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Tripathi M, Sheehan JP, Niranjan A, Ren L, Pikis S, Lunsford LD, Peker S, Samanci Y, Langlois AM, Mathieu D, Lee CC, Yang HC, Deng H, Rai A, Kumar N, Sahu JK, Sankhyan N, Deora H. Gamma Knife Radiosurgery for Hypothalamic Hamartoma: A Multi-Institutional Retrospective Study on Safety, Efficacy, and Complication Profile. Neurosurgery 2024:00006123-990000000-01280. [PMID: 38990006 DOI: 10.1227/neu.0000000000003110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/23/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Gamma knife radiosurgery (GKRS) is a safe and effective treatment option for hypothalamic hamartomas (HH), but there is no consensus opinion on its timing, dosage, and follow-up. The aim of this study was to define the safety, efficacy, outcome, and complication profile of GKRS in this patient population. METHODS This retrospective multicentric study involved 39 patients with the mean age of 16 ± 14.84 years. Early seizures resulted in an earlier age of diagnosis in 97% of patients. At baseline, no endocrine abnormalities were seen in 75% of patients while 18.9% showed precocious puberty (PP). The median target volume was 0.55 cc (0.1-10.00 cc), and a median margin dose of 16 Gy (8.1-20.0 Gy) was delivered in a single session. All patients were evaluated for clinical, endocrinological, and radiological outcomes. RESULTS The median follow-up was 5 (0.1-15) years. The median target volume of the cohort was 0.55 (0.35-1.77) cc. The largest HH was of 10 cc. 24/39 (61.5%) were small HH (Regis I-III). At presentation, 94.8% patients suffered from seizures (87.18% with gelastic seizures). 7/39 patients (17.9%) were presented with both PP and epilepsy. Only one (2.6%) patient presented with PP alone. 29 patients had more than 3-year follow-up. All received ≥16 Gy targeting complete HH. 28% of patients showed regression in HH volume. Patients with Regis grade I-III and longer follow-up (>75 months) showed gradual improvement in seizures. 16/29 patients (55.2%) achieved good seizure control (Engel I/II) while 13 (44.8%) were in Engel III/IV status. Nine patients needed adjuvant treatment because of poor seizure control. Eight patients suffered from transient increase in seizures. One patient developed poikilothermia, and 2 patients developed new onset hormonal deficiency. CONCLUSION GKRS is a safe and effective modality for treatment of HH with significant improvement in seizure control with minimal disruption of endocrine profile. It provides an excellent safety, efficacy, and complication profile, especially for small HH. Latency of results and its adjuvant nature remain the areas of research and breakthroughs among contemporary treatment options.
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Affiliation(s)
- Manjul Tripathi
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Lydia Ren
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Stylianos Pikis
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Anne Marie Langlois
- Department of Neurosurgery, Centre de recherche du CHUS, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - David Mathieu
- Department of Neurosurgery, Centre de recherche du CHUS, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Cheng Chia Lee
- Department of Neurosurgery, School of Medicine, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
- National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Huai Che Yang
- Department of Neurosurgery, School of Medicine, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
- National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Hansen Deng
- Department of Neurosurgery, School of Medicine, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
- National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Ashutosh Rai
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Narendra Kumar
- Department of Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jitendra Kuma Sahu
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Naveen Sankhyan
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harsh Deora
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, India
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Baumgartner ME, Qiu L, Philipp LR, Galligan K, Halpern C, Kennedy BC. Technological advances in pediatric epilepsy surgery. Curr Probl Pediatr Adolesc Health Care 2024; 54:101588. [PMID: 38494391 DOI: 10.1016/j.cppeds.2024.101588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Affiliation(s)
| | - Liming Qiu
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, USA
| | - Lucas R Philipp
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, USA
| | - Kathleen Galligan
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Casey Halpern
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA; Department of Neurosurgery, University of Pennsylvania, Philadelphia, USA
| | - Benjamin C Kennedy
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA; Department of Neurosurgery, University of Pennsylvania, Philadelphia, USA; Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, USA.
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Katlowitz KA, Curry DJ, Weiner HL. Novel Surgical Approaches in Childhood Epilepsy: Laser, Brain Stimulation, and Focused Ultrasound. Adv Tech Stand Neurosurg 2024; 49:291-306. [PMID: 38700689 DOI: 10.1007/978-3-031-42398-7_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Pediatric epilepsy has a worldwide prevalence of approximately 1% (Berg et al., Handb Clin Neurol 111:391-398, 2013) and is associated with not only lower quality of life but also long-term deficits in executive function, significant psychosocial stressors, poor cognitive outcomes, and developmental delays (Schraegle and Titus, Epilepsy Behav 62:20-26, 2016; Puka and Smith, Epilepsia 56:873-881, 2015). With approximately one-third of patients resistant to medical control, surgical intervention can offer a cure or palliation to decrease the disease burden and improve neurological development. Despite its potential, epilepsy surgery is drastically underutilized. Even today only 1% of the millions of epilepsy patients are referred annually for neurosurgical evaluation, and the average delay between diagnosis of Drug Resistant Epilepsy (DRE) and surgical intervention is approximately 20 years in adults and 5 years in children (Solli et al., Epilepsia 61:1352-1364, 2020). It is still estimated that only one-third of surgical candidates undergo operative intervention (Pestana Knight et al., Epilepsia 56:375, 2015). In contrast to the stable to declining rates of adult epilepsy surgery (Englot et al., Neurology 78:1200-1206, 2012; Neligan et al., Epilepsia 54:e62-e65, 2013), rates of pediatric surgery are rising (Pestana Knight et al., Epilepsia 56:375, 2015). Innovations in surgical approaches to epilepsy not only minimize potential complications but also expand the definition of a surgical candidate. In this chapter, three alternatives to classical resection are presented. First, laser ablation provides a minimally invasive approach to focal lesions. Next, both central and peripheral nervous system stimulation can interrupt seizure networks without creating permanent lesions. Lastly, focused ultrasound is discussed as a potential new avenue not only for ablation but also modulation of small, deep foci within seizure networks. A better understanding of the potential surgical options can guide patients and providers to explore all treatment avenues.
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Affiliation(s)
- Kalman A Katlowitz
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Department of Neurosurgery, Texas Children's Hospital, Houston, TX, USA
| | - Daniel J Curry
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Department of Neurosurgery, Texas Children's Hospital, Houston, TX, USA
| | - Howard L Weiner
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA.
- Department of Neurosurgery, Texas Children's Hospital, Houston, TX, USA.
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Ghatan S. Pediatric Neurostimulation and Practice Evolution. Neurosurg Clin N Am 2024; 35:1-15. [PMID: 38000833 DOI: 10.1016/j.nec.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Since the late nineteenth century, the prevailing view of epilepsy surgery has been to identify a seizure focus in a medically refractory patient and eradicate it. Sadly, only a select number of the many who suffer from uncontrolled seizures benefit from this approach. With the development of safe, efficient stereotactic methods and targeted surgical therapies that can affect deep structures and modulate broad networks in diverse disorders, epilepsy surgery in children has undergone a paradigmatic evolutionary change. With modern diagnostic techniques such as stereo electroencephalography combined with closed loop neuromodulatory systems, pediatric epilepsy surgery can reach a much broader population of underserved patients.
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Affiliation(s)
- Saadi Ghatan
- Neurological Surgery Icahn School of Medicine at Mt Sinai, New York, NY 10128, USA.
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Green TE, Fujita A, Ghaderi N, Heinzen EL, Matsumoto N, Klein KM, Berkovic SF, Hildebrand MS. Brain mosaicism of hedgehog signalling and other cilia genes in hypothalamic hamartoma. Neurobiol Dis 2023; 185:106261. [PMID: 37579995 DOI: 10.1016/j.nbd.2023.106261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 08/02/2023] [Accepted: 08/11/2023] [Indexed: 08/16/2023] Open
Abstract
Hypothalamic hamartoma (HH) is a rare benign developmental brain lesion commonly associated with a well characterized epilepsy phenotype. Most individuals with HH are non-syndromic without additional developmental anomalies nor a family history of disease. Nonetheless, HH is a feature of Pallister-Hall (PHS) and Oro-Facial-Digital Type VI (OFD VI) syndromes, both characterized by additional developmental anomalies. Initial genetic of analysis HH began with syndromic HH, where germline inherited or de novo variants in GLI3, encoding a central transcription factor in the sonic hedgehog (Shh) signalling pathway, were identified in most individuals with PHS. Following these discoveries in syndromic HH, the hypothesis that post-zygotic mosaicism in related genes may underly non-syndromic HH was tested. We discuss the identified mosaic variants within individuals with non-syndromic HH, review the analytical methodologies and diagnostic yields, and explore understanding of the functional role of the implicated genes with respect to Shh signalling, and cilia development and function. We also outline future challenges in studying non-syndromic HH and suggest potential novel strategies to interrogate brain mosaicism in HH.
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Affiliation(s)
- Timothy E Green
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Austin Health, Heidelberg, Victoria 3084, Australia
| | - Atsushi Fujita
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Japan
| | - Navid Ghaderi
- Departments of Clinical Neurosciences, Medical Genetics and Community Health Sciences, Hotchkiss Brain Institute & Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Canada
| | - Erin L Heinzen
- Eshelman School of Pharmacy, Division of Pharmacotherapy and Experimental Therapeutics, Department of Genetics, University of North Carolina, Chapel Hill, NC, USA
| | - Naomichi Matsumoto
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Japan
| | - Karl Martin Klein
- Departments of Clinical Neurosciences, Medical Genetics and Community Health Sciences, Hotchkiss Brain Institute & Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Canada; Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University and University Hospital Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Samuel F Berkovic
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Austin Health, Heidelberg, Victoria 3084, Australia
| | - Michael S Hildebrand
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Austin Health, Heidelberg, Victoria 3084, Australia; Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, Victoria, Australia.
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Chen JS, Lamoureux AA, Shlobin NA, Elkaim LM, Wang A, Ibrahim GM, Obaid S, Harroud A, Guadagno E, Dimentberg E, Bouthillier A, Bernhardt BC, Nguyen DK, Fallah A, Weil AG. Magnetic resonance-guided laser interstitial thermal therapy for drug-resistant epilepsy: A systematic review and individual participant data meta-analysis. Epilepsia 2023; 64:1957-1974. [PMID: 36824029 DOI: 10.1111/epi.17560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/30/2023] [Accepted: 02/22/2023] [Indexed: 02/25/2023]
Abstract
Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) has emerged as a popular minimally invasive alternative to open resective surgery for drug-resistant epilepsy (DRE). We sought to perform a systematic review and individual participant data meta-analysis to identify independent predictors of seizure outcome and complications following MRgLITT for DRE. Eleven databases were searched from January 1, 2010 to February 6, 2021 using the terms "MR-guided ablation therapy" and "epilepsy". Multivariable mixed-effects Cox and logistic regression identified predictors of time to seizure recurrence, seizure freedom, operative complications, and postoperative neurological deficits. From 8705 citations, 46 studies reporting on 450 MRgLITT DRE patients (mean age = 29.5 ± 18.1 years, 49.6% female) were included. Median postoperative seizure freedom and follow-up duration were 15.5 and 19.0 months, respectively. Overall, 240 (57.8%) of 415 patients (excluding palliative corpus callosotomy) were seizure-free at last follow-up. Generalized seizure semiology (hazard ratio [HR] = 1.78, p = .020) and nonlesional magnetic resonance imaging (MRI) findings (HR = 1.50, p = .032) independently predicted shorter time to seizure recurrence. Cerebral cavernous malformation (CCM; odds ratio [OR] = 7.97, p < .001) and mesial temporal sclerosis/atrophy (MTS/A; OR = 2.21, p = .011) were independently associated with greater odds of seizure freedom at last follow-up. Operative complications occurred in 28 (8.5%) of 330 patients and were independently associated with extratemporal ablations (OR = 5.40, p = .012) and nonlesional MRI studies (OR = 3.25, p = .017). Postoperative neurological deficits were observed in 53 (15.1%) of 352 patients and were independently predicted by hypothalamic hamartoma etiology (OR = 5.93, p = .006) and invasive electroencephalographic monitoring (OR = 4.83, p = .003). Overall, MRgLITT is particularly effective in treating patients with well-circumscribed lesional DRE, such as CCM and MTS/A, but less effective in nonlesional cases or lesional cases with a more diffuse epileptogenic network associated with generalized seizures. This study identifies independent predictors of seizure freedom and complications following MRgLITT that may help further guide patient selection.
