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Brown MG, Drees C, Nagae LM, Thompson JA, Ojemann S, Abosch A. Curative and palliative MRI-guided laser ablation for drug-resistant epilepsy. J Neurol Neurosurg Psychiatry 2018; 89:425-433. [PMID: 29084870 DOI: 10.1136/jnnp-2017-316003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/15/2017] [Accepted: 09/18/2017] [Indexed: 12/30/2022]
Abstract
Epilepsy is a common neurological disorder occurring in 3% of the US adult population. It is characterised by seizures resulting from aberrant hypersynchronous neural activity. Approximately one-third of newly diagnosed epilepsy cases fail to become seizure-free in response to antiseizure drugs. Optimal seizure control, in cases of drug-resistant epilepsy, often requires neurosurgical intervention targeting seizure foci, such as the temporal lobe. Advances in minimally invasive ablative surgical approaches have led to the development of MRI-guided laser interstitial thermal therapy (LITT). For refractory epilepsy, this surgical intervention offers many advantages over traditional approaches, including real-time lesion monitoring, reduced morbidity, and in some reports increased preservation of cognitive and language processes. We review the use of LITT for epileptic indications in the context of its application as a curative (seizure freedom) or palliative (seizure reduction) measure for both lesional and non-lesional forms of epilepsy. Furthermore, we address the use of LITT for a variety of extratemporal lobe epilepsies. Finally, we describe clinical outcomes, limitations and future applications of LITT for epilepsy.
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Affiliation(s)
- Mesha-Gay Brown
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Cornelia Drees
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Lidia M Nagae
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - John A Thompson
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Steven Ojemann
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Aviva Abosch
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado, USA
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Wright JM, Staudt MD, Alonso A, Miller JP, Sloan AE. A novel use of the NeuroBlate SideFire probe for minimally invasive disconnection of a hypothalamic hamartoma in a child with gelastic seizures. J Neurosurg Pediatr 2018; 21:302-307. [PMID: 29328005 DOI: 10.3171/2017.9.peds1747] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors describe the case of a 22-month-old boy who presented with gelastic seizures and developmental delay. Magnetic resonance imaging and video-electroencephalography monitoring revealed a primarily intraventricular hypothalamic hamartoma and gelastic seizures occurring 20-30 times daily. The patient was treated with various regimens of antiepileptic medications for 16 months, but the seizures remained medically intractable. At 3 years of age, he underwent stereotactic laser ablation with an aim of disconnection of the lesion. The procedure was performed with the NeuroBlate SideFire probe. To the authors' knowledge, this is the first reported use of this technology for this procedure and serves as proof of concept. There were no perioperative complications, and 2 years postprocedure, the patient remains seizure free with marked behavioral and cognitive improvements.
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Affiliation(s)
- James M Wright
- 1Department of Neurological Surgery, University Hospitals, Case Western Reserve University.,3Case Western Reserve University School of Medicine, Cleveland, Ohio; and
| | - Michael D Staudt
- 1Department of Neurological Surgery, University Hospitals, Case Western Reserve University.,4Department of Clinical Neurological Sciences, London Health Science Centre, Western University, London, Ontario, Canada
| | - Andrea Alonso
- 3Case Western Reserve University School of Medicine, Cleveland, Ohio; and
| | - Jonathan P Miller
- 1Department of Neurological Surgery, University Hospitals, Case Western Reserve University.,3Case Western Reserve University School of Medicine, Cleveland, Ohio; and
| | - Andrew E Sloan
- 1Department of Neurological Surgery, University Hospitals, Case Western Reserve University.,3Case Western Reserve University School of Medicine, Cleveland, Ohio; and
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Xu DS, Chen T, Hlubek RJ, Bristol RE, Smith KA, Ponce FA, Kerrigan JF, Nakaji P. Magnetic Resonance Imaging-Guided Laser Interstitial Thermal Therapy for the Treatment of Hypothalamic Hamartomas: A Retrospective Review. Neurosurgery 2018; 83:1183-1192. [DOI: 10.1093/neuros/nyx604] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 11/27/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- David S Xu
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Tsinsue Chen
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Randall J Hlubek
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ruth E Bristol
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona
| | - Kris A Smith
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Francisco A Ponce
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - John F Kerrigan
- Department of Pediatric Neurology, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Petito GT, Wharen RE, Feyissa AM, Grewal SS, Lucas JA, Tatum WO. The impact of stereotactic laser ablation at a typical epilepsy center. Epilepsy Behav 2018; 78:37-44. [PMID: 29172137 DOI: 10.1016/j.yebeh.2017.10.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/29/2017] [Accepted: 10/27/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Stereotactic laser ablation (SLA) is a novel form of epilepsy surgery for patients with drug-resistant focal epilepsy. We evaluated one hundred consecutive surgeries performed for patients with epilepsy to address the impact of SLA on our therapeutic approach, as well as patient outcomes. METHODS A retrospective, single center analysis of the last one hundred neurosurgeries for epilepsy was performed from 2013 to 2015. Demographics, surgical procedures, and postoperative measures were assessed up to 5years to compare the effect of SLA on outcome. Confidence intervals (CI) and comparative tests of proportions compared outcomes for SLA and resective surgery. Procedural categorical comparison used Chi-square and Kaplan-Meier curves. Student t-test was utilized for single variables such as age at procedure and seizure onset. RESULTS One hundred surgeries for epilepsy yielded thirty-three SLAs and twenty-one resections with a mean of 21.7-month and 21.3-month follow-up, respectively. The temporal lobe was the most common target for SLA (92.6%) and resection (75%). A discrete lesion was present on brain magnetic resonance imaging (MRI) in 27/32 (84.4%) of SLA patients compared with 7/20 (35%) of resection patients with a normal MRI. Overall, 55-60% of patients became seizure-free (SF). Four of five patients with initial failure to SLA became SF with subsequent resection surgery. Complications were more frequent with resection although SF outcomes did not differ (Chi square; p=0.79). Stereotactic laser ablation patients were older than those with resections (47.0years vs. 35.4years, p=0.001). The mean length of hospitalization prior to discharge was shorter for SLA (1.18days) compared with open resection (3.43days; SD: 3.16 days) (p=0.0002). CONCLUSION We now use SLA as a first line therapy at our center in patients with lesional temporal lobe epilepsy (TLE) before resection. Seizure-free outcome with SLA and resection was similar but with a shorter length of stay. Long-term follow-up is recommended to determine sustained SF status from SLA.
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Affiliation(s)
- Gabrielle T Petito
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Robert E Wharen
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Anteneh M Feyissa
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Sanjeet S Grewal
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - John A Lucas
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - William O Tatum
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Perioperative and Anesthetic Considerations for Neurosurgical Laser Interstitial Thermal Therapy Ablations. J Neurosurg Anesthesiol 2018; 30:10-17. [DOI: 10.1097/ana.0000000000000376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Khawaja AM, Pati S, Ng YT. Management of Epilepsy Due to Hypothalamic Hamartomas. Pediatr Neurol 2017; 75:29-42. [PMID: 28886982 DOI: 10.1016/j.pediatrneurol.2017.07.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 06/28/2017] [Accepted: 07/01/2017] [Indexed: 11/18/2022]
Abstract
A hypothalamic hamartoma consists of hyperplastic heterotopic tissue growing in a disorganized fashion. These lesions occur in about one per 50,000 to 100,000 people. Hypothalamic hamartomas can cause intrinsic epileptogenesis leading to gelastic seizures. Surrounding cortical structures may also develop secondary epileptogenesis. Persistent seizures caused by hypothalamic hamartomas can be debilitating and result in significant cognitive and behavioral impairment. Early recognition and treatment is important in controlling seizures and in preventing further cognitive deterioration. Some patients experience improved cognition and behavior following early treatment, suggesting that hypothalamic hamartomas represent a reversible epileptic encephalopathy. The outcome of epilepsy associated with these lesions has significantly evolved with the availability of new treatment techniques and an improved understanding of its pathogenesis. Increasing evidence supporting the role of hypothalamic hamartomas as a cause of gelastic seizures and secondary epileptogenesis has led to more frequent use of surgery as the definitive treatment. Several minimally invasive procedures have been devised, including neuroendoscopic approaches and different stereotactic radio and laser ablation techniques. Each of these techniques can lead to unique adverse events. We review the various classification schemes used to characterize hypothalamic hamartomas and the recommended surgical approaches for each subtype. We also review the literature for currently available treatment modalities and compare their efficacy in controlling seizures and their safety profiles.
