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Dabrowski A, Armstrong C. A pediatrician's guide to epilepsy surgery. Curr Probl Pediatr Adolesc Health Care 2024; 54:101578. [PMID: 38485613 PMCID: PMC11223955 DOI: 10.1016/j.cppeds.2024.101578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
Surgical intervention for epilepsy emerged in the second half of the 20th century as an important option for pediatric patients with medically refractory epilepsy. Both the number of patients undergoing epilepsy surgery and the available surgical procedures for epilepsy have expanded in the last 3 decades, and now range from surgical resection to neuromodulatory device placement1,2 Studies showing that many patients who would be excellent candidates for surgery are still not being offered appropriate interventions have prompted an interest in ensuring that all providers who see patients with epilepsy are aware of the options for epilepsy surgery to facilitate earlier referrals when medications have not been effective3 In this article, we will introduce the pediatrician to the process involved in determining epilepsy surgery candidacy and to surgical outcomes, with the goal of empowering pediatric providers to refer their medically refractory epilepsy patients to a pediatric epilepsy center.
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Affiliation(s)
- Ania Dabrowski
- Children's Hospital of Philadelphia, Division of Neurology, Philadelphia, PA, USA
| | - Caren Armstrong
- Children's Hospital of Philadelphia, Division of Neurology, Philadelphia, PA, USA.
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2
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Ou Y, Yuan J, Li C. Direct resection is a safe and effective strategy to control seizures in patients with hypothalamic hamartoma. Sci Rep 2024; 14:13001. [PMID: 38844500 PMCID: PMC11156988 DOI: 10.1038/s41598-024-63480-3] [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: 02/19/2024] [Accepted: 05/29/2024] [Indexed: 06/09/2024] Open
Abstract
Achieving favorable seizure outcomes is challenging in patients with seizures resulting from hypothalamic hamartoma. Although minimally invasive and non-invasive surgical procedures are used to treat this population, these procedures have limitations. Therefore, we analyzed the outcomes of patients with hypothalamic hamartoma following direct resection. We included 159 patients with hypothalamic hamartoma who underwent direct resection using the transcallosal interforniceal approach between 2011 and 2018. The relationships between clinical parameters and seizure outcomes were analyzed. In total, 55.3% achieved gross total resection and 25.2% underwent near-total resection. Of all patients, 79.2% were overall seizure-free at one year, but this number dropped to 77.0% at more than five years. Moreover, 88.4% (129/146) reached gelastic seizure (GS)-free status at one year and this number increased to 89.0% (97/109) at more than five years. Seventy-one patients took antiseizure medication (ASM) long-term, 68 took it for one year, and 11 took it for one-half year. The duration of ASM consumption (p < 0.001) and extent of hypothalamic hamartoma resection (p = 0.016) were significant independent predictors of long-term overall seizure-free survival, while the duration of ASM consumption (p = 0.011) and extent of hypothalamic hamartoma resection (p = 0.026) were significant independent predictors of long-term GS-free survival. Most patients' behavior, school performance, and intelligence were not affected after surgery. Direct resection is effective and safe strategy for patients with hypothalamic hamartomas. Hypothalamic hamartomas should be removed as completely as possible, and patients should take ASM long-term following surgery to reach long-term overall seizure-free or GS-free status.
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Affiliation(s)
- Yunwei Ou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- The Institute of Artificial Intelligence, Hefei Comprehensive National Science Center, Hefei, Anhui, China.
