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Closed-Bore Interventional MRI: Percutaneous Biopsies and Ablations. AJR Am J Roentgenol 2015; 205:W400-10. [DOI: 10.2214/ajr.15.14732] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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202
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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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203
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Fahrenholtz SJ, Moon TY, Franco M, Medina D, Danish S, Gowda A, Shetty A, Maier F, Hazle JD, Stafford RJ, Warburton T, Fuentes D. A model evaluation study for treatment planning of laser-induced thermal therapy. Int J Hyperthermia 2015; 31:705-14. [PMID: 26368014 DOI: 10.3109/02656736.2015.1055831] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
A cross-validation analysis evaluating computer model prediction accuracy for a priori planning magnetic resonance-guided laser-induced thermal therapy (MRgLITT) procedures in treating focal diseased brain tissue is presented. Two mathematical models are considered. (1) A spectral element discretisation of the transient Pennes bioheat transfer equation is implemented to predict the laser-induced heating in perfused tissue. (2) A closed-form algorithm for predicting the steady-state heat transfer from a linear superposition of analytic point source heating functions is also considered. Prediction accuracy is retrospectively evaluated via leave-one-out cross-validation (LOOCV). Modelling predictions are quantitatively evaluated in terms of a Dice similarity coefficient (DSC) between the simulated thermal dose and thermal dose information contained within N = 22 MR thermometry datasets. During LOOCV analysis, the transient model's DSC mean and median are 0.7323 and 0.8001 respectively, with 15 of 22 DSC values exceeding the success criterion of DSC ≥ 0.7. The steady-state model's DSC mean and median are 0.6431 and 0.6770 respectively, with 10 of 22 passing. A one-sample, one-sided Wilcoxon signed-rank test indicates that the transient finite element method model achieves the prediction success criteria, DSC ≥ 0.7, at a statistically significant level.
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Affiliation(s)
- Samuel J Fahrenholtz
- a Department of Imaging Physics , M.D. Anderson Cancer Center, University of Texas , Houston , Texas , USA .,b Graduate School of Biomedical Sciences, University of Texas , Houston , Texas , USA
| | - Tim Y Moon
- c Department of Computational and Applied Mathematics , Rice University , Houston , Texas , USA
| | - Michael Franco
- c Department of Computational and Applied Mathematics , Rice University , Houston , Texas , USA
| | - David Medina
- c Department of Computational and Applied Mathematics , Rice University , Houston , Texas , USA
| | - Shabbar Danish
- d Department of Neurosurgery , Robert Wood Johnson Hospital , New Brunswick, New Jersey , USA , and
| | | | | | - Florian Maier
- a Department of Imaging Physics , M.D. Anderson Cancer Center, University of Texas , Houston , Texas , USA
| | - John D Hazle
- a Department of Imaging Physics , M.D. Anderson Cancer Center, University of Texas , Houston , Texas , USA .,b Graduate School of Biomedical Sciences, University of Texas , Houston , Texas , USA
| | - Roger J Stafford
- a Department of Imaging Physics , M.D. Anderson Cancer Center, University of Texas , Houston , Texas , USA .,b Graduate School of Biomedical Sciences, University of Texas , Houston , Texas , USA
| | - Tim Warburton
- c Department of Computational and Applied Mathematics , Rice University , Houston , Texas , USA
| | - David Fuentes
- a Department of Imaging Physics , M.D. Anderson Cancer Center, University of Texas , Houston , Texas , USA .,b Graduate School of Biomedical Sciences, University of Texas , Houston , Texas , USA
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204
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Anterior temporal lobectomy compared with laser thermal hippocampectomy for mesial temporal epilepsy: A threshold analysis study. Epilepsy Res 2015. [DOI: 10.1016/j.eplepsyres.2015.05.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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205
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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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206
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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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207
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Tatsui CE, Stafford RJ, Li J, Sellin JN, Amini B, Rao G, Suki D, Ghia AJ, Brown P, Lee SH, Cowles CE, Weinberg JS, Rhines LD. Utilization of laser interstitial thermotherapy guided by real-time thermal MRI as an alternative to separation surgery in the management of spinal metastasis. J Neurosurg Spine 2015; 23:400-11. [PMID: 26140398 DOI: 10.3171/2015.2.spine141185] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT High-grade malignant spinal cord compression is commonly managed with a combination of surgery aimed at removing the epidural tumor, followed by spinal stereotactic radiosurgery (SSRS) aimed at local tumor control. The authors here introduce the use of spinal laser interstitial thermotherapy (SLITT) as an alternative to surgery prior to SSRS. METHODS Patients with a high degree of epidural malignant compression due to radioresistant tumors were selected for study. Visual analog scale (VAS) scores for pain and quality of life were obtained before and within 30 and 60 days after treatment. A laser probe was percutaneously placed in the epidural space. Real-time thermal MRI was used to monitor tissue damage in the region of interest. All patients received postoperative SSRS. The maximum thickness of the epidural tumor was measured, and the degree of epidural spinal cord compression (ESCC) was scored in pre- and postprocedure MRI. RESULTS In the 11 patients eligible for study, the mean VAS score for pain decreased from 6.18 in the preoperative period to 4.27 within 30 days and 2.8 within 60 days after the procedure. A similar VAS interrogating the percentage of quality of life demonstrated improvement from 60% preoperatively to 70% within both 30 and 60 days after treatment. Imaging follow-up 2 months after the procedure demonstrated a significant reduction in the mean thickness of the epidural tumor from 8.82 mm (95% CI 7.38-10.25) before treatment to 6.36 mm (95% CI 4.65-8.07) after SLITT and SSRS (p = 0.0001). The median preoperative ESCC Grade 2 was scored as 4, which was significantly higher than the score of 2 for Grade 1b (p = 0.04) on imaging follow-up 2 months after the procedure. CONCLUTIONS The authors present the first report on an innovative minimally invasive alternative to surgery in the management of spinal metastasis. In their early experience, SLITT has provided local control with low morbidity and improvement in both pain and the quality of life of patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Sun-Ho Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Charles E Cowles
- Anesthesiology, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
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Medvid R, Ruiz A, Komotar RJ, Jagid JR, Ivan ME, Quencer RM, Desai MB. Current Applications of MRI-Guided Laser Interstitial Thermal Therapy in the Treatment of Brain Neoplasms and Epilepsy: A Radiologic and Neurosurgical Overview. AJNR Am J Neuroradiol 2015; 36:1998-2006. [PMID: 26113069 DOI: 10.3174/ajnr.a4362] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Minimally invasive stereotactic tumor ablation is a viable option for the treatment of benign and malignant intracranial lesions. Although surgical excision constitutes first-line therapy for various brain pathologies, it can cause irreversible neurologic deficits. Additionally, many patients who may benefit from surgery do not qualify as surgical candidates due to multiple comorbidities. Recent advancements in laser interstitial thermal therapy, namely the ability to monitor ablation in real-time under MR imaging, have improved the safety and efficacy of the procedure. MRI-guided laser interstitial thermal therapy is currently used as a minimally invasive treatment for brain metastases, radiation necrosis, glioma, and epilepsy. This article will discuss the principles, suggested indications, complications, and imaging characteristics of MRI-guided laser interstitial thermal therapy as they pertain to the treatment of brain pathology.