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Affiliation(s)
- Ayaz M Khawaja
- Department of Neurology, University of Alabama at Birmingham Hospital, Birmingham, Alabama
| | - Sandipan Pati
- Department of Neurology, University of Alabama at Birmingham Hospital, Birmingham, Alabama.
| | - Yu-Tze Ng
- Department of Pediatrics, Baylor College of Medicine, The Children's Hospital of San Antonio, San Antonio, Texas
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57
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Drane DL. MRI-Guided stereotactic laser ablation for epilepsy surgery: Promising preliminary results for cognitive outcome. Epilepsy Res 2017; 142:170-175. [PMID: 28964596 DOI: 10.1016/j.eplepsyres.2017.09.016] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 08/14/2017] [Accepted: 09/20/2017] [Indexed: 12/01/2022]
Abstract
Cognitive outcome data are reviewed with respect to the use of magnetic-resonance guided stereotactic laser ablation (SLA) as an epilepsy surgical procedure, with comparisons drawn to traditional open resection procedures. Cognitive outcome with stereotactic laser amygdalohippocampotomy (SLAH) appears better than open resection for several functions dependent on extra-mesial temporal lobe (TL) structures, including category-related naming, verbal fluency, and object/familiar person recognition. Preliminary data suggests episodic, declarative verbal memory can decline following SLAH in the language dominant hemisphere, although early findings suggest comparable or even superior outcomes compared with open resection. The hippocampus has long been considered a central structure supporting episodic, declarative memory, with epilepsy surgical teams attempting to spare it whenever possible. However, ample data from animal and human neuroscience research suggests declarative memory deficits are greater following broader mesial TL lesions that include parahippocampal gyrus and lateral TL inputs. Therefore, employing a neurosurgical technique that restricts the surgical lesion zone holds promise for achieving a better cognitive outcome. Focal SLA lesions outside of the amygdalohippocampal complex may impair select cognitive functions, although few data have been published in such patients to date. SLA is being effectively employed with adults and children with TL or lesional epilepsies across several U.S. epilepsy centers, which may simultaneously optimize cognitive outcome while providing a curative treatment for seizures.
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Affiliation(s)
- Daniel L Drane
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA.
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58
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Abstract
While open surgical resection for medically refractory epilepsy remains the gold standard in current neurosurgical practice, modern techniques have targeted areas for improvement over open surgical resection. This review focuses on how a variety of these new techniques are attempting to address these various limitations. Stereotactic electroencephalography offers the possibility of localizing deep epileptic foci, improving upon subdural grid placement which limits localization to neocortical regions. Laser interstitial thermal therapy (LITT) and stereotactic radiosurgery can minimally or non-invasively ablate specific regions of interest, with near real-time feedback for laser interstitial thermal therapy. Finally, neurostimulation offers the possibility of seizure reduction without needing to ablate or resect any tissue. However, because these techniques are still being evaluated in current practice, there are no evidence-based guidelines for their use, and more research is required to fully evaluate their proper role in the current management of medically refractory epilepsy.
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Affiliation(s)
- Robert A McGovern
- Department of Neurological Surgery, The Neurological Institute, Columbia University Medical Center, 710 W. 168th St, New York, NY, 10032, USA.
| | - Garrett P Banks
- Department of Neurological Surgery, The Neurological Institute, Columbia University Medical Center, 710 W. 168th St, New York, NY, 10032, USA
| | - Guy M McKhann
- Department of Neurological Surgery, The Neurological Institute, Columbia University Medical Center, 710 W. 168th St, New York, NY, 10032, USA
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59
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Ravindra VM, Sweney MT, Bollo RJ. Recent developments in the surgical management of paediatric epilepsy. Arch Dis Child 2017; 102:760-766. [PMID: 28096104 DOI: 10.1136/archdischild-2016-311183] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 12/12/2016] [Accepted: 12/21/2016] [Indexed: 11/08/2022]
Abstract
Among the 1% of children affected by epilepsy, failure of pharmacological therapy and early age of seizure onset can lead to worse long-term cognitive outcomes, mental health disorders and impaired functional status. Surgical management often improves functional and cognitive outcomes in children with medically refractory epilepsy, especially when seizure remission is achieved. However, surgery remains underused in children with drug-resistant epilepsy, creating a large treatment gap. Several recent innovations have led to considerable improvement in surgical technique, including the recent development of minimally invasive diagnostic and therapeutic techniques such as stereotactic EEG, transcranial magnetic stimulation, MRI-guided laser ablation, as well as novel paradigms of neurostimulation. This article discusses the current landscape of surgical innovation in the management of paediatric epilepsy, leading to a paradigm shift towards minimally invasive therapy and closing the treatment gap in children suffering from drug-resistant seizures.
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Affiliation(s)
- Vijay M Ravindra
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah School of Medicine, Primary Children's Hospital, Slat Lake City, Utah, USA
| | - Matthew T Sweney
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Robert J Bollo
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah School of Medicine, Primary Children's Hospital, Slat Lake City, Utah, USA
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61
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Gosavi TD, Walker MC. A case of pure gelastic seizures due to hypothalamic hamartoma with a benign course. EPILEPSY & BEHAVIOR CASE REPORTS 2017; 8:111-113. [PMID: 29085777 PMCID: PMC5655395 DOI: 10.1016/j.ebcr.2017.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 05/31/2017] [Accepted: 06/11/2017] [Indexed: 11/28/2022]
Abstract
Hypothalamic hamartoma is a potentially complex entity with diverse clinical manifestations. We report a case of gelastic seizures associated with a hypothalamic hamartoma, which followed a benign course. A 31-year-old woman with episodes of laughter was referred for diagnostic evaluation. Her initial MRI and EEG were reported as normal. However, her episodes of laughter were typical of gelastic seizures from history and video review. Repeat MRI revealed a small HH. She declined any medical treatment and was medication free until last follow-up. This benign course of HH-associated epilepsy, not necessitating treatment, to our knowledge, has not been previously reported.
