Γ-Knife Hypothalamotomy for Refractory Aggressiveness€¦ · – Ilse Vasquez • Nursing –...
Transcript of Γ-Knife Hypothalamotomy for Refractory Aggressiveness€¦ · – Ilse Vasquez • Nursing –...
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