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Affiliation(s)
- R Medvid
- From the Department of Radiology (R.M., A.R., R.M.Q., M.B.D.), Division of Neuroradiology
| | - A Ruiz
- From the Department of Radiology (R.M., A.R., R.M.Q., M.B.D.), Division of Neuroradiology
| | - R J Komotar
- Department of Neurological Surgery (J.R.J., R.J.K., M.E.I.), Jackson Memorial Hospital/University of Miami Hospital, Miami, Florida
| | - J R Jagid
- Department of Neurological Surgery (J.R.J., R.J.K., M.E.I.), Jackson Memorial Hospital/University of Miami Hospital, Miami, Florida
| | - M E Ivan
- Department of Neurological Surgery (J.R.J., R.J.K., M.E.I.), Jackson Memorial Hospital/University of Miami Hospital, Miami, Florida
| | - R M Quencer
- From the Department of Radiology (R.M., A.R., R.M.Q., M.B.D.), Division of Neuroradiology
| | - M B Desai
- From the Department of Radiology (R.M., A.R., R.M.Q., M.B.D.), Division of Neuroradiology
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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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211
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Abstract
Laser interstitial thermal therapy (LITT) is a minimally invasive technique for treating intracranial tumors, originally introduced in 1983. Its use in neurosurgical procedures was historically limited by early technical difficulties related to the monitoring and control of the extent of thermal damage. The development of magnetic resonance thermography and its application to LITT have allowed for real-time thermal imaging and feedback control during laser energy delivery, allowing for precise and accurate provision of tissue hyperthermia. Improvements in laser probe design, surgical stereotactic targeting hardware, and computer monitoring software have accelerated acceptance and clinical utilization of LITT as a neurosurgical treatment alternative. Current commercially available LITT systems have been used for the treatment of neurosurgical soft-tissue lesions, including difficult to access brain tumors, malignant gliomas, and radiosurgery-resistant metastases, as well as for the ablation of such lesions as epileptogenic foci and radiation necrosis. In this review, the authors aim to critically analyze the literature to describe the advent of LITT as a neurosurgical, laser excision tool, including its development, use, indications, and efficacy as it relates to neurosurgical applications.
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Affiliation(s)
- Symeon Missios
- 1Department of Neurosurgery, Louisiana State University Health Sciences, Shreveport, Louisiana
| | - Kimon Bekelis
- 2Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Gene H. Barnett
- 3The Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
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212
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Willie JT, Laxpati NG, Drane DL, Gowda A, Appin C, Hao C, Brat DJ, Helmers SL, Saindane A, Nour SG, Gross RE. Real-time magnetic resonance-guided stereotactic laser amygdalohippocampotomy for mesial temporal lobe epilepsy. Neurosurgery 2015; 74:569-84; discussion 584-5. [PMID: 24618797 DOI: 10.1227/neu.0000000000000343] [Citation(s) in RCA: 251] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Open surgery effectively treats mesial temporal lobe epilepsy, but carries the risk of neurocognitive deficits, which may be reduced with minimally invasive alternatives. OBJECTIVE To describe technical and clinical outcomes of stereotactic laser amygdalohippocampotomy with real-time magnetic resonance thermal imaging guidance. METHODS With patients under general anesthesia and using standard stereotactic methods, 13 adult patients with intractable mesial temporal lobe epilepsy (with and without mesial temporal sclerosis [MTS]) prospectively underwent insertion of a saline-cooled fiberoptic laser applicator in amygdalohippocampal structures from an occipital trajectory. Computer-controlled laser ablation was performed during continuous magnetic resonance thermal imaging followed by confirmatory contrast-enhanced anatomic imaging and volumetric reconstruction. Clinical outcomes were determined from seizure diaries. RESULTS A mean 60% volume of the amygdalohippocampal complex was ablated in 13 patients (9 with MTS) undergoing 15 procedures. Median hospitalization was 1 day. With follow-up ranging from 5 to 26 months (median, 14 months), 77% (10/13) of patients achieved meaningful seizure reduction, of whom 54% (7/13) were free of disabling seizures. Of patients with preoperative MTS, 67% (6/9) achieved seizure freedom. All recurrences were observed before 6 months. Variances in ablation volume and length did not account for individual clinical outcomes. Although no complications of laser therapy itself were observed, 1 significant complication, a visual field defect, resulted from deviated insertion of a stereotactic aligning rod, which was corrected before ablation. CONCLUSION Real-time magnetic resonance-guided stereotactic laser amygdalohippocampotomy is a technically novel, safe, and effective alternative to open surgery. Further evaluation with larger cohorts over time is warranted.
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Affiliation(s)
- Jon T Willie
- Departments of *Neurosurgery, ‡Neurology, §Pathology, and ¶Radiology and Imaging Sciences, 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; **Department of Neurology, University of Washington School of Medicine, Seattle, Washington; ††Visualase, Inc., Houston, Texas
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Mathon B, Bédos-Ulvin L, Baulac M, Dupont S, Navarro V, Carpentier A, Cornu P, Clemenceau S. Évolution des idées et des techniques, et perspectives d’avenir en chirurgie de l’épilepsie. Rev Neurol (Paris) 2015; 171:141-56. [DOI: 10.1016/j.neurol.2014.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 08/10/2014] [Accepted: 09/30/2014] [Indexed: 10/24/2022]
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Xu DS, Rosenfeld A, Ponce FA, Nakaji P, Bhardwaj RD. Cerebral peduncle tumor ablated by novel 3-mm laser tip. Stereotact Funct Neurosurg 2015; 93:38-41. [PMID: 25662091 DOI: 10.1159/000368907] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 10/07/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND/OBJECTIVE Decisions to use open surgery or radiotherapy in pediatric patients with familial neoplastic syndromes must consider not only the symptomatic benefits of treatment, but also future limitations these treatments may impose. Specifically, open surgical resection of noncurable tumors may preclude or encumber future lesion resections, while radiotherapy has detrimental effects on pediatric cognitive development and increases the risk of future malignancy development. We provide the first report of using a novel 3.0-mm diffusing laser tip with laser-induced thermal therapy (LiTT) to treat a pediatric patient with neurofibromatosis type 1 (NF-1). METHODS A 12-year-old boy with NF-1 presented with a progressively enlarging lesion in the right midbrain. A stereotactic biopsy was performed, followed by LiTT with a novel 3.0-mm laser applicator. RESULTS MRI 1 week after LiTT showed stable gross total ablation of the lesion with reduction in fluid-attenuated inversion recovery signal. The patient remained neurologically intact 6 months after his procedure, and follow-up MRI showed no evidence of recurrence. CONCLUSION LiTT is a powerful adjunct to conventional open surgical and radiotherapy modalities in the treatment of patients with familial neoplastic syndromes or incurable lesions. The novel laser applicator tip described expands the treatment scope of this technique.
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Affiliation(s)
- David S Xu
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Ariz., USA
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215
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Drane DL, Loring DW, Voets NL, Price M, Ojemann JG, Willie JT, Saindane AM, Phatak V, Ivanisevic M, Millis S, Helmers SL, Miller JW, Meador KJ, Gross RE. Better object recognition and naming outcome with MRI-guided stereotactic laser amygdalohippocampotomy for temporal lobe epilepsy. Epilepsia 2015; 56:101-13. [PMID: 25489630 PMCID: PMC4446987 DOI: 10.1111/epi.12860] [Citation(s) in RCA: 221] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Patients with temporal lobe epilepsy (TLE) experience significant deficits in category-related object recognition and naming following standard surgical approaches. These deficits may result from a decoupling of core processing modules (e.g., language, visual processing, and semantic memory), due to "collateral damage" to temporal regions outside the hippocampus following open surgical approaches. We predicted that stereotactic laser amygdalohippocampotomy (SLAH) would minimize such deficits because it preserves white matter pathways and neocortical regions that are critical for these cognitive processes. METHODS Tests of naming and recognition of common nouns (Boston Naming Test) and famous persons were compared with nonparametric analyses using exact tests between a group of 19 patients with medically intractable mesial TLE undergoing SLAH (10 dominant, 9 nondominant), and a comparable series of TLE patients undergoing standard surgical approaches (n=39) using a prospective, nonrandomized, nonblinded, parallel-group design. RESULTS Performance declines were significantly greater for the patients with dominant TLE who were undergoing open resection versus SLAH for naming famous faces and common nouns (F=24.3, p<0.0001, η2=0.57, and F=11.2, p<0.001, η2=0.39, respectively), and for the patients with nondominant TLE undergoing open resection versus SLAH for recognizing famous faces (F=3.9, p<0.02, η2=0.19). When examined on an individual subject basis, no SLAH patients experienced any performance declines on these measures. In contrast, 32 of the 39 patients undergoing standard surgical approaches declined on one or more measures for both object types (p<0.001, Fisher's exact test). Twenty-one of 22 left (dominant) TLE patients declined on one or both naming tasks after open resection, while 11 of 17 right (nondominant) TLE patients declined on face recognition. SIGNIFICANCE Preliminary results suggest (1) naming and recognition functions can be spared in TLE patients undergoing SLAH, and (2) the hippocampus does not appear to be an essential component of neural networks underlying name retrieval or recognition of common objects or famous faces.