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Affiliation(s)
- T D Gosavi
- Dept. of Clinical and Experimental Epilepsy, National Hospital of Neurology and Neurosurgery, London, UK.,National Neuroscience Institute and Singapore General Hospital, Singapore
| | - M C Walker
- Dept. of Clinical and Experimental Epilepsy, National Hospital of Neurology and Neurosurgery, London, UK
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62
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Régis J, Helen Cross J, Kerrigan JF. Achieving a cure for hypothalamic hamartomas: a Sisyphean quest? Epilepsia 2017; 58 Suppl 2:7-11. [DOI: 10.1111/epi.13773] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Jean Régis
- Inserm UMR1106; Aix-Marseille University; Marseille France
- Functional and Stereotactic Neurosurgery Service and Gamma Knife Unit; Timone University Hospital; Marseille France
| | - J. Helen Cross
- The Prince of Wales's Chair of Childhood Epilepsy; UCL-Institute of Child Health; Great Ormond Street Hospital for Children; London United Kingdom
- Young Epilepsy; Lingfield United Kingdom
| | - John F. Kerrigan
- Pediatric Neurology Division and Hypothalamic Hamartoma Program; Barrow Neurological Institute at Phoenix Children's Hospital; Phoenix Arizona U.S.A
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63
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Kerrigan JF, Parsons A, Tsang C, Simeone K, Coons S, Wu J. Hypothalamic hamartoma: Neuropathology and epileptogenesis. Epilepsia 2017; 58 Suppl 2:22-31. [DOI: 10.1111/epi.13752] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2016] [Indexed: 01/06/2023]
Affiliation(s)
- John F. Kerrigan
- Hypothalamic Hamartoma Program and Pediatric Neurology Division; Barrow Neurological Institute at Phoenix Children's Hospital; Phoenix Children's Hospital; Phoenix Arizona U.S.A
- Hypothalamic Hamartoma Tissue Research Laboratory; Barrow Neurological Institute; St. Joseph's Hospital and Medical Center; Phoenix Arizona U.S.A
| | - Angela Parsons
- Hypothalamic Hamartoma Tissue Research Laboratory; Barrow Neurological Institute; St. Joseph's Hospital and Medical Center; Phoenix Arizona U.S.A
| | - Candy Tsang
- Hypothalamic Hamartoma Tissue Research Laboratory; Barrow Neurological Institute; St. Joseph's Hospital and Medical Center; Phoenix Arizona U.S.A
| | - Kristina Simeone
- Department of Pharmacology; Creighton University School of Medicine; Omaha Nebraska U.S.A
| | - Stephen Coons
- Division of Neuropathology; Barrow Neurological Institute; St. Joseph's Hospital and Medical Center; Phoenix Arizona U.S.A
| | - Jie Wu
- Hypothalamic Hamartoma Program and Division of Neurology; Barrow Neurological Institute; St. Joseph's Hospital and Medical Center; Phoenix Arizona U.S.A
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Du VX, Gandhi SV, Rekate HL, Mehta AD. Laser interstitial thermal therapy: A first line treatment for seizures due to hypothalamic hamartoma? Epilepsia 2017; 58 Suppl 2:77-84. [DOI: 10.1111/epi.13751] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2016] [Indexed: 12/16/2022]
Affiliation(s)
- Victor X. Du
- Northwell Health Department of Neurosurgery; Manhasset New York U.S.A
| | | | - Harold L. Rekate
- Northwell Health Department of Neurosurgery; Manhasset New York U.S.A
| | - Ashesh D. Mehta
- Northwell Health Department of Neurosurgery; Manhasset New York U.S.A
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65
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Fahrenholtz SJ, Madankan R, Danish S, Hazle JD, Stafford RJ, Fuentes D. Theoretical model for laser ablation outcome predictions in brain: calibration and validation on clinical MR thermometry images. Int J Hyperthermia 2017; 34:101-111. [PMID: 28540820 DOI: 10.1080/02656736.2017.1319974] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
PURPOSE Neurosurgical laser ablation is experiencing a renaissance. Computational tools for ablation planning aim to further improve the intervention. Here, global optimisation and inverse problems are demonstrated to train a model that predicts maximum laser ablation extent. METHODS A closed-form steady state model is trained on and then subsequently compared to N = 20 retrospective clinical MR thermometry datasets. Dice similarity coefficient (DSC) is calculated to provide a measure of region overlap between the 57 °C isotherms of the thermometry data and the model-predicted ablation regions; 57 °C is a tissue death surrogate at thermal steady state. A global optimisation scheme samples the dominant model parameter sensitivities, blood perfusion (ω) and optical parameter (μeff) values, throughout a parameter space totalling 11 440 value-pairs. This represents a lookup table of μeff-ω pairs with the corresponding DSC value for each patient dataset. The μeff-ω pair with the maximum DSC calibrates the model parameters, maximising predictive value for each patient. Finally, leave-one-out cross-validation with global optimisation information trains the model on the entire clinical dataset, and compares against the model naïvely using literature values for ω and μeff. RESULTS When using naïve literature values, the model's mean DSC is 0.67 whereas the calibrated model produces 0.82 during cross-validation, an improvement of 0.15 in overlap with the patient data. The 95% confidence interval of the mean difference is 0.083-0.23 (p < 0.001). CONCLUSIONS During cross-validation, the calibrated model is superior to the naïve model as measured by DSC, with +22% mean prediction accuracy. Calibration empowers a relatively simple model to become more predictive.
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Affiliation(s)
- Samuel John Fahrenholtz
- a Department of Imaging Physics , University of Texas MD Anderson Cancer Center , Houston , TX , USA.,b Department of Medical Physics , UTHealth Graduate School of Biomedical Sciences , Houston , TX , USA
| | - Reza Madankan
- a Department of Imaging Physics , University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Shabbar Danish
- c Section of Neurosurgery , Rutgers Cancer Institute of New Jersey , New Brunswick , NJ , USA
| | - John D Hazle
- a Department of Imaging Physics , University of Texas MD Anderson Cancer Center , Houston , TX , USA.,b Department of Medical Physics , UTHealth Graduate School of Biomedical Sciences , Houston , TX , USA
| | - R Jason Stafford
- a Department of Imaging Physics , University of Texas MD Anderson Cancer Center , Houston , TX , USA.,b Department of Medical Physics , UTHealth Graduate School of Biomedical Sciences , Houston , TX , USA
| | - David Fuentes
- a Department of Imaging Physics , University of Texas MD Anderson Cancer Center , Houston , TX , USA.,b Department of Medical Physics , UTHealth Graduate School of Biomedical Sciences , Houston , TX , USA
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66
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Brandmeir NJ, Sather MD. Letter to the Editor. Stereotactic laser ablation for hypothalamic hamartomas after SRS failure. Neurosurg Focus 2017; 42:E18. [PMID: 28463619 DOI: 10.3171/2016.11.focus16426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Michael D Sather
- Penn State Health, Milton S. Hershey Medical Center, Hershey, PA
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67
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Laser interstitial thermotherapy (LiTT) in epilepsy surgery. Seizure 2017; 48:45-52. [DOI: 10.1016/j.seizure.2017.04.002] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/02/2017] [Accepted: 04/04/2017] [Indexed: 01/15/2023] Open
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68
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Hidalgo ET, Weiner HL. Surgery for epileptogenic cerebral dysplasia in children. Dev Med Child Neurol 2017; 59:270-275. [PMID: 27730624 DOI: 10.1111/dmcn.13292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2016] [Indexed: 11/30/2022]
Abstract
New developments in diagnostic methods, technical improvements in the surgical field, and a better understanding of the effects of epilepsy on the developing brain are contributing to the general observation that more children with epilepsy are being treated surgically. Malformations of cortical development are the most common cause of seizures in pediatric surgical candidates, and the best predictor of seizure freedom after surgery appears to be the complete removal of the epileptogenic lesion. To achieve this goal in challenging cases, such as magnetic resonance imaging-negative or multifocal lesions, a staged approach with pre- and/or post-resective invasive electroencephalography monitoring has increasingly been used at a number of centers. As the experience with this approach has grown, and the risks and benefits are better understood, a larger number of patients with epilepsy have been identified as potential surgical candidates. In this review, a number of the recent developments in pediatric epilepsy surgery are discussed.
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Affiliation(s)
- Eveline Teresa Hidalgo
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Howard L Weiner
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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69
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Buckley RT, Wang AC, Miller JW, Novotny EJ, Ojemann JG. Stereotactic laser ablation for hypothalamic and deep intraventricular lesions. Neurosurg Focus 2017; 41:E10. [PMID: 27690656 DOI: 10.3171/2016.7.focus16236] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Laser ablation is a novel, minimally invasive procedure that utilizes MRI-guided thermal energy to treat epileptogenic and other brain lesions. In addition to treatment of mesial temporal lobe epilepsy, laser ablation is increasingly being used to target deep or inoperable lesions, including hypothalamic hamartoma (HH), subependymal giant cell astrocytoma (SEGA), and exophytic intrinsic hypothalamic/third ventricular tumors. The authors reviewed their early institutional experience with these patients to characterize clinical outcomes in patients undergoing this procedure. METHODS A retrospective cohort (n = 12) of patients undergoing laser ablation at a single institution was identified, and clinical and radiographic records were reviewed. RESULTS Laser ablation was successfully performed in all patients. No permanent neurological or endocrine complications occurred; 2 (17%) patients developed acute obstructive hydrocephalus or shunt malfunction following treatment. Laser ablation of HH resulted in seizure freedom (Engel Class I) in 67%, with the remaining patients having a clinically significant reduction in seizure frequency of greater than 90% compared with preoperative baseline (Engel Class IIB). Treatment of SEGAs resulted in durable clinical and radiographic tumor control in 2 of 3 cases, with one patient receiving adjuvant everolimus and the other receiving no additional therapy. Palliative ablation of hypothalamic/third ventricular tumors resulted in partial tumor control in 1 of 3 patients. CONCLUSIONS Early experience suggests that laser ablation is a generally safe, durable, and effective treatment for patients harboring HHs. It also appears effective for local control of SEGAs, especially in combination therapy with everolimus. Its use as a palliative treatment for intrinsic hypothalamic/deep intraventricular tumors was less successful and associated with a higher risk of serious complications. Additional experience and long-term follow-up will be beneficial in further characterizing the effectiveness and risk profile of laser ablation in treating these lesions in comparison with conventional resective surgery or stereotactic radiosurgery.
