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Mercer JP, Sobel RS, Wessell JE, Vandergrift WA, Edwards JC, Campbell ZM. Accounting for repeat intervention costs in the economic comparison of laser interstitial thermal therapy and anterior temporal lobectomy for treatment of refractory temporal lobe epilepsy. Epilepsy Behav 2024; 156:109810. [PMID: 38704985 DOI: 10.1016/j.yebeh.2024.109810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVE Laser interstitial thermal therapy (LITT) is an alternative to anterior temporal lobectomy (ATL) for the treatment of temporal lobe epilepsy that has been found by some to have a lower procedure cost but is generally regarded as less effective and sometimes results in a subsequent procedure. The goal of this study is to incorporate subsequent procedures into the cost and outcome comparison between ATL and LITT. METHODS This single-center, retrospective cohort study includes 85 patients undergoing ATL or LITT for temporal lobe epilepsy during the period September 2015 to December 2022. Of the 40 patients undergoing LITT, 35 % (N = 14) underwent a subsequent ATL. An economic cost model is derived, and difference in means tests are used to compare the costs, outcomes, and other hospitalization measures. RESULTS Our model predicts that whenever the percentage of LITT patients undergoing subsequent ATL (35% in our sample) exceeds the percentage by which the LITT procedure alone is less costly than ATL (7.2% using total patient charges), LITT will have higher average patient cost than ATL, and this is indeed the case in our sample. After accounting for subsequent surgeries, the average patient charge in the LITT sample ($103,700) was significantly higher than for the ATL sample ($88,548). A second statistical comparison derived from our model adjusts for the difference in effectiveness by calculating the cost per seizure-free patient outcome, which is $108,226 for ATL, $304,052 for LITT only, and $196,484 for LITT after accounting for the subsequent ATL surgeries. SIGNIFICANCE After accounting for the costs of subsequent procedures, we found in our cohort that LITT is not only less effective but also results in higher average costs per patient than ATL as a first course of treatment. While cost and effectiveness rates will vary across centers, we also provide a model for calculating cost effectiveness based on individual center data.
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Affiliation(s)
- J Preston Mercer
- Department of Neurology, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC 29466, USA.
| | - Russell S Sobel
- Baker School of Business, The Citadel, 171 Moultrie Street, Charleston 29409, SC, USA
| | - Jeffrey E Wessell
- Department of Neurosurgery, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC 29466, USA
| | - William A Vandergrift
- Department of Neurosurgery, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC 29466, USA
| | - Jonathan C Edwards
- Department of Neurology, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC 29466, USA
| | - Zeke M Campbell
- Department of Neurology, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC 29466, USA
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2
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Alomar SA, Moshref RH, Moshref LH, Sabbagh AJ. Outcomes after laser interstitial thermal ablation for temporal lobe epilepsy: a systematic review and meta-analysis. Neurosurg Rev 2023; 46:261. [PMID: 37779130 DOI: 10.1007/s10143-023-02164-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 08/01/2023] [Accepted: 09/23/2023] [Indexed: 10/03/2023]
Abstract
Epilepsy is a common condition that affects approximately 1% of the world's population, with about one-third being refractory epilepsy. Temporal lobe epilepsy is the most common type of drug-resistant epilepsy, and laser interstitial thermal therapy (LITT) is an innovative treatment. In this systematic review and meta-analysis, we aimed to summarize the current evidence on outcomes after LITT, including seizure freedom rate, complication rate, and neurocognitive outcome. PubMed and OVID Medline search engines were systematically searched for all indexed publications in the English language up to July15, 2023. The search was limited to human studies. Proportions and 95% confidence interval (CI) values were calculated for seizure, neurocognitive outcome, and complication rate. A total of 836 patients were included. Overall seizure outcomes, regardless of the pathology, included Engel I outcome in 56% (95% CI, 52.4-59.5%), Engel II outcome in 19.2% (95% CI, 15.4-23.6%), Engel III outcome in 17.3% (95% CI, 13.5-21.8%), and Engel IV outcome in 10.5% (95% CI 6.3-17%) of the patients. The overall decline in verbal and visual memory regardless of laterality was 24.2 (95% CI 8.6-52%) and 25.2% (8.3-55.8%). For naming, the decline was 13.4% (6.6-25.4%). The results of the pooled analysis in comparison with available data in the literature showed that seizure outcomes after LITT were slightly inferior to published data after temporal lobectomy. Data on cognitive outcomes after LITT are scarce and heterogeneous.
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Affiliation(s)
- Soha A Alomar
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine, King Abdulaziz University, 22254, Jeddah, Saudi Arabia.
| | - Rana H Moshref
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine, King Abdulaziz University, 22254, Jeddah, Saudi Arabia
| | - Leena H Moshref
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine, King Abdulaziz University, 22254, Jeddah, Saudi Arabia
| | - Abdulrahman J Sabbagh
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine, King Abdulaziz University, 22254, Jeddah, Saudi Arabia
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3
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Zheng B, Abdulrazeq H, Shao B, Liu DD, Leary O, Lauro PM, Bartolini L, Blum AS, Asaad WF. Seizure and anatomical outcomes of repeat laser amygdalohippocampotomy for temporal lobe epilepsy: A single-institution case series. Epilepsy Behav 2023; 146:109365. [PMID: 37523797 DOI: 10.1016/j.yebeh.2023.109365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/12/2023] [Accepted: 07/20/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVE In patients with treatment-refractory temporal lobe epilepsy (TLE), a single stereotactic laser interstitial thermotherapy (LITT) procedure is sometimes insufficient to ablate epileptogenic tissue, particularly the medial structures often implicated in TLE. In patients with seizure recurrence after initial ablation, the extent to which a second ablation may achieve improved seizure outcomes is uncertain. The objective of this study was to investigate the feasibility and potential efficacy of repeat LITT amygdalohippocampotomy as a worthwhile strategy for intractable temporal lobe epilepsy by quantifying changes to targeted mesial temporal lobe structures and seizure outcomes. METHODS Patients who underwent two LITT procedures for drug-resistant mesial TLE at our institution were included in the study. Lesion volumes for both procedures were calculated by comparing post-ablation intraoperative sequences to preoperative anatomy. Clinical outcomes after the initial procedure and repeat procedure were classified according to Engel scores. RESULTS Five consecutive patients were included in this retrospective case series: 3 with right- and 2 with left-sided TLE. The median interval between LITT procedures was 294 days (range: 227-1918). After the first LITT, 3 patients experienced class III outcomes, 1 experienced a class IV, and 1 experienced a class IB outcome. All patients achieved increased seizure freedom after a second procedure, with class I outcomes (3 IA, 2 IB). CONCLUSIONS Repeat LITT may be sufficient to achieve satisfactory seizure outcomes in some individuals who might otherwise be considered for more aggressive resection or palliative neuromodulation. A larger study to establish the potential value of repeat LITT amygdalohippocampotomy vs. other re-operation strategies for persistent, intractable temporal lobe epilepsy is worth pursuing.
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Affiliation(s)
- Bryan Zheng
- The Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Hael Abdulrazeq
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA.
| | - Belinda Shao
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - David D Liu
- Department of Neurosurgery, Brigham and Womens Hospital, Boston, MA, USA
| | - Owen Leary
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Peter M Lauro
- The Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Neuroscience, Brown University, Providence, RI, USA
| | - Luca Bartolini
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA; Deparment of Neurology, Rhode Island Hospital, Providence, RI, USA; Deparment of Pediatrics, Hasbro Children's Hospital, Providence, RI, USA
| | - Andrew S Blum
- Deparment of Neurology, Rhode Island Hospital, Providence, RI, USA
| | - Wael F Asaad
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA; Department of Neuroscience, Brown University, Providence, RI, USA; The Carney Institute for Brain Science, Brown University, Providence, RI, USA; The Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, RI, USA
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4
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Lamsam L, Brigido MM, Sivaraju A, Hirsch LJ, Spencer DD, Chiang V, Damisah E. Transfrontal Approach to the Amygdala for Ablation With Laser Interstitial Thermal Therapy: An Epilepsy Case Report. Oper Neurosurg (Hagerstown) 2023; 24:e381-e384. [PMID: 36715982 PMCID: PMC10158899 DOI: 10.1227/ons.0000000000000576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 10/06/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Stereotactic laser amygdalohippocampotomy (SLAH) using laser interstitial thermal therapy is a minimally invasive surgery used to treat mesial temporal lobe epilepsy. It uses laser probes inserted through occipital and temporo-occipital trajectories to ablate the hippocampus and amygdala. However, these trajectories are limited in their ability to ablate the superior amygdala and entorhinal cortex (ERC). We present a trajectory through the middle frontal gyrus as an alternative to the temporo-occipital trajectory, which provides more complete ablation of the amygdala and anterior ERC through a single pass. CLINICAL PRESENTATION A 70-year-old woman with seizures characterized by fear were localized to the left superomedial amygdala on intracranial electroencephalography. They developed after resection of a left temporal arteriovenous malformation and were refractory to medication. Her age and prior craniotomy made open resection less desirable. A frontal and occipital SLAH achieved Engel 1a at 1-year follow-up without decline in neuropsychological performance scores. CONCLUSION Typical SLAH uses trajectories that have limited ability to ablate the superior and medial amygdala and ERC in a single passage. A combined approach using an occipital and frontal trajectory allows more complete ablation of the amygdala, hippocampus, and ERC.
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Affiliation(s)
- Layton Lamsam
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Mauricio Mandel Brigido
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Adithya Sivaraju
- Department of Neurology, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Lawrence J. Hirsch
- Department of Neurology, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Dennis D. Spencer
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Veronica Chiang
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Eyiyemisi Damisah
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
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Kim MJ, Hwang B, Mampre D, Negoita S, Tsehay Y, Sair H, Kang JY, Anderson WS. Ablation of apparent diffusion coefficient hyperintensity clusters in mesial temporal lobe epilepsy improves seizure outcomes after laser interstitial thermal therapy. Epilepsia 2023; 64:654-666. [PMID: 36196769 DOI: 10.1111/epi.17432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 10/01/2022] [Accepted: 10/03/2022] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Laser interstitial thermal therapy (LiTT) is a minimally invasive surgical procedure for intractable mesial temporal epilepsy (mTLE). LiTT is safe and effective, but seizure outcomes are highly variable due to patient variability, suboptimal targeting, and incomplete ablation of the epileptogenic zone. Apparent diffusion coefficient (ADC) is a magnetic resonance imaging (MRI) sequence that can identify potential epileptogenic foci in the mesial temporal lobe to improve ablation and seizure outcomes. The objective of this study was to investigate whether ablation of tissue clusters with high ADC values in the mesial temporal structures is associated with seizure outcome in mTLE after LiTT. METHODS Twenty-seven patients with mTLE who underwent LiTT at our institution were analyzed. One-year seizure outcome was categorized as complete seizure freedom (International League Against Epilepsy [ILAE] Class I) and residual seizures (ILAE Class II-VI). Volumes of hippocampus and amygdala were segmented from the preoperative T1 MRI sequence. Spatially distinct hyperintensity clusters were identified in the preoperative ADC map. Proportion of cluster volume and number ablated were associated with seizure outcomes. RESULTS The mean age at surgery was 37.5 years and the mean follow-up duration was 1.9 years. Proportions of hippocampal cluster volume (p = .013) and number (p = .03) ablated were significantly higher in patients with seizure freedom. For amygdala clusters, the proportion of cluster number ablated was significantly associated with seizure outcome (p = .026). In the combined amygdalohippocampal complex, ablation of amygdalohippocampal clusters reliably predicted seizure outcome by their volume ablated (area under the curve [AUC] = 0.7670, p = .02). SIGNIFICANCE Seizure outcome after LiTT in patients with mTLE was associated significantly with the extent of cluster ablation in the amygdalohippocampal complex. The results suggest that preoperative ADC analysis may help identify high-yield pathological tissue clusters that represent epileptogenic foci. ADC-based cluster analysis can potentially assist ablation targeting and improve seizure outcome after LiTT in mTLE.