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Affiliation(s)
- Daniel L Drane
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A; Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, U.S.A; Department of Neurology, University of Washington School of Medicine, Seattle, Washington, U.S.A
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Tiwari P, Danish S, Madabhushi A. Identifying MRI markers associated with early response following laser ablation for neurological disorders: preliminary findings. PLoS One 2014; 9:e114293. [PMID: 25503713 PMCID: PMC4263602 DOI: 10.1371/journal.pone.0114293] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 11/07/2014] [Indexed: 01/10/2023] Open
Abstract
There is a renewed interest in MR-guided laser interstitial thermal therapy (LITT) as a minimally invasive alternative to craniotomy for local treatment of various brain tumors and epilepsy. LITT allows for focused delivery of laser energy monitored in real time by MRI, for precise ablation of the lesion. Although highly promising, the long-term effects of laser ablation as a viable treatment option for neurological disorders have yet to be rigorously studied and quantified. In this work, we present a quantitative framework for monitoring per-voxel thermal-induced changes post-LITT over time on multi parametric MRI. We demonstrate that voxel-by-voxel quantification of MRI markers over time can enable a careful and accurate (a) characterization of early LITT-related changes (if and when they are exaggerated and when they subside), and (b) identification and monitoring of MRI markers that potentially allow for better quantification of response to LITT therapy. The framework was evaluated on two distinct cohorts of patients (GBM, epilepsy), who were monitored post-LITT at regular time-intervals via multi-parametric MRI. On a cohort of six GBM studies we found that (a) it may be important for the initial treatment-related changes to subside to more reliably capture MRI markers relating to tumor recurrence, and (b) T1w MRI and T2-GRE may better differentiate changes that may correspond to tumor recurrence from patients with no recurrence, as compared to T2w-MRI, and FLAIR. Similarly, our preliminary analysis of four epilepsy studies suggests that (a) early LITT changes (attributed to swelling, edema) appear to subside within 4-weeks post-LITT, and (b) ADC may be more reflective of early treatment changes (up to 1 month), while T1w may be more reflective of early delayed treatment changes (1 month, 3 months), while T2-w and T2-FLAIR appeared to be more sensitive to late treatment related changes (6-months post-LITT) compared to the other MRI protocols under evaluation.
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Affiliation(s)
- Pallavi Tiwari
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, United States of America
- * E-mail:
| | - Shabbar Danish
- Division of Neurosurgery, Rutgers-RWJ Medical School, New Brunswick, New Jersey, United States of America
| | - Anant Madabhushi
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, United States of America
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Quigg M, Harden C. Minimally invasive techniques for epilepsy surgery: stereotactic radiosurgery and other technologies. J Neurosurg 2014; 121 Suppl:232-40. [DOI: 10.3171/2014.8.gks141608] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Minimally invasive surgical techniques for the treatment of medically intractable epilepsy, which have been developed by neurosurgeons and epileptologists almost simultaneously with standard open epilepsy surgery, provide benefits in the traditional realms of safety and efficacy and the more recently appreciated realms of patient acceptance and costs. In this review, the authors discuss the shortcomings of the gold standard of open epilepsy surgery and summarize the techniques developed to provide minimally invasive alternatives. These minimally invasive techniques include stereotactic radiosurgery using the Gamma Knife, stereotactic radiofrequency thermocoagulation, laser-induced thermal therapy, and MRI-guided focused ultrasound ablation.
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Affiliation(s)
- Mark Quigg
- 1Department of Neurology, University of Virginia Heath System, Charlottesville, Virginia; and
| | - Cynthia Harden
- 2Department of Neurology, Hofstra University, Hempsted, New York
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Calisto A, Dorfmüller G, Fohlen M, Bulteau C, Conti A, Delalande O. Endoscopic disconnection of hypothalamic hamartomas: safety and feasibility of robot-assisted, thulium laser-based procedures. J Neurosurg Pediatr 2014; 14:563-72. [PMID: 25325417 DOI: 10.3171/2014.8.peds13586] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Hypothalamic hamartomas (HH) may induce drug-resistant epilepsy (DRE), thereby requiring surgical treatment. Conventionally, treatment is aimed at removing the lesion, but a disconnection procedure has been shown to be safer and at least as effective. The thulium laser (Revolix) has been recently introduced in urological endoscopy because of its ability to deliver a smooth cut with good control of the extent of tissue damage. The authors sought to analyze the safety and efficacy of the thulium 2-μm laser applied through navigated, robot-assisted endoscopy in disconnection surgery for HHs. METHODS Twenty patients with HH who were drug resistant were treated during a 12-month period. Conventional disconnection by monopolar coagulation (endoscopic electrode) was performed in 13 patients, and thulium laser disconnection was performed in the remaining 7 patients. The endoscope was inserted into the ventricle contralateral to the attachment of the HH on the third ventricular wall. Results in terms of safety, efficacy, and ease of use of the instrument were analyzed. RESULTS All 20 patients achieved a satisfactory postoperative Engel score (Classes I-III). At 12 months, the Engel class was I or II in 8 of 13 patients (61.5%) who underwent monopolar coagulation and in 6 of 7 patients (85.7%) who underwent laser disconnection (p = 0.04). Seven of 13 patients (53.8%) who underwent monopolar coagulator disconnection and 2 of 7 patients (28.6%) who underwent laser disconnection had immediate postoperative complications. At the 3-month follow-up, only 2 patients (15.4%) treated by coagulation still experienced mild surgery-related recent memory deficits. No complications persisted at the 12-month follow-up. CONCLUSIONS The disconnection procedure is a safe and effective treatment strategy to treat drug-resistant epilepsy in patients with HHs. With the limitations of initial experience and a short-term follow-up, it appears that the thulium 2-μm laser has the technical features to replace the standard coagulation in this procedure.
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Affiliation(s)
- Amedeo Calisto
- Division of Pediatric Neurosurgery, Fondation Adolphe de Rothschild, Paris, France; and
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Abstract
This review summarises exciting recent and forthcoming advances that will impact on the surgical management of epilepsy in the near future. This does not cover the current accepted diagnostic methodologies or surgical treatments that are routinely practiced today. The content of this review was derived from a PubMed literature search, using the key words 'Epilepsy Surgery', 'Neuromodulation', 'Neuroablation', 'Advances', between 2010 and November 2013.
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Affiliation(s)
- Mark Nowell
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, London, UK MRI Unit, Epilepsy Society, Chalfont St Peter, UK Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Anna Miserocchi
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, London, UK Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Andrew W McEvoy
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, London, UK Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - John S Duncan
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, London, UK MRI Unit, Epilepsy Society, Chalfont St Peter, UK
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Serletis D, Bulacio J, Bingaman W, Najm I, González-Martínez J. The stereotactic approach for mapping epileptic networks: a prospective study of 200 patients. J Neurosurg 2014; 121:1239-46. [DOI: 10.3171/2014.7.jns132306] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Stereoelectroencephalography (SEEG) is a methodology that permits accurate 3D in vivo electroclinical recordings of epileptiform activity. Among other general indications for invasive intracranial electroencephalography (EEG) monitoring, its advantages include access to deep cortical structures, its ability to localize the epileptogenic zone when subdural grids have failed to do so, and its utility in the context of possible multifocal seizure onsets with the need for bihemispheric explorations. In this context, the authors present a brief historical overview of the technique and report on their experience with 2 SEEG techniques (conventional Leksell frame-based stereotaxy and frameless stereotaxy under robotic guidance) for the purpose of invasively monitoring difficult-to-localize refractory focal epilepsy.