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Affiliation(s)
| | | | - John W Miller
- Department of Neurology, University of Washington School of Medicine, Seattle, Washington
| | - Edward J Novotny
- Divisions of 1 Neurological Surgery and.,Pediatric Neurology, Seattle Children's Hospital; and.,Department of Neurology, University of Washington School of Medicine, Seattle, Washington
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70
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Abstract
In common with other stereotactic procedures, stereotactic laser thermocoagulation (SLT) promises gentle destruction of pathological tissue, which might become especially relevant for epilepsy surgery in the future. Compared to standard resection, no large craniotomy is necessary, cortical damage during access to deep-seated lesions can be avoided and interventions close to eloquent brain areas become possible. We describe the history and rationale of laser neurosurgery as well as the two available SLT systems (Visualase® and NeuroBlate®; CE marks pending). Both systems are coupled with magnetic resonance imaging (MRI) and MR thermometry, thereby increasing patient safety. We report the published clinical experiences with SLT in epilepsy surgery (altogether approximately 200 cases) with respect to complications, brain structural alterations, seizure outcome, neuropsychological findings and treatment costs. The rate of seizure-free patients seems to be slightly lower than for resection surgery. Due to the inadequate quality of studies, the neuropsychological superiority of SLT has not yet been unambiguously demonstrated.
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71
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Pure endoscopic management of epileptogenic hypothalamic hamartomas. Neurosurg Rev 2017; 40:647-653. [PMID: 28168619 DOI: 10.1007/s10143-017-0822-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 01/09/2017] [Accepted: 01/22/2017] [Indexed: 10/20/2022]
Abstract
Hypothalamic hamartomas (HH) are rare congenital malformations located in the region of the tuber cinereum and third ventricle. Their usual clinical presentation is characterized by gelastic/dacrystic seizures which often become pharmaco-resistant and progress to secondary focal/generalized intractable epilepsy causing mostly in children cognitive and behavioral problems (particularly in cases of progressive epileptic encephalopathy) and precocious puberty. Whereas gelastic seizures can be surgically controlled either by resection of the lesion or disconnection (tissue-destructive) procedures, aimed at functionally prevent the spreading of the epileptic burst; generalized seizures tend to respond better to HH excision rather than isolated neocortical resections, which generally fail to control them. Prospective analysis of 14 consecutive patients harboring HH treated in an 8-year period; 12 patients had unilateral and two bilateral HH. All patients were managed by pure endoscopic excision of the HH. The mean operative time was 48 min and mean hospital stay was 2 days; perioperative blood loss was negligible in all cases. Two patients showed a transient diabetes insipidus (DI); no transient or permanent postoperative neurological deficit or memory impairment was recorded. Complete HH excision was achieved in 10/14 patients. At a mean follow-up of 48 months, no wound infection, meningitis, postoperative hydrocephalus, and/or mortality were recorded in this series of patients. Eight patients became seizure free (Engel class I), 2 other experienced worthwhile improvement of disabling seizures (Engel class II); 2 patients were cured from gelastic attacks while still experiencing focal dyscognitive seizures; and 2, having bilateral HH (both undergoing unilateral HH excision), did not experience significant improvement and required later on a temporal lobectomy coupled to amygdalohyppocampectomy. Overall, the followings resulted to be predictive factors for better outcomes in terms of seizure control: (1) cases of unilateral, Delalande class B, HH, (2) shorter history of epilepsy. Endoscopic resection of HH proved, in our series, to be effective in achieving complete control or in reducing the frequency of seizures. Furthermore, this approach has confirmed its minimally invasive nature with a very low morbidity rate: of note, it allowed to better preserve short-term memory and hypothalamic function.
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72
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An Undiagnosed Case of Hypothalamic Hamartoma with a Rare Presentation. Case Rep Med 2017; 2017:2432315. [PMID: 28246530 PMCID: PMC5299200 DOI: 10.1155/2017/2432315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 12/05/2016] [Accepted: 12/22/2016] [Indexed: 11/17/2022] Open
Abstract
Background. Hypothalamic hamartomas (HHs) are rare tumor-like malformations that may present with complex partial seizures refractory to anticonvulsants in adulthood. The condition may be misdiagnosed because of rarity. Case Presentation. We report a 25-year-old man with complaint of seizures presented by falling, tonic spasm of limbs, oral automatism, vocalization, and hypermotor activities. His seizures started at the age of one month and presented as eye deviation and upper limbs myoclonic jerk, followed by frequent seizures with variable frequency. The patient had delayed developmental milestones and was mentally retarded. He was hospitalized and underwent video-EEG monitoring and neuroimaging, and the diagnosis of HH was made. The patient became candidate for surgery after that. Conclusion. In this case, the underlying etiology of seizures was diagnosed after 25 years. HH is a rare condition and neurologists may encounter very small number of these cases during their practice. Therefore, they should consider it in patients who present with suspected signs and symptoms.
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73
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Büntjen L, Voges J, Heinze HJ, Hinrichs H, Schmitt FC. Stereotaktische Laserablation. ZEITSCHRIFT FÜR EPILEPTOLOGIE 2017. [DOI: 10.1007/s10309-016-0099-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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74
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Shukla ND, Ho AL, Pendharkar AV, Sussman ES, Halpern CH. Laser interstitial thermal therapy for the treatment of epilepsy: evidence to date. Neuropsychiatr Dis Treat 2017; 13:2469-2475. [PMID: 29026310 PMCID: PMC5627747 DOI: 10.2147/ndt.s139544] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Medically intractable epilepsy is associated with increased morbidity and mortality. For those with focal epilepsy and correlated electrophysiological or radiographic features, open surgical resection can achieve high rates of seizure control, but can be associated with neurologic deficits and cognitive effects. Recent innovations have allowed for more minimally invasive methods of surgical seizure control such as magnetic resonance-guided laser interstitial therapy (MRgLITT). MRgLITT achieves the goal of ablating seizure foci while preserving neuropsycho-logical function and offering real-time feedback and monitoring of tissue ablation. This review summarizes the utilization of MRgLITT for mesial temporal lobe epilepsy and other seizure disorders. Overall, the efficacy of MRgLITT is comparable to that of open surgery and offers a less invasive approach in patients with significantly less morbidity.
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Affiliation(s)
- Navika D Shukla
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Allen L Ho
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | | | - Eric S Sussman
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
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75
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Kang JY, Sperling MR. Magnetic Resonance Imaging-Guided Laser Interstitial Thermal Therapy for Treatment of Drug-Resistant Epilepsy. Neurotherapeutics 2017; 14:176-181. [PMID: 27905093 PMCID: PMC5233636 DOI: 10.1007/s13311-016-0498-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Surgery is the most effective treatment for drug-resistant epilepsy. Long-term studies demonstrate that about 60% to 80% of patients become seizure-free after anterior temporal lobectomy and a majority of patients (about 95%) report significant seizure reduction after surgery. In the last few years, there has been significant advances in minimally invasive surgical techniques to treat drug-resistant epilepsy. These minimally invasive procedures have significant advantages over open surgery in that they produce less immediate discomfort and disability, while allowing for greater preservation of functional tissue. Laser interstitial thermal therapy (LiTT) is an example of such a procedure. Recent advances in imaging, surgical navigation, and real-time thermal monitoring have made LiTT safer and easier to implement, offering an effective and powerful neurosurgical tool for drug-resistant epilepsy. This article will review the technical considerations, uses, and potential future directions for LiTT in drug-resistant epilepsy.
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Affiliation(s)
- Joon Y Kang
- Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Meyer 2-147, Baltimore, MD, 21287, USA.
| | - Michael R Sperling
- Thomas Jefferson University Hospital, 900 Walnut Street Suite 200, Philadelphia, PA, 19107, USA
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76
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Ghali MGZ, Srinivasan VM, Mohan AC, Jones JY, Kan PT, Lam S. Pediatric cerebral cavernous malformations: Genetics, pathogenesis, and management. Surg Neurol Int 2016; 7:S1127-S1134. [PMID: 28194299 PMCID: PMC5299150 DOI: 10.4103/2152-7806.196921] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/14/2016] [Indexed: 12/15/2022] Open
Affiliation(s)
- Michael G Z Ghali
- Department of Neurobiology, Drexel University College of Medicine, Philadelphia, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Arvind C Mohan
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Jeremy Y Jones
- Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Peter T Kan
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Sandi Lam
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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77
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LaRiviere MJ, Gross RE. Stereotactic Laser Ablation for Medically Intractable Epilepsy: The Next Generation of Minimally Invasive Epilepsy Surgery. Front Surg 2016; 3:64. [PMID: 27995127 PMCID: PMC5136731 DOI: 10.3389/fsurg.2016.00064] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 11/21/2016] [Indexed: 12/02/2022] Open
Abstract
Epilepsy is a common, disabling illness that is refractory to medical treatment in approximately one-third of patients, particularly among those with mesial temporal lobe epilepsy. While standard open mesial temporal resection is effective, achieving seizure freedom in most patients, efforts to develop safer, minimally invasive techniques have been underway for over half a century. Stereotactic ablative techniques, in particular, radiofrequency (RF) ablation, were first developed in the 1960s, with refinements in the 1990s with the advent of modern computed tomography and magnetic resonance-based imaging. In the past 5 years, the most recent techniques have used MRI-guided laser interstitial thermotherapy (LITT), the development of which began in the 1980s, saw refinements in MRI thermal imaging through the 1990s, and was initially used primarily for the treatment of intracranial and extracranial tumors. The present review describes the original stereotactic ablation trials, followed by modern imaging-guided RF ablation series for mesial temporal lobe epilepsy. The developments of LITT and MRI thermometry are then discussed. Finally, the two currently available MRI-guided LITT systems are reviewed for their role in the treatment of mesial temporal lobe and other medically refractory epilepsies.