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Affiliation(s)
- Min Jae Kim
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Brian Hwang
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - David Mampre
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Serban Negoita
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Yohannes Tsehay
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Haris Sair
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Joon Y Kang
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - William S Anderson
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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6
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Yossofzai O, Stone S, Madsen J, Moineddin R, Wang S, Ragheb J, Mohamed I, Bollo R, Clarke D, Perry MS, Weil AG, Raskin J, Pindrik J, Ahmed R, Lam S, Fallah A, Maniquis C, Andrade A, Ibrahim GM, Drake J, Rutka J, Tailor J, Mitsakakis N, Puka K, Widjaja E. Seizure outcome of pediatric magnetic resonance-guided laser interstitial thermal therapy versus open surgery: A matched noninferiority cohort study. Epilepsia 2023; 64:114-126. [PMID: 36318088 DOI: 10.1111/epi.17451] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/27/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Minimally invasive magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) has been proposed as an alternative to open epilepsy surgery, to address concerns regarding the risk of open surgery. Our primary hypothesis was that seizure freedom at 1 year after MRgLITT is noninferior to open surgery in children with drug-resistant epilepsy (DRE). The secondary hypothesis was that MRgLITT has fewer complications and shorter hospitalization than surgery. The primary objective was to compare seizure outcome of MRgLITT to open surgery in children with DRE. The secondary objective was to compare complications and length of hospitalization of the two treatments. METHODS This retrospective multicenter cohort study included children with DRE treated with MRgLITT or open surgery with 1-year follow-up. Exclusion criteria were corpus callosotomy, neurostimulation, multilobar or hemispheric surgery, and lesion with maximal dimension > 60 mm. MRgLITT patients were propensity matched to open surgery patients. The primary outcome was seizure freedom at 1 year posttreatment. The difference in seizure freedom was compared using noninferiority test, with noninferiority margin of -10%. The secondary outcomes were complications and length of hospitalization. RESULTS One hundred eighty-five MRgLITT patients were matched to 185 open surgery patients. Seizure freedom at 1 year follow-up was observed in 89 of 185 (48.1%) MRgLITT and 114 of 185 (61.6%) open surgery patients (difference = -13.5%, one-sided 97.5% confidence interval = -23.8% to ∞, pNoninferiority = .79). The lower confidence interval boundary of -23.8% was below the prespecified noninferiority margin of -10%. Overall complications were lower in MRgLITT compared to open surgery (10.8% vs. 29.2%, respectively, p < .001). Hospitalization was shorter for MRgLITT than open surgery (3.1 ± 2.9 vs. 7.2 ± 6.1 days, p < .001). SIGNIFICANCE Seizure outcome of MRgLITT at 1 year posttreatment was inferior to open surgery. However, MRgLITT has the advantage of better safety profile and shorter hospitalization. The findings will help counsel children and parents on the benefits and risks of MRgLITT and contribute to informed decision-making on treatment options.
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Affiliation(s)
- Omar Yossofzai
- Department of Diagnostic Imaging, Hospital for Sick Children Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Scellig Stone
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Joseph Madsen
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rahim Moineddin
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shelly Wang
- Department of Neurosurgery, Nicklaus Children's Hospital, Miami, Florida, USA
| | - John Ragheb
- Department of Neurosurgery, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Ismail Mohamed
- Division of Pediatric Neurology, University of Alabama, Birmingham, Alabama, USA
| | - Robert Bollo
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Dave Clarke
- Department of Neurology, Dell Medical School, Austin, Texas, USA
| | - M Scott Perry
- Justin Neurosciences Center, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Alexander G Weil
- Department of Neurosurgery, Saint Justine University Hospital Center, Montreal, Quebec, Canada
| | - Jeffrey Raskin
- Department of Neurological Surgery, Indiana University, Indianapolis, Indiana, USA.,Division of Neurosurgery, Lurie Children's Hospital, Chicago, Illinois, USA
| | - Jonathan Pindrik
- Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Raheel Ahmed
- Department of Neurosurgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Sandi Lam
- Division of Neurosurgery, Lurie Children's Hospital, Chicago, Illinois, USA
| | - Aria Fallah
- Department of Neurosurgery, University of California, Los Angeles Mattel Children's Hospital, Los Angeles, California, USA
| | - Cassia Maniquis
- Department of Neurosurgery, University of California, Los Angeles Mattel Children's Hospital, Los Angeles, California, USA
| | - Andrea Andrade
- Department of Paediatrics, Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - George M Ibrahim
- Department of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - James Drake
- Department of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - James Rutka
- Department of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jignesh Tailor
- Department of Neurological Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Nicholas Mitsakakis
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Klajdi Puka
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Elysa Widjaja
- Department of Diagnostic Imaging, Hospital for Sick Children Toronto, Toronto, Ontario, Canada.,Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Miller KJ, Fine AL. Decision-making in stereotactic epilepsy surgery. Epilepsia 2022; 63:2782-2801. [PMID: 35908245 PMCID: PMC9669234 DOI: 10.1111/epi.17381] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 11/27/2022]
Abstract
Surgery can cure or significantly improve both the frequency and the intensity of seizures in patients with medication-refractory epilepsy. The set of diagnostic and therapeutic interventions involved in the path from initial consultation to definitive surgery is complex and includes a multidisciplinary team of neurologists, neurosurgeons, neuroradiologists, and neuropsychologists, supported by a very large epilepsy-dedicated clinical architecture. In recent years, new practices and technologies have emerged that dramatically expand the scope of interventions performed. Stereoelectroencephalography has become widely adopted for seizure localization; stereotactic laser ablation has enabled more focal, less invasive, and less destructive interventions; and new brain stimulation devices have unlocked treatment of eloquent foci and multifocal onset etiologies. This article articulates and illustrates the full framework for how epilepsy patients are considered for surgical intervention, with particular attention given to stereotactic approaches.
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Affiliation(s)
- Kai J. Miller
- Neurosurgery, Mayo Clinic, 200 First St., Rochester, MN, 55902
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Candela-Cantó S, Muchart J, Ramírez-Camacho A, Becerra V, Alamar M, Pascual A, Forero C, Rebollo Polo M, Munuera J, Aparicio J, Rumià J, Hinojosa J. Robot-assisted, real-time, MRI-guided laser interstitial thermal therapy for pediatric patients with hypothalamic hamartoma: surgical technique, pitfalls, and initial results. J Neurosurg Pediatr 2022:1-12. [PMID: 35334464 DOI: 10.3171/2022.2.peds21516] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 02/02/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Real-time, MRI-guided laser interstitial thermal therapy (MRgLITT) has been reported as a safe and effective technique for the treatment of epileptogenic foci in children and adults. After the recent approval of MRgLITT by the European Medicines Agency in April 2018, the authors began to use it for the treatment of hypothalamic hamartomas (HHs) in pediatric patients with the assistance of a robotic arm. In this study, the authors report their initial experience describing the surgical technique, accuracy of the robotic arm, safety, and efficacy. METHODS The laser fiber was placed with the assistance of the stereotactic robotic arm. The accuracy of the robotic arm for this procedure was calculated by comparing the intraoperative MRI to the preoperative plan. Common demographic and seizure characteristics of the patients, laser ablation details, complications, and short-term seizure outcomes were prospectively collected. RESULTS Sixteen procedures (11 first ablations and 5 reablations) were performed in 11 patients between 15 months and 17 years of age (mean age 6.4 years) with drug-resistant epilepsy related to HHs. The mean target point localization error was 1.69 mm. No laser fiber needed to be repositioned. The mean laser power used per procedure was 4.29 W. The trajectory of the laser fiber was accidentally ablated in 2 patients, provoking transient hemiparesis in one of these patients. One patient experienced postoperative somnolence and syndrome of inappropriate antidiuretic hormone secretion, and 2 patients had transient oculomotor (cranial nerve III) palsy. Fifty-four percent of the patients were seizure free after the first ablation (mean follow-up 22 months, range 15-33 months). All 5 patients who experienced an epilepsy relapse underwent a second treatment, and 4 remain seizure free at least 5 months after reablation. CONCLUSIONS In the authors' experience, the robotic arm was sufficiently accurate for laser fiber insertion, even in very young patients. MRgLITT appears to be an effective treatment for selected cases of HH. MRgLITT for HH is a minimally invasive procedure with appealing safety features, as it allows delivery of energy precisely under real-time MRI control. Nonetheless, complications may occur, especially in voluminous HHs. The amount of delivered energy and the catheter cooling system must be closely monitored during the procedure. A larger sample size and longer follow-up duration are needed to judge the efficacy and safety of MRgLITT for HH more rigorously. This initial experience was very promising.
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Affiliation(s)
- Santiago Candela-Cantó
- 1Neurosurgery Department.,4Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Spain
| | - Jordi Muchart
- 2Diagnostic Imaging Department.,4Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Spain
| | - Alia Ramírez-Camacho
- 4Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Spain
| | - Victoria Becerra
- 1Neurosurgery Department.,4Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Spain
| | - Mariana Alamar
- 1Neurosurgery Department.,4Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Spain
| | | | | | - Mónica Rebollo Polo
- 2Diagnostic Imaging Department.,4Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Spain
| | | | - Javier Aparicio
- 4Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Spain
| | - Jordi Rumià
- 1Neurosurgery Department.,4Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Spain
| | - José Hinojosa
- 1Neurosurgery Department.,4Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Spain
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9
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Wu C, Schwalb JM, Rosenow JM, McKhann GM, Neimat JS. The American Society for Stereotactic and Functional Neurosurgery Position Statement on Laser Interstitial Thermal Therapy for the Treatment of Drug-Resistant Epilepsy. Neurosurgery 2022; 90:155-160. [PMID: 34995216 DOI: 10.1227/neu.0000000000001799] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 09/29/2021] [Indexed: 11/19/2022] Open
Abstract
Magnetic resonance image-guided laser interstitial thermal therapy (MRgLITT) is a novel tool in the neurosurgical armamentarium for the management of drug-resistant epilepsy. Given the recent introduction of this technology, the American Society for Stereotactic and Functional Neurosurgery (ASSFN), which acts as the joint section representing the field of stereotactic and functional neurosurgery on behalf of the Congress of Neurological Surgeons and the American Association of Neurological Surgeons, provides here the expert consensus opinion on evidence-based best practices for the use and implementation of this treatment modality. Indications for treatment are outlined, consisting of failure to respond to, or intolerance of, at least 2 appropriately chosen medications at appropriate doses for disabling, localization-related epilepsy in the setting of well-defined epileptogenic foci, or critical pathways of seizure propagation accessible by MRgLITT. Applications of MRgLITT in mesial temporal lobe epilepsy and hypothalamic hamartoma, along with its contraindications in the treatment of epilepsy, are discussed based on current evidence. To put this position statement in perspective, we detail the evidence and authority on which this ASSFN position statement is based.
