Aggressiveness is a complex social behavior that ranges from adaptive to pathological forms. This review synthesizes current knowledge of the neural circuits underlying aggression and explores how this informs neurosurgical strategies for severe, treatment-resistant cases.

We reviewed recent experimental and clinical studies of the anatomical, functional, and neurochemical bases of aggression, focusing on reactive and proactive subtypes. Emphasis was placed on animal models, optogenetics, and human deep brain stimulation (DBS) approaches.

Internal states – such as hormonal status, energy balance, and prior experience – modulate the threshold for aggression. The ventrolateral part of the ventromedial nucleus of the hypothalamus (VMHvl), particularly its ERα-expressing neurons, plays a central role in triggering aggressive behavior. The core aggression circuit (CAC) includes the VMHvl, amygdala, bed nucleus of the stria terminalis, and ventral premammillary nucleus, under modulation by prefrontal inputs. Aggression is expressed through a direct VMHvl–periaqueductal gray (PAG) pathway for innate actions and an indirect, dopamine-dependent striatal pathway for learned aggression. Serotonin inhibits, while dopamine promotes, proactive aggression.

Pathological impulsive aggression, often linked to neurodevelopmental disorders and intellectual disability, may become refractory to pharmacotherapy. In such cases, neurosurgical approaches targeting the Sano triangle—originally described as part of the posterior hypothalamus—have shown promise. Understanding the connectivity and functional role of this region is essential for optimizing targeted interventions. Viewing aggression as a disorder of internal state regulation within defined circuits provides a framework for ethical and effective neuromodulation.