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Affiliation(s)
- Michael J. LaRiviere
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert E. Gross
- Departments of Neurosurgery and Neurology, Emory University School of Medicine, Atlanta, GA, USA
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78
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Burrows AM, Marsh WR, Worrell G, Woodrum DA, Pollock BE, Gorny KR, Felmlee JP, Watson RE, Kaufmann TJ, Goerss S, Van Gompel JJ. Magnetic resonance imaging–guided laser interstitial thermal therapy for previously treated hypothalamic hamartomas. Neurosurg Focus 2016; 41:E8. [DOI: 10.3171/2016.7.focus16218] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Hypothalamic hamartomas (HHs) are associated with gelastic seizures and the development of medically refractory epilepsy. Magnetic resonance imaging–guided laser interstitial thermal therapy (MRg-LITT) is a minimally invasive ablative treatment that may have applicability for these deep-seated lesions. Here, the authors describe 3 patients with refractory HHs who they treated with MRg-LITT.
METHODS
An institutional review board–approved prospective database of patients undergoing Visualase MRg-LITT was retrospectively reviewed. Demographic and historical medical data, including seizure and medication histories, previous surgeries, procedural details, and surgical complications, along with radiological interpretation of the HHs, were recorded. The primary outcome was seizure freedom, and secondary outcomes included medication reduction, seizure frequency, operative morbidity, and clinical outcome at the latest follow-up.
RESULTS
All 3 patients in the multi-institutional database had developed gelastic seizures related to HH at the ages of 7, 7, and 9 years. They presented for further treatment at 25, 28, and 48 years of age, after previous treatments with stereotactic radiosurgery in all cases and partial hamartoma resection in one case. One ablation was complicated by a small tract hemorrhage, which was stable on postoperative imaging. One patient developed hyponatremia and experienced weight gain, which were respectively managed with fluid restriction and counseling. At the most recent follow-up at a mean of 21 months (range 1–32 months), one patient was seizure free while another had meaningful seizure reduction. Medication was reduced in one case.
CONCLUSIONS
Adults with gelastic seizures despite previous treatments can undergo MRg-LITT with reasonable safety and efficacy. This novel therapy may provide a minimally invasive alternative for primary and recurrent HH as the technique is refined.
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79
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Boerwinkle VL, Wilfong AA, Curry DJ. Resting-state functional connectivity by independent component analysis-based markers corresponds to areas of initial seizure propagation established by prior modalities from the hypothalamus. Brain Connect 2016; 6:642-651. [PMID: 27503346 PMCID: PMC5069733 DOI: 10.1089/brain.2015.0404] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE The aims of this study were to evaluate a clinically practical functional connectivity protocol designed to blindly identify the corresponding areas of initial seizure propagation and also to differentiate these areas from remote secondary areas affected by seizure. The patients in this cohort had intractable epilepsy caused by intrahypothalamic hamartoma, which is the location of the ictal focus. The ictal propagation pathway is homogeneous and established, thus creating the optimum situation for the proposed method validation study. METHODS Twelve patients with seizures from hypothalamic hamartoma and 6 normal control patients underwent resting state functional MRI, using independent component analysis to identify network differences in patients. This was followed by seed-based connectivity measures to determine the extent of functional connectivity derangement between hypothalamus and these areas. The areas with significant change in connectivity were compared with the results of prior studies' modalities used to evaluate seizure propagation. RESULTS The left amygdala-parahippocampal gyrus area, cingulate gyrus, and occipito-temporal gyrus demonstrated the highest derangement in connectivity with the hypothalamus, p < 0.01, corresponding to the initial seizure propagation areas established by prior modalities. Areas of secondary ictal propagation were differentiated from these initial locations by first being identified as an abnormal neuronal signal source via independent component analysis, but did not show significant connectivity directly with the known ictal focus. CONCLUSION Non-invasive connectivity measures correspond to areas of initial ictal propagation and differentiate such areas from secondary ictal propagation, which may aid in ictal focus surgical disconnection planning and support the use of this newer modality for adjunctive information in epilepsy surgery evaluation.
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Affiliation(s)
| | - Angus A Wilfong
- Baylor College of Medicine, Pediatrics, Houston, Texas, United States ;
| | - Daniel J Curry
- Baylor College of Medicine, Neurosurgery, Houston, Texas, United States ;
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80
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Bollo RJ. Surgical advancements in pediatric epilepsy surgery: from the mysterious to the minimally invasive. Transl Pediatr 2016; 5:180-182. [PMID: 27709100 PMCID: PMC5035754 DOI: 10.21037/tp.2016.05.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Robert J Bollo
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City, UT, USA
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81
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Ducis K, Guan J, Karsy M, Bollo RJ. Preoperative evaluation and surgical decision-making in pediatric epilepsy surgery. Transl Pediatr 2016; 5:169-179. [PMID: 27709099 PMCID: PMC5035764 DOI: 10.21037/tp.2016.06.02] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Epilepsy is a common disease in the pediatric population, and the majority of cases are controlled with medications and lifestyle modification. For the children whose seizures are pharmacoresistant, continued epileptic activity can have a severely detrimental impact on cognitive development. Early referral of children with drug-resistant seizures to a pediatric epilepsy surgery center for evaluation is critical to achieving optimal patient outcomes. There are several components to a thorough presurgical evaluation, including a detailed medical history and physical examination, noninvasive testing including electroencephalogram, magnetic resonance imaging (MRI) of the brain, and often metabolic imaging. When necessary, invasive diagnostic testing using intracranial monitoring can be used. The identification of an epileptic focus may allow resection or disconnection from normal brain structures, with the ultimate goal of complete seizure remission. Additional operative measures can decrease seizure frequency and/or intensity if a clear epileptic focus cannot be identified. In this review, we will discuss the nuances of presurgical evaluation and decision-making in the management of children with drug-resistant epilepsy (DRE).
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Affiliation(s)
- Katrina Ducis
- Department of Neurosurgery, University of Vermont School of Medicine, Burlington, VT, USA; ; Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jian Guan
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Michael Karsy
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Robert J Bollo
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA; ; Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, UT, USA
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82
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Pruitt R, Gamble A, Black K, Schulder M, Mehta AD. Complication avoidance in laser interstitial thermal therapy: lessons learned. J Neurosurg 2016; 126:1238-1245. [PMID: 27257839 DOI: 10.3171/2016.3.jns152147] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Complications of laser interstitial thermal therapy (LITT) are underreported. The authors discuss how they have modified their technique in the context of technical and treatment-related adverse events. METHODS The Medtronic Visualase system was used in 49 procedures in 46 patients. Between 1 and 3 cooling catheters/laser fiber assemblies were placed, for a total of 62 implanted devices. Devices were placed using frameless stereotaxy (n = 3), frameless stereotaxy with intraoperative MRI (iMRI) (n = 9), iMRI under direct vision (n = 2), MRI alone (n = 1), or frame-based (n = 47) techniques. LITT was performed while monitoring MRI thermometry. Indications included brain tumors (n = 12), radiation necrosis (n = 2), filum terminale ependymoma (n = 1), mesial temporal lobe epilepsy (n = 21), corpus callosotomy for bifrontal epilepsy (n = 3), cavernoma (n = 1), and hypothalamic hamartomas (n = 6). RESULTS Some form of adverse event occurred in 11 (22.4%) of 49 procedures. These included 4 catheter malpositions, 3 intracranial hemorrhages, 3 cases of neurological deficit related to thermal injury, and 1 technical malfunction resulting in an aborted procedure. Of these, direct thermal injury was the only cause of prolonged neurological morbidity and occurred in 3 of 49 procedures. Use of frameless stereotaxy and increased numbers of devices were associated with significantly increased complication rates (p < 0.05). A number of procedural modifications were made to avoid complications, including the use of 1) frame-based catheter placement, a 1.8-mm alignment rod to create a track and titanium skull anchors for long trajectories to improve accuracy; 2) a narrow-gauge instrument for dural puncture and coregistration of contrast MRI with CT angiography to reduce intracranial hemorrhage; 3) general endotracheal anesthesia for posterior-placed skull anchors to reduce the likelihood of damage to the cooling catheter; 4) use of as few probes as possible to reduce complications overall; and 5) dose modification of thermal treatment and use of short (3-mm) diffusing tips to limit treatment when structures to be spared do not have intervening CSF spaces to act as heat sinks. CONCLUSIONS Laser ablation treatment may be used for a variety of neurosurgical procedures for patients with tumors and epilepsy. While catheter placement and thermal treatment may be associated with a range of suboptimal operative and postoperative courses, permanent neurological morbidity is less common. The authors' institutional experience illustrates a number of measures that may be taken to improve outcomes using this important new tool in the neurosurgical arsenal.