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Beihang University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
| | - Jingzhe Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- The Institute of Artificial Intelligence, Hefei Comprehensive National Science Center, Hefei, Anhui, China
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Beihang University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Chunde Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Huang Q, Xie P, Zhou J, Ding H, Liu Z, Li T, Guan Y, Wang M, Wang J, Teng P, Zhu M, Ma K, Wu H, Luan G, Zhai F. Predictors of seizure outcomes in stereo-electroencephalography-guided radio-frequency thermocoagulation for MRI-negative epilepsy. Ther Adv Chronic Dis 2024; 15:20406223241236258. [PMID: 38496233 PMCID: PMC10943718 DOI: 10.1177/20406223241236258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 02/14/2024] [Indexed: 03/19/2024] Open
Abstract
Background One-third of intractable epilepsy patients have no visually identifiable focus for neurosurgery based on imaging tests [magnetic resonance imaging (MRI)-negative cases]. Stereo-electroencephalography-guided radio-frequency thermocoagulation (SEEG-guided RF-TC) is utilized in the clinical treatment of epilepsy to lower the incidence of complications post-open surgery. Objective This study aimed to identify prognostic factors and long-term seizure outcomes in SEEG-guided RF-TC for patients with MRI-negative epilepsy. Design This was a single-center retrospective cohort study. Methods We included 30 patients who had undergone SEEG-guided RF-TC at Sanbo Brain Hospital, Capital Medical University, from April 2015 to December 2019. The probability of remaining seizure-free and the plotted survival curves were analyzed. Prognostic factors were analyzed using log-rank tests in univariate analysis and the Cox regression model in multivariate analysis. Results With a mean time of 31.07 ± 2.64 months (median 30.00, interquartile range: 18.00-40.00 months), 11 out of 30 patients (36.7%) were classified as International League Against Epilepsy class 1 in the last follow-up. The mean time of remaining seizure-free was 21.33 ± 4.55 months [95% confidence interval (CI) 12.41-30.25], and the median time was 3.00 ± 0.54 months (95% CI 1.94-4.06). Despite falling in the initial year, the probability of remaining seizure-free gradually stabilizes in the subsequent years. The patients were more likely to obtain seizure freedom when the epileptogenic zone was located in the insular lobe or with one focus on the limbic system (p = 0.034, hazard ratio 5.019, 95% CI 1.125-22.387). Conclusion Our findings may be applied to guide individualized surgical interventions and help clinicians make better decisions.
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Affiliation(s)
- Qi Huang
- Department of Neurosurgery, Center of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Pandeng Xie
- Department of Neurosurgery, Center of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Jian Zhou
- Department of Neurosurgery, Center of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Haoran Ding
- Department of Neurosurgery, Center of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Zhao Liu
- Department of Neurosurgery, Center of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Tianfu Li
- Department of Brain Institute, Center of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Haidian District, Beijing, China
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Yuguang Guan
- Department of Neurosurgery, Center of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Mengyang Wang
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Jing Wang
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Pengfei Teng
- Department of Magnetoencephalography, Sanbo Brain Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Mingwang Zhu
- Department of Radiology, Sanbo Brain Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Kaiqiang Ma
- Department of Neurosurgery, Center of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Han Wu
- Department of Neurosurgery, Center of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Guoming Luan
- Department of Neurosurgery, Center of Epilepsy, Sanbo Brain Hospital, Capital Medical University, XiangshanYikesong 50, Haidian District, Beijing 100093, China
| | - Feng Zhai
- Department of Neurosurgery, Center of Epilepsy, Sanbo Brain Hospital, Capital Medical University, XiangshanYikesong 50, Haidian District, Beijing 100093, China
- Department of Functional Neurosurgery, Neurological Center, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing 100045, China
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Schijns OE. Functional hemispheric disconnection procedures for chronic epilepsy: history, indications, techniques, complications and current practice in Europe. A consensus statement on behalf of the EANS functional neurosurgery section. BRAIN & SPINE 2024; 4:102754. [PMID: 38510638 PMCID: PMC10951757 DOI: 10.1016/j.bas.2024.102754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/08/2024] [Accepted: 01/21/2024] [Indexed: 03/22/2024]
Abstract
Introduction The surgical procedure for severe, drug-resistant, unilateral hemispheric epilepsy is challenging. Over the last decades the surgical landscape for hemispheric disconnection procedures changed from anatomical hemispherectomy to functional hemispherotomy with a reduction of complications and stable good seizure outcome. Here, a task force of European epilepsy surgeons prepared, on behalf of the EANS Section for Functional Neurosurgery, a consensus statement on different aspects of the hemispheric disconnection procedure. Research question To determine history, indication, timing, techniques, complications and current practice in Europe for hemispheric disconnection procedures in drug-resistant epilepsy. Material and methods Relevant literature on the topic was collected by a literature search based on the PRISMA 2020 guidelines. Results A comprehensive overview on the historical development of hemispheric disconnection procedures for epilepsy is presented, while discussing indications, timing, surgical techniques and complications. Current practice for this procedure in European epilepsy surgery centers is provided. At present, our knowledge of long-term seizure outcomes primarily stems from open surgical disconnection procedures. Although minimal invasive surgical techniques in epilepsy are rapidly developing and reported in case reports or small case series, long-term seizure outcome remain uncertain and needs to be reported. Discussion and conclusion This is the first paper presenting a European consensus statement regarding history, indications, techniques and complications of hemispheric disconnection procedures for different causes of chronic, drug-resistant epilepsy. Furthermore, it serves as the pioneering document to report a comprehensive overview of the current surgical practices regarding this type of surgery employed in renowned epilepsy surgery centers across Europe.
