Mechanical malfunction of the Leksell Gamma knife during patient treatment.

Overview

abstract

During the course of a patient treatment with a North American U-type gamma unit, the remote hydraulic valve controlling the direction of couch motion failed to change state. The couch, helmet and patient remained in treatment position after the expiration of treatment time for one of the target shots. No unusual equipment warning indications had been observed prior to the malfunction. The gamma unit was new, having been used to treat approximately 20 patients since it had begun to be used clinically 11 weeks previously. This specific situation was not addressed in our posted Emergency Procedures, which dealt explicitly with loss of electrical power, and loss of hydraulic pressure. In the present case, the hydraulic gauges indicated full pressure. After attempts to disengage the patient remotely proved unsuccessful, personnel entered the room. The table clutch at the foot of the couch was operated to disengage the couch/helmet assembly from its docked position. While this was not mentioned in our emergency procedures, the act had the effect of causing the cobalt-60 sources to be misaligned with the collimator apertures, thereby immediately terminating the patient treatment. This also had the unanticipated effect of substantially reducing radiation leakage exposure rate next to the couch near the tunnel opening. The patient was released from the helmet trunnions using a manufacturer-supplied long-handled special Allen key. The key was used conventionally, to release the trunnion locking mechanism, and also unconventionally to force a separation of a trunnion from the docking slot on the patient head frame. The patient was then removed from the tunnel by sliding out the pad on which she was lying. Anesthesiology personnel accompanied the patient out of the room. The unit functioned properly upon the replacement of the valve by manufacturer service personnel the next day. The patient returned for completion of treatment 1 week later. There were only minor changes to the overall patient dosimetry as a result of the malfunction. Personnel exposures were very low. The malfunction was reported to State authorities, who conducted an investigation, that was in turn followed up by an investigation by the Nuclear Regulatory Commission.