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Affiliation(s)
- Jia-Shu Chen
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Audrey-Anne Lamoureux
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Nathan A Shlobin
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Lior M Elkaim
- Division of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Andrew Wang
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - George M Ibrahim
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Sami Obaid
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Montreal, Quebec, Canada
- Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Adil Harroud
- Division of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
- Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Elena Guadagno
- Harvey E. Beardmore Division of Pediatric Surgery, McGill University Health Center, Montreal, Quebec, Canada
| | - Evan Dimentberg
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Montreal, Quebec, Canada
- Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Alain Bouthillier
- Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Boris C Bernhardt
- McConnell Brain Imaging Center, Montreal Neurological Institute and Hospital, McGill University, Quebec, Canada
| | - Dang K Nguyen
- Division of Neurology, University of Montreal Medical Center, Montreal, Quebec, Canada
| | - Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Alexander G Weil
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Montreal, Quebec, Canada
- Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
- Brain and Child Development Axis, Sainte Justine Research Center, Montreal, Quebec, Canada
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Lu D, Wang T, Yang Y, Fan X, Chen S, Wei P, Shan Y, Zhao G. Advances in hypothalamic hamartoma research over the past 30 years (1992-2021): a bibliometric analysis. Front Neurol 2023; 14:1176459. [PMID: 37416311 PMCID: PMC10322195 DOI: 10.3389/fneur.2023.1176459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/16/2023] [Indexed: 07/08/2023] Open
Abstract
Background Hypothalamic hamartoma (HH) is a rare intracranial disease whose manifestations include gelastic seizures and precocious puberty. The diagnosis and treatment of HH have changed substantially over the past three decades as medical care has improved. Bibliometrics can reveal the evolution and development of a scientific field. Methods Documents on HH were retrieved from the Web of Science Core Collection (WoSCC) database on September 8, 2022. The search terms were as follows: "hypothalamic hamartoma" or "hamartoma of the hypothalamus" or "hypothalamic hamartomas." The types of documents were restricted to articles, case reports, and reviews. VOSviewer, CiteSpace, and the R package "bibliometrix" were used for a bibliometric analysis. Results A total of 667 independent documents on HH were obtained from the WoSCC database. The most common types of documents were articles (n = 498, 75%) and reviews (n = 103, 15%). The number of annual publications fluctuated but showed an upward trend overall, and the annual growth rate was 6.85%. The cumulative publication data indicated that the most influential journals in the HH field include Epilepsia, Epileptic Disorders, Child's Nervous System, Neurosurgery, and the Journal of Neurosurgery. Kerrigan JF, Ng YT, Rekate HL, Regis J, and Kameyama S were among the most prominent authors in the field of HH, with numerous publications and citations. American research institutions, especially the Barrow Neurological Institute, occupied a pivotal position in HH research. Other countries and institutions were catching up and producing considerable research results. Research on HH has steadily switched its emphasis from Pallister-Hall syndrome (PHS) and precocious puberty to epilepsy and new diagnostic and therapeutic techniques, including Gamma Knife, laser ablation, and interstitial thermal therapy. Conclusion HH remains a special neurological disease with significant research prospects. The development of novel technologies, including MRI-guided laser-induced thermal therapy (MRg-LiTT) and stereotactic radiofrequency thermocoagulation (RF-TC), has enabled the efficient treatment of gelastic seizures in HH while minimizing the risks associated with craniotomies. Through bibliometric analysis, this study points out the direction for future HH research.
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Affiliation(s)
- Di Lu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Tianren Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Yanfeng Yang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Xiaotong Fan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Sichang Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Penghu Wei
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, China
| | - Yongzhi Shan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Guoguang Zhao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, China
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The use of stereotactic MRI-guided laser interstitial thermal therapy for the treatment of pediatric cavernous malformations: the SUNY Upstate Golisano Children's Hospital experience. Childs Nerv Syst 2023; 39:417-424. [PMID: 36416952 DOI: 10.1007/s00381-022-05701-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 10/03/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Cavernous malformations (CM) are central nervous system lesions characterized by interlaced vascular sinusoids coated with endothelial cells without intervening parenchyma. Magnetic resonance imaging-guided laser interstitial thermal therapy (MRIgLITT) is a minimally invasive treatment modality that can precisely treat pathologic cerebral tissue, making it an effective alternative for the management of cavernomas. We describe the outcomes of a series of pediatric patients with cavernous brain malformations treated with MRIgLITT between 2014 and 2018 at our institution. METHODS We retrospectively analyzed 11 cavernomas in 6 pediatric patients treated with MRIgLITT. Both the Visualase System® and/or Neuroblate® systems were used. A variation of the surgical technique on the application of the laser was developed. Post-ablation MRIs were obtained to assess ablated areas. RESULTS A total of 11 cavernomas in 6 patients were treated with MRIgLITT. Median age was 15 years (12 to 17 years); 75% were males. Presenting symptoms were headache (75%) and seizures (25%). Two patients presented with multiple CMs. All lesions in this study were supratentorial (cerebral hemispheres 81.8%, corpus callosum 9.1%, basal ganglia 9.1%). Our surgical technique was well-tolerated, with no significant adverse events observed. Hospital stay for all patients was less than 48 hours. CONCLUSION MRIgLITT is an effective minimally invasive technique for the treatment of pediatric CMs. It represents a useful and safe tool, when other therapeutic alternatives may represent a greater risk of surgical morbidity.
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Riviello JJ, Curry DJ, Weiner HL. An Introduction to Minimally Invasive Pediatric Epilepsy Surgery. JOURNAL OF PEDIATRIC EPILEPSY 2022. [DOI: 10.1055/s-0042-1759876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AbstractThe field of minimally invasive surgery has evolved over the past 50 years, including neurosurgery, with an evolution to “minimally invasive neurosurgery” when feasible. Epilepsy surgery has followed this trend, with a transition from standard neurosurgical techniques to minimally invasive techniques in all phases of neurosurgical involvement. These include the diagnostic intracranial electroencephalogram with a subdural exploration to stereoelectroencephalography, the actual resection from an open craniotomy to a less destructive technique, or the multiple modalities of neuromodulation instead of a destructive surgery.The influence of these minimally invasive techniques has resulted in a change in the overall philosophy of pediatric epilepsy surgery. The expectations of what is considered “successful” epilepsy surgery has changed from total seizure control, in other words, a “cure,” to palliative epilepsy surgery with a decrease in the targeted seizures, especially “disabling seizures.” This has led to an overall greater acceptance of epilepsy surgery. This article summarizes the major reasons behind the explosion of minimally invasive pediatric epilepsy surgery, which are amplified in the subsequent articles. Some of this chapter includes the authors' opinions.
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Affiliation(s)
- James J. Riviello
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, Unites States
- Department of Neurology, Texas Children's Hospital, Houston, Texas, Unites States
| | - Daniel J. Curry
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, Unites States
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, Unites States
| | - Howard L. Weiner
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, Unites States
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, Unites States
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Muacevic A, Adler JR, Jimenez MJD, Budnick HC, Raskin J. Thermal Damage Estimate Artifact Following Antecedent Biopsy: A Case Report. Cureus 2022; 14:e31913. [PMID: 36579245 PMCID: PMC9792349 DOI: 10.7759/cureus.31913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2022] [Indexed: 11/27/2022] Open
Abstract
MR-guided laser interstitial therapy (MRgLITT) is becoming more commonly used for minimal access approaches to intracranial lesions of all etiologies. The short-term safety profile of MRgLITT is favorable compared with sweeping incisions and open craniotomies, especially for lesions located in deep, periventricular, and highly eloquent areas. The Visualase software (Medtronic Inc., Minneapolis, MN, USA) has multiple adaptations to assist with this safety margin, including the thermal damage estimate (TDE), which applies predictive mathematical modeling to a two-dimensional (2D) graphical representation. TDE has been shown to highly correlate with actual tissue destruction in a priori MRgLITT cases and to anecdotally be imprecise when MRgLITT is combined with biopsy. We present a case regarding a 17-year-old male patient with intractable focal epilepsy. He underwent stereotactic biopsy and then ablation where it was shown that TDE is ~35% larger in the coronal plane than in the actual ablation zone. Air may have caused this artifact in the biopsy cavity, which affected the proton resonance frequency (PRF) and caused TDE pigment deposition. We believe in the need for a more comprehensive understanding and investigation regarding this TDE artifact. Future prospective studies into MRgLITT should attend carefully in cases where it is combined with biopsy.
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Almojuela A, Xu Q, O'Carroll A, Ritchie L, Serletis D. Paediatric epilepsy surgery: Techniques and outcomes. J Paediatr Child Health 2022; 58:1952-1957. [PMID: 36197046 DOI: 10.1111/jpc.16236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 07/23/2022] [Accepted: 09/21/2022] [Indexed: 11/28/2022]
Abstract
Epilepsy is a neurological condition characterised by recurrent and persistent seizures. For paediatric patients, achieving early seizure freedom can have positive impacts on cognition, development, social integration and mental health, leading to improved quality of life. In general, one third of patients with epilepsy are refractory to medication; for these patients, epilepsy surgery may offer the only chance for improved seizure control. Epilepsy surgery as a therapeutic intervention has become increasingly accepted in the past few decades, with more diverse options available (including neuromodulatory and minimally invasive techniques). In this context, we discuss here the pre-operative workup for paediatric patients with medically refractory epilepsy and provide an updated review on current and emerging surgical therapies for this condition. We also discuss the clinical, neuropsychological, quality of life and economic impacts of epilepsy surgery.