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Affiliation(s)
- Olaf E.M.G. Schijns
- Corresponding author. Department of Neurosurgery, Maastricht University Medical Center, Maastricht, the Netherlands.
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Katlowitz KA, Curry DJ, Weiner HL. Novel Surgical Approaches in Childhood Epilepsy: Laser, Brain Stimulation, and Focused Ultrasound. Adv Tech Stand Neurosurg 2024; 49:291-306. [PMID: 38700689 DOI: 10.1007/978-3-031-42398-7_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Pediatric epilepsy has a worldwide prevalence of approximately 1% (Berg et al., Handb Clin Neurol 111:391-398, 2013) and is associated with not only lower quality of life but also long-term deficits in executive function, significant psychosocial stressors, poor cognitive outcomes, and developmental delays (Schraegle and Titus, Epilepsy Behav 62:20-26, 2016; Puka and Smith, Epilepsia 56:873-881, 2015). With approximately one-third of patients resistant to medical control, surgical intervention can offer a cure or palliation to decrease the disease burden and improve neurological development. Despite its potential, epilepsy surgery is drastically underutilized. Even today only 1% of the millions of epilepsy patients are referred annually for neurosurgical evaluation, and the average delay between diagnosis of Drug Resistant Epilepsy (DRE) and surgical intervention is approximately 20 years in adults and 5 years in children (Solli et al., Epilepsia 61:1352-1364, 2020). It is still estimated that only one-third of surgical candidates undergo operative intervention (Pestana Knight et al., Epilepsia 56:375, 2015). In contrast to the stable to declining rates of adult epilepsy surgery (Englot et al., Neurology 78:1200-1206, 2012; Neligan et al., Epilepsia 54:e62-e65, 2013), rates of pediatric surgery are rising (Pestana Knight et al., Epilepsia 56:375, 2015). Innovations in surgical approaches to epilepsy not only minimize potential complications but also expand the definition of a surgical candidate. In this chapter, three alternatives to classical resection are presented. First, laser ablation provides a minimally invasive approach to focal lesions. Next, both central and peripheral nervous system stimulation can interrupt seizure networks without creating permanent lesions. Lastly, focused ultrasound is discussed as a potential new avenue not only for ablation but also modulation of small, deep foci within seizure networks. A better understanding of the potential surgical options can guide patients and providers to explore all treatment avenues.
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Affiliation(s)
- Kalman A Katlowitz
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Department of Neurosurgery, Texas Children's Hospital, Houston, TX, USA
| | - Daniel J Curry
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Department of Neurosurgery, Texas Children's Hospital, Houston, TX, USA
| | - Howard L Weiner
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA.
- Department of Neurosurgery, Texas Children's Hospital, Houston, TX, USA.
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Ghatan S. Pediatric Neurostimulation and Practice Evolution. Neurosurg Clin N Am 2024; 35:1-15. [PMID: 38000833 DOI: 10.1016/j.nec.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Since the late nineteenth century, the prevailing view of epilepsy surgery has been to identify a seizure focus in a medically refractory patient and eradicate it. Sadly, only a select number of the many who suffer from uncontrolled seizures benefit from this approach. With the development of safe, efficient stereotactic methods and targeted surgical therapies that can affect deep structures and modulate broad networks in diverse disorders, epilepsy surgery in children has undergone a paradigmatic evolutionary change. With modern diagnostic techniques such as stereo electroencephalography combined with closed loop neuromodulatory systems, pediatric epilepsy surgery can reach a much broader population of underserved patients.
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Affiliation(s)
- Saadi Ghatan
- Neurological Surgery Icahn School of Medicine at Mt Sinai, New York, NY 10128, USA.