Methods
Over a period of 4 years, the authors prospectively identified 200 patients with refractory epilepsy who collectively underwent 2663 tailored SEEG electrode implantations for invasive intracranial EEG monitoring and extraoperative mapping. The first 122 patients underwent conventional Leksell frame-based SEEG electrode placement; the remaining 78 patients underwent frameless stereotaxy under robotic guidance, following acquisition of a stereotactic ROSA robotic device at the authors' institution. Electrodes were placed according to a preimplantation hypothesis of the presumed epileptogenic zone, based on a standardized preoperative workup including video-EEG monitoring, MRI, PET, ictal SPECT, and neuropsychological assessment. Demographic features, seizure semiology, number and location of implanted SEEG electrodes, and location of the epileptogenic zone were recorded and analyzed for all patients. For patients undergoing subsequent craniotomy for resection, the type of resection and procedure-related complications were prospectively recorded. These results were analyzed and correlated with pathological diagnosis and postoperative seizure outcomes.
Results
The epileptogenic zone was confirmed by SEEG in 154 patients (77%), of which 134 (87%) underwent subsequent craniotomy for epileptogenic zone resection. Within this cohort, 90 patients had a minimum follow-up of at least 12 months; therein, 61 patients (67.8%) remained seizure free, with an average follow-up period of 2.4 years. The most common pathological diagnosis was focal cortical dysplasia Type I (55 patients, 61.1%). Per electrode, the surgical complications included wound infection (0.08%), hemorrhagic complications (0.08%), and a transient neurological deficit (0.04%) in a total of 5 patients (2.5%). One patient (0.5%) ultimately died due to intracerebral hematoma directly ensuing from SEEG electrode placement.
Conclusions
Based on these results, SEEG methodology is safe, reliable, and effective. It is associated with minimal morbidity and mortality, and serves as a practical, minimally invasive approach to extraoperative localization of the epileptogenic zone in patients with refractory epilepsy.
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Affiliation(s)
- Demitre Serletis
- 1Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and
| | - Juan Bulacio
- 2Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - William Bingaman
- 2Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Imad Najm
- 2Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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Hawasli AH, Bandt SK, Hogan RE, Werner N, Leuthardt EC. Laser ablation as treatment strategy for medically refractory dominant insular epilepsy: therapeutic and functional considerations. Stereotact Funct Neurosurg 2014; 92:397-404. [PMID: 25359500 DOI: 10.1159/000366001] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 07/14/2014] [Indexed: 11/19/2022]
Abstract
Since its introduction to neurosurgery in 2008, laser ablative techniques have been largely confined to the management of unresectable tumors. Application of this technology for the management of focal epilepsy in the adult population has not been fully explored. Given that nearly 1,000,000 Americans live with medically refractory epilepsy and current surgical techniques only address a fraction of epileptic pathologies, additional therapeutic options are needed. We report the successful treatment of dominant insular epilepsy in a 53-year-old male with minimally invasive laser ablation complicated by mild verbal and memory deficits. We also report neuropsychological test data on this patient before surgery and at 8 months after the ablation procedure. This account represents the first reported successful patient outcome of laser ablation as an effective treatment option for medically refractory post-stroke epilepsy in an adult.
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Affiliation(s)
- Ammar H Hawasli
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Mo., USA
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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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Hawasli AH, Bagade S, Shimony JS, Miller-Thomas M, Leuthardt EC. Magnetic resonance imaging-guided focused laser interstitial thermal therapy for intracranial lesions: single-institution series. Neurosurgery 2014; 73:1007-17. [PMID: 24056317 PMCID: PMC3871404 DOI: 10.1227/neu.0000000000000144] [Citation(s) in RCA: 143] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND: Surgical treatments for deep-seated intracranial lesions have been limited by morbidities associated with resection. Real-time magnetic resonance imaging–guided focused laser interstitial thermal therapy (LITT) offers a minimally invasive surgical treatment option for such lesions. OBJECTIVE: To review treatments and results of patients treated with LITT for intracranial lesions at Washington University School of Medicine. METHODS: In a review of 17 prospectively recruited LITT patients (34-78 years of age; mean, 59 years), we report demographics, treatment details, postoperative imaging characteristics, and peri- and postoperative clinical courses. RESULTS: Targets included 11 gliomas, 5 brain metastases, and 1 epilepsy focus. Lesions were lobar (n = 8), thalamic/basal ganglia (n = 5), insular (n = 3), and corpus callosum (n = 1). Mean target volume was 11.6 cm3, and LITT produced 93% target ablation. Patients with superficial lesions had shorter intensive care unit stays. Ten patients experienced no perioperative morbidities. Morbidities included transient aphasia, hemiparesis, hyponatremia, deep venous thrombosis, and fatal meningitis. Postoperative magnetic resonance imaging showed blood products within the lesion surrounded by new thin uniform rim of contrast enhancement and diffusion restriction. In conjunction with other therapies, LITT targets often showed stable or reduced local disease. Epilepsy focus LITT produced seizure freedom at 8 months. Preliminary overall median progression-free survival and survival from LITT in tumor patients were 7.6 and 10.9 months, respectively. However, this small cohort has not been followed for a sufficient length of time, necessitating future outcomes studies. CONCLUSION: Early peri- and postoperative clinical data demonstrate that LITT is a safe and viable ablative treatment option for intracranial lesions, and may be considered for select patients. ABBREVIATION: LITT, laser interstitial thermal therapy
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Affiliation(s)
- Ammar H Hawasli
- Departments of Neurosurgery and Mallinckrodt Institute of Radiology, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri
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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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226
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Riordan M, Tovar-Spinoza Z. Laser induced thermal therapy (LITT) for pediatric brain tumors: case-based review. Transl Pediatr 2014; 3:229-35. [PMID: 26835340 PMCID: PMC4729851 DOI: 10.3978/j.issn.2224-4336.2014.07.07] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Integration of Laser induced thermal therapy (LITT) to magnetic resonance imaging (MRI) have created new options for treating surgically challenging tumors in locations that would otherwise have represented an intrinsic comorbidity by the approach itself. As new applications and variations of the use are discussed, we present a case-based review of the history, development, and subsequent updates of minimally invasive MRI-guided laser interstitial thermal therapy (MRgLITT) ablation in pediatric brain tumors.
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Affiliation(s)
- Margaret Riordan
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Zulma Tovar-Spinoza
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY, USA
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Warnke P. Stereotactic lesioning in focal epilepsy or less is more--but why has it not worked in the past? J Neurol Neurosurg Psychiatry 2014; 85:594. [PMID: 23868950 DOI: 10.1136/jnnp-2013-305937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Engel J. Approaches to refractory epilepsy. Ann Indian Acad Neurol 2014; 17:S12-7. [PMID: 24791078 PMCID: PMC4001229 DOI: 10.4103/0972-2327.128644] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 01/08/2014] [Accepted: 01/08/2014] [Indexed: 11/30/2022] Open
Abstract
Epilepsy is one of the most common serious neurological conditions, and 30 to 40% of people with epilepsy have seizures that are not controlled by medication. Patients are considered to have refractory epilepsy if disabling seizures continue despite appropriate trials of two antiseizure drugs, either alone or in combination. At this point, patients should be referred to multidisciplinary epilepsy centers that perform specialized diagnostic testing to first determine whether they are, in fact, pharmacoresistant, and then, if so, offer alternative treatments. Apparent pharmacoresistance can result from a variety of situations, including noncompliance, seizures that are not epileptic, misdiagnosis of the seizure type or epilepsy syndrome, inappropriate use of medication, and lifestyle issues. For patients who are pharmacoresistant, surgical treatment offers the best opportunity for complete freedom from seizures. Surgically remediable epilepsy syndromes have been identified, but patients with more complicated epilepsy can also benefit from surgical treatment and require more specialized evaluation, including intracranial EEG monitoring. For patients who are not surgical candidates, or who are unwilling to consider surgery, a variety of other alternative treatments can be considered, including peripheral or central neurostimulation, ketogenic diet, and complementary and alternative approaches. When such alternative treatments are not appropriate or effective, quality of life can still be greatly improved by the psychological and social support services offered by multidisciplinary epilepsy centers. A major obstacle remains the fact that only a small proportion of patients with refractory epilepsy are referred for expert evaluation and treatment.