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Affiliation(s)
- Alysa Almojuela
- Section of Neurosurgery, Department of Surgery, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Qi Xu
- Section of Pediatric Neurology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada
| | - Aoife O'Carroll
- Section of Pediatric Neurology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada
| | - Lesley Ritchie
- Department of Clinical Health Psychology, University of Manitoba, Winnipeg, Canada
| | - Demitre Serletis
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, United States.,Cleveland Clinic Epilepsy Center, Neurological Institute, Cleveland, Ohio, United States
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12
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Iranmehr A, Dabbagh Ohadi MA, Chavoshi M, Jahanbakhshi A, Slavin KV. Minimally invasive procedures for hypothalamic hamartoma–related epilepsy: a systematic review and meta-analysis. Neurosurg Focus 2022; 53:E8. [DOI: 10.3171/2022.7.focus22296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 07/25/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE
Hypothalamic hamartoma (HH) is a rare, nonmalignant, heterotopic developmental malformation that consists of a mixture of normal neurons and glial cells. Resection of HHs has been associated with high rates of mortality and morbidity. Therefore, minimally invasive ablation methods could be the best treatment option for HH. The most frequently used minimally invasive options for HH ablation are radiofrequency thermocoagulation (RFT), laser ablation (LA), and stereotactic radiosurgery.
METHODS
To investigate three minimally invasive procedures in the treatment of refractory seizures related to HH, the authors conducted a systematic search in March 2022 in the MEDLINE, Embase, Scopus, and Web of Science databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Seizure freedom was the primary outcome of interest. The authors defined seizure freedom as Engel class I or International League Against Epilepsy class 1 or 2 or as the reported term “seizure freedom.” The secondary outcome was long-term complications reported in studies. Both random- and fixed-effects models were used to calculate the pooled proportion of seizure freedom and complication rate with 95% confidence intervals. A modified version of the Joanna Briggs Institute (JBI) Critical Appraisal to assess the risk of bias was used.
RESULTS
The authors included 15 studies with 422 patients (RFT, n = 190; LA, n = 171; and Gamma Knife Radiosurgery [GKRS], n = 61). Generally, the mean incidences of overall seizure freedom after minimally invasive procedures were 77% (95% CI 0.74–0.81) and 68% (95% CI 0.57–0.79) using fixed- and random-effects models, respectively. The mean incidence of overall seizure freedom after RFT was 69% (95% CI 0.63–0.75), and the mean incidences of overall seizure freedom after LA and GKRS were 87% (95% CI 0.82–0.92) and 44% (95% CI 0.32–0.57), respectively. The total complication rate with minimally invasive procedures was 13% (95% CI 0.01–0.26). The complication rate in each treatment was as follows: 5% (95% CI 0.0–0.12) for RFT, 20% (95% CI 0.0–0.47) for LA, and 22% (95% CI 0–0.65) for GKRS. Meta-regression analysis showed an association between older age and higher complication rates in the LA group.
CONCLUSIONS
In this meta-analysis, LA showed superiority in seizure freedom over the other two methods. The complication rate associated with RFT was less than those in the other two methods; however, this difference was not statistically significant.
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Affiliation(s)
- Arad Iranmehr
- Neurosurgery Department, Imam Khomeini Hospital Complex (IKHC), Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Amin Dabbagh Ohadi
- Neurosurgery Department, Imam Khomeini Hospital Complex (IKHC), Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Chavoshi
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amin Jahanbakhshi
- Stem Cell and Regenerative Medicine Research Center, Iran University of Medical Sciences, Tehran, Iran; and
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Candela-Cantó S, Muchart J, Ramírez-Camacho A, Becerra V, Alamar M, Pascual A, Forero C, Rebollo Polo M, Munuera J, Aparicio J, Rumià J, Hinojosa J. Robot-assisted, real-time, MRI-guided laser interstitial thermal therapy for pediatric patients with hypothalamic hamartoma: surgical technique, pitfalls, and initial results. J Neurosurg Pediatr 2022:1-12. [PMID: 35334464 DOI: 10.3171/2022.2.peds21516] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 02/02/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Real-time, MRI-guided laser interstitial thermal therapy (MRgLITT) has been reported as a safe and effective technique for the treatment of epileptogenic foci in children and adults. After the recent approval of MRgLITT by the European Medicines Agency in April 2018, the authors began to use it for the treatment of hypothalamic hamartomas (HHs) in pediatric patients with the assistance of a robotic arm. In this study, the authors report their initial experience describing the surgical technique, accuracy of the robotic arm, safety, and efficacy. METHODS The laser fiber was placed with the assistance of the stereotactic robotic arm. The accuracy of the robotic arm for this procedure was calculated by comparing the intraoperative MRI to the preoperative plan. Common demographic and seizure characteristics of the patients, laser ablation details, complications, and short-term seizure outcomes were prospectively collected. RESULTS Sixteen procedures (11 first ablations and 5 reablations) were performed in 11 patients between 15 months and 17 years of age (mean age 6.4 years) with drug-resistant epilepsy related to HHs. The mean target point localization error was 1.69 mm. No laser fiber needed to be repositioned. The mean laser power used per procedure was 4.29 W. The trajectory of the laser fiber was accidentally ablated in 2 patients, provoking transient hemiparesis in one of these patients. One patient experienced postoperative somnolence and syndrome of inappropriate antidiuretic hormone secretion, and 2 patients had transient oculomotor (cranial nerve III) palsy. Fifty-four percent of the patients were seizure free after the first ablation (mean follow-up 22 months, range 15-33 months). All 5 patients who experienced an epilepsy relapse underwent a second treatment, and 4 remain seizure free at least 5 months after reablation. CONCLUSIONS In the authors' experience, the robotic arm was sufficiently accurate for laser fiber insertion, even in very young patients. MRgLITT appears to be an effective treatment for selected cases of HH. MRgLITT for HH is a minimally invasive procedure with appealing safety features, as it allows delivery of energy precisely under real-time MRI control. Nonetheless, complications may occur, especially in voluminous HHs. The amount of delivered energy and the catheter cooling system must be closely monitored during the procedure. A larger sample size and longer follow-up duration are needed to judge the efficacy and safety of MRgLITT for HH more rigorously. This initial experience was very promising.
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Affiliation(s)
- Santiago Candela-Cantó
- 1Neurosurgery Department.,4Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Spain
| | - Jordi Muchart
- 2Diagnostic Imaging Department.,4Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Spain
| | - Alia Ramírez-Camacho
- 4Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Spain
| | - Victoria Becerra
- 1Neurosurgery Department.,4Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Spain
| | - Mariana Alamar
- 1Neurosurgery Department.,4Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Spain
| | | | | | - Mónica Rebollo Polo
- 2Diagnostic Imaging Department.,4Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Spain
| | | | - Javier Aparicio
- 4Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Spain
| | - Jordi Rumià
- 1Neurosurgery Department.,4Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Spain
| | - José Hinojosa
- 1Neurosurgery Department.,4Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Spain
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14
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Lehner KR, D'Amico RS, Rahme R, Schneider JR, Privler GG, Faltings LJ, Du VX, Boockvar JA, Rekate HL, Langer DJ. Microsurgical management of complex hypothalamic hamartomas in the era of minimally invasive therapy: a case series and narrative review. World Neurosurg 2022; 160:e388-e397. [PMID: 35032713 DOI: 10.1016/j.wneu.2022.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/06/2022] [Accepted: 01/07/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION There has been a paradigm shift in the management of hypothalamic hamartoma (HH) from traditional microsurgical techniques to less invasive alternatives. However, large and extensive HH may fail to respond to these therapies, ultimately necessitating craniotomies. METHODS All patients who underwent microsurgical resection of a complex HH by the 2 senior authors from 2011-2021 were included. Charts were retrospectively reviewed and demographic, clinical, imaging, and outcome data were recorded. RESULTS 8 patients (mean age 7 years) were included. 2 had failed previous treatments. All 7 presented with gelastic seizures and cognitive dysfunction, 6 exhibited central precocious puberty, and 3 had behavioral problems. Mean lesion size was 21.6 mm and all had interpeduncular extension, 5 had intraventricular extension (Delalande type I: 3, type III: 4, type IV: 1). A frontotemporal orbitozygomatic (FTOZ) approach with optic nerve decompression was used in all patients, supplemented by another approach in 3 (endoscopic transventricular: 3, transcallosal: 1). Gross total resection was achieved in 6 patients and subtotal resection in 2. Transient complications occurred in 3 patients (37.5%): self-limited sodium imbalance (n=3), subdural hygroma (n=2). Permanent complications occurred in 2 patients (25%): perforator infarct (n=1), short-term memory loss (n=1). All patients experienced seizure resolution with preserved hypothalamic-pituitary axis function. After a mean follow-up of 41 months (2-66), 7 patients remain seizure-free, while 1 has rare seizures. Cognitive and behavioral symptoms improved in all patients. CONCLUSION For large HH with interpeduncular extension, microsurgery via the FTOZ approach is a safe and highly effective treatment modality.
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Affiliation(s)
- Kurt R Lehner
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Randy S D'Amico
- Department of Neurosurgery, Lenox Hill Hospital, Hofstra/Northwell School of Medicine, New York, NY, USA; Department of Neurosurgery, Wyckoff Heights Medical Center, Brooklyn, NY, USA
| | - Ralph Rahme
- Department of Neurosurgery, Lenox Hill Hospital, Hofstra/Northwell School of Medicine, New York, NY, USA
| | - Julia R Schneider
- Department of Neurosurgery, Lenox Hill Hospital, Hofstra/Northwell School of Medicine, New York, NY, USA
| | - Gloria G Privler
- Department of Neurosurgery, Lenox Hill Hospital, Hofstra/Northwell School of Medicine, New York, NY, USA
| | - Lukas J Faltings
- Department of Neurosurgery, Lenox Hill Hospital, Hofstra/Northwell School of Medicine, New York, NY, USA
| | - Victor X Du
- Department of Neurosurgery, North Shore University Hospital, Hofstra/Northwell School of Medicine, Manhasset, NY, USA
| | - John A Boockvar
- Department of Neurosurgery, Lenox Hill Hospital, Hofstra/Northwell School of Medicine, New York, NY, USA; Department of Neurosurgery, North Shore University Hospital, Hofstra/Northwell School of Medicine, Manhasset, NY, USA; Department of Neurosurgery, Long Island Jewish/Cohen Children's Medical Center, Hofstra/Northwell School of Medicine, Queens, NY, USA
| | - Harold L Rekate
- Department of Neurosurgery, Lenox Hill Hospital, Hofstra/Northwell School of Medicine, New York, NY, USA; Department of Neurosurgery, North Shore University Hospital, Hofstra/Northwell School of Medicine, Manhasset, NY, USA; Department of Neurosurgery, Long Island Jewish/Cohen Children's Medical Center, Hofstra/Northwell School of Medicine, Queens, NY, USA
| | - David J Langer
- Department of Neurosurgery, Lenox Hill Hospital, Hofstra/Northwell School of Medicine, New York, NY, USA; Department of Neurosurgery, North Shore University Hospital, Hofstra/Northwell School of Medicine, Manhasset, NY, USA; Department of Neurosurgery, Long Island Jewish/Cohen Children's Medical Center, Hofstra/Northwell School of Medicine, Queens, NY, USA.
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15
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Melikyan AG. [Surgical treatment of epilepsy in patients with hypothalamic hamartomas]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:83-88. [PMID: 35942841 DOI: 10.17116/neiro202286041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
UNLABELLED The purpose of this review was to analyze the current ideas about various techniques and methods for treating epilepsy in patients with hypothalamic hamartomas including microsurgery, endoscopy, radiofrequency thermal destruction, stereotactic laser ablation and radiosurgery. Data characterizing their effectiveness, limitations and complications are considered. CONCLUSION When choosing the optimal treatment option, it is necessary to take into account patient age and course of disease, anatomical and topographic features of hamartoma location, previous attempts of treatment, opinion of the patient and his guardians, as well as surgical experience.