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Xu X, Wang Q, Zhao Y, Xu X, Gan Z, Zhang S, Chen X. Intraventricular SEEG and laser ablation for the treatment of infantile spasm: Technical note. Brain Behav 2023; 13:e3184. [PMID: 37492027 PMCID: PMC10570471 DOI: 10.1002/brb3.3184] [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: 10/25/2022] [Revised: 06/27/2023] [Accepted: 07/17/2023] [Indexed: 07/27/2023] Open
Abstract
OBJECTIVES Infantile spasm (IS) is an epileptic encephalopathy with ongoing neurological damage due to seizures and epileptiform abnormalities. Epilepsy surgery is considered for children refractory to drug therapy, especially when there is a focal brain lesion. In this study, we investigated the feasibility and efficacy of intraventricular stereotactic electroencephalography (SEEG) and laser ablation for the treatment of IS children with focal brain lesions. METHODS We performed the first reported study using ventriculoscopic laser ablation to treat IS. Seven IS children with drug-resistant epilepsy and definite encephalomalacia on brain magnetic resonance imaging scan were included in this study. Ablation was performed after confirmation of epileptiform discharges by SEEG under the surveillance of ventriculoscope. RESULTS The median follow-up time for the cohort was 3.1 years and 86% (6/7) of the children had an Engel class ≤III epilepsy at the final follow-up. Five (71%) children had a reduction in seizure medication usage, and the other two were on the same amount as preablation. None of the children experienced serious new neurological deficits. Laser ablation might result in seizure freedom by destroying the local brain network and blocking the spread of abnormal discharges. CONCLUSIONS Intraventricular SEEG and laser ablation was feasible and effective for the treatment of IS. Further studies are warranted.
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Affiliation(s)
- Xinghua Xu
- Department of NeurosurgeryThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Qun Wang
- Department of NeurosurgeryThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Yining Zhao
- Department of NeurosurgeryErlangen‐Nuremberg University HospitalErlangenGermany
| | - Xin Xu
- Department of NeurosurgeryThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Zhichao Gan
- Department of NeurosurgeryThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Shiyu Zhang
- Department of NeurosurgeryThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Xiaolei Chen
- Department of NeurosurgeryThe First Medical Center of Chinese PLA General HospitalBeijingChina
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Brandel MG, Kunwar N, Alattar AA, Kang KM, Forseth KJ, Rennert RC, Shih JJ, Ben-Haim S. A cost analysis of MR-guided laser interstitial thermal therapy for adult refractory epilepsy. Epilepsia 2023; 64:2286-2296. [PMID: 37350343 DOI: 10.1111/epi.17693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 06/12/2023] [Accepted: 06/20/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVE MR-guided laser interstitial thermal therapy (LITT) is used increasingly for refractory epilepsy. The goal of this investigation is to directly compare cost and short-term adverse outcomes for adult refractory epilepsy treated with temporal lobectomy and LITT, as well as to identify risk factors for increased costs and adverse outcomes. METHODS The National Inpatient Sample (NIS) was queried for patients who received LITT between 2012 and 2019. Patients with adult refractory epilepsy were identified. Multivariable mixed-effects models were used to analyze predictors of cost, length of stay (LOS), and complications. RESULTS LITT was associated with reduced LOS and overall cost relative to temporal lobectomy, with a statistical trend toward lower incidence of postoperative complications. High-volume surgical epilepsy centers had lower LOS overall. Longer LOS was a significant driver of increased cost for LITT, and higher comorbidity was associated with non-routine discharge. SIGNIFICANCE LITT is an affordable alternative to temporal lobectomy for adult refractory epilepsy with an insignificant reduction in inpatient complications. Patients may benefit from expanded access to this treatment modality for both its reduced LOS and lower cost.