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Affiliation(s)
- Chengyuan Wu
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jason M Schwalb
- Department of Neurological Surgery, Henry Ford Health System, Detroit, Michigan, USA
| | - Joshua M Rosenow
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Guy M McKhann
- Department of Neurological Surgery, Neurological Institute of New York, Columbia University Medical Center, New York, New York, USA
| | - Joseph S Neimat
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
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10
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Barot N, Batra K, Zhang J, Klem ML, Castellano J, Gonzalez-Martinez J, Bagic A. Surgical outcomes between temporal, extratemporal epilepsies and hypothalamic hamartoma: systematic review and meta-analysis of MRI-guided laser interstitial thermal therapy for drug-resistant epilepsy. J Neurol Neurosurg Psychiatry 2022; 93:133-143. [PMID: 34321344 DOI: 10.1136/jnnp-2021-326185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/20/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Approximately 1/3 of patients with epilepsy have drug-resistant epilepsy (DRE) and require surgical interventions. This meta-analysis aimed to review the effectiveness of MRI-guided laser interstitial thermal therapy (MRgLITT) in DRE. METHODS The Population, Intervention, Comparator and Outcome approach and Preferred Reporting Items for Systematic Reviews and Meta-Analyses were followed. PubMed, MEDLINE and EMBASE databases were systematically searched for English language publications from 2012 to Nov 2020. Data on the prevalence outcome using the Engel Epilepsy Surgery Outcome Scale (Class I-IV), and postoperative complications were analysed with 95% CIs. RESULTS Twenty-eight studies that included a total of 559 patients with DRE were identified. The overall prevalence of Engel class I outcome was 56% (95% CI 0.52% to 0.60%). Hypothalamic hamartomas (HH) patients had the highest seizure freedom rate of 67% (95% CI 0.57% to 0.76%) and outcome was overall comparable between mesial temporal lobe epilepsy (mTLE) (56%, 95% CI 0.50% to 0.61%) and extratemporal epilepsy (50% 95% CI 0.40% to 0.59%). The mTLE cases with mesial temporal sclerosis had better outcome vs non-lesional cases of mTLE. The prevalence of postoperative adverse events was 19% (95% CI 0.14% to 0.25%) and the most common adverse event was visual field deficits. The reoperation rate was 9% (95% CI 0.05% to 0.14%), which included repeat ablation and open resection. CONCLUSION MRgLITT is an effective and safe intervention for DRE with different disease aetiologies. The seizure freedom outcome is overall comparable in between extratemporal and temporal lobe epilepsy; and highest with HH. TRAIL REGISTRATION NUMBER The study protocol was registered with the National Institute for Health Research (CRD42019126365), which serves as a prospective register of systematic reviews. It is an international database of prospectively registered systematic reviews with a focus on health-related outcomes. Details about the protocol can be found at https://wwwcrdyorkacuk/PROSPERO/.
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Affiliation(s)
- Niravkumar Barot
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kavita Batra
- Office of Research, University of Nevada, Las vegas, Nevada, USA
| | - Jerry Zhang
- University of Pittsburgh, Biostatistical Consulting Laboratory, Pittsburgh, Pennsylvania, USA
| | - Mary Lou Klem
- Library System, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James Castellano
- Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Anto Bagic
- Neurology, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
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11
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Marathe K, Alim-Marvasti A, Dahele K, Xiao F, Buck S, O'Keeffe AG, Duncan JS, Vakharia VN. Resective, Ablative and Radiosurgical Interventions for Drug Resistant Mesial Temporal Lobe Epilepsy: A Systematic Review and Meta-Analysis of Outcomes. Front Neurol 2021; 12:777845. [PMID: 34956057 PMCID: PMC8695716 DOI: 10.3389/fneur.2021.777845] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/01/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: One-third of individuals with focal epilepsy do not achieve seizure freedom despite best medical therapy. Mesial temporal lobe epilepsy (MTLE) is the most common form of drug resistant focal epilepsy. Surgery may lead to long-term seizure remission if the epileptogenic zone can be defined and safely removed or disconnected. We compare published outcomes following open surgical techniques, radiosurgery (SRS), laser interstitial thermal therapy (LITT) and radiofrequency ablation (RF-TC). Methods: PRISMA systematic review was performed through structured searches of PubMed, Embase and Cochrane databases. Inclusion criteria encompassed studies of MTLE reporting seizure-free outcomes in ≥10 patients with ≥12 months follow-up. Due to variability in open surgical approaches, only comparative studies were included to minimize the risk of bias. Random effects meta-analysis was performed to calculate effects sizes and a pooled estimate of the probability of seizure freedom per person-year. A mixed effects linear regression model was performed to compare effect sizes between interventions. Results: From 1,801 screened articles, 41 articles were included in the quantitative analysis. Open surgery included anterior temporal lobe resection as well as transcortical and trans-sylvian selective amygdalohippocampectomy. The pooled seizure-free rate per person-year was 0.72 (95% CI 0.66-0.79) with trans-sylvian selective amygdalohippocampectomy, 0.59 (95% CI 0.53-0.65) with LITT, 0.70 (95% CI 0.64-0.77) with anterior temporal lobe resection, 0.60 (95% CI 0.49-0.73) with transcortical selective amygdalohippocampectomy, 0.38 (95% CI 0.14-1.00) with RF-TC and 0.50 (95% CI 0.34-0.73) with SRS. Follow up duration and study sizes were limited with LITT and RF-TC. A mixed-effects linear regression model suggests significant differences between interventions, with LITT, ATLR and SAH demonstrating the largest effects estimates and RF-TC the lowest. Conclusions: Overall, novel "minimally invasive" approaches are still comparatively less efficacious than open surgery. LITT shows promising seizure effectiveness, however follow-up durations are shorter for minimally invasive approaches so the durability of the outcomes cannot yet be assessed. Secondary outcome measures such as Neurological complications, neuropsychological outcome and interventional morbidity are poorly reported but are important considerations when deciding on first-line treatments.
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Affiliation(s)
- Kajol Marathe
- Department of Clinical and Experimental Epilepsy, University College London, London, United Kingdom
| | - Ali Alim-Marvasti
- Department of Clinical and Experimental Epilepsy, University College London, London, United Kingdom.,National Hospital for Neurology and Neurosurgery, London, United Kingdom.,Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Karan Dahele
- Department of Clinical and Experimental Epilepsy, University College London, London, United Kingdom
| | - Fenglai Xiao
- Department of Clinical and Experimental Epilepsy, University College London, London, United Kingdom
| | - Sarah Buck
- Department of Clinical and Experimental Epilepsy, University College London, London, United Kingdom
| | - Aidan G O'Keeffe
- Department of Statistical Science, University College London, London, United Kingdom
| | - John S Duncan
- Department of Clinical and Experimental Epilepsy, University College London, London, United Kingdom.,National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Vejay N Vakharia
- Department of Clinical and Experimental Epilepsy, University College London, London, United Kingdom.,National Hospital for Neurology and Neurosurgery, London, United Kingdom
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12
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Hines K, Stefanelli A, Haddad T, Matias CM, Sharan A, Wu C. Costs Associated with Laser Interstitial Thermal Therapy Are Lower Than Anterior Temporal Lobectomy for Treatment of Temporal Lobe Epilepsy. World Neurosurg 2021; 157:e215-e222. [PMID: 34653705 DOI: 10.1016/j.wneu.2021.09.144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Laser interstitial thermal therapy (LITT) is a minimally invasive alternative to anterior temporal lobectomy (ATL) for treatment of temporal lobe epilepsy. It has gained popularity as familiarity with technique increases and outcomes are better characterized. There has been no direct cost comparison between the 2 techniques in literature to date. The current study directly compares hospital costs associated with LITT with those of ATL patients and analyzes the factors potentially responsible for those costs. METHODS Patients who underwent ATL (27) and LITT (15) were retrospectively reviewed for total hospital costs along with demographic, surgical, and postoperative factors potentially affecting cost. T-tests were used to compare costs and independent linear regressions, and hierarchical regressions were used to examine predictors of cost for each procedure. RESULTS Mean hospital costs of admission for single-trajectory LITT ($104,929.88) were significantly less than for ATL ($134,980.04) (P = 0.001). In addition, length of stay, anesthesia costs, operative room costs, and postoperative hospitalization costs were all significantly lower in LITT. CONCLUSIONS Given the minimally invasive nature of LITT, it is associated with shorter length of stay and lower hospital costs than ATL in the first head-to-head comparison of procedural costs in literature to date. Long-term efficacy as it relates to these costs associated with LITT and ATL should be further investigated to better characterize the utility of LITT in temporal lobe epilepsy patients.
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Affiliation(s)
- Kevin Hines
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA.
| | - Anthony Stefanelli
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Taylor Haddad
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Caio M Matias
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Ashwini Sharan
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Chengyuan Wu
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
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13
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Larson PS. Improved Delivery Methods for Gene Therapy and Cell Transplantation in Parkinson's Disease. JOURNAL OF PARKINSONS DISEASE 2021; 11:S199-S206. [PMID: 34366372 PMCID: PMC8543258 DOI: 10.3233/jpd-212710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A number of cell transplantation and gene therapy trials have been performed over the last three decades in an effort to restore function in Parkinson’s disease. Much has been learned about optimizing delivery methods for these therapeutics. This is particularly true in gene therapy, which has predominated the clinical trial landscape in recent years; however, cell transplantation for Parkinson’s disease is currently undergoing a renaissance. Innovations such as cannula design, iMRI-guided surgery and an evolution in delivery strategy has radically changed the way investigators approach clinical trial design. Future therapeutic strategies may employ newer delivery methods such as chronically implanted infusion devices and focal opening of the blood brain barrier with focused ultrasound.
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Affiliation(s)
- Paul S Larson
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
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14
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Kim MJ, Hwang B, Mampre D, Negoita S, Tsehay Y, Sair H, Kang JY, Anderson W. Apparent diffusion coefficient is associated with seizure outcome after magnetic resonance-guided laser interstitial thermal therapy for mesial temporal lobe epilepsy. Epilepsy Res 2021; 176:106726. [PMID: 34298428 DOI: 10.1016/j.eplepsyres.2021.106726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/08/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Magnetic resonance-guided laser interstitial thermal therapy (MRgLiTT) is becoming a first-line surgical therapy for mesial temporal lobe epilepsy (mTLE) due to good seizure control and low complication risk. However, seizure outcomes after MRgLiTT remain highly variable and there is a need to improve patient selection and post-operative prognostication. In this retrospective study, we investigated whether the pre-operative MRI-derived apparent diffusion coefficient (ADC), used as a marker of tissue pathology in the mesial temporal structures could help predict seizure outcome. METHODS Thirty-five patients who underwent MRgLiTT at our institution between 2014 and 2019 were included in the study. Demographic and clinical data were retrospectively collected. Seizure outcome was defined as good (ILAE Class I-II) and poor (ILAE Class III-VI). Volumetrics were performed on pre-ablation hippocampus and amygdala. Ablation volumes, and the proportion of ablated hippocampus and amygdala calculated via their respective mean voxel-wise ADC intensities were quantified from pre-operative and intra-operative post-ablation MRIs and statistically compared between the two outcome cohorts. Univarate and multivariate regression analysis was performed to identify demographic, clinical, and radiographic predictors of seizure outcome. RESULTS Mean age at LiTT was 36 years and 14 (40 %) were female. Mean follow-up duration was 1.90 ± 0.17 years. Twenty-seven (77 %) patients had mesial temporal sclerosis. There was no significant difference in the ablation volumes and proportion of ablated volume of hippocampus and amygdala between the two outcome groups. Patients with good seizure outcome had significantly higher normalized ADC intensities in the ablated mesial temporal structures compared to those with poor outcome (0.01 ± 0.08 vs.-0.29 ± 0.06; p = 0.015). CONCLUSIONS mTLE patients with higher ADC intensities in the ablated regions of the hippocampus and the amygdala are more likely to have good seizure outcome following MRgLiTT. Our results suggest that pre-operative ADC analysis may improve both patient selection and epileptogenic zone targeting during MRgLiTT. Further investigation with large, prospective cohorts is needed to validate the clinical utility of ADC in improving seizure outcome following MRgLiTT.