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Tripathi M, Maskara P, Sankhyan N, Sahu JK, Kumar R, Kumar N, Ahuja CK, Kaur P, Kaur R, Batish A, Mohindra S. Safety and Efficacy of Primary Hypofractionated Gamma Knife Radiosurgery for Giant Hypothalamic Hamartoma. Indian J Pediatr 2021; 88:1086-1091. [PMID: 33501606 DOI: 10.1007/s12098-020-03637-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 12/18/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe the feasibility, safety, efficacy, and complication profile of primary hypofractionated gamma knife radiosurgery (GKRS), and practical nuances of performing the same in pediatric patients. METHODS Three pediatric patients (age range 17-65 mo) underwent primary hypofractionated GKRS in 2-3 consecutive days with interfraction interval of 24 h. All patients had precocious puberty and were on GnRH analogue. Frame based GKRS done with 8.1-9.2 Gy radiation per fraction at 50% isodose in 2-3 fractions targeting the entire hamartoma volume. The mean target volume was 5.67 cc (4.45-7.39 cc). The authors followed these patients for clinical and endocrinological assessment at every 6 mo interval while the repeat MRI done at 6 mo and then annually. The seizure outcome analysis was done using Engel scale. RESULTS At a mean follow up of 27 mo (24-30 mo), 2 patients became Engel class 3 while one achieved Engel class 1 control. 2 patients showed halted pubertal growth with no additional hormonal aberration. 2 patients showed significant volumetric reduction (48% and 32%) and patchy necrosis inside the hypothalamic hamartoma (HH). There was no deficit in visual function, memory and cognition. One patient showed reduction in aggressiveness. CONCLUSION Giant HH are exceptionally difficult neurological diseases. Primary hypofractionated GKRS may be an alternative approach as mono/multitherapy with promising results and minimal complication.
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Affiliation(s)
- Manjul Tripathi
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India. .,National Institute of Health Research (NIHR) Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK.
| | - Prasant Maskara
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Naveen Sankhyan
- Department of Pediatric Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jitendra Kumar Sahu
- Department of Pediatric Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kumar
- Department of Pediatric Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Narendra Kumar
- Department of Radiotherapy, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Chirag K Ahuja
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Parwinder Kaur
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Rupinder Kaur
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Aman Batish
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Sandeep Mohindra
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
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17
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Guglielmi G, Eschbach KL, Alexander AL. Smaller Knife, Fewer Seizures? Recent Advances in Minimally Invasive Techniques in Pediatric Epilepsy Surgery. Semin Pediatr Neurol 2021; 39:100913. [PMID: 34620456 DOI: 10.1016/j.spen.2021.100913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 02/02/2023]
Abstract
Children with drug-resistant epilepsy are at high risk for developmental delay, increased mortality, psychiatric comorbidities, and requiring assistance with activities of daily living. Despite the advent of new and effective pharmacologic therapies, about one in 5 children will develop drug-resistant epilepsy, and most of these children continue to have seizures despite trials of other medication. Epilepsy surgery is often a safe and effective option which may offer seizure freedom or at least a significant reduction in seizure burden in many children. However, despite published evidence of safety and efficacy, epilepsy surgery remains underutilized in the pediatric population. Patient and family fears about the risks of surgery may contribute to this gap. Less invasive surgical techniques may be more palatable to children with epilepsy and their caregivers. In this review, we present recent advances in minimally invasive techniques for the surgical treatment of epilepsy as well as intriguing possibilities for the future. We describe the indications for, benefits of, and limits to minimally-invasive techniques including Stereo-encephalography, laser interstitial thermal ablation, deep brain stimulation, focused ultrasound, stereo-encephalography-guided radiofrequency ablation, endoscopic disconnections, and responsive neurostimulation.
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Affiliation(s)
- Gina Guglielmi
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO
| | - Krista L Eschbach
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO
| | - Allyson L Alexander
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO.
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Shirozu H, Masuda H, Kameyama S. Long-term seizure outcomes in patients with hypothalamic hamartoma treated by stereotactic radiofrequency thermocoagulation. Epilepsia 2021; 62:2697-2706. [PMID: 34541660 DOI: 10.1111/epi.17071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/25/2021] [Accepted: 09/03/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate long-term seizure outcomes in patients with hypothalamic hamartoma (HH) following stereotactic radiofrequency thermocoagulation (SRT). METHODS A total of 131 patients with HH who underwent SRT and were followed for at least three years after the last SRT were enrolled. Seizure outcomes were evaluated for gelastic seizures (GS) and other types of seizures (nGS) separately using the International League Against Epilepsy classification. Classes 1 and 2 were considered seizure-free. Kaplan-Meier survival analyses were used to estimate the proportion remaining seizure-free after the first and last SRTs. Risk factors relating to outcomes were analyzed by log-rank tests and a multivariate Cox proportional hazards model. RESULTS Reoperation was performed in 34 patients (26.2%). Median total follow-up was 61 (range, 36-202) months. Seizure freedom was obtained in 116 patients (88.6%) for GS and 85 of 108 patients (78.7%) for nGS at the last follow-up. Mean GS-free survival times improved from after the first (64.1 [95%CI 57.3-70.9] months) to after the last SRT (80.2 [95%CI 75.7-84.8] months). About 90% of GS recurrences after the first SRT were found within 6 months, though a few patients recurred more than 2 years after the first SRT. On the other hand, mean nGS-free survival times after the first and last SRTs were not different between after the first SRT (84.4 [95%CI 73.0-90.7] months) and after the last SRT (83.1 [95%CI 74.1-92.0] months). There was no factor related to GS outcomes, but the significant factor for nGS-free survival after the last SRT was multiple previous treatments (p=0.01, hazard ratio=15.65, 95%CI 1.79-137.16). SIGNIFICANCE The last SRT was almost equivalent to achieving complete disconnection of HHs from the hypothalamus according to our strategy. Considering the epileptogenic network, GS outcomes depend on complete disconnection, whereas nGS outcomes are not affected by surgical factors but independency of secondary epileptogenesis.
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Affiliation(s)
- Hiroshi Shirozu
- Department of Functional Neurosurgery, National Hospital Organization Nishiniigata Chuo Hospital, Niigata, Japan.,Hypothalamic Hamartoma Center, National Hospital Organization Nishiniigata Chuo Hospital, Niigata, Japan
| | - Hiroshi Masuda
- Department of Functional Neurosurgery, National Hospital Organization Nishiniigata Chuo Hospital, Niigata, Japan.,Hypothalamic Hamartoma Center, National Hospital Organization Nishiniigata Chuo Hospital, Niigata, Japan
| | - Shigeki Kameyama
- Department of Neurosurgery, Niigata Seiro Hospital, Niigata, Japan
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Zeller S, Kaye J, Jumah F, Mantri SS, Mir J, Raju B, Danish SF. Current applications and safety profile of laser interstitial thermal therapy in the pediatric population: a systematic review of the literature. J Neurosurg Pediatr 2021; 28:360-367. [PMID: 34214984 DOI: 10.3171/2021.2.peds20721] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 02/08/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Laser interstitial thermal therapy (LITT) provides a minimally invasive alternative to open brain surgery, making it a powerful neurosurgical tool especially in pediatric patients. This systematic review aimed to highlight the indications and complications of LITT in the pediatric population. METHODS In line with the PRISMA guidelines, the authors conducted a systematic review to summarize the current applications and safety profiles of LITT in pediatrics. PubMed and Embase were searched for studies that reported the outcomes of LITT in patients < 21 years of age. Retrospective studies, case series, and case reports were included. Two authors independently screened the articles by title and abstract followed by full text. Relevant variables were extracted from studies that met final eligibility, and results were pooled using descriptive statistics. RESULTS The selection process captured 303 pediatric LITT procedures across 35 studies. Males comprised approximately 60% of the aggregate sample, with a mean age of 10.5 years (range 0.5-21 years). The LITT technologies used included Visualase (89%), NeuroBlate (9%), and Multilase 2100 (2%). The most common indication was treatment of seizures (86%), followed by brain tumors (16%). The mean follow-up duration was 15.6 months (range 1.3-48 months). The overall complication rate was 15.8%, which comprised transient neurological deficits, cognitive and electrolyte disturbances, hemorrhage, edema, and hydrocephalus. No deaths were reported. CONCLUSIONS As of now, LITT's most common applications in pediatrics are focused on treating medically refractory epilepsy and brain tumors that can be difficult to resect. The safety of LITT can provide an attractive alternative to open brain surgery in the pediatric population.
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Affiliation(s)
- Sabrina Zeller
- 1Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School and Robert Wood Johnson University Hospital, New Brunswick
| | - Joel Kaye
- 1Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School and Robert Wood Johnson University Hospital, New Brunswick
| | - Fareed Jumah
- 1Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School and Robert Wood Johnson University Hospital, New Brunswick
| | - Shilpa S Mantri
- 2Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey; and
| | - Jamshaid Mir
- 3College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - Bharath Raju
- 1Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School and Robert Wood Johnson University Hospital, New Brunswick
| | - Shabbar F Danish
- 1Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School and Robert Wood Johnson University Hospital, New Brunswick
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20
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Liu C, Zheng Z, Shao XQ, Li CD, Yang XL, Zhang C, Sang L, Xie F, Zhou F, Hu WH, Zhang K. Stereoelectroencephalography-guided radiofrequency thermocoagulation for hypothalamic hamartoma: Electroclinical patterns and the relationship with surgical prognosis. Epilepsy Behav 2021; 118:107957. [PMID: 33872942 DOI: 10.1016/j.yebeh.2021.107957] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/01/2021] [Accepted: 03/23/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Radiofrequency thermocoagulation (RFTC) guided by stereo-electroencephalography (SEEG) has been proved to be a safe method to reduce seizure frequency in patients with drug-resistant epilepsy. However, there are few reports addressing the value and safety of this procedure in hypothalamic hamartoma (HH). OBJECTIVE To present the results of our experience using SEEG-guided RFTC in HH patients with drug-resistant epilepsy, and identify outcome predictors. METHODS We retrospectively reviewed the clinical and surgical characteristics of 27 HH-related patients with epilepsy in our center between 2015 and 2019. All patients underwent invasive recordings with SEEG before RFTC was performed. We reported surgical outcome predictors and postoperative follow-up concerning safety and efficacy (mean follow-up, 27.3 months; range, 12-63). Surgical strategy was also analyzed. RESULTS Nineteen patients (70.4%) achieved Engel's class I outcome, while 4 patients (14.8%) did not show significant improvement. Of all observed seizures, two different onset patterns of intracranial electrophysiology recorded by SEEG were observed. Patients presented with focal low-voltage fast activity were more likely to obtain seizure freedom (p = 0.045), while classification (p = 0.478), volume (p = 0.546), history of resection (p = 0.713), seizure types (p = 0.859), or seizure duration (p = 0.415) showed no significant effect on the outcome. Weight gain was the most common long-term complication (18.5%). CONCLUSION The SEEG can guide the ablation of HH and serve as an important factor to predict favorable seizure outcomes. Radiofrequency thermocoagulation guided by SEEG can offer a minimally invasive and low-risk surgical approach with excellent outcomes. Disconnecting the attachment of HH should be the appropriate strategy to obtain the best seizure outcome.
