Gouveia Flavia Venetucci, Germann Jürgen, de Morais Rosa, Fonoff Erich Talamoni, Hamani Clement, Alho Eduardo Joaquim, Brentani Helena, Martins Ana Paula, Devenyi Gabriel, Patel Raihaan, Steele Christopher, Gramer Robert, Chakravarty Mallar, Martinez Raquel Chacon Ruiz
Laboratory of Neuromodulation, Teaching and Research Institute, Hospital Sirio-Libanes, Sao Paulo, Brazil.
Sunnybrook Research Institute, Toronto, Canada.
Neurosurgery. 2021 Jan 13;88(2):E158-E169. doi: 10.1093/neuros/nyaa378.
Intractable 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.
To Report clinical and imaging findings from a case series of iAB patients treated with bilateral amygdala ablation.
This 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).
Postsurgery 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.
These findings provide new insight into the whole brain neurocircuitry of aggression and suggest a role of altered somatosensation and possible novel neuromodulation targets.
顽固性攻击性行为（iAB）是一种可能影响精神科患者的毁灭性行为障碍。这些患者的生活质量下降，由于给护理人员带来沉重负担且需要特殊护理，治疗难度更大。针对杏仁核（攻击性行为神经回路中的关键枢纽）的神经调节干预可能会缓解症状。
报告一组接受双侧杏仁核消融治疗的iAB患者的临床和影像学结果。
该系列包括4例患者（3例男性，年龄19 - 32岁），他们因以危及生命的自我伤害和社交攻击为特征的iAB接受了双侧杏仁核射频消融术。术前和术后评估包括全面的临床、精神和神经外科评估，包括量化攻击性行为、一般激越、生活质量的量表以及磁共振成像（MRI）。
术后评估显示攻击性行为和激越减少，生活质量改善。男性的攻击性行为与睾酮水平及睾酮/皮质醇比值相关。未观察到具有临床意义的副作用。影像学分析显示术前杏仁核体积在正常人群范围内，并确认了病变位置。攻击症状的减轻伴随着术后与攻击性行为经典相关脑区体积的显著减小以及与躯体感觉相关区域的增加。利用艾伦脑图谱提供的基因表达数据发现，局部体积减小的区域在正常大脑中显示与攻击性行为相关基因（如胺能传递）的高表达水平。
这些发现为攻击性行为的全脑神经回路提供了新的见解，并提示了躯体感觉改变的作用以及可能的新型神经调节靶点。
