Γ-Knife Hypothalamotomy forRefractory Aggressiveness

Centro Medico ImbanacoCali

No Disclosures

The Truth• Patient:

– Threat, fatigue and distress– Poor response to treatment

• Caregiver:– Threat, fatigue and distress– Difficult healthcare access

• Health– Lack of therapeutic options– Safety of implanted devices

• System– Excessive cost of treatment

DBS, we have a problem…

Eyes Widely Shut

Rules of Engagement

• We want pHyp• We don’t want infections• We want to help the family• We want to help the system• We hope one right lesion is enough• We think we should start with 120Gy @ 100%• We think we should wait 12mo. for second GK

Scales

• Psychiatry– Overt Aggression Scale– Global Assesemet of Function scale (GAF)– CGI/SI

• Neuropsychology– Wechsler adult intelligence scale– Mental retardations criteria – DSM V– Rey Auditory Verbal Learning Test (RAVTL)

• Social Work– Zarit Burden Interview

The Oracle

• Kondziolka/Flickinger– VIM: 120Gy vs. 140Gy

• Duma– VIM: 140Gy vs. 150Gy

• Keep– STn: 120Gy

• Phone call; Kondziolka:– 120Gy @ 100%; 120° Gamma-angle (Franzini)

COHORT

13 Patients

3 women, 10 men

7 (26) 49 y.o.

7 HPPN3 Autism2 Skizophreina1 Encephalitis

Targets

6 bilateral pHyp

5 unilateral pHyp

2 n.acc + pHyp

Planning

• ½ (AC-PC)– X lateral 2mm-3mm– Y posterior 2mm-3mm– Z Inferior 5mm-6mm

• 4mm• 120° gamma angle• 120Gy @ 100%

2 (26) 36mo.

OVERT

Transforming lives

Transforming lives

Transforming lives

Conclusions

• Right pHyp 120Gy @ 100%• Left pHyp 6mo. POP• No cognitive impairment• No infections• Easy follow-up• <20% cost

Conclusions

• Decrease of caregiver burden• Higher expectations of family• Changes in patient’s needs

Medical Ethics Commitee• Neurosurgery

– Bernardo Perez– Adriana Serrano

• Psychiatry– Andrea Otero– Cesar Gonzalez

• Neuropsychiatry– Angela Maria Perez

• Radiation Oncology– Ilse Vasquez

• Nursing– Johanna Gomez

• Medical Physics– Johnny Burbano– Oscar Garzon

• Anesthesia– Claudia Elena Osorio

• Neurology– Adriana Caballero– Paula Andrea Millan

• Social Work– Anabolena Mesa

• Administration– Gloria Florez

Always present

• L. Dade Lunsford• Douglas S. Kondziolka• John C. Flickinger• Ann Maitz