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Affiliation(s)
- Chang Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Stereotactic and Functional Neurosurgery, Beijing Neurosurgical Institute, Beijing, China
| | - Zhong Zheng
- Epilepsy Center, Beijing Fengtai Hospital, Beijing, China
| | - Xiao-Qiu Shao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chun-de Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiao-Li Yang
- Epilepsy Center, Beijing Fengtai Hospital, Beijing, China
| | - Chao Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Stereotactic and Functional Neurosurgery, Beijing Neurosurgical Institute, Beijing, China
| | - Lin Sang
- Epilepsy Center, Beijing Fengtai Hospital, Beijing, China
| | - Fei Xie
- Epilepsy Center, Beijing Fengtai Hospital, Beijing, China
| | - Feng Zhou
- Epilepsy Center, Beijing Fengtai Hospital, Beijing, China
| | - Wen-Han Hu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Stereotactic and Functional Neurosurgery, Beijing Neurosurgical Institute, Beijing, China
| | - Kai Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Stereotactic and Functional Neurosurgery, Beijing Neurosurgical Institute, Beijing, China.
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Wang M, Zhang Y, Xue P, Zhou Y, Shi W, Zhou S, Wang Y, Li H, Zhao R. Optimized SEEG-guided radiofrequency thermocoagulation in the treatment of pediatric hypothalamic hamartomas. Seizure 2021; 86:102-108. [PMID: 33588305 DOI: 10.1016/j.seizure.2021.01.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/19/2021] [Accepted: 01/30/2021] [Indexed: 11/24/2022] Open
Abstract
PURPOSE This study investigated the role of one-stage stereo-array radiofrequency thermocoagulation based on stereotactic electroencephalography in the treatment of pediatric hypothalamic hamartomas. METHODS We analyzed the clinical data of 28 patients with hypothalamic hamartoma. A high-density focal stereo-array electrode implantation strategy was adopted. Stereotactic electroencephalography guided bipolar coagulations were performed between two contiguous contacts of the same electrode, or between two adjacent contacts of different electrodes. Patients with hypothalamic hamartoma were divided into two groups based on hamartoma size (maximum diameter < 15 mm vs maximum diameter ≥ 15 mm). Numbers of implanted electrodes and contacts used for thermocoagulation were documented. Seizure outcome was evaluated according to Engel's classification. RESULTS Surgical procedures were well tolerated and no repeated surgery was performed. The median number of electrodes implanted in the two groups was significantly different (p = 0.0009), as well as the median number of contacts where radiofrequency thermocoagulation was applied (p = 0.0006). Moreover, the number of implanted electrodes and contacts used for thermocoagulation were positively correlated with the hamartoma volume (Spearman's rho = 0.7074, p<0.0001 and Spearman's rho = 0.7435, p<0.0001, respectively). The overall seizure-free rate was 82.1 %, with 92.9 % of the patients having favorable outcomes for at least 12 months of follow-up. Seizure outcomes between two groups were not statistically significant (p = 0.3138). CONCLUSION One-stage high-density focal stereo-array stereotactic electroencephalography guided radiofrequency thermocoagulation using cross-bonded electrode contacts for ablation range expansion is a safe and effective surgical approach for children with hypothalamic hamartoma.
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Affiliation(s)
- Min Wang
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center (Shanghai), Shanghai, 201102, PR China
| | - Yi Zhang
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center (Shanghai), Shanghai, 201102, PR China
| | - Ping Xue
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center (Shanghai), Shanghai, 201102, PR China
| | - Yuanfeng Zhou
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center (Shanghai), Shanghai, 201102, PR China
| | - Wei Shi
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center (Shanghai), Shanghai, 201102, PR China
| | - Shuizhen Zhou
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center (Shanghai), Shanghai, 201102, PR China
| | - Yi Wang
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center (Shanghai), Shanghai, 201102, PR China
| | - Hao Li
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center (Shanghai), Shanghai, 201102, PR China.
| | - Rui Zhao
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center (Shanghai), Shanghai, 201102, PR China.
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22
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Bakr SM, Patel A, Zaazoue MA, Wagner K, Lam SK, Curry DJ, Raskin JS. Standard work tools for dynamic stereoelectroencephalography using ROSA: naming convention and perioperative planning. J Neurosurg Pediatr 2021; 27:411-419. [PMID: 33482632 DOI: 10.3171/2020.8.peds20420] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The grid-based orthogonal placement of depth electrodes (DEs), initially defined by Jean Talairach and Jean Bancaud, is known as stereo-electroencephalography (sEEG). Although acceptance in the United States was initially slow, advances in imaging and technology have spawned a proliferation of North American epilepsy centers offering sEEG. Despite publications highlighting minimal access techniques and varied indications, standard work for phase I targeted DE has not been defined. In this article, the authors propose the term "dynamic sEEG" and define standard work tools and related common data elements to promote uniformity in the field. METHODS A multidisciplinary approach from July to August 2016 resulted in the production of 4 standard work tools for dynamic sEEG using ROSA: 1) a 34-page illustrated manual depicting a detailed workflow; 2) a planning form to collocate all the phase I data; 3) a naming convention for DEs that encodes the data defining it; and 4) a reusable portable perioperative planning and documentation board. A retrospective review of sEEG case efficiency was performed comparing those using standard work tools (between July 2016 and April 2017) with historical controls (between March 2015 and June 2016). The standard work tools were then instituted at another epilepsy surgery center, and the results were recorded. RESULTS The process for dynamic sEEG was formally reviewed, including anesthesia, positioning, perioperative nursing guidelines, surgical steps, and postoperative care for the workflow using cranial fixation and ROSA-guided placement. There was a 40% improvement in time per electrode, from 44.7 ± 9.0 minutes to 26.9 ± 6.5 minutes (p = 0.0007) following the development and use of the manual, the naming convention, and the reusable portable perioperative planning and documentation board. This standardized protocol was implemented at another institution and yielded a time per electrode of 22.3 ± 4.4 minutes. CONCLUSIONS The authors propose the term dynamic sEEG for stereotactic depth electrodes placed according to phase I workup data with the intention of converting to ablation. This workflow efficiency can be optimized using the standard work tools presented. The authors also propose a novel naming convention that encodes critical data and allows portability among providers. Use of a planning form for common data elements optimizes research, and global adoption could facilitate multicenter studies correlating phase I modality and seizure onset zone identification.
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Affiliation(s)
- Salma M Bakr
- 1Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana.,2Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ajay Patel
- 1Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mohamed A Zaazoue
- 1Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kathryn Wagner
- 3Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sandi K Lam
- 4Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital, Chicago; and.,5Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Daniel J Curry
- 3Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Jeffrey S Raskin
- 1Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Caruso JP, Janjua MB, Dolce A, Price AV. Retrospective analysis of open surgical versus laser interstitial thermal therapy callosotomy in pediatric patients with refractory epilepsy. J Neurosurg Pediatr 2021; 27:420-428. [PMID: 33482643 DOI: 10.3171/2020.7.peds20167] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 07/28/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Corpus callosotomy remains an established surgical treatment for certain types of medically refractory epilepsy in pediatric patients. While the traditional surgical approach is often well tolerated, the advent of MR-guided laser interstitial thermal therapy (LITT) provides a new opportunity to ablate the callosal body in a minimally invasive fashion and minimize the risks associated with an open interhemispheric approach. However, the literature is sparse regarding the comparative efficacy and safety profiles of open corpus callosotomy (OCC) and LITT callosotomy. To this end, the authors present a novel retrospective analysis comparing the efficacy and safety of these methods. METHODS Patients who underwent OCC and LITT callosotomy during the period from 2005 to 2018 were included in a single-center retrospective analysis. Patient demographic and procedural variables were collected, including length of stay, procedural blood loss, corticosteroid requirements, postsurgical complications, and postoperative disposition. Pre- and postoperative seizure frequency (according to seizure type) were recorded. RESULTS In total, 19 patients, who underwent 24 interventions (16 OCC and 8 LITT), were included in the analysis. The mean follow-up durations for the OCC and LITT cohorts were 83.5 months and 12.3 months, respectively. Both groups experienced reduced frequencies of seizure and drop attack frequency postoperatively. Additionally, LITT callosotomy was associated with a significant decrease in estimated blood loss and decreased length of pediatric ICU stay, with a trend of shorter length of hospitalization. CONCLUSIONS Longer-term follow-up and a larger population are required to further delineate the comparative efficacies of LITT callosotomy and OCC for the treatment of pediatric medically refractory epilepsy. However, the authors' data demonstrate that LITT shows promise as a safe and effective alternative to OCC.
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Affiliation(s)
| | | | - Alison Dolce
- 2Neurology, Children's Medical Center, University of Texas Southwestern, Dallas, Texas
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24
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Gadgil N, Lam S, Pan IW, LoPresti M, Wagner K, Ali I, Wilfong A, Curry DJ. Staged Magnetic Resonance-Guided Laser Interstitial Thermal Therapy for Hypothalamic Hamartoma: Analysis of Ablation Volumes and Morphological Considerations. Neurosurgery 2020; 86:808-816. [PMID: 31990344 DOI: 10.1093/neuros/nyz378] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 06/27/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Hypothalamic hamartomas (HH) are a challenging pathology that cause gelastic seizures. Magnetic Resonance Imaging-guided Laser Interstitial Thermal Therapy (MRgLITT) offers a safe and effective treatment for HHs via a minimally invasive technique. OBJECTIVE To determine how clinical outcome correlates to residual tumor volume and surgical strategy by analyzing radiographic data and reconstructing volumetric imaging. METHODS Clinical and radiographic information of 58 pediatric patients who underwent MRgLITT for HH with at least 6 mo of follow-up were retrospectively reviewed. MR imaging was volumetrically reconstructed to analyze the impact of hamartoma and ablation volumes on outcome. Primary outcome measure was freedom from gelastic seizures. RESULTS Eighty-one percent of patients were completely free of gelastic seizures at last follow-up; of 22 patients with secondary nongelastic epilepsy, 15 were free of additional seizures. Postoperative complication rate was low. There was no significant difference in gelastic seizure outcome related to pre- or postoperative hamartoma size. Residual hamartoma percentage in those free of gelastic seizures was 43% compared to 71% in those with continued seizures (P = .021). Larger hamartomas required multiple ablations to achieve seizure freedom. CONCLUSION This large series of patients confirms the safety and efficacy of MRgLITT for pediatric HH and describes morphological considerations that predict success. Our data suggest that complete ablation of the lesion is not necessary, and that the focus should be on appropriate disconnection of the epileptogenic network. We have found that a staged approach to hamartoma ablation allows adequate disconnection of the hamartoma while mitigating risk to surrounding structures.