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Affiliation(s)
- Min Jae Kim
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, 21205, United States; Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, 21205, United States; Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, MD, 21205, United States.
| | - Brian Hwang
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, 21205, United States.
| | - David Mampre
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, 21205, United States.
| | - Serban Negoita
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, 21205, United States.
| | - Yohannes Tsehay
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, 21205, United States.
| | - Haris Sair
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD, 21205, United States.
| | - Joon Y Kang
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, 21205, United States.
| | - William Anderson
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, 21205, United States; Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, MD, 21205, United States.
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15
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Ali R, Englot DJ, Yu H, Naftel R, Haas KF, Konrad PE. Experience From 211 Transcortical Selective Amygdalohippocampectomy Procedures: Relevant Surgical Anatomy and Review of the Literature. Oper Neurosurg (Hagerstown) 2021; 21:181-188. [PMID: 34228100 DOI: 10.1093/ons/opab206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 04/27/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Selective amygdalohippocampectomy (SelAH) is designed to treat medically refractory mesial temporal lobe epilepsy with reduced morbidity compared to standard anterior temporal lobectomy. At our institution, we perform SelAH via a transcortical approach via small corticectomy in the middle temporal gyrus. OBJECTIVE To discuss the surgical anatomy and nuances of SelAH, share our institutional experience, and perform a review of literature. METHODS Institutional experience was recorded by collecting demographic and outcome data from 1999 to 2017 under an Institutional Review Board protocol in a prospective manner using a REDCap database. RESULTS A total of 211 SelAH procedures were performed at our institution between 1999 and 2017. Of these patients, 54% (113/211) were females. The average age at surgery was 39.4 yr. Two-year Engel outcome data were available for 168 patients, of which 73% (123/168) had Engel I outcomes. Engel II outcomes were reported in 16.6% (28/168), III in 4.7% (8/168), and IV in 5.3% (9/168). Our review of literature showed that this is comparable to the seizure freedom rates reported by other groups. We then reviewed our surgical methodology based on operative reports and created illustrations of the surgical anatomy of temporal lobe approach. These illustrations were compared with postoperative magnetic resonance imaging to provide a better 3D understanding of the complex architecture of mesial temporal structures. CONCLUSION SelAH is a minimally invasive, safe, and effective approach for the treatment of medically refractory epilepsy with good surgical outcomes and low morbidity. We feel that mastering the complex anatomy of this approach helps achieve successful outcomes.
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Affiliation(s)
- Rushna Ali
- Department of Neurosciences, Spectrum Health Medical Group, Grand Rapids, Michigan, USA
| | - Dario J Englot
- Department of Neurosurgery, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Hong Yu
- Department of Neurosurgery, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Robert Naftel
- Department of Neurosurgery, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Kevin F Haas
- Department of Neurology, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Peter E Konrad
- Department of Neurosurgery, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
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16
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Remick M, McDowell MM, Gupta K, Felker J, Abel TJ. Emerging indications for stereotactic laser interstitial thermal therapy in pediatric neurosurgery. Int J Hyperthermia 2021; 37:84-93. [PMID: 32672117 DOI: 10.1080/02656736.2020.1769868] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Surgical treatment of deep or difficult to access lesions represents a unique and significant challenge for pediatric neurosurgeons. The introduction of stereotactic magnetic resonance-guided laser interstitial thermal therapy (LITT) over the last decade has had a dramatic impact on the landscape of pediatric neurosurgery. LITT provides a safe and effective option for children with epilepsy from hypothalamic hamartoma that represents a ground-breaking new therapy for a condition which was historically very difficult to treat with previous neurosurgical techniques. LITT has also been used as an alternative surgical technique for mesial temporal sclerosis, focal cortical dysplasia, MR-negative epilepsy, cavernoma-related epilepsy, insular epilepsy, and corpus callosotomy among other epilepsy etiologies. In some cases, LITT has been associated with improved cognitive outcomes compared to standard techniques, as in mesial temporal lobe epilepsy. Initial experiences with LITT for neuro-oncologic processes are also promising. LITT is often attractive to patients and providers as a minimally invasive approach, but the differences in safety and clinical outcome between LITT and traditional approaches are still being studied. In this review, we examine the emerging indications and clinical evidence for LITT in pediatric neurosurgery.
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Affiliation(s)
- Madison Remick
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael M McDowell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kanupriya Gupta
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - James Felker
- Department of Pediatric Neuro-Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
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17
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Kohlhase K, Zöllner JP, Tandon N, Strzelczyk A, Rosenow F. Comparison of minimally invasive and traditional surgical approaches for refractory mesial temporal lobe epilepsy: A systematic review and meta-analysis of outcomes. Epilepsia 2021; 62:831-845. [PMID: 33656182 DOI: 10.1111/epi.16846] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 01/29/2021] [Accepted: 01/29/2021] [Indexed: 01/10/2023]
Abstract
Magnetic resonance-guided laser interstitial laser therapy (MRgLITT) and radiofrequency ablation (RFA) represent two minimally invasive methods for the treatment of drug-refractory mesial temporal lobe epilepsy (mTLE). We performed a systematic review and a meta-analysis to compare outcomes and complications between MRgLITT, RFA, and conventional surgical approaches to the temporal lobe (i.e., anterior temporal lobe resection [ATL] or selective amygdalohippocampectomy [sAHE]). Forty-three studies (13 MRgLITT, 6 RFA, and 24 surgery studies) involved 554, 123, 1504, and 1326 patients treated by MRgLITT, RFA, ATL, or sAHE, respectively. Engel Class I (Engel-I) outcomes were achieved after MRgLITT in 57% (315/554, range = 33.3%-67.4%), RFA in 44% (54/123, range = 0%-67.2%), ATL in 69% (1032/1504, range = 40%-92.9%), and sAHE in 66% (887/1326, range = 21.4%-93.3%). Meta-analysis revealed no significant difference in seizure outcome between MRgLITT and RFA (Q = 2.74, p = .098), whereas ATL and sAHE were both superior to MRgLITT (ATL: Q = 8.92, p = .002; sAHE: Q = 4.33, p = .037) and RFA (ATL: Q = 6.42, p = .0113; sAHE: Q = 5.04, p = .0247), with better outcome in patients at follow-up of 60 months or more. Mesial hippocampal sclerosis (mTLE + hippocampal sclerosis) was associated with significantly better outcome after MRgLITT (Engel-I outcome in 64%; Q = 8.55, p = .0035). The rate of major complications was 3.8% for MRgLITT, 3.7% for RFA, 10.9% for ATL, and 7.4% for sAHE; the differences did not show statistical significance. Neuropsychological deficits occurred after all procedures, with left-sided surgeries having a higher rate of verbal memory impairment. Lateral functions such as naming or object recognition may be more preserved in MRgLITT. Thermal therapies are effective techniques but show a significantly lower rate of Engel-I outcome in comparison to ATL and sAHE. Between MRgLITT and RFA there were no significant differences in Engel-I outcome, whereby the success of treatment seems to depend on the approach used (e.g., occipital approach). MRgLITT shows a similar rate of complications compared to RFA, whereas patients undergoing MRgLITT may experience fewer major complications compared to ATL or sAHE and might have a more beneficial neuropsychological outcome.
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Affiliation(s)
- Konstantin Kohlhase
- Department of Neurology, Epilepsy Center Frankfurt Rhine-Main, University Hospital Frankfurt, Frankfurt am Main, Germany.,Landes-Offensive zur Entwicklung wissenschaftlich-ökonomischer Exzellen, Center for Personalized and Translational Epilepsy Research, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Johann Philipp Zöllner
- Department of Neurology, Epilepsy Center Frankfurt Rhine-Main, University Hospital Frankfurt, Frankfurt am Main, Germany.,Landes-Offensive zur Entwicklung wissenschaftlich-ökonomischer Exzellen, Center for Personalized and Translational Epilepsy Research, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Nitin Tandon
- Department of Neurosurgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Adam Strzelczyk
- Department of Neurology, Epilepsy Center Frankfurt Rhine-Main, University Hospital Frankfurt, Frankfurt am Main, Germany.,Landes-Offensive zur Entwicklung wissenschaftlich-ökonomischer Exzellen, Center for Personalized and Translational Epilepsy Research, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Department of Neurology, Epilepsy Center Frankfurt Rhine-Main, University Hospital Frankfurt, Frankfurt am Main, Germany.,Landes-Offensive zur Entwicklung wissenschaftlich-ökonomischer Exzellen, Center for Personalized and Translational Epilepsy Research, Goethe University Frankfurt, Frankfurt am Main, Germany
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18
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Chua MMJ, Bushlin I, Stredny CM, Madsen JR, Patel AA, Stone S. Magnetic resonance imaging-guided laser-induced thermal therapy for functional hemispherotomy in a child with refractory epilepsy and multiple medical comorbidities. J Neurosurg Pediatr 2021; 27:30-35. [PMID: 33096521 DOI: 10.3171/2020.6.peds20455] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/16/2020] [Indexed: 11/06/2022]
Abstract
Magnetic resonance imaging-guided laser-induced thermal therapy (MRgLITT) is a minimally invasive surgical approach increasingly employed for precise targeted ablation of epileptogenic brain foci. Recent reports have described corpus callosotomy using MRgLITT, though its application in more extensive functional disconnections has not been documented. Here, the authors detail its use in achieving a palliative hemispherotomy in a 5-year-old with medically refractory hemiclonic seizures following a hemispheric infarction, highlighting a novel use of this surgical technique. In this particular case, open craniotomy was deemed high risk given the multiple medical comorbidities including congenital cardiac disease and end-stage renal failure. MRgLITT was considered an alternative approach with a lower risk for periprocedural hemodynamic perturbations. The patient tolerated the procedure well, attaining an Engel class IB outcome at 16 months' follow-up. This suggests that MRgLITT may be an alternative approach to an open hemispherectomy, particularly in cases in which multiple comorbidities pose significant risks and preclude an open procedure.
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Affiliation(s)
- Melissa M J Chua
- 1Department of Neurosurgery, Brigham and Women's Hospital/Harvard Medical School, Boston
- 2Department of Neurosurgery, Boston Children's Hospital/Harvard Medical School, Boston; and
| | - Ittai Bushlin
- 3Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Coral M Stredny
- 3Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Joseph R Madsen
- 2Department of Neurosurgery, Boston Children's Hospital/Harvard Medical School, Boston; and
| | - Archana A Patel
- 3Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Scellig Stone
- 2Department of Neurosurgery, Boston Children's Hospital/Harvard Medical School, Boston; and
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19
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Youngerman BE, Save AV, McKhann GM. Magnetic Resonance Imaging-Guided Laser Interstitial Thermal Therapy for Epilepsy: Systematic Review of Technique, Indications, and Outcomes. Neurosurgery 2020; 86:E366-E382. [PMID: 31980831 DOI: 10.1093/neuros/nyz556] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 11/20/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND For patients with focal drug-resistant epilepsy (DRE), surgical resection of the epileptogenic zone (EZ) may offer seizure freedom and benefits for quality of life. Yet, concerns remain regarding invasiveness, morbidity, and neurocognitive side effects. Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) has emerged as a less invasive option for stereotactic ablation rather than resection of the EZ. OBJECTIVE To provide an introduction to MRgLITT for epilepsy, including historical development, surgical technique, and role in therapy. METHODS The development of MRgLITT is briefly recounted. A systematic review identified reported techniques and indication-specific outcomes of MRgLITT for DRE in human studies regardless of sample size or follow-up duration. Potential advantages and disadvantages compared to available alternatives for each indication are assessed in an unstructured review. RESULTS Techniques and outcomes are reported for mesial temporal lobe epilepsy, hypothalamic hamartoma, focal cortical dysplasia, nonlesional epilepsy, tuberous sclerosis, periventricular nodular heterotopia, cerebral cavernous malformations, poststroke epilepsy, temporal encephalocele, and corpus callosotomy. CONCLUSION MRgLITT offers access to foci virtually anywhere in the brain with minimal disruption of the overlying cortex and white matter, promising fewer neurological side effects and less surgical morbidity and pain. Compared to other ablative techniques, MRgLITT offers immediate, discrete lesions with real-time monitoring of temperature beyond the fiber tip for damage estimates and off-target injury prevention. Applications of MRgLITT for epilepsy are growing rapidly and, although more evidence of safety and efficacy is needed, there are potential advantages for some patients.