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Affiliation(s)
- Jerome Engel
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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Schmitt FC, Kaufmann J, Hoffmann MB, Tempelmann C, Kluge C, Rampp S, Voges J, Heinze HJ, Buentjen L, Grueschow M. Case report: practicability of functionally based tractography of the optic radiation during presurgical epilepsy work up. Neurosci Lett 2014; 568:56-61. [PMID: 24690576 DOI: 10.1016/j.neulet.2014.03.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 03/05/2014] [Accepted: 03/17/2014] [Indexed: 10/25/2022]
Abstract
Pre-operative tractography of the optic radiation (OR) has been advised to assess the risk for postoperative visual field deficit (VFD) in certain candidates for resective epilepsy surgery. Diffusion tensor imaging (DTI) tractography relies on a precise anatomical determination of start and target regions of interest (ROIs), such as the lateral geniculate nucleus (LGN) and the primary visual cortex (V1). The post-chiasmal visual pathway and V1 show considerable inter-individual variability, and in epilepsy patients parenchymatous lesions might further complicate this matter. A functionally based tractography (FBT) seems beneficial for precise OR identification. We assessed practicability of FBT for OR identification in a patient with occipital lobe epilepsy due to a temporo-occipital maldevelopmental tumor. The MRI protocol at 3T included a T1-weighted sagittal 3D scan, a T2-weighted axial 2D scan and a DTI scan using an echo planar spin echo sequence. ROIs for fiber tracking of OR (LGN & V1) were determined with T2*-weighted fMRI-based retinotopic assessment. After DTI pre-processing and fiber tracking, paths with similar properties were combined in clusters for visual presentation and OR localization. Retinotopic phase maps allowed for the identification of V1 and LGN for a precise DTI-based reconstruction of OR, which was distant to the patient's tumor. Location and structure of ORs were comparable in each hemisphere. FBT could thus influence the human research of the extrastriate visual pathway and the risk management of post-operative VFD in epilepsy surgery.
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Affiliation(s)
- F C Schmitt
- Department of Neurology, Otto-von-Guericke University, Leipziger Str. 44, D-39120 Magdeburg, Germany.
| | - J Kaufmann
- Department of Neurology, Otto-von-Guericke University, Leipziger Str. 44, D-39120 Magdeburg, Germany
| | - M B Hoffmann
- Department of Ophthalmology, Otto-von-Guericke University, Leipziger Str. 44, D-39120 Magdeburg, Germany; Center for Behavioural Brain Science (CBBS), Otto-von-Guericke-University, Universitätsplatz 2, D-39106 Magdeburg, Germany
| | - C Tempelmann
- Department of Neurology, Otto-von-Guericke University, Leipziger Str. 44, D-39120 Magdeburg, Germany
| | - C Kluge
- Department of Neurology, Otto-von-Guericke University, Leipziger Str. 44, D-39120 Magdeburg, Germany; Center for Behavioural Brain Science (CBBS), Otto-von-Guericke-University, Universitätsplatz 2, D-39106 Magdeburg, Germany
| | - S Rampp
- Epilepsy Center Erlangen, University of Erlangen-Nürnberg, Schwabachanlage 6, 91054 Erlangen, Germany
| | - J Voges
- Department of Stereotactic Neurosurgery, Otto-von-Guericke University, Leipziger Str. 44, D-39120 Magdeburg, Germany; Leibnitz Institute of Neurobiology, Leipziger Str. 44, D-39120 Magdeburg, Germany
| | - H J Heinze
- Department of Neurology, Otto-von-Guericke University, Leipziger Str. 44, D-39120 Magdeburg, Germany; Leibnitz Institute of Neurobiology, Leipziger Str. 44, D-39120 Magdeburg, Germany
| | - L Buentjen
- Department of Stereotactic Neurosurgery, Otto-von-Guericke University, Leipziger Str. 44, D-39120 Magdeburg, Germany
| | - M Grueschow
- Department of Neurology, Otto-von-Guericke University, Leipziger Str. 44, D-39120 Magdeburg, Germany; Department of Economics, University Zurich, Blümlisalpstrasse 10, CH-8006 Zurich, Switzerland
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Tiwari P, Danish S, Madabhushi A. Identifying MRI markers to evaluate early treatment related changes post laser ablation for cancer pain management. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2014; 9036:90362L. [PMID: 25075271 PMCID: PMC4112118 DOI: 10.1117/12.2043729] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Laser interstitial thermal therapy (LITT) has recently emerged as a new treatment modality for cancer pain management that targets the cingulum (pain center in the brain), and has shown promise over radio-frequency (RF) based ablation which is reported to provide temporary relief. One of the major advantages enjoyed by LITT is its compatibility with magnetic resonance imaging (MRI), allowing for high resolution in vivo imaging to be used in LITT procedures. Since laser ablation for pain management is currently exploratory and is only performed at a few centers worldwide, its short-, and long-term effects on the cingulum are currently unknown. Traditionally treatment effects are evaluated by monitoring changes in volume of the ablation zone post-treatment. However, this is sub-optimal since it involves evaluating a single global parameter (volume) to detect changes pre-, and post-MRI. Additionally, the qualitative observations of LITT-related changes on multi-parametric MRI (MP-MRI) do not specifically address differentiation between the appearance of treatment related changes (edema, necrosis) from recurrence of the disease (pain recurrence). In this work, we explore the utility of computer extracted texture descriptors on MP-MRI to capture early treatment related changes on a per-voxel basis by extracting quantitative relationships that may allow for an in-depth understanding of tissue response to LITT on MRI, subtle changes that may not be appreciable on original MR intensities. The second objective of this work is to investigate the efficacy of different MRI protocols in accurately capturing treatment related changes within and outside the ablation zone post-LITT. A retrospective cohort of studies comprising pre- and 24-hour post-LITT 3 Tesla T1-weighted (T1w), T2w, T2-GRE, and T2-FLAIR acquisitions was considered. Our scheme involved (1) inter-protocol as well as inter-acquisition affine registration of pre- and post-LITT MRI, (2) quantitation of MRI parameters by correcting for intensity drift in order to examine tissue-specific response, and (3) quantification of MRI maps via texture and intensity features to evaluate changes in MR markers pre- and post-LITT. A total of 78 texture features comprising of non-steerable and steerable gradient and second order statistical features were extracted from pre- and post-LITT MP-MRI on a per-voxel basis. Quantitative, voxel-wise comparison of the changes in MRI texture features between pre-, and post-LITT MRI indicate that (a) steerable and non-steerable gradient texture features were highly sensitive as well as specific in predicting subtle micro-architectural changes within and around the ablation zone pre- and post-LITT, (b) FLAIR was identified as the most sensitive MRI protocol in identifying early treatment changes yielding a normalized percentage change of 360% within the ablation zone relative to its pre-LITT value, and (c) GRE was identified as the most sensitive MRI protocol in quantifying changes outside the ablation zone post-LITT. Our preliminary results thus indicate great potential for non-invasive computerized MRI features in determining localized micro-architectural focal treatment related changes post-LITT.