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Affiliation(s)
- Rachel Pruitt
- Hofstra Northwell School of Medicine, Hempstead; and
| | | | - Karen Black
- Hofstra Northwell School of Medicine, Hempstead; and.,Radiology, North Shore University Hospital, Manhasset, New York
| | - Michael Schulder
- Hofstra Northwell School of Medicine, Hempstead; and.,Departments of 2 Neurosurgery and
| | - Ashesh D Mehta
- Hofstra Northwell School of Medicine, Hempstead; and.,Departments of 2 Neurosurgery and
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83
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Seizure outcomes in nonresective epilepsy surgery: an update. Neurosurg Rev 2016; 40:181-194. [PMID: 27206422 DOI: 10.1007/s10143-016-0725-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 01/31/2016] [Accepted: 03/06/2016] [Indexed: 12/18/2022]
Abstract
In approximately 30 % of patients with epilepsy, seizures are refractory to medical therapy, leading to significant morbidity and increased mortality. Substantial evidence has demonstrated the benefit of surgical resection in patients with drug-resistant focal epilepsy, and in the present journal, we recently reviewed seizure outcomes in resective epilepsy surgery. However, not all patients are candidates for or amenable to open surgical resection for epilepsy. Fortunately, several nonresective surgical options are now available at various epilepsy centers, including novel therapies which have been pioneered in recent years. Ablative procedures such as stereotactic laser ablation and stereotactic radiosurgery offer minimally invasive alternatives to open surgery with relatively favorable seizure outcomes, particularly in patients with mesial temporal lobe epilepsy. For certain individuals who are not candidates for ablation or resection, palliative neuromodulation procedures such as vagus nerve stimulation, deep brain stimulation, or responsive neurostimulation may result in a significant decrease in seizure frequency and improved quality of life. Finally, disconnection procedures such as multiple subpial transections and corpus callosotomy continue to play a role in select patients with an eloquent epileptogenic zone or intractable atonic seizures, respectively. Overall, open surgical resection remains the gold standard treatment for drug-resistant epilepsy, although it is significantly underutilized. While nonresective epilepsy procedures have not replaced the need for resection, there is hope that these additional surgical options will increase the number of patients who receive treatment for this devastating disorder-particularly individuals who are not candidates for or who have failed resection.
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84
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Kameyama S, Shirozu H, Masuda H, Ito Y, Sonoda M, Akazawa K. MRI-guided stereotactic radiofrequency thermocoagulation for 100 hypothalamic hamartomas. J Neurosurg 2016; 124:1503-12. [DOI: 10.3171/2015.4.jns1582] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECT
The aim of this study was to elucidate the invasiveness, effectiveness, and feasibility of MRI-guided stereotactic radiofrequency thermocoagulation (SRT) for hypothalamic hamartoma (HH).
METHODS
The authors examined the clinical records of 100 consecutive patients (66 male and 34 female) with intractable gelastic seizures (GS) caused by HH, who underwent SRT as a sole surgical treatment between 1997 and 2013.
The median duration of follow-up was 3 years (range 1–17 years). Seventy cases involved pediatric patients. Ninety percent of patients also had other types of seizures (non-GS). The maximum diameter of the HHs ranged from 5 to 80 mm (median 15 mm), and 15 of the tumors were giant HHs with a diameter of 30 mm or more. Comorbidities included precocious puberty (33.0%), behavioral disorder (49.0%), and mental retardation (50.0%).
RESULTS
A total of 140 SRT procedures were performed. There was no adaptive restriction for the giant or the subtype of HH, regardless of any prior history of surgical treatment or comorbidities. Patients in this case series exhibited delayed precocious puberty (9.0%), pituitary dysfunction (2.0%), and weight gain (7.0%), besides the transient hypothalamic symptoms after SRT. Freedom from GS was achieved in 86.0% of patients, freedom from other types of seizures in 78.9%, and freedom from all seizures in 71.0%. Repeat surgeries were not effective for non-GS. Seizure freedom led to disappearance of behavioral disorders and to intellectual improvement.
CONCLUSIONS
The present SRT procedure is a minimally invasive and highly effective surgical procedure without adaptive limitations. SRT involves only a single surgical procedure appropriate for all forms of epileptogenic HH and should be considered in patients with an early history of GS.
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Affiliation(s)
- Shigeki Kameyama
- 1Hypothalamic Hamartoma Center, Department of Functional Neurosurgery, Nishi-Niigata Chuo National Hospital; and
| | - Hiroshi Shirozu
- 1Hypothalamic Hamartoma Center, Department of Functional Neurosurgery, Nishi-Niigata Chuo National Hospital; and
| | - Hiroshi Masuda
- 1Hypothalamic Hamartoma Center, Department of Functional Neurosurgery, Nishi-Niigata Chuo National Hospital; and
| | - Yosuke Ito
- 1Hypothalamic Hamartoma Center, Department of Functional Neurosurgery, Nishi-Niigata Chuo National Hospital; and
| | - Masaki Sonoda
- 1Hypothalamic Hamartoma Center, Department of Functional Neurosurgery, Nishi-Niigata Chuo National Hospital; and
| | - Kohei Akazawa
- 2Department of Medical Informatics, Niigata University Medical and Dental Hospital, Niigata, Japan
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85
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Abstract
The use of epilepsy surgery in various medically resistant epilepsies is well established. For patients with intractable pediatric epilepsy, the role of intracranial electrodes, resective surgery, hemispherectomy, corpus callosotomy, neurostimulation, and multiple subpial transections continues to be very effective in select cases. Newer treatment and diagnostic methods include laser thermal ablation, minimally invasive surgeries, stereo electroencephalography, electrocorticography, and other emerging techniques. This article will review the established and emerging surgical therapies for severe pediatric epilepsies, their respective indications and overall efficacy.
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86
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Brandmeir N, Acharya V, Sather M. Robot Assisted Stereotactic Laser Ablation for a Radiosurgery Resistant Hypothalamic Hamartoma. Cureus 2016; 8:e581. [PMID: 27217984 PMCID: PMC4876011 DOI: 10.7759/cureus.581] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hypothalamic hamartomas (HH) are benign tumors that can cause significant morbidity in adults as a cause of epilepsy, particularly gelastic seizures. Open and endoscopic resections of HH offer good seizure control but have high rates of morbidity and are technically challenging. Stereotactic radiosurgery has been an alternative treatment; however, it results in comparably poor seizure control. Recently, in children, stereotactic laser ablation has shown promise as a surgical technique that can combine the best features of both of these approaches for the treatment of HH. Here we present the first reported use of a frameless robot-assisted stereotactic system to treat an HH. The patient had failed two previous Gamma Knife radiosurgery treatments. Post-procedure he had a stable, but unintentional weight loss of 20 kg and a transient episode of hemiparesis the night of the operation. At six months postoperatively the patient remained seizure free. Stereotactic laser ablation may represent a new standard in the treatment of HH in adults, especially in those who have failed radiosurgery. Further study is warranted in this population to determine efficacy and safety profiles.
