrical instrument of varying size and shape called
a trephine.[44] The use of trepanation to relieve neuropsychiatric symptoms has been shown to date
back to 5100 BC; therefore, the history of psychosurgery, currently named NPD,[45] is as old as the history of psychiatric illnesses.[46]
In the 19th century, during the neuroscientific era of brain-behavior correlation, Broca and
Wernicke established a clinicopathological parallelism between the neuroanatomical
substrate and cognitive functions such as language.[40] Influenced by these discoveries, in 1888, the Swiss psychiatrist Johann Gottlieb
Burckhardt inaugurated modern psychosurgery, performing the first procedure of the
modern era. He excised various brain regions from six chronic psychiatric patients
under his care. As a result, three progressed successfully and one died. The difficulty
in establishing a good outcome in the postoperative period led to the discredit of
the technique and to the consequent abandonment of the project even before its publication,
in 1891.[47]
In spite of this, neurosurgeons continued their investigation of ablative brain surgery:
the Estonian Lodovicus Puusepp performed frontal lobotomies with relative success;[40] the American-Canadian Wilder Graves Penfield obtained symptomatic psychological
relief after resection of tumors, abscesses, and other brain injuries[48]; in 1935, at the Second World Congress of Neurology, the American John Farquhar
Fulton presented, together with the American animal psychologist Carlyle F. Jacobsen,
the resection of the anterior frontal cortex with behavioral changes in apes,[9]
[40] whereas the Portuguese António Egas Moniz proposed, for the first time, the ablation
of the frontal cortex in humans with psychiatric diseases.[40]
In fact, Moniz was the first one to introduce the term “psychosurgery”, and following
the footsteps of Fulton and Jacobsen, in 1936, he and Pedro Almeida Lima performed
the first neurosurgery to treat psychiatric disorders in humans, called “prefrontal
lobotomy.” The surgery performed by the Portuguese neurosurgeons achieved good effectiveness,
but a relevant number of patients had frontal lobe syndrome as a complication (apathy,
euphoria, distraction, and disinhibition), returned to nursing homes, and were no
longer seen.[9]
[40]
Between 1936 and 1949, the American neurologist Walter Jackson Freeman and neurosurgeon
James W. Watts modified the technique of Moniz and Lima and developed the transorbital
lobotomy. Between 1936 and 1956, ∼ 60,000 lobotomies were performed in the USA, some
of them without precise indications and in poor conditions, generating a large number
of complications, ranging from convulsive disorders in the postoperative period to
infection and death.[9]
[40] This surgical intervention was received with prejudice and discrimination, especially
during World War II, when it was indiscriminately used in humans in the absence of
a bioethical protocol.[49]
The development of sophisticated stereotactic target localization techniques, brain
atlases, and imaging methods made stereotaxis possible. This surgical procedure is
performed with a geometric orientation device fixed on the head, which directs the
instrument to the coordinates of the target, increasing the precision of neurosurgery
and reducing brain damage.[5]
[50]
In the 1940s, the Austrian neurologist Ernest A. Spigel and the American neurosurgeon
Henry T. Wycis performed stereotactic surgery in humans using dorsomedial thalamotomy
in schizophrenic patients for the first time. Their technique increased the accuracy
of neurosurgery and decreased brain damage.[51] Since the 1950s, the demand for psychosurgery has significantly decreased due to
the development of psychotropic drugs.[9]
[40]
[49] Nonetheless, for some patients presenting with psychiatric diseases refractory to
clinical treatment, the use of psychosurgery remains valid. Stereotactic surgeries
are, therefore, used especially in these cases, mainly for obsessive compulsive disorder
(OCD), chronic pain, and Parkinson disease, among others.[52]
[53]
[54]
Nowadays, the main targets addressed in psychosurgery for pathological aggressiveness
are the hypothalamus, the amygdala, the anterior capsule, the cingulate gyrus, and
the NAcc. The procedures can be neuromodulatory and ablative, used separately or together.[55] The most used ablative procedures are posteromedial hypothalamotomy, amygdaloidotomy,
anterior capsulotomy, anterior cingulotomy, subcaudate tractotomy, and limbic leucotomy.[52]
[55]
In 1966, bilateral lesions of the posteromedial hypothalamus resulted in a significant
reduction in aggressiveness. An interval of 7 to 10 days between the completion of
the 2 lesions was recommended, since severe and potentially fatal hypothalamic dysfunction
was observed in cases in which they were performed simultaneously.[56] This procedure is based on the hypothalamic functions, namely processing information
from the external environment, controlling aggressive behavior, and ceasing the activity
of the middle-basal hypothalamus (area of aggression). Therefore, posteromedial hypothalamotomy
leads to reduced activation of the limbic system and, consequently, of aggressive
behavior. This target has also been used in deep brain stimulation (DBS), leading
to improvement in epileptic seizures.[9]
[51]
[53]
Amygdaloidotomy is performed especially by thermocoagulation. It is based on the association
between the amygdala and the modulation of aggressive behavior, its connections with
the prefrontal, parietal, and insular cortexes, the cingulate gyrus, the hypothalamus,
and the reticular formation, and its role in controlling neuroendocrine and autonomic
responses.[9] A reduction in aggressive behavior has been reported as a result of bilateral lesions
to the central nucleus of the amygdala.[57]
[58] Nonetheless, this procedure has the rare complication of Klüver-Bucy syndrome.[58]
Anterior capsulotomy, developed by the Swedish neurosurgeon Lars Leskell and the French
psychiatrist and neurosurgeon Jean Talairach in 1949, is based on the disruption of
the orbitofrontal cortex and of the limbic system by targeting the fibers that connect
them, located between the caudate nucleus and the putamen. This procedure has adverse
effects such as mental confusion, weight gain, nocturnal enuresis, headache, and impaired
memory.[40]
[55] Although these effects rarely occur, they can last long in the postoperative period.