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Affiliation(s)
- Brett E Youngerman
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Akshay V Save
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Guy M McKhann
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
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20
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Rennert RC, Khan U, Bartek J, Tatter SB, Field M, Toyota B, Fecci PE, Judy K, Mohammadi AM, Landazuri P, Sloan AE, Kim AH, Leuthardt EC, Chen CC. Laser Ablation of Abnormal Neurological Tissue Using Robotic Neuroblate System (LAANTERN): Procedural Safety and Hospitalization. Neurosurgery 2020; 86:538-547. [PMID: 31076762 DOI: 10.1093/neuros/nyz141] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 12/25/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Stereotactic laser ablation (SLA) has demonstrated potential utility for a spectrum of difficult to treat neurosurgical pathologies in multiple small and/or retrospective single-institutional series. Here, we present the safety profile of SLA of intracranial lesions from the Laser Ablation of Abnormal Neurological Tissue using Robotic NeuroBlate System (LAANTERN; Monteris Medical) multi-institutional, international prospective observational registry. OBJECTIVE To determine the procedural safety of SLA for intracranial lesions. METHODS Prospective procedural safety and hospitalization data from the first 100 treated LAANTERN patients was collected and analyzed. RESULTS Mean age and baseline Karnofsky Performance Status (KPS) were 51(± 17) yr and 83(± 15), respectively. In total, 81.2% of patients had undergone prior surgical or radiation treatment. Most patients had a single lesion (79%) ablated through 1 burr hole (1.2 ± 0.7 per patient), immediately following a lesion biopsy. In total, >90% of the lesion was ablated in 72% of treated lesions. Average total procedural time was 188.2 ± 69.6 min, and average blood loss was 17.7 ± 55.6 ccs. The average length of intensive care unit (ICU) and hospital stays before discharge were 38.1 ± 62.7 h and 61.1 ± 87.2 h, respectively. There were 5 adverse events (AEs) attributable to SLA (5/100; 5%). After the procedure, 84.8% of patients were discharged home. There was 1 mortality within 30 d of the procedure (1/100; 1%), which was not attributable to SLA. CONCLUSION SLA is a safe, minimally invasive procedure with favorable postprocedural ICU and hospital utilization profiles.
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Affiliation(s)
- Robert C Rennert
- Department of Neurosurgery, University of California San Diego, San Diego, California
| | - Usman Khan
- Department of Neurosurgery, University of California San Diego, San Diego, California
| | - Jiri Bartek
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Denmark.,Department of Clinical Neuroscience and Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | - Brian Toyota
- Division of Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Kevin Judy
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alireza M Mohammadi
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick Landazuri
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas
| | - Andrew E Sloan
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Albert H Kim
- Department of Neurosurgery, Washington University, St. Louis, Missouri
| | - Eric C Leuthardt
- Department of Neurosurgery, Washington University, St. Louis, Missouri
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota
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21
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Highly realistic simulation for robot-assisted hypothalamic hamartoma real-time MRI-guided laser interstitial thermal therapy (LITT). Childs Nerv Syst 2020; 36:1131-1142. [PMID: 32166344 DOI: 10.1007/s00381-020-04563-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 02/27/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Real-time MRI-guided laser interstitial thermal therapy (LITT) is a challenging procedure due to its technical complexity, as well as the need for efficient multidisciplinary teamwork and transfer of an anesthetized patient between operating room (OR) and magnetic resonance (MR). A highly realistic simulation was developed to design the safest process before being applied to real patients. In this report, authors address the description of the methodology used for this simulation and its purposefulness. METHODS The entire image planning, anesthetic, and surgical process were performed on a modified pediatric simulation mannequin with a brain made of medical grade silicone including a hypothalamic hamartoma. Preoperative CT and MR were acquired. Stereotactic insertion of the optical fiber was assisted by the Neuromate® stereotactic robot. Laser ablation was performed with the Medtronic Visualase® MRI-guided system in a 3T Phillips Ingenia® MR scanner. All the stages of the process, participants, and equipment were the same as planned for a real surgery. RESULTS No critical errors were found in the process design that prevented the procedure from being performed with adequate safety. Specific proposals for team positioning and interaction in patient transfers and in MR room were validated. Some specific elements that could improve safety were identified. CONCLUSION Highly realistic simulation has been an extremely useful tool for safely planning LITT, because professionals were able to take actions in the workflow based not on ideas but on lived experiences. It contributed definitively to build a well-coordinated surgical team that worked safely and more efficiently.
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22
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Abe K, Yamaguchi T, Hori H, Sumi M, Horisawa S, Taira T, Hori T. Magnetic resonance-guided focused ultrasound for mesial temporal lobe epilepsy: a case report. BMC Neurol 2020; 20:160. [PMID: 32349706 PMCID: PMC7189704 DOI: 10.1186/s12883-020-01744-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 04/22/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND We report the first case of transcranial magnetic resonance-guided focused ultrasound (MRgFUS) for mesial temporal lobe epilepsy (MTLE). CASE PRESENTATION The target was located 20 mm lateral from the midline and 15 mm above the skull base (left hippocampus). Despite the application of maximal energy, the ablation temperature did not exceed 50 °C, probably because of the low number of effective transducer elements with incident angles below 25 degrees. The skull density ratio was 0.56. Post-operative magnetic resonance imaging did not reveal any lesion and the patient remained almost seizure-free for up to 12 months. CONCLUSIONS This preliminary case report suggests that MRgFUS may be effective for treating cases of MTLE. Therefore, the safety and feasibility of MRgFUS should be evaluated in future studies with larger numbers of participants and longer follow-up duration.
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Affiliation(s)
- Keiichi Abe
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku-ku, Kawata-cho, 8-1, Tokyo, 162-0054, Japan.
| | - Toshio Yamaguchi
- Department of Radiology, Shinyurigaoka General Hospital, Kawasaki, Japan
| | - Hiroki Hori
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering & Science, Graduate School of Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Masatake Sumi
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku-ku, Kawata-cho, 8-1, Tokyo, 162-0054, Japan
| | - Shiro Horisawa
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku-ku, Kawata-cho, 8-1, Tokyo, 162-0054, Japan
| | - Takaomi Taira
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku-ku, Kawata-cho, 8-1, Tokyo, 162-0054, Japan
| | - Tomokatsu Hori
- Department of Neurosurgery, Moriyama Neurological Center Hospital, Tokyo, Japan
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23
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Jermakowicz WJ, Wu C, Neal E, Cajigas I, D'Haese PF, Donahue DJ, Sharan AD, Vale FL, Jagid JR. Clinically Significant Visual Deficits after Laser Interstitial Thermal Therapy for Mesiotemporal Epilepsy. Stereotact Funct Neurosurg 2020; 97:347-355. [PMID: 31935727 DOI: 10.1159/000504856] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 11/18/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Laser interstitial thermal therapy (LITT) has recently gained popularity as a minimally invasive surgical option for the treatment of mesiotemporal epilepsy (mTLE). Similar to traditional open procedures for epilepsy, the most frequent neurological complications of LITT are visual deficits; however, a critical analysis of these injuries is lacking. OBJECTIVES To evaluate the visual deficits that occur after LITT for mTLE and their etiology. METHOD We surveyed five academic epilepsy centers that regularly perform LITT for cases of self-reported postoperative visual deficits. For these patients all pre-, intra- and postoperative MRIs were co-registered with an anatomic atlas derived from 7T MRI data. This was used to estimate thermal injury to early visual pathways and measure imaging variables relevant to the LITT procedure. Using logistic regression, we then compared 14 variables derived from demographics, mesiotemporal anatomy, and the surgical procedure for the patients with visual deficits to a normal cohort comprised of the first 30 patients to undergo this procedure at a single institution. RESULTS Of 90 patients that underwent LITT for mTLE, 6 (6.7%) reported a postoperative visual deficit. These included 2 homonymous hemianopsias (HHs), 2 quadrantanopsias, and 2 cranial nerve (CN) IV palsies. These deficits localized to the posterior aspect of the ablation, corresponding to the hippocampal body and tail, and tended to have greater laser energy delivered in that region than the normal cohort. The patients with HH had insult localized to the lateral geniculate nucleus, which was -associated with young age and low choroidal fissure CSF volume. Quadrantanopsia, likely from injury to the optic radiation in Meyer's loop, was correlated with a lateral trajectory and excessive energy delivered at the tail end of the ablation. Patients with CN IV injury had extension of contrast to the tentorial edge associated with a mesial laser trajectory. CONCLUSIONS LITT for epilepsy may be complicated by various classes of visual deficit, each with distinct etiology and clinical significance. It is our hope that by better understanding these injuries and their mechanisms we can eventually reduce their occurrence by identifying at-risk patients and trajectories and appropriately tailoring the ablation procedure.
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Affiliation(s)
| | - Chengyuan Wu
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Elliot Neal
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Iahn Cajigas
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Pierre-François D'Haese
- Department of Electrical and Computer Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - David J Donahue
- Department of Neurological Surgery, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Ashwini D Sharan
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Fernando L Vale
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Jonathan R Jagid
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA,
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24
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Widjaja E, Papastavros T, Sander B, Snead C, Pechlivanoglou P. Early economic evaluation of MRI-guided laser interstitial thermal therapy (MRgLITT) and epilepsy surgery for mesial temporal lobe epilepsy. PLoS One 2019; 14:e0224571. [PMID: 31747402 PMCID: PMC6867628 DOI: 10.1371/journal.pone.0224571] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/16/2019] [Indexed: 12/02/2022] Open
Abstract
Background MRI-guided laser interstitial thermal therapy (MRgLITT) is a new minimally invasive treatment for temporal lobe epilepsy (TLE), with limited effectiveness data. It is unknown if the cost savings associated with shorter hospitalization could offset the high equipment cost of MRgLITT. We examined the cost-utility of MRgLITT versus surgery for TLE from healthcare payer perspective, and the value of additional research to inform policy decision on MRgLITT. Methods We developed a microsimulation model to evaluate quality adjusted life years (QALYs), costs, and incremental cost-effectiveness ratio (ICER) of MRgLITT versus surgery in TLE, assuming life-time horizon and 1.5% discount rate. Model inputs were derived from the literature. We conducted threshold and sensitivity analyses to examine parameter uncertainties, and expected value of partial perfect information analyses to evaluate the expected monetary benefit of eliminating uncertainty on probabilities associated with MRgLITT. Results MRgLITT yielded 0.08 more QALYs and cost $7,821 higher than surgery, with ICER of $94,350/QALY. Influential parameters that could change model outcomes include probabilities of becoming seizure-free from disabling seizures state and returning to disabling seizures from seizure-free state 5 years after surgery and MRgLITT, cost of MRgLITT disposable equipment, and utilities of disabling seizures and seizure-free states of surgery and MRgLITT. The cost-effectiveness acceptability curve showed surgery was preferred in more than 50% of iterations. The expected monetary benefit of eliminating uncertainty for probabilities associated with MRgLITT was higher than for utilities associated with MRgLITT. Conclusions MRgLITT resulted in more QALYs gained and higher costs compared to surgery in the base-case. The model was sensitive to variations in the cost of MRgLITT disposable equipment. There is value in conducting more research to reduce uncertainty on the probabilities and utilities of MRgLITT, but priority should be given to research focusing on improving the precision of estimates on effectiveness of MRgLITT.