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Affiliation(s)
| | - Vinita Acharya
- Department of Neurology, Penn State Milton S Hershey Medical Center
| | - Michael Sather
- Department of Neurosurgery, Penn State Milton S Hershey Medical Center
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87
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Abstract
Pediatric epilepsy is a debilitating condition that impacts millions of patients throughout the world. Approximately 20-30% of children with recurrent seizures have drug-resistant epilepsy (DRE). For these patients, surgery offers the possibility of not just seizure freedom but significantly improved neurocognitive and behavioral outcomes. The spectrum of surgical options is vast, ranging from outpatient procedures such as vagus nerve stimulation to radical interventions including hemispherectomy. The thread connecting all of these interventions is a common goal-seizure freedom, an outcome that can be achieved safely and durably in a large proportion of patients. In this review, we discuss many of the most commonly performed surgical interventions and describe the indications, complications, and outcomes specific to each.
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Affiliation(s)
- Jian Guan
- 1 Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA ; 2 Division of Neurosurgery, University of Vermont, Burlington, Vermont, USA
| | - Michael Karsy
- 1 Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA ; 2 Division of Neurosurgery, University of Vermont, Burlington, Vermont, USA
| | - Katrina Ducis
- 1 Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA ; 2 Division of Neurosurgery, University of Vermont, Burlington, Vermont, USA
| | - Robert J Bollo
- 1 Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA ; 2 Division of Neurosurgery, University of Vermont, Burlington, Vermont, USA
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88
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Abstract
In the approximately 1% of children affected by epilepsy, pharmacoresistance and early age of seizure onset are strongly correlated with poor cognitive outcomes, depression, anxiety, developmental delay, and impaired activities of daily living. These children often require multiple surgical procedures, including invasive diagnostic procedures with intracranial electrodes to identify the seizure-onset zone. The recent development of minimally invasive surgical techniques, including stereotactic electroencephalography (SEEG) and MRI-guided laser interstitial thermal therapy (MRgLITT), and new applications of neurostimulation, such as responsive neurostimulation (RNS), are quickly changing the landscape of the surgical management of pediatric epilepsy. In this review, the authors discuss these various technologies, their current applications, and limitations in the treatment of pediatric drug-resistant epilepsy, as well as areas for future research. The development of minimally invasive diagnostic and ablative surgical techniques together with new paradigms in neurostimulation hold vast potential to improve the efficacy and reduce the morbidity of the surgical management of children with drug-resistant epilepsy.
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Affiliation(s)
- Michael Karsy
- 1 Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, USA ; 2 Division of Neurosurgery, University of Vermont, Burlington, USA ; 3 Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, USA
| | - Jian Guan
- 1 Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, USA ; 2 Division of Neurosurgery, University of Vermont, Burlington, USA ; 3 Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, USA
| | - Katrina Ducis
- 1 Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, USA ; 2 Division of Neurosurgery, University of Vermont, Burlington, USA ; 3 Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, USA
| | - Robert J Bollo
- 1 Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, USA ; 2 Division of Neurosurgery, University of Vermont, Burlington, USA ; 3 Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, USA
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89
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Rolston JD, Chang EF. Stereotactic Laser Ablation for Hypothalamic Hamartoma. Neurosurg Clin N Am 2016; 27:59-67. [DOI: 10.1016/j.nec.2015.08.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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90
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Devine IM, Burrell CJ, Shih JJ. Curative laser thermoablation of epilepsy secondary to bottom-of-sulcus dysplasia near eloquent cortex. Seizure 2016; 34:35-7. [DOI: 10.1016/j.seizure.2015.11.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 11/07/2015] [Accepted: 11/24/2015] [Indexed: 10/22/2022] Open
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91
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Weiner HL. Editorial: Hypothalamic hamartomas. J Neurosurg 2015; 124:1501-2. [PMID: 26587659 DOI: 10.3171/2015.5.jns15785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Howard L Weiner
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
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92
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McCracken DJ, Willie JT, Fernald BA, Saindane AM, Drane DL, Barrow DL, Gross RE. Magnetic Resonance Thermometry-Guided Stereotactic Laser Ablation of Cavernous Malformations in Drug-Resistant Epilepsy: Imaging and Clinical Results. Oper Neurosurg (Hagerstown) 2015; 12:39-48. [PMID: 27959970 DOI: 10.1227/neu.0000000000001033] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Surgery is indicated for cerebral cavernous malformations (CCM) that cause medically refractory epilepsy. Real-time magnetic resonance thermography (MRT)-guided stereotactic laser ablation (SLA) is a minimally invasive approach to treating focal brain lesions. SLA of CCM has not previously been described. OBJECTIVE To describe MRT-guided SLA, a novel approach to treating CCM-related epilepsy, with respect to feasibility, safety, imaging, and seizure control in 5 consecutive patients. METHODS Five patients with medically refractory epilepsy undergoing standard presurgical evaluation were found to have corresponding lesions fulfilling imaging characteristics of CCM and were prospectively enrolled. Each underwent stereotactic placement of a saline-cooled cannula containing an optical fiber to deliver 980-nm diode laser energy via twist drill craniostomy. MR anatomic imaging was used to evaluate targeting prior to ablation. MR imaging provided evaluation of targeting and near real-time feedback regarding extent of tissue thermocoagulation. Patients maintained seizure diaries, and remote imaging (6-21 months post-ablation) was obtained in all patients. RESULTS Imaging revealed no evidence of acute hemorrhage following fiber placement within presumed CCM. MRT during treatment and immediate post-procedure imaging confirmed desired extent of ablation. We identified no adverse events or neurological deficits. Four of 5 (80%) patients achieved freedom from disabling seizures after SLA alone (Engel class 1 outcome), with follow-up ranging 12-28 months. Reimaging of all subjects (6-21 months) indicated lesion diminution with surrounding liquefactive necrosis, consistent with the surgical goal of extended lesionotomy. CONCLUSION Minimally invasive MRT-guided SLA of epileptogenic CCM is a potentially safe and effective alternative to open resection. Additional experience and longer follow-up are needed.
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Affiliation(s)
- D Jay McCracken
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jon T Willie
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia.,Department of Neurology, Emory University School of Medicine, Atlanta, Georgia.,Interventional MRI Program, Emory University Hospital, Atlanta, Georgia
| | | | - Amit M Saindane
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Daniel L Drane
- Department of Neurology, University of Washington School of Medicine, Seattle, Washington
| | - Daniel L Barrow
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Robert E Gross
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia.,Department of Neurology, Emory University School of Medicine, Atlanta, Georgia.,Interventional MRI Program, Emory University Hospital, Atlanta, Georgia.,Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia
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93
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Zubkov S, Del Bene VA, MacAllister WS, Shepherd TM, Devinsky O. Disabling amnestic syndrome following stereotactic laser ablation of a hypothalamic hamartoma in a patient with a prior temporal lobectomy. EPILEPSY & BEHAVIOR CASE REPORTS 2015; 4:60-2. [PMID: 26288758 PMCID: PMC4536301 DOI: 10.1016/j.ebcr.2015.07.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 07/04/2015] [Indexed: 11/18/2022]
Abstract
A 19-year-old man with cortical dysplasia and intractable focal seizures underwent a right temporal lobectomy. A hypothalamic hamartoma was subsequently recognized, and he then underwent MRI-guided stereotactic laser ablation. Unfortunately, he sustained damage to the bilateral medial mammillary bodies and suffered significant memory loss. We review laser ablation therapy for hypothalamic hamartomas and the anatomy of the memory network. We postulate that his persistent memory disorder resulted from a combination of the right temporal lobectomy and injury to the bilateral medial mammillary bodies.
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Affiliation(s)
- Sarah Zubkov
- NYU Langone Medical Center, New York, NY 10016, USA
| | - Victor A. Del Bene
- Ferkauf Graduate School of Psychology, Yeshiva University, 1165 Morris Park Avenue, Bronx, NY 10461, USA
| | | | | | - Orrin Devinsky
- NYU Langone Medical Center, New York, NY 10016, USA
- Corresponding author at: Comprehensive Epilepsy Center, 223 East 34th Street, New York, NY 10016, USA. Tel.: + 1 646 558 0800; fax: + 1 646 385 7164.
