Directional deep brain stimulation of the posteromedial hypothalamus for refractory intermittent explosive disorder: a case series using a novel neurostimulation device and intraoperative microdialysis
【Abstract】 Intermittent Explosive Disorder (IED) is a psychiatric disorder characterized by recurrent outbursts of aggressive behaviour. Deep brain stimulation (DBS) in the posteromedial nucleus of the hypothalamus (pHyp) is an alternative therapy for extreme cases and shows promising results. Intraoperative microdialysis can help elucidate the neurobiological mechanism of pHyp-DBS. To evaluate efficacy and safety of pHyp-DBS using eight-contact directional leads in patients with refractory IED (rIED) and the accompanying changes in neurotransmitters. A prospective study in which patients with a diagnosis of rIED were treated with pHyp-DBS for symptom alleviation. Bilateral pHyp-DBS was performed with eight-contact directional electrodes. Follow-up was performed at 3, 6 and 12 months after surgery. Four patients (3 men, mean age 27 ± 2.8 yr) were included. All patients were diagnosed with rIED and severe intellectual disability. Two patients had congenital rubella, one has co-diagnosis of infantile autism and the fourth presents with drug-resistant epilepsy. There was a marked increase in the levels of GABA and glycine during intraoperative stimulation. The average improvement in aggressive behaviour in the last follow-up was 6 points (Δ: 50%, p= 0.003) while also documenting an important improvement of the SF-36 in all domains except bodily pain. No adverse events associated with pHyp-DBS were observed. This is the first study to show the safety and beneficial effect of directional lead pHyp-DBS in patients with refractory Intermittent Explosive Disorder and to demonstrate the corresponding mechanism of action through increases in GABA and glycine concentration in the pHyp.
【Author】 William OmarContreras LopezMD PhD12, Paula AlejandraNavarroMD23, Flavia VenetucciGouveiaPhD4, Erich TalamoniFonoffMD PhD5, IvoLebrunPhD6, Aline V.V.AuadaPhD6, Eduardo JoaquimLopes AlhoMD PhD5, Raquel C.R.MartinezPhD78
【Keywords】 Deep Brain Stimulation, Hypothalamus, Aggressive Behaviour, Neuromodulation, Intermittent Explosive Disorder, IED, Intermittent Explosive Disorder, rIED, refractory IED, DBS, Deep brain stimulation, pHyp, posteromedial nucleus of the hypothalamus, HFS, high-frequency stimulation, OAS, Overt Agression Scale, MRI, magnetic resonance imaging, CT, Computed Tomography, GABA, gamma-Aminobutyric acid
【Journal】 World Neurosurgery(IF：1.7) Time：2021-07-27