This procedure has been indicated in cases of intractable OCD, with a success rate
of up to 70%.[9]
[53]
Anterior cingulotomy was developed by the American neurosurgeon H. Thomas Ballantine
in the early 1960s as a treatment for patients with anxiety, intractable pain, and
mood disorders.[40] Bilateral MRI-guided thermocoagulation is used to create ablation lesions of fibers
that connect the cingulate cortex, the orbitofrontal cortex, and the limbic system.
Currently, it is mainly used in the treatment of OCD.[40]
[53]
[55] This procedure has a low rate of adverse effects. A study listing > 800 cases of
cingulotomy at the Massachusetts General Hospital over a 40-year period revealed no
casualties and only 2 cases of infection.[53]
Subcaudate tractotomy, developed by the British neurosurgeon Geoffrey Knight in 1964,
is the interruption of the fibers that connect the orbitofrontal cortex to the subcortical
limbic structures through the ablation of the innominate substance in the area inferior
to the head of the caudate nucleus.[53] Since 1970, the Brook General Hospital in London has reported > 1,300 cases of subcaudate
tractotomy performed in patients with affective disorders such as OCD and chronic
anxiety. An improvement has been observed in between 40 and 60% of the patients 1
year after the procedure.[59] Complications are usually induced edema, transient postoperative disorientation,
and long-term seizures.[9]
[53]
[55]
Limbic leucotomy, introduced by Desmond Kelly and Nita Mitchell-Heggs in England in
1973, is a combination of bilateral cingulotomy and subcaudate tractotomy[40] that causes the interruption of the Papez circuit by disconnecting the frontolimbic
and the corpus callosum. The lesion is made on the lower side of the head of the caudate
nucleus and on the anterior cingulate gyrus, and also involves the mid-lower quadrant
of the frontal lobe.[55] In the first 24 to 48 hours after surgery, patients may experience confusion and
drowsiness, with subsequent recovery.[53]
Since the NAcc plays a role in immediate reward circuits and also in modulating repulsive
stimuli, it has also been proposed as a target to control aggressive behavior.[60] Its stimulation is effective to control addiction to drugs, nicotine, and alcohol,
as well as to reduce aggressive behavior in patients with OCD, Tourette syndrome,
and pathological obesity.[61]
All the multiple targets described can be used, isolated or in combinations, in NPDs,
depending on the psychiatric illness and on the experience of the neurosurgeon.[10] A 27-year-old male patient diagnosed with organic delusional disorder, absence epilepsy,
and pathological aggressiveness underwent NPD using the stereotactic technique, combining
left medial hypothalamotomy and bilateral anterior capsulotomy. Although schizophrenia
and epilepsy remained unchanged, the patient had important improvement in his aggressive
behavior immediately after the procedure.[9]
A 14-year-old and a 16-year-old male patient, both diagnosed with severe pathological
aggressiveness refractory to clinical pharmacological treatment, were operated on
using the multitarget stereotactic technique. In the former, four interventions were
performed with 3-month intervals between the procedures: 1) left posteromedial hypothalamotomy;
2) anterior capsulotomy; 3) right posteromedial hypothalamotomy and bilateral reinforcement
of the lesion to the anterior limb of the internal capsule; 4) NAcc lesion. In the
latter, 2 procedures were performed: left posteromedial hypothalamotomy and, after
1 year, right posteromedial hypothalamotomy associated with anterior capsulotomy.
Both patients experienced significant improvement in symptoms and no recurrence of
aggressive behavior.[60]
Bilateral anterior capsulotomy was performed in 13 patients with epilepsy and psychiatric
comorbidities such as psychotic symptoms, pathological aggressiveness, impulsivity,
anxiety, depression, and intellectual disability. The neurosurgical procedure was
considered an effective treatment for epileptic patients presenting with refractory
psychotic symptoms and aggressive behavior. It also improved the compliance of the
patients with antiepileptic medication regimens. The most common but transient side
effects of this surgery were fatigue and laziness.[62]
The combination of anterior cingulotomy and anterior capsulotomy was employed for
the treatment of pathological aggressiveness in 10 patients, who showed improvement
in their condition and reintegration into society. A total of 13 adverse effects related
to the surgical procedure were reported, but all complications were temporary.[63]
Additionally, the combination of NAcc DBS with anterior capsulotomy is an effective
treatment for drug addiction. A 28-year-old male patient who had a polysubstance use
disorder (bucinnazine, morphine, and hypnotics) for 13 years, severe depression, and
anxiety underwent a combination of bilateral NAcc DBS with bilateral anterior capsulotomy.
After the procedure, he had an evident decrease in his craving for the three drugs.
Furthermore, he showed significant improvements in depression, anxiety, sleep, quality
of life, and most aspects of cognitive functioning.[64]
In the case reported in the present article, the patient underwent multitarget stereotactic
surgery to control chronic pathological aggressiveness refractory to clinical treatment.
The targets were selected based on the clinical manifestations of the patient. The
procedure was uneventful and resulted in a decrease in the aggressive behavior and
in a partial decrease in sexual impulse, leading to improvement in the quality of
life of the patient and her family. The patient also showed improvement in the symptoms
of binge eating disorder, with reduced searches for food. Our outcomes corroborate
the findings that lesions to the NAcc address behaviors associated with vandalism
and irritability,[10] and also confirm its role in compulsive behavior, which may be connected with binge
eating disorder.[61]