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Affiliation(s)
- Nisha Gadgil
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Sandi Lam
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - I-Wen Pan
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Melissa LoPresti
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Kathryn Wagner
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Irfan Ali
- Department of Neurology and Developmental Neuroscience, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Angus Wilfong
- Department of Pediatric Neurology, Phoenix Children's Hospital, Phoenix, Arizona
| | - Daniel J Curry
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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25
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Youngerman BE, Save AV, McKhann GM. Magnetic Resonance Imaging-Guided Laser Interstitial Thermal Therapy for Epilepsy: Systematic Review of Technique, Indications, and Outcomes. Neurosurgery 2020; 86:E366-E382. [PMID: 31980831 DOI: 10.1093/neuros/nyz556] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 11/20/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND For patients with focal drug-resistant epilepsy (DRE), surgical resection of the epileptogenic zone (EZ) may offer seizure freedom and benefits for quality of life. Yet, concerns remain regarding invasiveness, morbidity, and neurocognitive side effects. Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) has emerged as a less invasive option for stereotactic ablation rather than resection of the EZ. OBJECTIVE To provide an introduction to MRgLITT for epilepsy, including historical development, surgical technique, and role in therapy. METHODS The development of MRgLITT is briefly recounted. A systematic review identified reported techniques and indication-specific outcomes of MRgLITT for DRE in human studies regardless of sample size or follow-up duration. Potential advantages and disadvantages compared to available alternatives for each indication are assessed in an unstructured review. RESULTS Techniques and outcomes are reported for mesial temporal lobe epilepsy, hypothalamic hamartoma, focal cortical dysplasia, nonlesional epilepsy, tuberous sclerosis, periventricular nodular heterotopia, cerebral cavernous malformations, poststroke epilepsy, temporal encephalocele, and corpus callosotomy. CONCLUSION MRgLITT offers access to foci virtually anywhere in the brain with minimal disruption of the overlying cortex and white matter, promising fewer neurological side effects and less surgical morbidity and pain. Compared to other ablative techniques, MRgLITT offers immediate, discrete lesions with real-time monitoring of temperature beyond the fiber tip for damage estimates and off-target injury prevention. Applications of MRgLITT for epilepsy are growing rapidly and, although more evidence of safety and efficacy is needed, there are potential advantages for some patients.
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Affiliation(s)
- Brett E Youngerman
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Akshay V Save
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Guy M McKhann
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
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26
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Wang Y, Xu J, Liu T, Chen F, Chen S, Xie Z, Fang T, Liang S. Magnetic resonance–guided laser interstitial thermal therapy versus stereoelectroencephalography-guided radiofrequency thermocoagulation for drug-resistant epilepsy: A systematic review and meta-analysis. Epilepsy Res 2020; 166:106397. [DOI: 10.1016/j.eplepsyres.2020.106397] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 11/30/2022]
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27
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Alomari SO, El Houshiemy MN, Bsat S, Moussalem CK, Allouh M, Omeis IA. Hypothalamic Hamartomas: A comprehensive review of literature – Part 2: Medical and surgical management update. Clin Neurol Neurosurg 2020; 195:106074. [DOI: 10.1016/j.clineuro.2020.106074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/25/2020] [Accepted: 07/06/2020] [Indexed: 11/25/2022]
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28
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Alomari SO, El Houshiemy MN, Bsat S, Moussalem CK, Allouh M, Omeis IA. Hypothalamic Hamartomas: A Comprehensive Review of Literature - Part 3: Updates on Radiotherapy Management. Clin Neurol Neurosurg 2020; 197:106077. [PMID: 32717560 DOI: 10.1016/j.clineuro.2020.106077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/25/2020] [Accepted: 07/06/2020] [Indexed: 10/23/2022]
Abstract
Hypothalamic hamartomas (HH) are rare, non-neoplastic heterotopic tissues which contains normal neurons and glia including oligodendrocytes and fibrillary astrocytes but in an abnormal distribution. They arise from the floor of the third ventricle, tuber cinereum, or mammillary bodies. Estimated incidence ranges from 1 in 50,000 to 1 in 1,000,000. Hypothalamic hamartomas are associated with different clinical presentations including various types of seizures, most characteristically; the gelastic seizures, precocious puberty, cognitive impairment and behavioral changes. In this review, the authors discuss the recent advancements in different modalities of radiotherapy and their application in hypothalamic hamartomas management.
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Affiliation(s)
- Safwan O Alomari
- Division of Neurosurgery, Department of Surgery, American University of Beirut Medical Center, Lebanon
| | - Mohammed N El Houshiemy
- Division of Neurosurgery, Department of Surgery, American University of Beirut Medical Center, Lebanon
| | - Shadi Bsat
- Division of Neurosurgery, Department of Surgery, American University of Beirut Medical Center, Lebanon
| | - Charbel K Moussalem
- Division of Neurosurgery, Department of Surgery, American University of Beirut Medical Center, Lebanon
| | - Mohammed Allouh
- Anatomy Department, College of Medicine and Health Sciences, United Arab Emirates University, United Arab Emirates
| | - Ibrahim A Omeis
- Division of Neurosurgery, Department of Surgery, American University of Beirut Medical Center, Lebanon.
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29
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Ono KE, Bearden DJ, Adams E, Doescher J, Koh S, Eksioglu Y, Gross RE, Drane DL. Cognitive and behavioral outcome of stereotactic laser amydalohippocampotomy in a pediatric setting. Epilepsy Behav Rep 2020; 14:100370. [PMID: 32642637 PMCID: PMC7334373 DOI: 10.1016/j.ebr.2020.100370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/16/2020] [Accepted: 05/18/2020] [Indexed: 11/28/2022] Open
Abstract
We present neuropsychological and functional outcome data in a teenager undergoing stereotactic laser amygdalohippocampotomy (SLAH) who had drug-resistant mesial temporal lobe epilepsy due to left hippocampal sclerosis. Given strong baseline cognitive performance, there was concern for post-operative declines in language and verbal memory were this patient to undergo open resection. She was evaluated pre- and post-ablation with clinical and experimental neuropsychological measures including semantic memory, category-specific object/face recognition and naming, spatial learning, and socio-emotional processing. The patient became seizure-free following SLAH and experienced significant improvements in school performance and social engagement. She experienced improvement in recognition and naming of multiple object categories, memory functions, and verbal fluency. In contrast, the patient declined significantly in her ability to recognize emotional tone from facial expressions, a socio-emotional process that had been normal prior to surgery. We believe this decline was related to surgical disruption of the limbic system, an area highly involved in emotional processing, and suspect such deficits are an under-assessed and unrecognized risk for all surgeries involving the amygdalohippocampal complex and broader limbic system regions. We hope this positive SLAH outcome will serve as impetus for group level research to establish its safety and efficacy in the pediatric setting. Stereotactic laser ablation can be used successfully in pediatric epilepsy. At risk cognitive abilities did not decline after focal ablation in this teenager. Functional improvement was observed that paralleled gains in seizure status and cognition. Deficits still occurred in select areas related to focal structures ablated. Socio-emotional deficits can result from surgeries restricted to the amygdalohippocampal complex.
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Affiliation(s)
- Kim E Ono
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Children's Hospital of Atlanta, Atlanta, GA, USA
| | - Donald J Bearden
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Children's Hospital of Atlanta, Atlanta, GA, USA
| | - Elizabeth Adams
- Department of Neurology, Minnesota Epilepsy Group, Minneapolis, MN, USA
| | - Jason Doescher
- Department of Neurology, Minnesota Epilepsy Group, Minneapolis, MN, USA
| | - Sookyong Koh
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Children's Hospital of Atlanta, Atlanta, GA, USA
| | - Yaman Eksioglu
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Children's Hospital of Atlanta, Atlanta, GA, USA
| | - Robert E Gross
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA.,Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.,Coulter Department of Biomedical Engineering, Emory University, GA, USA
| | - Daniel L Drane
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.,Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
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30
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Highly realistic simulation for robot-assisted hypothalamic hamartoma real-time MRI-guided laser interstitial thermal therapy (LITT). Childs Nerv Syst 2020; 36:1131-1142. [PMID: 32166344 DOI: 10.1007/s00381-020-04563-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 02/27/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Real-time MRI-guided laser interstitial thermal therapy (LITT) is a challenging procedure due to its technical complexity, as well as the need for efficient multidisciplinary teamwork and transfer of an anesthetized patient between operating room (OR) and magnetic resonance (MR). A highly realistic simulation was developed to design the safest process before being applied to real patients. In this report, authors address the description of the methodology used for this simulation and its purposefulness. METHODS The entire image planning, anesthetic, and surgical process were performed on a modified pediatric simulation mannequin with a brain made of medical grade silicone including a hypothalamic hamartoma. Preoperative CT and MR were acquired. Stereotactic insertion of the optical fiber was assisted by the Neuromate® stereotactic robot. Laser ablation was performed with the Medtronic Visualase® MRI-guided system in a 3T Phillips Ingenia® MR scanner. All the stages of the process, participants, and equipment were the same as planned for a real surgery. RESULTS No critical errors were found in the process design that prevented the procedure from being performed with adequate safety. Specific proposals for team positioning and interaction in patient transfers and in MR room were validated. Some specific elements that could improve safety were identified. CONCLUSION Highly realistic simulation has been an extremely useful tool for safely planning LITT, because professionals were able to take actions in the workflow based not on ideas but on lived experiences. It contributed definitively to build a well-coordinated surgical team that worked safely and more efficiently.
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31
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Wang S, Zhao M, Li T, Zhang C, Zhou J, Wang M, Wang X, Liu Z, Ma K, Luan G, Guan Y. Stereotactic radiofrequency thermocoagulation and resective surgery for patients with hypothalamic hamartoma. J Neurosurg 2020; 134:1019-1026. [PMID: 32302977 DOI: 10.3171/2020.2.jns193423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 02/13/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE In this study, the authors compared the efficacy and safety of stereotactic radiofrequency thermocoagulation (SRT) and resective surgery (RS) for patients with hypothalamic hamartoma (HH). METHODS The authors included all patients with HHs who were treated by SRT or hamartoma resection. Seizure outcomes were assessed by blinded observers according to the International League Against Epilepsy (ILAE) classification. Favorable seizure outcomes were defined as ILAE classes 1 and 2, and unfavorable seizure outcomes were defined as ILAE classes 3-6. RESULTS Twenty-nine patients who underwent SRT or RS met the inclusion criteria; 3 were excluded because they had completed less than 12 months of follow-up. Most of the patients (20 of 26; 76.9%) had small HHs (i.e., maximum HH diameter less than 20 mm). The patients' follow-up time ranged from 12 to 66 months (median 60 months). At the last follow-up, favorable outcomes were observed in 9 patients (69.2%) who had undergone SRT and 10 patients (76.9%) who had undergone HH resection. No significant difference was found in seizure outcomes between SRT and RS recipients. Patients with giant HHs were more likely than patients with smaller tumors to undergo multiple resections (p = 0.043, univariate logistic regression; significant). However, no significant difference was found between SRT and RS recipients in terms of the number of procedures per patient. SRT recipients had fewer and less-severe adverse events than RS recipients. CONCLUSIONS For patients with small HHs, SRT provides similar seizure outcomes to RS with a less invasive procedure. Patients who underwent SRT experienced fewer and lighter adverse effects than patients who had RS. Patients with giant HHs were more likely to undergo multiple HH resections.