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Affiliation(s)
- Pallavi Tiwari
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH USA
| | - Shabbar Danish
- University of Medicine and Dentistry New Jersey, New Brunswick, USA
| | - Anant Madabhushi
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH USA
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231
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Wilfong AA, Curry DJ. Hypothalamic hamartomas: optimal approach to clinical evaluation and diagnosis. Epilepsia 2014; 54 Suppl 9:109-14. [PMID: 24328883 DOI: 10.1111/epi.12454] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hypothalamic hamartomas (HHs) present a difficult medical problem, manifested by gelastic seizures, which are often medically intractable. Although existing techniques offer modest surgical outcomes with the potential for significant morbidity, the relatively novel technique of magnetic resonance imaging (MRI)-guided stereotactic laser ablation (SLA) offers a potentially safer, minimally invasive method with high efficacy for the HH treatment. We report here on 14 patients with medically refractory gelastic epilepsy who underwent stereotactic frame-based placement of an MR-compatible laser catheter (1.6 mm diameter) through a 3.2-mm twist drill hole. A U.S. Food and Drug Administration (FDA)-cleared laser surgery system (Visualase, Inc.) was utilized to ablate the HH, using real-time MRI thermometry. Seizure freedom was obtained in 12 (86%) of 14 cases, with mean follow-up of 9 months. There were no permanent surgical complications, neurologic deficits, or neuroendocrine disturbances. One patient had a minor subarachnoid hemorrhage that was asymptomatic. Most patients were discharged home within 1 day. SLA was demonstrated to be a safe and effective minimally invasive tool in the ablation of epileptogenic HH. Because use of SLA for HH is being adopted by other medical centers, further data will be acquired to help treat this difficult disorder.
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Affiliation(s)
- Angus A Wilfong
- Division of Pediatric Neurology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, U.S.A
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Esquenazi Y, Kalamangalam GP, Slater JD, Knowlton RC, Friedman E, Morris SA, Shetty A, Gowda A, Tandon N. Stereotactic laser ablation of epileptogenic periventricular nodular heterotopia. Epilepsy Res 2014; 108:547-54. [PMID: 24518890 DOI: 10.1016/j.eplepsyres.2014.01.009] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 12/09/2013] [Accepted: 01/14/2014] [Indexed: 11/27/2022]
Abstract
Periventricular nodular heterotopia (PVNH) is a neuronal migrational disorder often associated with pharmacoresistant epilepsy (PRE). Resective surgery for PVNH is limited by its deep location, and the overlying eloquent cortex or white matter. Stereotactic MR guided laser interstitial thermal therapy (MRgLITT) has recently become available for controlled focal ablation, enabling us to target these lesions. We here demonstrate the novel application and techniques for the use of MRgLITT in the management of PVNH epilepsy. Comprehensive presurgical evaluation, including intracranial EEG monitoring in two patients revealed the PVNH to be crucially involved in their PRE. We used MRgLITT to maximally ablate the PVNH in both cases. In the first case, seizure medication adjustment coupled with PVNH ablation, and in the second, PVNH ablation in addition to temporal lobectomy rendered the patient seizure free. A transient visual deficit occurred following ablation in the second patient. MRgLITT is a promising minimally invasive technique for ablation of epileptogenic PVNH, a disease not generally viewed as surgically treatable epilepsy. We also show here the feasibility of applying this technique through multiple trajectories and to create lesions of complex shapes. The broad applicability and long term efficacy of MRgLITT need to be elaborated further.
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Affiliation(s)
- Yoshua Esquenazi
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Medical School, Houston, TX, USA
| | - Giridhar P Kalamangalam
- Department of Neurology, University of Texas Health Science Center at Houston, Medical School, Houston, TX, USA
| | - Jeremy D Slater
- Department of Neurology, University of Texas Health Science Center at Houston, Medical School, Houston, TX, USA
| | - Robert C Knowlton
- Department of Neurology, University of Texas Health Science Center at Houston, Medical School, Houston, TX, USA
| | - Elliott Friedman
- Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston, Medical School, Houston, TX, USA
| | - Saint-Aaron Morris
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Medical School, Houston, TX, USA
| | | | | | - Nitin Tandon
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Medical School, Houston, TX, USA; Mischer Neuroscience Institute, Memorial Hermann Hospital, Texas Medical Center, USA.
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233
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Gonzalez-Martinez J, Vadera S, Mullin J, Enatsu R, Alexopoulos AV, Patwardhan R, Bingaman W, Najm I. Robot-Assisted Stereotactic Laser Ablation in Medically Intractable Epilepsy: Operative Technique. Oper Neurosurg (Hagerstown) 2014; 10 Suppl 2:167-72; discussion 172-3. [DOI: 10.1227/neu.0000000000000286] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Stereotactic laser ablation offers an advantage over open surgical procedures for treatment of epileptic foci, tumors, and other brain pathology. Robot-assisted stereotactic laser ablation could offer an accurate, efficient, minimally invasive, and safe method for placement of an ablation catheter into the target.
OBJECTIVE:
To determine the feasibility of placement of a stereotactic laser ablation catheter into a brain lesion with the use of robotic assistance, via a safe, accurate, efficient, and minimally invasive manner.
METHODS:
A laser ablation catheter (Visualase, Inc) was placed by using robotic guidance (ROSA, Medtech Surgical, Inc) under general anesthesia into a localized epileptogenic periventricular heterotopic lesion in a 19-year-old woman with 10-year refractory focal seizure history. The laser applicator (1.65 mm diameter) position was confirmed by using magnetic resonance imaging (MRI). Ablation using the Visualase system was performed under multiplanar imaging with real-time thermal imaging and treatment estimates in each plane. A postablation MRI sequence (T1 postgadolinium contrast injection) was used to immediately confirm the ablation.
RESULTS:
MRI showed accurate skin entry point and trajectory, with the applicator advanced to the lesion's distal boundary. Ablation was accomplished in less than 3 minutes of heating. The overall procedure, from time of skin incision to end of last ablation, was approximately 90 minutes. After confirmation of proper lesioning by using a T1 contrast-enhanced MRI, the applicator was removed, and the incision was closed using a single stitch. No hemorrhage or other untoward complication was visualized. The patient awoke without any complication, was observed overnight after admitting to a regular floor bed, and was discharged to home the following day.
CONCLUSION:
This technique, using a combination of Visualase laser ablation, ROSA robot, and intraoperative MRI, facilitated a safe, efficacious, efficient, and minimally invasive approach that could be used for placement of 1 or multiple electrodes in the future.
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Affiliation(s)
| | - Sumeet Vadera
- Epilepsy Center, Neuroscience Institute Cleveland Clinic, Cleveland, Ohio
| | - Jeffrey Mullin
- Epilepsy Center, Neuroscience Institute Cleveland Clinic, Cleveland, Ohio
| | - Rei Enatsu
- Epilepsy Center, Neuroscience Institute Cleveland Clinic, Cleveland, Ohio
| | | | - Ravish Patwardhan
- Epilepsy Center, Neuroscience Institute Cleveland Clinic, Cleveland, Ohio
| | - William Bingaman
- Epilepsy Center, Neuroscience Institute Cleveland Clinic, Cleveland, Ohio
| | - Imad Najm
- Epilepsy Center, Neuroscience Institute Cleveland Clinic, Cleveland, Ohio
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234
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Choi H, Tovar-Spinoza Z. MRI-guided laser interstitial thermal therapy of intracranial tumors and epilepsy: State-of-the-art review and a case study from pediatrics. ACTA ACUST UNITED AC 2014. [DOI: 10.1515/plm-2014-0002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractMRI-guided laser interstitial thermal therapy (MRgLITT) is gaining momentum in neurosurgery and has been described to treat brain metastases, primary tumors and radiation-induced necrosis with an excellent safety profile. LITT has been also used as a minimally invasive alternative to surgical treatment of refractory epilepsy for ablating single epileptogenic foci, such as tumors, hypothalamic hamartomas, cortical dysplasia and mesial temporal sclerosis. Novelty initial experience with multi-foci epileptogenic zones and tuberosclerosis patients is also reported. As new applications for this technology are developing and variations on its use are discussed, we present a review of the current uses and results of the LITT application on brain lesions.