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MESH Headings
- Adult
- Computer Simulation
- Cost-Benefit Analysis
- Drug Resistant Epilepsy/diagnostic imaging
- Drug Resistant Epilepsy/economics
- Drug Resistant Epilepsy/surgery
- Epilepsy, Temporal Lobe/diagnostic imaging
- Epilepsy, Temporal Lobe/economics
- Epilepsy, Temporal Lobe/surgery
- Female
- Humans
- Hyperthermia, Induced/economics
- Hyperthermia, Induced/methods
- Magnetic Resonance Imaging, Interventional/economics
- Magnetic Resonance Imaging, Interventional/methods
- Male
- Minimally Invasive Surgical Procedures/economics
- Minimally Invasive Surgical Procedures/methods
- Models, Economic
- Neurosurgical Procedures/economics
- Neurosurgical Procedures/methods
- Patient Selection
- Quality-Adjusted Life Years
- Surgery, Computer-Assisted/economics
- Surgery, Computer-Assisted/methods
- Treatment Outcome
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Affiliation(s)
- Elysa Widjaja
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada
- Division of Neurology, Hospital for Sick Children, Toronto, Canada
- * E-mail:
| | - Tina Papastavros
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Toronto Health Economics Technology Assessment, University Health Network, Toronto, Canada
- Institute of Clinical Evaluative Sciences (ICES), Toronto, Canada
- Public Health Ontario, Toronto, Canada
| | - Carter Snead
- Division of Neurology, Hospital for Sick Children, Toronto, Canada
| | - Petros Pechlivanoglou
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, Canada
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25
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Holanda VM, Gungor A, Baydin S, Middlebrooks EH, Danish SF. Anatomic Investigation of the Trajectory for Stereotactic Laser Amygdalohippocampectomy. Oper Neurosurg (Hagerstown) 2019; 15:194-206. [PMID: 29140463 DOI: 10.1093/ons/opx218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 09/16/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Magnetic resonance imaging-guided laser interstitial thermal therapy (LITT) has emerged as a promising treatment for mesial temporal lobe epilepsy. Surgeons must understand the relevant anatomy that is traversed by the catheter and affected by ablation. OBJECTIVE To study the anatomic structures crossed by the LITT catheter until it reaches the amygdala. METHODS Three human cadaveric heads were implanted with catheters using a frameless stereotactic technique. The Visualase® system (Medtronic, Dublin, Ireland) was utilized to ablate along the trajectory. Coronal and oblique axial slices were created. Fiber tract dissections were performed in a lateral-medial and inferior-superior scheme. Magnetic resonance tractography was acquired to illustrate the tracts dissected. RESULTS Entry points occurred within 4 cm of the transverse and sagittal sinus, inferior to the lambdoid suture. The cortex of the inferior occipital gyrus was crossed in the region of the transverse occipital sulcus. The vertical occipital fasciculus was crossed en route to passing through the optic radiations. The catheter crossed through or inferior to the optic radiations before piercing the parahippocampal gyrus at about 4 cm from the skull. The catheter entered the hippocampus as it pierced the superior margin of the parahippocampus at 6 cm. The catheter entered the head of the hippocampus to lie inferolateral to the amygdala in the last centimeter of the trajectory. CONCLUSION Understanding the anatomic principles of LITT catheter trajectories will improve the ability to perform this procedure. The current study is the first to examine the anatomy of this trajectory and will serve as the basis for future studies.
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Affiliation(s)
- Vanessa M Holanda
- Center of Neurology and Neurosurgery Associates (NeuroCENNA), Beneficência Portuguesa of São Paulo Hospital, São Paulo-SP, Brazil
| | - Abuzer Gungor
- Department of Neurosurgery, Bakirkoy Research and Training Hospital for Neurology, Neurosurgery, and Psychiatry, Istanbul, Turkey
| | - Serhat Baydin
- Department of Neurosurgery, Kanuni Sultan Suleyman Research and Training Hospital, Istanbul, Turkey
| | - Erik H Middlebrooks
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Shabbar F Danish
- Division of Neurosurgery, Rutgers-RWJ Medical School, New Brunswick, New Jersey
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26
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Tovar-Spinoza Z, Ziechmann R, Zyck S. Single and staged laser interstitial thermal therapy ablation for cortical tubers causing refractory epilepsy in pediatric patients. Neurosurg Focus 2019; 45:E9. [PMID: 30173608 DOI: 10.3171/2018.6.focus18228] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a novel, minimally invasive treatment for the surgical treatment of epilepsy. In this paper, the authors report on clinical outcomes for a series of pediatric patients with tuberous sclerosis complex (TSC) and medication-refractory epileptogenic cortical tubers. METHODS A retrospective chart review was performed at SUNY Upstate Golisano Children's Hospital in Syracuse, New York. The authors included all cases involving pediatric patients (< 18 years) who underwent MRgLITT for ablation of epileptogenic cortical tubers between February 2013 and November 2015. RESULTS Seven patients with cortical tubers were treated (4 female and 3 male). The patients' average age was 6.6 years (range 2-17 years). Two patients had a single procedure, and 5 patients had staged procedures. The mean time between procedures in the staged cases was 6 months. All of the patients had a meaningful reduction in seizure frequency as reported by Engel and ILAE seizure outcome classifications, and most (71.4%) of the patients experienced a reduction in AED burden. Three of the 4 patients who presented with neuropsychiatric symptoms had some improvement in these domains after laser ablation. No perioperative complications were noted. The mean duration of follow-up was 19.3 months (range 4-49 months). CONCLUSIONS Laser ablation represents a minimally invasive alternative to resective epilepsy surgery and is an effective treatment for refractory epilepsy due to cortical tubers.
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27
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Voets NL, Alvarez I, Qiu D, Leatherday C, Willie JT, Sotiropoulos S, Gleichgerrcht E, Bonilha L, Pedersen NP, Kadom N, Saindane AM, Gross RE, Drane DL. Mechanisms and Risk Factors Contributing to Visual Field Deficits following Stereotactic Laser Amygdalohippocampotomy. Stereotact Funct Neurosurg 2019; 97:255-265. [PMID: 31618749 PMCID: PMC6979425 DOI: 10.1159/000502701] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 08/09/2019] [Indexed: 11/19/2022]
Abstract
Selective laser amygdalohippocampotomy (SLAH) is a minimally invasive surgical treatment for medial temporal lobe epilepsy. Visual field deficits (VFDs) are a significant potential complication. The objective of this study was to determine the relationship between VFDs and potential mechanisms of injury to the optic radiations and lateral geniculate nucleus. We performed a retrospective cross-sectional analysis of 3 patients (5.2%) who developed persistent VFDs after SLAH within our larger series (n = 58), 15 healthy individuals and 10 SLAH patients without visual complications. Diffusion tractography was used to evaluate laser catheter penetration of the optic radiations. Using a complementary approach, we evaluated evidence for focal microstructural tissue damage within the optic radiations and lateral geniculate nucleus. Overablation and potential heat radiation were assessed by quantifying ablation and choroidal fissure CSF volumes as well as energy deposited during SLAH.SLAH treatment parameters did not distinguish VFD patients. Atypically high overlap between the laser catheter and optic radiations was found in 1/3 VFD patients and was accompanied by focal reductions in fractional anisotropy where the catheter entered the lateral occipital white matter. Surprisingly, lateral geniculate tissue diffusivity was abnormal following, but also preceding, SLAH in patients who subsequently developed a VFD (all p = 0.005).In our series, vision-related complications following SLAH, which appear to occur less frequently than following open temporal lobe -surgery, were not directly explained by SLAH treatment parameters. Instead, our data suggest that variations in lateral geniculate structure may influence susceptibility to indirect heat injury from transoccipital SLAH.
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Affiliation(s)
- Natalie L Voets
- Wellcome Centre for Integrative Neuroimaging, FMRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Ivan Alvarez
- Wellcome Centre for Integrative Neuroimaging, FMRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Deqiang Qiu
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christopher Leatherday
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jon T Willie
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Stamatios Sotiropoulos
- Wellcome Centre for Integrative Neuroimaging, FMRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.,Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Ezequiel Gleichgerrcht
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Leonardo Bonilha
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nigel P Pedersen
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Nadja Kadom
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.,Children's Hospital of Atlanta, Atlanta, Georgia, USA
| | - Amit M Saindane
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Robert E Gross
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Daniel L Drane
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA, .,Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA, .,Department of Neurology, University of Washington School of Medicine, Seattle, Washington, USA,
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28
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Huang Y, Leung SA, Parker JJ, Ho AL, Wintermark M, Patel SH, Pauly KB, Kakusa BW, Beres SJ, Henderson JM, Grant GA, Halpern CH. Anatomic and Thermometric Analysis of Cranial Nerve Palsy after Laser Amygdalohippocampotomy for Mesial Temporal Lobe Epilepsy. Oper Neurosurg (Hagerstown) 2019; 18:684-691. [DOI: 10.1093/ons/opz279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/31/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Laser interstitial thermal therapy (LITT) is a minimally invasive therapy for treating medication-resistant mesial temporal lobe epilepsy. Cranial nerve (CN) palsy has been reported as a procedural complication, but the mechanism of this complication is not understood.
OBJECTIVE
To identify the cause of postoperative CN palsy after LITT.
METHODS
Four medial temporal lobe epilepsy patients with CN palsy after LITT were identified for comparison with 22 consecutive patients with no palsy. We evaluated individual variation in the distance between CN III and the uncus, and CN IV and the parahippocampal gyrus using preoperative T1- and T2-weighted magnetic resonance (MR) images. Intraoperative MR thermometry was used to estimate temperature changes.
RESULTS
CN III (n = 2) and CN IV palsies (n = 2) were reported. On preoperative imaging, the majority of identified CN III (54%) and CN IV (43%) were located within 1 to 2 mm of the uncus and parahippocampal gyrus tissue border, respectively. Affected CN III and CN IV were more likely to be found < 1 mm of the tissue border (PCNIII = .03, PCNIV < .01; chi-squared test). Retrospective assessment of thermal profile during ablation showed higher temperature rise along the mesial temporal lobe tissue border in affected CNs than unaffected CNs after controlling for distance (12.9°C vs 5.8°C; P = .03; 2-sample t-test).
CONCLUSION
CN palsy after LITT likely results from direct heating of the respective CN running at extreme proximity to the mesial temporal lobe. Low-temperature thresholds set at the border of the mesial temporal lobe in patients whose CNs are at close proximity may reduce this risk.