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Affiliation(s)
| | | | - Tianfu Li
- 2Neurology, SanBo Brain Hospital, Capital Medical University, Beijing.,3Beijing Key Laboratory of Epilepsy, Beijing; and.,4Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | | | - Jian Zhou
- Departments of1Neurosurgery and.,3Beijing Key Laboratory of Epilepsy, Beijing; and.,4Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | - Mengyang Wang
- 2Neurology, SanBo Brain Hospital, Capital Medical University, Beijing
| | - Xiongfei Wang
- Departments of1Neurosurgery and.,3Beijing Key Laboratory of Epilepsy, Beijing; and.,4Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | | | | | - Guoming Luan
- Departments of1Neurosurgery and.,3Beijing Key Laboratory of Epilepsy, Beijing; and.,4Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | - Yuguang Guan
- Departments of1Neurosurgery and.,3Beijing Key Laboratory of Epilepsy, Beijing; and.,4Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
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Hoppe C, Helmstaedter C. Laser interstitial thermotherapy (LiTT) in pediatric epilepsy surgery. Seizure 2020; 77:69-75. [DOI: 10.1016/j.seizure.2018.12.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/07/2018] [Accepted: 12/17/2018] [Indexed: 01/06/2023] Open
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Ferrand-Sorbets S, Fohlen M, Delalande O, Zuber K, Bulteau C, Levy M, Chamard P, Taussig D, Dorison N, Bekaert O, Tisdall M, Chipaux M, Dorfmüller G. Seizure outcome and prognostic factors for surgical management of hypothalamic hamartomas in children. Seizure 2020; 75:28-33. [DOI: 10.1016/j.seizure.2019.11.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/25/2019] [Accepted: 11/27/2019] [Indexed: 10/25/2022] Open
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34
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Bhansali AP, Gwinn RP. Ablation: Radiofrequency, Laser, and HIFU. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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35
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Alexander H, Cobourn K, Fayed I, Oluigbo CO. Magnetic Resonance-Guided Laser Interstitial Thermal Therapy for the Treatment of Nonlesional Insular Epilepsy in Pediatric Patients: Technical Considerations. Pediatr Neurosurg 2020; 55:155-162. [PMID: 32750699 DOI: 10.1159/000509006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/26/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The insula presents anatomic challenges to surgical exploration and intervention. Open neurosurgical intervention is associated with high rates of complications despite improved seizure control. Minimally invasive techniques using novel energy delivery methods have gained popularity due to their relative safety and ability to overcome access-related barriers. The goal of this paper is to present an operative technical report and methodological considerations on the application of magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) for the treatment of nonlesional, medically refractory, insular epilepsy in pediatric patients. METHODS Visualase laser probe(s) were implanted using ROSA robotic stereotactic guidance into the insula using a parasagittal trajectory. After confirmation of placement using intraoperative MRI, thermal energy was delivered under real-time MR guidance. Laser wire pullback was performed when the initial dose of thermal energy was insufficient to ablate the target in its entirety. Thermal ablation within the intended target was confirmed using gadolinium-enhanced brain MRI. Following removal of laser wires, a final T1-weighted axial brain MRI was performed to confirm no evidence of hemorrhage. RESULTS Three patients underwent MRgLITT of nonlesional insular epilepsy over an 11-month period. The epileptogenic focus was localized to the insula using stereoelectroencephalography. The anterior and middle portions of the insula were accessed using a parasagittal trajectory. Laser ablation was performed for up to 3 min using an output of 10.5 W. No complications were encountered, and all patients were discharged within 24 h after the surgery. At the most recent follow-up, all patients had an Engel I outcome without any new neurologic deficits. CONCLUSION This small cohort shows that insular ablation can be achieved safely with promising seizure outcomes in the short term.
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Affiliation(s)
- Hepzibha Alexander
- Division of Neurosurgery, Children's National Medical Center, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Kelsey Cobourn
- Division of Neurosurgery, Children's National Medical Center, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Islam Fayed
- Division of Neurosurgery, Children's National Medical Center, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Chima O Oluigbo
- Division of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA,
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Prablek MA, Giridharan N, Weiner HL. Pediatric Epilepsy. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Sacino M, Huang SS, Alexander H, Fayed I, Keating RF, Oluigbo CO. An Initial Cost-Effectiveness Analysis of Magnetic Resonance-Guided Laser Interstitial Thermal Therapy in Pediatric Epilepsy Surgery. Pediatr Neurosurg 2020; 55:141-148. [PMID: 32829333 DOI: 10.1159/000509329] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 06/09/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a new technology that provides a clinically efficacious and minimally invasive alternative to conventional microsurgical resection. However, little data exist on how costs compare to traditional open surgery. The goal of this paper is to investigate the cost-effectiveness of MRgLITT in the treatment of pediatric epilepsy. METHODS We retrospectively analyzed the medical records of pediatric patients who underwent MRgLITT via the Visualase® thermal therapy system (Medtronic, Inc., Minneapolis, MN, USA) between December 2013 and September 2017. Direct costs associated with preoperative, operative, and follow-up care were extracted. Benefit was calculated in quality-adjusted life years (QALYs), and the cost-effectiveness was derived from the discounted total direct costs over QALY. Sensitivity analysis on 4 variables was utilized to assess the validity of our results. RESULTS Twelve consecutive pediatric patients with medically refractory epilepsy underwent MRgLITT procedures. At the last postoperative follow-up, 8 patients were seizure free (Engel I, 66.7%), 2 demonstrated significant improvement (Engel II, 16.7%), and 2 patients showed worthwhile improvement (Engel III, 16.7%). The average cumulative discounted QALY was 2.11 over the lifetime of a patient. Adjusting for inflation, MRgLITT procedures had a cost-effectiveness of USD 22,211 per QALY. Our sensitivity analysis of cost variables is robust and supports the procedure to be cost--effective. CONCLUSION Our data suggests that MRgLITT may be a cost-effective alternative to traditional surgical resection in pediatric epilepsy surgery.
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Affiliation(s)
- Matthew Sacino
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA
| | - Sean S Huang
- Department of Health Systems Administration, Georgetown University, Washington, District of Columbia, USA
| | - Hepzibha Alexander
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA.,Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Islam Fayed
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA.,Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Robert F Keating
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA.,Department of Neurosurgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Chima O Oluigbo
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA, .,Department of Neurosurgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA,
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Lee EJ, Kalia SK, Hong SH. A Primer on Magnetic Resonance-Guided Laser Interstitial Thermal Therapy for Medically Refractory Epilepsy. J Korean Neurosurg Soc 2019; 62:353-360. [PMID: 31085962 PMCID: PMC6514321 DOI: 10.3340/jkns.2019.0105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 04/29/2019] [Indexed: 01/04/2023] Open
Abstract
Epilepsy surgery that eliminates the epileptogenic focus or disconnects the epileptic network has the potential to significantly improve seizure control in patients with medically intractable epilepsy. Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) has been an established option for epilepsy surgery since the US Food and Drug Administration cleared the use of MRgLITT in neurosurgery in 2007. MRgLITT is an ablative stereotactic procedure utilizing heat that is converted from laser energy, and the temperature of the tissue is monitored in real-time by MR thermography. Real-time quantitative thermal monitoring enables titration of laser energy for cellular injury, and it also estimates the extent of tissue damage. MRgLITT is applicable for lesion ablation in cases that the epileptogenic foci are localized and/or deep-seated such as in the mesial temporal lobe epilepsy and hypothalamic hamartoma. Seizure-free outcomes after MRgLITT are comparable to those of open surgery in well-selected patients such as those with mesial temporal sclerosis. Particularly in patients with hypothalamic hamartoma. In addition, MRgLITT can also be applied to ablate multiple discrete lesions of focal cortical dysplasia and tuberous sclerosis complex without the need for multiple craniotomies, as well as disconnection surgery such as corpus callosotomy. Careful planning of the target, the optimal trajectory of the laser probe, and the appropriate parameters for energy delivery are paramount to improve the seizure outcome and to reduce the complication caused by the thermal damage to the surrounding critical structures.
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Roland JL, Smyth MD. Recent advances in the neurosurgical treatment of pediatric epilepsy: JNSPG 75th Anniversary Invited Review Article. J Neurosurg Pediatr 2019; 23:411-421. [PMID: 30970205 DOI: 10.3171/2018.12.peds18350] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The field of epilepsy surgery has seen tremendous growth in recent years. Innovative new devices have driven much of this growth, but some has been driven by revisions of existing products. Devices have also helped to rejuvenate existing procedures, as in the case of robotic assistance for electrode placement for stereo-electroencephalography, and these devices have brought significant attention along with their introduction. Other devices, such as responsive neurostimulators or laser interstitial thermal therapy systems, have introduced novel treatment modalities and broadened the surgical indications. Collectively, these advances are rapidly changing much of the landscape in the world of pediatric neurosurgery for medically refractory epilepsy. The foundations for indications for neurosurgical intervention are well supported in strong research data, which has also been expanded in recent years. In this article, the authors review advances in the neurosurgical treatment of pediatric epilepsy, beginning with trials that have repeatedly demonstrated the value of neurosurgical procedures for medically refractory epilepsy and following with several recent advances that are largely focused on less-invasive intervention. ABBREVIATIONS AED = antiepileptic drug; ANT = anterior nucleus of the thalamus; BOLD = blood oxygen level dependent; CCEP = cortico-cortical evoked potential; DBS = deep brain stimulation; ECoG = electrocorticography; ERSET = Early Randomized Surgical Epilepsy Trial; FCD = focal cortical dysplasia; HH = hypothalamic hamartoma; LITT = laser interstitial thermal therapy; RCT = randomized controlled trial; r-fMRI = resting-state functional MRI; RNS = responsive neurostimulation; SEEG = stereo-electroencephalography; VNS = vagus nerve stimulation.
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Malformations of cortical development: New surgical advances. Rev Neurol (Paris) 2019; 175:183-188. [DOI: 10.1016/j.neurol.2019.01.392] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/23/2018] [Accepted: 01/04/2019] [Indexed: 11/18/2022]
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Marashly A, Loman MM, Lew SM. Stereotactic laser ablation for nonlesional cingulate epilepsy: case report. J Neurosurg Pediatr 2018; 22:481-488. [PMID: 30074447 DOI: 10.3171/2018.5.peds18120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/22/2018] [Indexed: 11/06/2022]
Abstract
Stereotactic laser ablation (SLA) is being increasingly used to treat refractory focal epilepsy, especially mesial temporal lobe epilepsy. However, emerging evidence suggests it can be used for extratemporal lobe epilepsy as well.The authors report the case of a 17-year-old male who presented with refractory nocturnal seizures characterized by bilateral arms stiffening or rhythmic jerking lasting several seconds. Semiology suggested an epileptogenic zone close to one of the supplementary sensory motor areas. Electroencephalography showed seizures arising from the central region without consistent lateralization. Brain imaging showed no abnormality. An invasive evaluation using bilateral stereoelectroencephalography (SEEG) was utilized in 2 steps, first to establish the laterality of seizures, and second to further cover the mesial cingulate region of the right hemisphere. Seizures arose from the middle portion of the right cingulate gyrus. Extraoperative electrical mapping revealed that the seizure onset zone was adjacent to eloquent motor areas. SLA targeting the right midcingulate gyrus was performed. The patient has remained seizure free since immediately after the procedure with no postoperative deficits (follow-up of 17 months).This case highlights the utility of SEEG in evaluating difficult-to-localize, focal epilepsy. It also demonstrates that the use of SLA can be extended to nonlesional, extratemporal epilepsies.
