Bilateral Hypothalamotomy plus Dominant Amygdalotomy with Gamma Knife Radiosurgery: Case Report From Columbia

Out on PubMed, from authors in Colombia and Spain, is this case report:

Bilateral hypothalamotomy plus dominant amygdalotomy with Gamma Knife radiosurgery. A non-invasive alternative when everything has failed in the management of aggressive behavior disorder.

Romero OIM, Diez-Palma JC, Fonnegra-Caballero A, Segura-Hernández A, Matinez-Alvarez R, Yamhure E, Camargo JF, Fonnegra-Pardo JR.Surg Neurol Int. 2024 Dec 20;15:469. doi: 10.25259/SNI_860_2024. eCollection 2024.PMID: 39777183

The abstract is copied below:

Background: Impulsive aggression is the core symptom of intermittent explosive disorder, which can be a feature of several psychiatric disorders. There is a subset of individuals who do not respond adequately to medical treatment; they are treatment refractory. The objective of this report is to describe a case of a patient with a background of schizophrenia and concomitant refractory aggressiveness disorder, treated with two-stage bilateral hypothalamotomy and unilateral amygdalotomy with Gamma Knife radiosurgery (GKR).

Case description: A 36-year-old male presented with a background of paranoid schizophrenia. Episodes of self- and hetero-aggressiveness were present at the initial diagnosis. High dosages of psychotropic medication were taken, and 70 sessions of electroconvulsive therapy were performed; however, no adequate response was obtained. Bilateral hypothalamotomy plus left amygdalotomy through GKR was performed. After 25 months of follow-up, a marked decrease in the frequency, degree, severity of aggressiveness and the requirement for psychotropic medications was observed.

Conclusion: Hypothalamotomy plus amygdalotomy with Gamma Knife may be an effective ablative technique for the management of refractory aggressive disorder in patients with mental illness.

Keywords: Aggressive behavior disorder; Amygdalotomy; Gamma Knife radiosurgery; Hypothalamotomy; Stereotactic radiosurgery.

The report is here.

And from the text:

This is a fascinating case report of a modern version of psychosurgery using the gamma knife. The report is woefully thin on details of the "no adequate response" ECT, as well as how the patient was actually functioning in the follow up period. Not to mention the claim of no complications.

Nonetheless, this is a truly remarkable case report. It begs many ethical questions. The authors call the technique "non-invasive" and I suppose, technically, that is correct.

I recall seeing a couple of similar patients with severe psychosis/aggression in my career whom I thought actually needed, and would benefit from, psychosurgery.

Severe, refractory OCD is still an indication for some surgical procedures, see below:

Bilateral Anterior Capsulotomy for Treatment-Resistant Obsessive-Compulsive Disorder.

Hurwitz T, Ching G, Bogod NM, Honey CR.Stereotact Funct Neurosurg. 2024;102(6):356-370. doi: 10.1159/000540503. Epub 2024 Aug 23.PMID: 39182480

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