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235
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McClain CD, Landrigan-Ossar M. Challenges in pediatric neuroanesthesia: awake craniotomy, intraoperative magnetic resonance imaging, and interventional neuroradiology. Anesthesiol Clin 2013; 32:83-100. [PMID: 24491651 DOI: 10.1016/j.anclin.2013.10.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article gives a review of 3 challenges in caring for children undergoing neurosurgical and neurointerventional procedures. Anesthesiologists may have experience with certain aspects of these situations but may not have extensive experience with each clinical setting. This review addresses issues with awake craniotomy, intraoperative magnetic resonance imaging, and neurointerventional procedures in children with neurologic disease. Familiarization with these complex clinical scenarios and their unique considerations allows the anesthesiologist to deliver optimal care and helps facilitate the best possible outcome for these patients.
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Affiliation(s)
- Craig D McClain
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Bader 3, Boston, MA 02115, USA.
| | - Mary Landrigan-Ossar
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Bader 3, Boston, MA 02115, USA
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236
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Comber DB, Barth EJ, Webster RJ. Design and Control of an Magnetic Resonance Compatible Precision Pneumatic Active Cannula Robot. J Med Device 2013. [DOI: 10.1115/1.4024832] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The versatile uses and excellent soft tissue distinction afforded by magnetic resonance imaging (MRI) has led to the development of many MR-compatible devices for MRI-guided interventions. This paper presents a fully pneumatic MR-compatible robotic platform designed for neurosurgical interventions. Actuated by nonmagnetic pneumatic piston-cylinders, the robotic platform manipulates a five degree-of-freedom active cannula designed for deep brain interventions. Long lines of tubing connect the cylinders to remotely located pressure sensors and valves, and MRI-compatible optical sensors mounted on the robot provide the robot joint positions. A robust, nonlinear, model-based controller precisely translates and rotates the robot joints, with mean steady-state errors of 0.032 mm and 0.447 deg, respectively. MRI-compatibility testing in a 3-Tesla closed-bore scanner has shown that the robot has no impact on the signal-to-noise ratio, and that geometric distortion remains within recommended calibration limits for the scanner. These results demonstrate that pneumatic actuation is a promising solution for neurosurgical interventions that either require or can benefit from submillimeter precision. Additionally, this paper provides a detailed solution to the control problems imposed by severe nonlinearities in the pneumatic system, which has not previously been discussed in the context of MR-compatible devices.
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Affiliation(s)
| | | | - Robert J. Webster
- Assistant Professor Mem. ASME e-mail: Department of Mechanical Engineering, Vanderbilt University, Nashville, TN 37235
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237
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Tovar-Spinoza Z, Carter D, Ferrone D, Eksioglu Y, Huckins S. The use of MRI-guided laser-induced thermal ablation for epilepsy. Childs Nerv Syst 2013; 29:2089-94. [PMID: 23732793 DOI: 10.1007/s00381-013-2169-6] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 05/16/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Epilepsy surgery is constantly researching for new options for patients with refractory epilepsy. MRI-guided laser-induced thermal ablation for epilepsy is an exciting new minimally invasive technology with an emerging use for lesionectomy of a variety of epileptogenic focuses (hypothalamic hamartomas, cortical dysplasias, cortical malformations, tubers) or as a disconnection tool allowing a new option of treatment without the hassles of an open surgery. METHODS MRI-guided laser interstitial thermal therapy (MRgLITT) is a procedure for destroying tissue-using heat. To deliver this energy in a minimally invasive fashion, a small diameter fiber optic applicator is inserted into the lesion through a keyhole stereotactic procedure. The thermal energy induces damage to intracellular DNA and DNA-binding structures, ultimately leading to cell death. The ablation procedure is supervised by real-time MRI thermal mapping and confirmed by immediate post-ablation T1 or FLAIR MRI images. RESULTS The present report includes an overview of the development and practice of an MR-guided laser ablation therapy known as MRI-guided laser interstitial thermal therapy (MRgLITT). The role of modern image-guided trajectory planning in MRgLITT will also be discussed, with particular emphasis on the treatment of refractory epilepsy using this novel, minimally invasive technique. CONCLUSION MRI-guided laser-induced thermal ablation for epilepsy is an exciting new minimally invasive technology that finds potential new applications every day in the neurosurgical field. It certainly brings a new perspective on the way we practice epilepsy surgery even though long-term results should be properly collected and analyzed.
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Affiliation(s)
- Zulma Tovar-Spinoza
- Department of Neurosurgery, SUNY Upstate Medical University, 604 Jacobsen Hall, 750 E Adams St, Syracuse, NY, 13210, USA,
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238
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Fridley J, Reddy G, Curry D, Agadi S. Surgical treatment of pediatric epileptic encephalopathies. EPILEPSY RESEARCH AND TREATMENT 2013; 2013:720841. [PMID: 24288601 PMCID: PMC3833057 DOI: 10.1155/2013/720841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 08/31/2013] [Accepted: 09/04/2013] [Indexed: 11/17/2022]
Abstract
Pediatric epileptiform encephalopathies are a group of neurologically devastating disorders related to uncontrolled ictal and interictal epileptic activity, with a poor prognosis. Despite the number of pharmacological options for treatment of epilepsy, many of these patients are drug resistant. For these patients with uncontrolled epilepsy, motor and/or neuropsychological deterioration is common. To prevent these secondary consequences, surgery is often considered as either a curative or a palliative option. Magnetic resonance imaging to look for epileptic lesions that may be surgically treated is an essential part of the workup for these patients. Many surgical procedures for the treatment of epileptiform encephalopathies have been reported in the literature. In this paper the evidence for these procedures for the treatment of pediatric epileptiform encephalopathies is reviewed.
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Affiliation(s)
- J. Fridley
- Department of Neurosurgery, Baylor College of Medicine, 1709 Dryden, Houston, TX 77030, USA
| | - G. Reddy
- Department of Neurosurgery, Baylor College of Medicine, 1709 Dryden, Houston, TX 77030, USA
| | - D. Curry
- Department of Neurosurgery, Baylor College of Medicine, 1709 Dryden, Houston, TX 77030, USA
- Department of Surgery, Section of Pediatric Neurosurgery, Texas Children's Hospital, CCC Suite 1230, 6621 Fannin Street, Houston, TX 77030, USA
| | - S. Agadi
- Department of Neurology, Baylor College of Medicine, 6501 Fannin Street, NB302, Houston, TX 77030, USA
- Department of Pediatrics, Section of Neurology and Developmental Neuroscience, One Baylor Plaza, Houston, TX 77030, USA
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239
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Yeniaras E, Fuentes DT, Fahrenholtz SJ, Weinberg JS, Maier F, Hazle JD, Stafford RJ. Design and initial evaluation of a treatment planning software system for MRI-guided laser ablation in the brain. Int J Comput Assist Radiol Surg 2013; 9:659-67. [PMID: 24091853 DOI: 10.1007/s11548-013-0948-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 09/14/2013] [Indexed: 11/28/2022]
Abstract
PURPOSE An open-source software system for planning magnetic resonance (MR)-guided laser-induced thermal therapy (MRgLITT) in brain is presented. The system was designed to provide a streamlined and operator-friendly graphical user interface (GUI) for simulating and visualizing potential outcomes of various treatment scenarios to aid in decisions on treatment approach or feasibility. METHODS A portable software module was developed on the 3D Slicer platform, an open-source medical imaging and visualization framework. The module introduces an interactive GUI for investigating different laser positions and power settings as well as the influence of patient-specific tissue properties for quickly creating and evaluating custom treatment options. It also provides a common treatment planning interface for use by both open-source and commercial finite element solvers. In this study, an open-source finite element solver for Pennes' bioheat equation is interfaced to the module to provide rapid 3D estimates of the steady-state temperature distribution and potential tissue damage in the presence of patient-specific tissue boundary conditions identified on segmented MR images. RESULTS The total time to initialize and simulate an MRgLITT procedure using the GUI was [Formula: see text]5 min. Each independent simulation took [Formula: see text]30 s, including the time to visualize the results fused with the planning MRI. For demonstration purposes, a simulated steady-state isotherm contour [Formula: see text] was correlated with MR temperature imaging (N = 5). The mean Hausdorff distance between simulated and actual contours was 2.0 mm [Formula: see text], whereas the mean Dice similarity coefficient was 0.93 [Formula: see text]. CONCLUSIONS We have designed, implemented, and conducted initial feasibility evaluations of a software tool for intuitive and rapid planning of MRgLITT in brain. The retrospective in vivo dataset presented herein illustrates the feasibility and potential of incorporating fast, image-based bioheat predictions into an interactive virtual planning environment for such procedures.
