• Flavia Venetucci Gouveia, Jürgen Germann, Rosa de Morais, Erich Talamoni Fonoff, Clement Hamani, Eduardo Joaquim Alho, Helena Brentani, Ana Paula Martins, Gabriel Devenyi, Raihaan Patel, Christopher Steele, Robert Gramer, Mallar Chakravarty, and Martinez Raquel Chacon Ruiz RCR Laboratory of Neuromodulation, Teaching and Research Institute, Hospital Sirio-Libanes, Sao Paulo, Brazil..
• Laboratory of Neuromodulation, Teaching and Research Institute, Hospital Sirio-Libanes, Sao Paulo, Brazil.
• Neurosurgery. 2021 Jan 13; 88 (2): E158-E169.

BackgroundIntractable aggressive behavior (iAB) is a devastating behavioral disorder that may affect psychiatric patients. These patients have reduced quality of life, are more challenging to treat as they impose a high caregiver burden and require specialized care. Neuromodulatory interventions targeting the amygdala, a key hub in the circuitry of aggressive behavior (AB), may provide symptom alleviation.ObjectiveTo Report clinical and imaging findings from a case series of iAB patients treated with bilateral amygdala ablation.MethodsThis series included 4 cases (3 males, 19-32 years old) who underwent bilateral amygdala radiofrequency ablation for iAB hallmarked by life-threatening self-injury and social aggression. Pre- and postassessments involved full clinical, psychiatric, and neurosurgical evaluations, including scales quantifying AB, general agitation, quality of life, and magnetic resonance imaging (MRI).ResultsPostsurgery assessments revealed decreased aggression and agitation and improved quality of life. AB was correlated with testosterone levels and testosterone/cortisol ratio in males. No clinically significant side effects were observed. Imaging analyses showed preoperative amygdala volumes within normal populational range and confirmed lesion locations. The reductions in aggressive symptoms were accompanied by significant postsurgical volumetric reductions in brain areas classically associated with AB and increases in regions related to somatosensation. The local volumetric reductions are found in areas that in a normal brain show high expression levels of genes related to AB (eg, aminergic transmission) using gene expression data provided by the Allen brain atlas.ConclusionThese findings provide new insight into the whole brain neurocircuitry of aggression and suggest a role of altered somatosensation and possible novel neuromodulation targets.Copyright © 2020 by the Congress of Neurological Surgeons.

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