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Affiliation(s)
- Yuhao Huang
- Department of Neurosurgery, School of Medicine, Stanford University, Stanford, California
| | - Steven A Leung
- Department of Bioengineering, School of Medicine, Stanford University, Stanford, California
| | - Jonathon J Parker
- Department of Neurosurgery, School of Medicine, Stanford University, Stanford, California
| | - Allen L Ho
- Department of Neurosurgery, School of Medicine, Stanford University, Stanford, California
| | - Max Wintermark
- Department of Radiology, School of Medicine, Stanford University, Stanford, California
| | - Sohil H Patel
- Department of Radiology and Medical Imaging, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Kim Butts Pauly
- Department of Radiology, School of Medicine, Stanford University, Stanford, California
| | - Bina W Kakusa
- Department of Neurosurgery, School of Medicine, Stanford University, Stanford, California
| | - Shannon J Beres
- Department of Neurology, School of Medicine, Stanford University, Stanford, California
| | - Jaimie M Henderson
- Department of Neurosurgery, School of Medicine, Stanford University, Stanford, California
| | - Gerald A Grant
- Department of Neurosurgery, School of Medicine, Stanford University, Stanford, California
| | - Casey H Halpern
- Department of Neurosurgery, School of Medicine, Stanford University, Stanford, California
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29
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Vakharia VN, Sparks RE, Li K, O'Keeffe AG, Pérez-García F, França LGS, Ko AL, Wu C, Aronson JP, Youngerman BE, Sharan A, McKhann G, Ourselin S, Duncan JS. Multicenter validation of automated trajectories for selective laser amygdalohippocampectomy. Epilepsia 2019; 60:1949-1959. [PMID: 31392717 PMCID: PMC6771574 DOI: 10.1111/epi.16307] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 07/08/2019] [Accepted: 07/10/2019] [Indexed: 11/29/2022]
Abstract
Objective Laser interstitial thermal therapy (LITT) is a novel minimally invasive alternative to open mesial temporal resection in drug‐resistant mesial temporal lobe epilepsy (MTLE). The safety and efficacy of the procedure are dependent on the preplanned trajectory and the extent of the planned ablation achieved. Ablation of the mesial hippocampal head has been suggested to be an independent predictor of seizure freedom, whereas sparing of collateral structures is thought to result in improved neuropsychological outcomes. We aim to validate an automated trajectory planning platform against manually planned trajectories to objectively standardize the process. Methods Using the EpiNav platform, we compare automated trajectory planning parameters derived from expert opinion and machine learning to undertake a multicenter validation against manually planned and implemented trajectories in 95 patients with MTLE. We estimate ablation volumes of regions of interest and quantify the size of the avascular corridor through the use of a risk score as a marker of safety. We also undertake blinded external expert feasibility and preference ratings. Results Automated trajectory planning employs complex algorithms to maximize ablation of the mesial hippocampal head and amygdala, while sparing the parahippocampal gyrus. Automated trajectories resulted in significantly lower calculated risk scores and greater amygdala ablation percentage, whereas overall hippocampal ablation percentage did not differ significantly. In addition, estimated damage to collateral structures was reduced. Blinded external expert raters were significantly more likely to prefer automated to manually planned trajectories. Significance Retrospective studies of automated trajectory planning show much promise in improving safety parameters and ablation volumes during LITT for MTLE. Multicenter validation provides evidence that the algorithm is robust, and blinded external expert ratings indicate that the trajectories are clinically feasible. Prospective validation studies are now required to determine if automated trajectories translate into improved seizure freedom rates and reduced neuropsychological deficits.
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Affiliation(s)
- Vejay N Vakharia
- Department of Clinical and Experimental Epilepsy, Queen Square Institute of Neurology, University College London, London, UK.,National Hospital for Neurology and Neurosurgery, London, UK.,Chalfont Centre for Epilepsy London, London, UK
| | - Rachel E Sparks
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Kuo Li
- The First Affiliated Hospital of Xi'an, Jiaotong University, Xi'an, China
| | - Aidan G O'Keeffe
- Department of Statistical Science, University College London, London, UK
| | - Fernando Pérez-García
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Lucas G S França
- Department of Clinical and Experimental Epilepsy, Queen Square Institute of Neurology, University College London, London, UK
| | - Andrew L Ko
- Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Chengyuan Wu
- Division of Epilepsy and Neuromodulation Neurosurgery, Department of Neurosurgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Joshua P Aronson
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Ashwini Sharan
- Division of Epilepsy and Neuromodulation Neurosurgery, Department of Neurosurgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Guy McKhann
- Columbia University Medical Center, New York, New York
| | - Sebastien Ourselin
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - John S Duncan
- Department of Clinical and Experimental Epilepsy, Queen Square Institute of Neurology, University College London, London, UK.,National Hospital for Neurology and Neurosurgery, London, UK.,Chalfont Centre for Epilepsy London, London, UK
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Cajigas I, Kanner AM, Ribot R, Casabella AM, Mahavadi A, Jermakowicz W, Sur S, Millan C, Saporta A, Lowe M, Velez-Ruiz N, Rey G, Ibrahim GM, Ivan ME, Jagid JR. Magnetic Resonance–Guided Laser Interstitial Thermal Therapy for Mesial Temporal Epilepsy: A Case Series Analysis of Outcomes and Complications at 2-Year Follow-Up. World Neurosurg 2019; 126:e1121-e1129. [DOI: 10.1016/j.wneu.2019.03.057] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/05/2019] [Accepted: 03/06/2019] [Indexed: 11/29/2022]
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Magnetic Resonance–Guided Laser Interstitial Thermal Therapy Versus Stereotactic Radiosurgery for Medically Intractable Temporal Lobe Epilepsy: A Systematic Review and Meta-Analysis of Seizure Outcomes and Complications. World Neurosurg 2019; 122:e32-e47. [DOI: 10.1016/j.wneu.2018.08.227] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 08/29/2018] [Accepted: 08/31/2018] [Indexed: 11/23/2022]
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Laser interstitial thermal therapy (LITT): Seizure outcomes for refractory mesial temporal lobe epilepsy. Epilepsy Behav 2018; 89:37-41. [PMID: 30384097 DOI: 10.1016/j.yebeh.2018.09.040] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 09/28/2018] [Accepted: 09/29/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Laser interstitial thermal therapy (LITT) is a minimally invasive alternative with less cognitive risks compared with traditional surgery for focal drug-resistant epilepsy. OBJECTIVE We describe seizure outcomes and complications after LITT in our cohort with intractable mesial temporal lobe epilepsy (MTLE). MATERIAL AND METHODS We prospectively tracked Stanford's MTLE cases treated with LITT from October 2014 to October 2017. Primary endpoints were seizure outcomes by (1) Engel classification and (2) reduction in baseline seizure frequency. Secondary outcomes were postablation complications. RESULTS A total of 30 patients underwent selective amygdalohippocampotomy via LITT. Mesial temporal sclerosis (MTS) was present in 23/30 (77%) patients. Median follow-up was 18 ± 12 months (range: 6-44 months). Almost all 28/29 (97%) patients had >50% reduction, and 22/29 (76%) patients had >90% reduction in seizure frequency. Engel Class I outcome was achieved in 18/29 (62%) patients; with complete seizure freedom in 9/29 (31%) patients (Engel Class IA). Three (10%) patients have had only focal aware seizures (Engel Class 1B). Seizures only occurred with medication withdrawal in 6/29 (21%) patients (Engel Class ID). Class II was achieved by 6/29 (21%) and Class III by 5/29 (17%) patients. Complications included perioperative seizures in 10/29 (34%) and nonseizure complaints in 6/29 (21%) patients. Three (10%) patients had neurological deficits including one permanent superior quadrantanopsia, one transient trochlear, and one transient oculomotor nerve palsy. CONCLUSIONS Overall, Engel Class I outcome was achieved in 62% of patients with MTLE, and 97% of patients achieved >50% seizure frequency reduction. Complications were largely temporary, though there was one persistent visual field deficit. Laser ablation is well-tolerated and offers marked seizure reduction for the majority of patients.
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Benbadis SR, Geller E, Ryvlin P, Schachter S, Wheless J, Doyle W, Vale FL. Putting it all together: Options for intractable epilepsy: An updated algorithm on the use of epilepsy surgery and neurostimulation. Epilepsy Behav 2018; 88S:33-38. [PMID: 30241957 DOI: 10.1016/j.yebeh.2018.05.030] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 05/15/2018] [Accepted: 05/16/2018] [Indexed: 01/17/2023]
Abstract
For drug-resistant epilepsy, nonpharmacologic treatments should be considered early rather than late. Of the nondrug treatments, only resective surgery can be curative. Neurostimulation is palliative, i.e., not expected to achieve a seizure-free outcome. While resective surgery is the goal, other options are necessary because the majority of patients with drug-resistant epilepsy are not surgical candidates, and others have seizures that fail to improve with surgery or have only partial improvement but not seizure freedom. Neurostimulation modalities include vagus nerve stimulation (VNS), responsive neurostimulation (RNS), and deep brain stimulation (DBS), each with its own advantages, disadvantages, and side effects. In most scenarios, determined by noninvasive evaluation, especially EEG and MRI, several strategies are reasonable. For focal epilepsies, the choices are between resective surgery, with or without intracranial EEG, and all three modalities of neurostimulation. In situations where resective surgery is likely to result in seizure freedom, such as mesiotemporal lobe epilepsy or lesional focal epilepsy, resection (standard, laser, or radiofrequency) is preferred. For difficult cases like extratemporal nonlesional epilepsies, neurostimulation offers a less invasive option than resective surgery. For generalized and multifocal epilepsies, VNS is an option, RNS is not, and DBS has only limited evidence. "This article is part of the Supplement issue Neurostimulation for Epilepsy."
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Affiliation(s)
| | - Eric Geller
- Institute For Neurology and Neurosurgery at St. Barnabas, Livingston, NJ, United States
| | - Philippe Ryvlin
- Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | | | - James Wheless
- Le Bonheur Children's Hospital, Memphis, TN, United States
| | - Werner Doyle
- New York University, New York, NY, United States
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Donos C, Breier J, Friedman E, Rollo P, Johnson J, Moss L, Thompson S, Thomas M, Hope O, Slater J, Tandon N. Laser ablation for mesial temporal lobe epilepsy: Surgical and cognitive outcomes with and without mesial temporal sclerosis. Epilepsia 2018; 59:1421-1432. [DOI: 10.1111/epi.14443] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Cristian Donos
- Vivian L. Smith Department of Neurosurgery; McGovern Medical School; Houston TX USA
| | - Joshua Breier
- Children's Learning Institute; University of Texas Health Science Center at Houston; Houston TX USA
| | - Elliott Friedman
- Department of Radiology; McGovern Medical School; Houston TX USA
| | - Patrick Rollo
- Vivian L. Smith Department of Neurosurgery; McGovern Medical School; Houston TX USA
| | - Jessica Johnson
- Vivian L. Smith Department of Neurosurgery; McGovern Medical School; Houston TX USA
| | - Lauren Moss
- Children's Learning Institute; University of Texas Health Science Center at Houston; Houston TX USA
| | - Stephen Thompson
- Department of Neurology; McGovern Medical School; Houston TX USA
| | - Melissa Thomas
- Department of Neurology; McGovern Medical School; Houston TX USA
| | - Omotola Hope
- Department of Neurology; McGovern Medical School; Houston TX USA
| | - Jeremy Slater
- Department of Neurology; McGovern Medical School; Houston TX USA
| | - Nitin Tandon
- Vivian L. Smith Department of Neurosurgery; McGovern Medical School; Houston TX USA
- Mischer Neuroscience Institute; Memorial Hermann Hospital Texas Medical Center; Houston TX USA
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Boone CE, Wojtasiewicz T, Moukheiber E, Butala A, Jordao L, Mills KA, Sair H, Anderson WS. MR-Guided Functional Neurosurgery: Laser Ablation and Deep Brain Stimulation. Top Magn Reson Imaging 2018; 27:171-177. [PMID: 29870469 DOI: 10.1097/rmr.0000000000000152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Intraoperative magnetic resonance imaging (iMRI) is increasingly implemented for image-guided procedures in functional neurosurgery. iMRI facilitates accurate electrode implantation for deep brain stimulation (DBS) and is currently an alternative method for DBS electrode targeting. The application of iMRI also allows for greater accuracy and precision in laser-induced thermal therapy (LITT). The expanding use of functional neurosurgical procedures makes safety and feasibility of iMRI important considerations, particularly in patients with comorbidities or complex medical histories. We review here the applications of iMRI and discuss its safety, feasibility, and limitations in functional neurosurgery.To motivate discussion of this topic, we also present a 52-year-old patient with an implanted cardioverter-defibrillator (ICD) who successfully underwent iMRI-guided DBS electrode implantation for advanced Parkinson disease (PD). Neither iMRI nor the passage of electrical current through the implanted DBS electrodes demonstrated detectable interference in ICD function. This case demonstrates that, even in complex clinical contexts, iMRI is a promising tool that merits further exploration for procedures requiring highly accurate and precise identification of target structures.