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Affiliation(s)
- E Yeniaras
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77054, USA,
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240
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Abstract
Surgical treatment for epilepsy has made tremendous strides in the past few decades as a result of advances in neurodiagnostics-particularly structural and functional neuroimaging-and improved surgical techniques. This has not only resulted in better outcomes with respect to epileptic seizures and quality of life, and reduced surgical morbidity and mortality, but it has also increased the population of patients now considered as surgical candidates, particularly in the pediatric age range, and enhanced cost-effectiveness sufficient to make surgical treatment available to countries with limited resources. Yet surgical treatment for epilepsy remains arguably the most underutilized of all accepted medical interventions. In the United States, less than 1% of patients with pharmacoresistant epilepsy are referred to epilepsy centers. Although the number of epilepsy surgery centers has increased appreciably over the past two decades, the number of therapeutic surgical procedures performed for epilepsy has not increased at all. For patients who are referred, the average delay from onset of epilepsy to surgery is more than 20 years-too late for many to avoid a lifetime of disability or premature death. Not only has there been no consistent message to convince neurologists and primary care physicians to refer patients for surgery, but the increase in epilepsy surgery centers in the United States has appeared to result in a divergence of approaches to surgical treatment. Efforts are still needed to further improve the safety and efficacy of surgical treatment, including the identification of biomarkers that can reliably determine the extent of the epileptogenic region; however, the greatest benefits would derive from increasing access for potential surgical candidates to epilepsy surgery facilities. Information is needed to determine why appropriate surgical referrals are not being made. Consensus conferences are necessary to resolve controversies that still exist regarding presurgical evaluation and surgical approaches. Standards should be established for certifying epilepsy centers as recommended by the Institute of Medicine's report on epilepsy. Finally, the epilepsy community should not be promoting epilepsy surgery per se but instead emphasize that epilepsy centers do more than epilepsy surgery, promoting the message: All patients with disabling pharmacoresistant seizures deserve evaluation by specialists at epilepsy centers who can provide a variety of advanced diagnostic and therapeutic services.
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Affiliation(s)
- J Engel
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA
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241
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Esquenazi Y, Sandberg DI, Rekate HL. Successful treatment of hyperphagia by resection of a hypothalamic hamartoma. J Neurosurg Pediatr 2013; 11:630-4. [PMID: 23570442 DOI: 10.3171/2013.2.peds12552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Hypothalamic hamartomas (HHs) are benign lesions that are often associated with central precocious puberty and may present with gelastic seizures. Treatment modalities for HH include medical therapy with long-term gonadotropin-releasing hormone analogs or resection. The authors report the case of a 7-year-old girl who was diagnosed with an HH due to precocious puberty and was treated medically with a gonadotropin-releasing hormone analog for 3 years. Despite normalization of her plasma levels of luteinizing hormone, follicle-stimulating hormone, and estradiol and arrest of her precocious puberty, the patient developed progressive weight gain associated with extreme hyperphagia and morbid obesity by the age of 10 years. Her compulsive eating patterns were refractory to counseling and other interventions attempted by her parents and physicians. After resection of the HH, her hyperphagia resolved and her weight stabilized. To the authors' knowledge, this is the first report describing resection of an HH for the purpose of treating hyperphagia and obesity.
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Affiliation(s)
- Yoshua Esquenazi
- Departments of Neurosurgery and Pediatric Surgery, The University of Texas Health Science Center at Houston Medical School, Children's Memorial Hermann Hospital, and Mischer Neuroscience Institute, Houston, Texas, USA
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242
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Vale FL, Reintjes S, Garcia HG. Complications after mesial temporal lobe surgery via inferiortemporal gyrus approach. Neurosurg Focus 2013; 34:E2. [DOI: 10.3171/2013.3.focus1354] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The purpose of this study was to identify the complications associated with the inferior temporal gyrus approach to anterior mesial temporal lobe resection for temporal lobe epilepsy.
Methods
This retrospective study examined complications experienced by 483 patients during the 3 months after surgery. All surgeries were performed during 1998–2012 by the senior author (F.L.V.).
Results
A total of 13 complications (2.7%) were reported. Complications were 8 delayed subdural hematomas (1.6%), 2 superficial wound infections (0.4%), 1 delayed intracranial hemorrhage (0.2%), 1 small lacunar stroke (0.2%), and 1 transient frontalis nerve palsy (0.2%). Three patients with subdural hematoma (0.6%) required readmission and surgical intervention. One patient (0.2%) with delayed intracranial hemorrhage required readmission to the neuroscience intensive care unit for observation. No deaths or severe neurological impairments were reported. Among the 8 patients with subdural hematoma, 7 were older than 40 years (87.5%); however, this finding was not statistically significant (p = 0.198).
Conclusions
The inferior temporal gyrus approach to mesial temporal lobe resection is a safe and effective method for treating temporal lobe epilepsy. Morbidity and mortality rates associated with this procedure are lower than those associated with other neurosurgical procedures. The finding that surgical complications seem to be more common among older patients emphasizes the need for early surgical referral of patients with medically refractory epilepsy.
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Affiliation(s)
- Fernando L. Vale
- 1Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida; and
| | - Stephen Reintjes
- 1Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida; and
| | - Hermes G. Garcia
- 2Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
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243
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Fahrenholtz SJ, Stafford RJ, Maier F, Hazle JD, Fuentes D. Generalised polynomial chaos-based uncertainty quantification for planning MRgLITT procedures. Int J Hyperthermia 2013; 29:324-35. [PMID: 23692295 DOI: 10.3109/02656736.2013.798036] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE A generalised polynomial chaos (gPC) method is used to incorporate constitutive parameter uncertainties within the Pennes representation of bioheat transfer phenomena. The stochastic temperature predictions of the mathematical model are critically evaluated against MR thermometry data for planning MR-guided laser-induced thermal therapies (MRgLITT). METHODS The Pennes bioheat transfer model coupled with a diffusion theory approximation of laser tissue interaction was implemented as the underlying deterministic kernel. A probabilistic sensitivity study was used to identify parameters that provide the most variance in temperature output. Confidence intervals of the temperature predictions are compared to MR temperature imaging (MRTI) obtained during phantom and in vivo canine (n = 4) MRgLITT experiments. The gPC predictions were quantitatively compared to MRTI data using probabilistic linear and temporal profiles as well as 2-D 60 °C isotherms. RESULTS Optical parameters provided the highest variance in the model output (peak standard deviation: anisotropy 3.51 °C, absorption 2.94 °C, scattering 1.84 °C, conductivity 1.43 °C, and perfusion 0.94 °C). Further, within the statistical sense considered, a non-linear model of the temperature and damage-dependent perfusion, absorption, and scattering is captured within the confidence intervals of the linear gPC method. Multivariate stochastic model predictions using parameters with the dominant sensitivities show good agreement with experimental MRTI data. CONCLUSIONS Given parameter uncertainties and mathematical modelling approximations of the Pennes bioheat model, the statistical framework demonstrates conservative estimates of the therapeutic heating and has potential for use as a computational prediction tool for thermal therapy planning.
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Affiliation(s)
- Samuel J Fahrenholtz
- Department of Imaging Physics, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77054, USA
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