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Boerwinkle VL, Foldes ST, Torrisi SJ, Temkit H, Gaillard WD, Kerrigan JF, Desai VR, Raskin JS, Vedantam A, Jarrar R, Williams K, Lam S, Ranjan M, Broderson JS, Adelson D, Wilfong AA, Curry DJ. Subcentimeter epilepsy surgery targets by resting state functional magnetic resonance imaging can improve outcomes in hypothalamic hamartoma. Epilepsia 2018; 59:2284-2295. [DOI: 10.1111/epi.14583] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/10/2018] [Accepted: 09/24/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Varina L. Boerwinkle
- Division of Pediatric Neurology; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Stephen T. Foldes
- Neuroscience Research; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Salvatore J. Torrisi
- Section on the Neurobiology of Fear and Anxiety; National Institute of Mental Health; National Institutes of Health; Bethesda Maryland
| | - Hamy Temkit
- Department of Research; Phoenix Children’s Hospital; Phoenix Arizona
| | - William D. Gaillard
- Department of Neurology; Children’s National Medical Center; Washington District of Columbia
| | - John F. Kerrigan
- Division of Pediatric Neurology; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Virendra R. Desai
- Department of Neurosurgery; Houston Methodist Hospital; Houston Methodist Neurological Institute; Houston Texas
| | - Jeffrey S. Raskin
- Department of Pediatric Neurosurgery; Texas Children’s Hospital; Baylor College of Medicine; Houston Texas
| | - Aditya Vedantam
- Department of Pediatric Neurosurgery; Texas Children’s Hospital; Baylor College of Medicine; Houston Texas
| | - Randa Jarrar
- Division of Pediatric Neurology; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Korwyn Williams
- Division of Pediatric Neurology; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Sandi Lam
- Department of Pediatric Neurosurgery; Texas Children’s Hospital; Baylor College of Medicine; Houston Texas
| | - Manish Ranjan
- Division of Pediatric Neurosurgery; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Janna S. Broderson
- Division of Pediatric Neurology; Texas Children’s Hospital; Baylor College of Medicine; Houston Texas
| | - David Adelson
- Division of Pediatric Neurology; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
- Division of Pediatric Neurosurgery; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Angus A. Wilfong
- Division of Pediatric Neurology; Barrow Neurological Institute at Phoenix Children’s Hospital; Phoenix Arizona
| | - Daniel J. Curry
- Department of Pediatric Neurosurgery; Texas Children’s Hospital; Baylor College of Medicine; Houston Texas
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van Tonder L, Burn S, Iyer A, Blair J, Didi M, Carter M, Martland T, Mallucci C, Chawira A. Open resection of hypothalamic hamartomas for intractable epilepsy revisited, using intraoperative MRI. Childs Nerv Syst 2018; 34:1663-1673. [PMID: 29752488 DOI: 10.1007/s00381-018-3786-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 03/27/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Hypothalamic hamartomas (HHs) are rare non-neoplastic lesions which cause drug-resistant epilepsy with associated behavioural, psychiatric and endocrine issues. With the development of new minimally invasive techniques for the treatment of HH, there is a need to reappraise the effectiveness and safety of each approach. We review the outcomes of HH patients treated surgically, utilizing intraoperative magnetic resonance imaging (IOMRI), by a team of Alder Hey NHS Foundation Trust tumour and epilepsy neurosurgeons since 2011. METHODS Patient records of all HH cases operated on since 2011 were reviewed to confirm history of presentation and clinical outcomes. RESULTS Ten patients have undergone surgery for HH under the dual care of Alder Hey tumour and epilepsy neurosurgeons during this period. Eight cases had a midline transcallosal, interforniceal approach with the remaining 2 having a transcallosal, transforaminal approach. All patients had an IOMRI scan, with 40% needing further tumour resection post-IOMRI. Forty percent had a total resection, 3 patients had near-total resection and 3 patients had subtotal resection (~ 30% tumour residual on post-operative MRI). No new neurological complications developed post-operatively. Hypothalamic axis derangements were seen in 3 cases, including 1 diabetes insipidus with hypocortisolaemia, 1 hypodipsia and 1 transient hyperphagia. Eighty percent are seizure free; the remaining two patients have had significant improvements in seizure frequency. CONCLUSIONS IOMR was used to tailor the ideal tumour resection volume safely based on anatomy of the lesion, which combined with the open transcallosal, interforniceal route performed by surgeons experienced in the approach resulted in excellent, safe and effective seizure control.
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Affiliation(s)
- Libby van Tonder
- Department of Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool, L12 2AP, UK.
| | - Sasha Burn
- Department of Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool, L12 2AP, UK
| | - Anand Iyer
- Department of Paediatric Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, L12 2AP, UK
| | - Jo Blair
- Department of Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, L12 2AP, UK
| | - Mohammed Didi
- Department of Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, L12 2AP, UK
| | - Michael Carter
- Department of Neurosurgery, Bristol Royal Hospital for Children, Bristol, BS2 8BJ, UK
| | - Timothy Martland
- Department of Paediatric Neurology, Royal Manchester Children's Hospital (RMCH), Manchester, M13 9WL, UK
| | - Conor Mallucci
- Department of Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool, L12 2AP, UK
| | - Athanasius Chawira
- Department of Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool, L12 2AP, UK
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Donos C, Breier J, Friedman E, Rollo P, Johnson J, Moss L, Thompson S, Thomas M, Hope O, Slater J, Tandon N. Laser ablation for mesial temporal lobe epilepsy: Surgical and cognitive outcomes with and without mesial temporal sclerosis. Epilepsia 2018; 59:1421-1432. [DOI: 10.1111/epi.14443] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Cristian Donos
- Vivian L. Smith Department of Neurosurgery; McGovern Medical School; Houston TX USA
| | - Joshua Breier
- Children's Learning Institute; University of Texas Health Science Center at Houston; Houston TX USA
| | - Elliott Friedman
- Department of Radiology; McGovern Medical School; Houston TX USA
| | - Patrick Rollo
- Vivian L. Smith Department of Neurosurgery; McGovern Medical School; Houston TX USA
| | - Jessica Johnson
- Vivian L. Smith Department of Neurosurgery; McGovern Medical School; Houston TX USA
| | - Lauren Moss
- Children's Learning Institute; University of Texas Health Science Center at Houston; Houston TX USA
| | - Stephen Thompson
- Department of Neurology; McGovern Medical School; Houston TX USA
| | - Melissa Thomas
- Department of Neurology; McGovern Medical School; Houston TX USA
| | - Omotola Hope
- Department of Neurology; McGovern Medical School; Houston TX USA
| | - Jeremy Slater
- Department of Neurology; McGovern Medical School; Houston TX USA
| | - Nitin Tandon
- Vivian L. Smith Department of Neurosurgery; McGovern Medical School; Houston TX USA
- Mischer Neuroscience Institute; Memorial Hermann Hospital Texas Medical Center; Houston TX USA
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Tandon V, Lang M, Chandra PS, Sharan A, Garg A, Tripathi M. Is Edema a Matter of Concern After Laser Ablation of Epileptogenic Focus? World Neurosurg 2018; 113:366-372.e3. [DOI: 10.1016/j.wneu.2018.01.201] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 01/28/2018] [Accepted: 01/30/2018] [Indexed: 10/18/2022]
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Southwell DG, Birk HS, Larson PS, Starr PA, Sugrue LP, Auguste KI. Laser ablative therapy of sessile hypothalamic hamartomas in children using interventional MRI: report of 5 cases. J Neurosurg Pediatr 2018; 21:460-465. [PMID: 29451455 DOI: 10.3171/2017.10.peds17292] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Hypothalamic hamartomas (HHs) are benign lesions that cause medically refractory seizures, behavioral disturbances, and endocrine dysfunction. Open resection of HHs does not guarantee seizure freedom and carries a relatively high risk of morbidity. Minimally invasive stereotactic laser ablation has recently been described as an effective and safe alternative for HH treatment. Prior studies have not, however, assessed HH lesion size and morphology, 2 factors that may influence treatment results and, ultimately, the generalizability of their findings. In this paper, the authors describe seizure outcomes for 5 pediatric patients who underwent laser ablation of sessile HHs. Lesions were treated using a frameless, interventional MRI-guided approach, which facilitated laser targeting to specific components of these complex lesions. The authors' experiences in these cases substantiate prior work demonstrating the effectiveness of laser therapy for HHs, while elucidating HH complexity as a potentially important factor in laser treatment planning, and in the interpretation of early studies describing this treatment method.
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Affiliation(s)
| | - Harjus S Birk
- 2Department of Neurosurgery, University of California, San Diego; and
| | | | | | - Leo P Sugrue
- 3Radiology and Biomedical Imaging, University of California, San Francisco.,4University of California, San Francisco Benioff Children's Hospitals, Oakland and San Francisco, California
| | - Kurtis I Auguste
- Departments of1Neurological Surgery and.,4University of California, San Francisco Benioff Children's Hospitals, Oakland and San Francisco, California
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MR-guided laser ablation for the treatment of hypothalamic hamartomas. Epilepsy Res 2018; 142:131-134. [DOI: 10.1016/j.eplepsyres.2018.03.013] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 02/27/2018] [Accepted: 03/11/2018] [Indexed: 11/24/2022]
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Vakharia VN, Duncan JS, Witt JA, Elger CE, Staba R, Engel J. Getting the best outcomes from epilepsy surgery. Ann Neurol 2018. [PMID: 29534299 PMCID: PMC5947666 DOI: 10.1002/ana.25205] [Citation(s) in RCA: 141] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neurosurgery is an underutilized treatment that can potentially cure drug‐refractory epilepsy. Careful, multidisciplinary presurgical evaluation is vital for selecting patients and to ensure optimal outcomes. Advances in neuroimaging have improved diagnosis and guided surgical intervention. Invasive electroencephalography allows the evaluation of complex patients who would otherwise not be candidates for neurosurgery. We review the current state of the assessment and selection of patients and consider established and novel surgical procedures and associated outcome data. We aim to dispel myths that may inhibit physicians from referring and patients from considering neurosurgical intervention for drug‐refractory focal epilepsies. Ann Neurol 2018;83:676–690
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Affiliation(s)
- Vejay N Vakharia
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, London, United Kingdom, and Chalfont Centre for Epilepsy
| | - John S Duncan
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, London, United Kingdom, and Chalfont Centre for Epilepsy
| | - Juri-Alexander Witt
- Department of Epileptology, University of Bonn Medical Center, Bonn, Germany
| | - Christian E Elger
- Department of Epileptology, University of Bonn Medical Center, Bonn, Germany
| | - Richard Staba
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Jerome Engel
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
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North RY, Raskin JS, Curry DJ. MRI-Guided Laser Interstitial Thermal Therapy for Epilepsy. Neurosurg Clin N Am 2018; 28:545-557. [PMID: 28917283 DOI: 10.1016/j.nec.2017.06.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
MRI-guided laser interstitial thermal therapy for epilepsy (LITT-E) has become an established, minimally invasive alternative to traditional epilepsy surgery. LITT-E is particularly valuable in cases in which open surgery poses unacceptably high morbidity or patient preference precludes craniotomy. Here we present a focused review of technical details and application of LITT to both focal and generalized epilepsy.
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Affiliation(s)
- Robert Y North
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge, Suite 9A, Houston, TX 77030, USA
| | - Jeffrey S Raskin
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 1230, Houston, TX 77030, USA
| | - Daniel J Curry
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 1230, Houston, TX 77030, USA.
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