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Affiliation(s)
| | | | | | | | | | | | - Haris Sair
- Department of Radiology, Neuroradiology, The Johns Hopkins University, Baltimore, MD
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36
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Tao JX, Wu S, Lacy M, Rose S, Issa NP, Yang CW, Dorociak KE, Bruzzone M, Kim J, Daif A, Choi J, Towle VL, Warnke PC. Stereotactic EEG-guided laser interstitial thermal therapy for mesial temporal lobe epilepsy. J Neurol Neurosurg Psychiatry 2018; 89:542-548. [PMID: 29183959 DOI: 10.1136/jnnp-2017-316833] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 10/28/2017] [Accepted: 11/08/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine the outcomes of combined stereo-electroencephalography-guided and MRI-guided stereotactic laser interstitial thermal therapy (LITT) in the treatment of patients with drug-resistant mesial temporal lobe epilepsy (mTLE). METHODS We prospectively assessed the surgical and neuropsychological outcomes in 21 patients with medically refractory mTLE who underwent LITT at the University of Chicago Medical Center. We further compared the surgical outcomes in patients with and without mesial temporal sclerosis (MTS). RESULTS Of the 21 patients, 19 (90%) underwent Invasive EEG study and 11 (52%) achieved freedom from disabling seizures with a mean duration of postoperative follow-up of 24±11 months after LITT. Eight (73%) of 11 patients with MTS achieved freedom from disabling seizures, whereas 3 (30 %) of 10 patients without MTS achieved freedom from disabling seizures. Patients with MTS were significantly more likely to become seizure-free, as compared with those without MTS (P=0.002). There was no significant difference in total ablation volume and the percentage of the ablated amygdalohippocampal complex between seizure-free and non-seizure-free patients. Presurgical and postsurgical neuropsychological assessments were obtained in 10 of 21 patients. While there was no group decline in any neuropsychological assessment, a significant postoperative decline in verbal memory and confrontational naming was observed in individual patients. CONCLUSIONS MRI-guided LITT is a safe and effective alternative to selective amygdalohippocampectomy and anterior temporal lobectomy for mTLE with MTS. Nevertheless, its efficacy in those without MTS seems modest. Large multicentre and prospective studies are warranted to further determine the efficacy and safety of LITT.
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Affiliation(s)
- James X Tao
- Department of Neurology, The University of Chicago, Chicago, Illinois, USA
| | - Shasha Wu
- Department of Neurology, The University of Chicago, Chicago, Illinois, USA
| | - Maureen Lacy
- Department of Psychiatry, The University of Chicago, Chicago, Illinois, USA
| | - Sandra Rose
- Department of Neurology, The University of Chicago, Chicago, Illinois, USA
| | - Naoum P Issa
- Department of Neurology, The University of Chicago, Chicago, Illinois, USA
| | - Carina W Yang
- Department of Radiology, The University of Chicago, Chicago, Illinois, USA
| | | | - Maria Bruzzone
- Department of Neurology, The University of Chicago, Chicago, Illinois, USA
| | - Jisoon Kim
- Department of Neurology, The University of Chicago, Chicago, Illinois, USA
| | - Ahmad Daif
- Department of Neurology, The University of Chicago, Chicago, Illinois, USA
| | - Jason Choi
- Department of Neurosurgery, The University of Chicago, Chicago, Illinois, USA
| | - Vernon L Towle
- Department of Neurology, The University of Chicago, Chicago, Illinois, USA
| | - Peter C Warnke
- Department of Neurosurgery, The University of Chicago, Chicago, Illinois, USA
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37
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North RY, Raskin JS, Curry DJ. MRI-Guided Laser Interstitial Thermal Therapy for Epilepsy. Neurosurg Clin N Am 2018; 28:545-557. [PMID: 28917283 DOI: 10.1016/j.nec.2017.06.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
MRI-guided laser interstitial thermal therapy for epilepsy (LITT-E) has become an established, minimally invasive alternative to traditional epilepsy surgery. LITT-E is particularly valuable in cases in which open surgery poses unacceptably high morbidity or patient preference precludes craniotomy. Here we present a focused review of technical details and application of LITT to both focal and generalized epilepsy.
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Affiliation(s)
- Robert Y North
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge, Suite 9A, Houston, TX 77030, USA
| | - Jeffrey S Raskin
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 1230, Houston, TX 77030, USA
| | - Daniel J Curry
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 1230, Houston, TX 77030, USA.
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38
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Brown MG, Drees C, Nagae LM, Thompson JA, Ojemann S, Abosch A. Curative and palliative MRI-guided laser ablation for drug-resistant epilepsy. J Neurol Neurosurg Psychiatry 2018; 89:425-433. [PMID: 29084870 DOI: 10.1136/jnnp-2017-316003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/15/2017] [Accepted: 09/18/2017] [Indexed: 12/30/2022]
Abstract
Epilepsy is a common neurological disorder occurring in 3% of the US adult population. It is characterised by seizures resulting from aberrant hypersynchronous neural activity. Approximately one-third of newly diagnosed epilepsy cases fail to become seizure-free in response to antiseizure drugs. Optimal seizure control, in cases of drug-resistant epilepsy, often requires neurosurgical intervention targeting seizure foci, such as the temporal lobe. Advances in minimally invasive ablative surgical approaches have led to the development of MRI-guided laser interstitial thermal therapy (LITT). For refractory epilepsy, this surgical intervention offers many advantages over traditional approaches, including real-time lesion monitoring, reduced morbidity, and in some reports increased preservation of cognitive and language processes. We review the use of LITT for epileptic indications in the context of its application as a curative (seizure freedom) or palliative (seizure reduction) measure for both lesional and non-lesional forms of epilepsy. Furthermore, we address the use of LITT for a variety of extratemporal lobe epilepsies. Finally, we describe clinical outcomes, limitations and future applications of LITT for epilepsy.
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Affiliation(s)
- Mesha-Gay Brown
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Cornelia Drees
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Lidia M Nagae
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - John A Thompson
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Steven Ojemann
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Aviva Abosch
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado, USA
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39
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Youngerman BE, Oh JY, Anbarasan D, Billakota S, Casadei CH, Corrigan EK, Banks GP, Pack AM, Choi H, Bazil CW, Srinivasan S, Bateman LM, Schevon CA, Feldstein NA, Sheth SA, McKhann GM. Laser ablation is effective for temporal lobe epilepsy with and without mesial temporal sclerosis if hippocampal seizure onsets are localized by stereoelectroencephalography. Epilepsia 2018; 59:595-606. [DOI: 10.1111/epi.14004] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Brett E. Youngerman
- Department of Neurological Surgery; Columbia University Medical Center; New York NY USA
| | - Justin Y. Oh
- Department of Neurological Surgery; Columbia University Medical Center; New York NY USA
| | - Deepti Anbarasan
- Department of Neurology; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Santoshi Billakota
- Department of Neurology; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Camilla H. Casadei
- Department of Neurology; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Emily K. Corrigan
- Department of Neurological Surgery; Columbia University Medical Center; New York NY USA
| | - Garret P. Banks
- Department of Neurological Surgery; Columbia University Medical Center; New York NY USA
| | - Alison M. Pack
- Department of Neurology; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Hyunmi Choi
- Department of Neurology; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Carl W. Bazil
- Department of Neurology; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Shraddha Srinivasan
- Department of Neurology; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Lisa M. Bateman
- Department of Neurology; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Catherine A. Schevon
- Department of Neurology; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Neil A. Feldstein
- Department of Neurological Surgery; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Sameer A. Sheth
- Department of Neurological Surgery; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Guy M. McKhann
- Department of Neurological Surgery; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
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40
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Kang JY, Sperling MR. Epileptologist's view: Laser interstitial thermal ablation for treatment of temporal lobe epilepsy. Epilepsy Res 2017; 142:149-152. [PMID: 28774708 DOI: 10.1016/j.eplepsyres.2017.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 06/23/2017] [Accepted: 07/11/2017] [Indexed: 11/29/2022]
Abstract
A procedure called laser interstitial thermal ablation has been utilized to treat drug resistant epilepsy. With this technique, a probe is stereotactically inserted into a target structure responsible for seizures, such as mesial temporal lobe, hypothalamic hamartoma, or a small malformation of cortical development, and the tip is then heated by application of laser energy to ablate structures adjacent to the probe tip. This procedure has the advantage of selectively targeting small lesions responsible for seizures, and is far less invasive than open surgery with shorter hospitalization, less pain, and rapid return to normal activities. Initial results in mesial temporal lobe epilepsy are promising, with perhaps half of patients becoming free of seizures after the procedure. Neuropsychological deficits appear to be reduced because of the smaller volume of ablated cortex in contrast to large resections. More research must be done to establish optimal targeting of structures for ablation and selection of candidates for surgery, and more patients must be studied to better establish efficacy and adverse effect rates.
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Affiliation(s)
- Joon Y Kang
- Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
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41
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Shukla ND, Ho AL, Pendharkar AV, Sussman ES, Halpern CH. Laser interstitial thermal therapy for the treatment of epilepsy: evidence to date. Neuropsychiatr Dis Treat 2017; 13:2469-2475. [PMID: 29026310 PMCID: PMC5627747 DOI: 10.2147/ndt.s139544] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Medically intractable epilepsy is associated with increased morbidity and mortality. For those with focal epilepsy and correlated electrophysiological or radiographic features, open surgical resection can achieve high rates of seizure control, but can be associated with neurologic deficits and cognitive effects. Recent innovations have allowed for more minimally invasive methods of surgical seizure control such as magnetic resonance-guided laser interstitial therapy (MRgLITT). MRgLITT achieves the goal of ablating seizure foci while preserving neuropsycho-logical function and offering real-time feedback and monitoring of tissue ablation. This review summarizes the utilization of MRgLITT for mesial temporal lobe epilepsy and other seizure disorders. Overall, the efficacy of MRgLITT is comparable to that of open surgery and offers a less invasive approach in patients with significantly less morbidity.
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Affiliation(s)
- Navika D Shukla
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Allen L Ho
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | | | - Eric S Sussman
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
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