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94
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Lewis EC, Weil AG, Duchowny M, Bhatia S, Ragheb J, Miller I. MR-guided laser interstitial thermal therapy for pediatric drug-resistant lesional epilepsy. Epilepsia 2015; 56:1590-8. [PMID: 26249524 DOI: 10.1111/epi.13106] [Citation(s) in RCA: 136] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To report the feasibility, safety, and clinical outcomes of an exploratory study of MR-guided Laser Interstitial Thermal Therapy (MRgLITT) as a minimally invasive surgical procedure for the ablation of epileptogenic foci in children with drug-resistant, lesional epilepsy. METHODS Retrospective chart review of all MRgLITT procedures at a single tertiary care center. All procedures were performed using a U.S. Food and Drug Administration (FDA)-cleared surgical laser ablation system (Visualase Thermal Therapy System). Predefined clinical and surgical variables were extracted from archived medical records. RESULTS Seventeen patients underwent 19 MRgLITT procedures from May 2011 to January 2014. Mean age at seizure onset was 7.1 years (range 0.1-14.8 years). Mean age at surgery was 15.3 years (range 5.9-20.6 years). Surgical substrates were mixed but mainly composed of focal cortical dysplasia (n = 11). Complications occurred in four patients. Average length of hospitalization postsurgery was 1.56 days. Mean follow-up was 16.1 months (n = 16; range 3.5-35.9 months). Engel class I outcome was achieved in seven patients (7/17; 41%), Engel class II in one (1/17; 6%), Engel class III in three (3/17; 18%), and Engel class IV in six (6/17; 35%). Three patients (3/8; 38%) with class I and II outcomes and five patients (5/9; 56%) with class III and IV outcomes had at least one prior resection. Fisher's exact test was not statistically significant for the association between Engel class outcome and previous resection (p = 0.64). SIGNIFICANCE This study provides descriptive results regarding the use of MRgLITT in a mixed population of pediatric, lesional, drug-resistant epilepsy cases. The ability to classify case-specific outcomes and reduce technical complications is anticipated as experience develops. Further multicenter, prospective studies are required to delineate optimal candidates for MRgLITT, and larger cohorts are needed to more accurately define outcome and complication rates.
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Affiliation(s)
- Evan Cole Lewis
- Division of Neurology, Miami Children's Hospital, Miami, Florida, U.S.A
| | - Alexander G Weil
- Division of Neurosurgery, Miami Children's Hospital, Miami, Florida, U.S.A
| | - Michael Duchowny
- Division of Neurology, Miami Children's Hospital, Miami, Florida, U.S.A
| | - Sanjiv Bhatia
- Division of Neurosurgery, Miami Children's Hospital, Miami, Florida, U.S.A
| | - John Ragheb
- Division of Neurosurgery, Miami Children's Hospital, Miami, Florida, U.S.A
| | - Ian Miller
- Division of Neurology, Miami Children's Hospital, Miami, Florida, U.S.A
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95
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Abstract
Medically refractory epilepsy is a significant cause of morbidity and mortality in pediatric neurology. Surgical intervention has been well established as a viable treatment option in certain cases. This article reviews the process of selecting appropriate patients using the latest advances in neuroimaging and electrophysiologic techniques. It also discusses the various surgical techniques currently available, including recent advances in minimally invasive approaches.
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96
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97
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Governale LS. Minimally invasive pediatric neurosurgery. Pediatr Neurol 2015; 52:389-97. [PMID: 25771997 DOI: 10.1016/j.pediatrneurol.2014.08.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 08/20/2014] [Accepted: 12/30/2014] [Indexed: 10/24/2022]
Abstract
Advances in technology have facilitated the development of minimally invasive neurosurgical options for the treatment of pediatric neurological disease. This review seeks to familiarize pediatric neurologists with some of the techniques of minimally invasive pediatric neurosurgery, focusing on treatments for hydrocephalus, arachnoid cysts, intracranial mass lesions, and craniosynostosis.
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Affiliation(s)
- Lance S Governale
- Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio; Department of Neurosurgery, Ohio State University, Columbus, Ohio.
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98
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Sommer B, Schlaffer SM, Coras R, Blumcke I, Hamer HM, Stefan H, Buchfelder M. Intraoperative use of high-field MRI in hypothalamic hamartomas associated with epilepsy: clinico-pathological presentation of five adult patients. Acta Neurochir (Wien) 2014; 156:1865-78. [PMID: 25085541 DOI: 10.1007/s00701-014-2172-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 06/24/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hypothalamic harmartomas (HHs) are either occasionally associated with medically intractable epileptic syndromes or precocious puberty. Due to the extraordinary location and the expansive intra-axial growth, surgical resection is difficult and challenging without causing severe neurological, hypothalamic or endocrinological deficits, which account for higher mortality and morbidity. METHODS We present a series of five adult patients with drug-resistant epilepsy who had been operated on for HH using neuronavigation and intraoperative 1.5-T magnetic resonance imaging (MRI). In this retrospective investigation, we compared our surgical strategy and postoperative results to existing series. RESULTS During surgery, we identified remnant HH in the first intraoperative MRI control scan in three out of five patients. After re-segmentation of the residual lesion using neuronavigation, complete resection was achieved in two of the three patients as confirmed by final intraoperative and late follow-up MRI, raising the rate of total resections to four out of five patients. Two patients died during the observation period. One patient suffered from a permanent third nerve palsy and one from a transient monoparesis of the left arm. New endocrinological disturbances included diabetes insipidus centralis in two and secondary hypothyroidism and hypogonadism in one patient. Four out of five patients had favourable seizure control (Engel I or II) after 64.8 (34-83) months of mean follow-up. CONCLUSIONS Neuronavigation and intraoperative MRI are valuable tools to encounter difficulties while performing surgery in patients with HHs. Intraoperative resection control increases the amount of maximum resection.
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Affiliation(s)
- Bjoern Sommer
- Department of Neurosurgery, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany,
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Wagner K, Buschmann F, Zentner J, Trippel M, Schulze-Bonhage A. Memory outcome one year after stereotactic interstitial radiosurgery in patients with epilepsy due to hypothalamic hamartomas. Epilepsy Behav 2014; 37:204-9. [PMID: 25062290 DOI: 10.1016/j.yebeh.2014.06.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 06/23/2014] [Accepted: 06/26/2014] [Indexed: 11/19/2022]
Abstract
Epileptic seizures caused by hypothalamic hamartomas (HHs) are highly pharmacoresistant. Resective surgical approaches have shown some efficacy in controlling seizures; however, they bear a significant risk of postoperative mnemonic deterioration due to the close anatomical proximity of the HHs to structures essential for memory functions. We report on cognitive outcome in 26 patients with structural epilepsy due to HHs one year after interstitial radiosurgery. Individually, deteriorations occurred more frequently in declarative memory functions (in 20 to 50% of the patients), whereas more than 80% of the patients revealed stable or even improved performance in attentional functions. Preoperative better memory functions were associated with higher risk of postoperative performance decline. After radiosurgery, half of the patients showed more than 50%, and some up to 90%, of seizure reduction. Hypothalamic hamartoma volumes were significantly reduced at follow-up. Transient radiogenic edema found in 10/26 patients was not associated with further cognitive decline after radiosurgery. These results are highly relevant for therapeutic decisions and patient consultation on timing and choice of nonmedical treatment options for HHs.
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Affiliation(s)
| | | | - Josef Zentner
- Department of Neurosurgery, University Hospital Freiburg, Germany
| | - Michael Trippel
- Department of Stereotactic and Functional Neurosurgery, University Hospital Freiburg, Germany
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100
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[New aspects in the field of epilepsy]. DER NERVENARZT 2014; 85:955-64. [PMID: 25022893 DOI: 10.1007/s00115-014-4039-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Regarding epilepsy several new developments can be reported. The International League Against Epilepsy (ILAE) has suggested a new definition of epilepsy, for the first time including a definition of epilepsy resolution. Progress in the diagnosis relates to new genetic findings, improvements in magnetic resonance imaging (MRI) and the increasing use of stereo electroencephalograms (sEEG). Regarding treatment there are new clinically relevant data on the pathophysiology and prevention of sudden unexpected death in epilepsy (SUDEP). Zonisamide has been approved by the European Medicines Agency (EMA) for monotherapy in adults with focal seizures and combination therapy in children aged ≥ 6 years. Retigabin and perampanel have been approved but are currently taken off the market in Germany (only) because the Gemeinsamer Bundesausschuss (GBA, Joint Federal Committee) did not find any additional therapeutic value as compared to lamotrigine due to a lack of data. A decision regarding a new application for perampanel is pending. Regarding surgical treatment novel ablation techniques (e.g. stereotactic radiofrequency and laser ablation as well as focussed ultrasound ablation) and brain stimulation paradigms are under investigation. Experimental studies, generously supported by the European Union (EU) and the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) are focusing on (opto-)genetic (e.g. using lentoviral transfection), epigenetic (e.g. micro-RNA-related) approaches and on the investigation of neuronal micronetworks.
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