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Affiliation(s)
- Michael G Brandel
- Department of Neurosurgery, University of California San Diego, San Diego, California, USA
| | - Nikhita Kunwar
- Department of Neurosurgery, University of California San Diego, San Diego, California, USA
| | - Ali A Alattar
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Keiko M Kang
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
| | - Kiefer J Forseth
- Department of Neurosurgery, University of California San Diego, San Diego, California, USA
| | - Robert C Rennert
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Jerry J Shih
- Department of Neurosciences, University of California San Diego, San Diego, California, USA
| | - Sharona Ben-Haim
- Department of Neurosurgery, University of California San Diego, San Diego, California, USA
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Kulkarni N, Nageotte RA, Klamer BG, Rekate HL, Bristol RE, Scharnweber T, Bobrowitz M, Kerrigan JF. Long term outcome after surgical treatment for hypothalamic hamartoma. Epilepsy Res 2023; 195:107186. [PMID: 37454523 DOI: 10.1016/j.eplepsyres.2023.107186] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/03/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE To determine long-term outcome for seizure control and clinical predictors for seizure freedom in patients undergoing surgical treatment for epilepsy associated with hypothalamic hamartoma (HH). METHODS 155 patients underwent surgical treatment for HHs and treatment-resistant epilepsy at one center (Barrow Neurological Institute at St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA) between February 2003 and June 2010. Data collection included medical record review and direct follow-up interviews to determine seizure outcome. Statistical analysis included descriptive summaries of patient characteristics and time-to-event analysis for seizure freedom. RESULTS Long-term survival with follow-up of at least five years since first surgical treatment was available for 108 patients (69.7% of the treatment cohort). The surgical approach for first HH intervention consisted of transventricular endoscopic resection (n = 57; 52.8%), transcallosal interforniceal resection (n = 35; 32.4%), pterional resection (n = 7; 6.5%), and gamma knife radiosurgery (n = 9; 8.3%). Multiple surgical procedures were required for 39 patients (36.1%). There were 10 known deaths from all causes in the treatment cohort (6.5%). Of these, one (0.6%) was related to immediate complications of HH surgery, three (1.9%) were attributed to Sudden Unexpected Death in Epileptic Persons (SUDEP), and one (0.6%) to complications of status epilepticus. For surviving patients with long-term follow-up, 55 (50.9%) were seizure-free for all seizure types. Univariable analysis showed that seizure-freedom was related to 1) absence of a pre-operative history for central precocious puberty (p = 0.01), and 2) higher percentage of HH lesion disconnection after surgery (p = 0.047). Kaplan-Meier survival analysis shows that long-term seizure outcome following HH surgery is comparable to short-term results. SUMMARY These uncontrolled observational results show that long-term seizure control following HH surgical treatment is comparable to other forms of epilepsy surgery. Late relapse (at least one year after surgery) and SUDEP do occur, but in a relatively small number of treated patients. These results inform clinical practice and serve as a comparable benchmark for newer technologies for HH surgery, such as magnetic resonance imaging-guided laser interstitial thermal therapy, where long-term outcome results are not yet available.
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Affiliation(s)
- Neil Kulkarni
- Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Rachel Ayn Nageotte
- Department of Family Medicine, HonorHealth Scottsdale Osborn Medical Center, Scottsdale, AZ, USA
| | - Brett G Klamer
- Biostatistics Resource at Nationwide Children's Hospital, Columbus, OH, USA; Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
| | - Harold L Rekate
- Long Island Jewish Medical Center, North Shore University Hospital, The Chiari Institute, Manhasset, NY, USA
| | - Ruth E Bristol
- Division of Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Travis Scharnweber
- Department of Neuroradiology, Barrow Neurological Institute at St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Margaret Bobrowitz
- Department of Neurosurgery, Barrow Neurological Institute at St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - John F Kerrigan
- Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, University of Arizona College of Medicine, Phoenix, AZ, USA
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Katlowitz KA, Athukuri P, Sharma H, Dang H, Soni A, Khan AB, Malbari F, Gadgil N, Weiner HL. Seizure outcomes after resection of primary brain tumors in pediatric patients: a systematic review and meta-analysis. J Neurooncol 2023; 164:525-533. [PMID: 37707753 DOI: 10.1007/s11060-023-04446-9] [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: 08/09/2023] [Accepted: 09/07/2023] [Indexed: 09/15/2023]
Abstract
PURPOSE Primary brain neoplasms are the most common solid tumors in pediatric patients and seizures are a common presenting symptom. Surgical intervention improves oncologic outcomes and seizure burden. A better understanding of factors that influence seizure outcomes in the surgical management of primary brain tumors of childhood can guide treatment approach thereby improving patient quality of life. METHODS We performed a systematic analysis using articles queried from PubMed, EMBASE, and Cochrane published from January 1990 to August 2022 to determine predictors of seizure outcomes in pediatric patients undergoing resection of primary brain tumors. RESULTS We identified 24 retrospective cohort studies, one prospective cohort study, and one mixed retrospective and prospective study for the systematic analysis. A total of 831 pediatric patients were available for analysis. 668 (80.4%) patients achieved seizure freedom after surgery. Complete tumor resection increased the likelihood of a seizure-free (Engel I) outcome compared to subtotal resection (OR 7.1, 95% CI 2.3-21.9). Rates of Engel I seizure outcomes did not significantly differ based on factors such as age at seizure onset, duration of epilepsy, gender, tumor laterality, or age at surgery, but trended towards significance for improved outcomes in temporal lobe tumors. CONCLUSION Primary brain tumors in the pediatric population are commonly associated with seizures. Resection of these lesions reduces seizure burden and is associated with high rates of seizure freedom. Complete resection, compared to subtotal resection, significantly increases the likelihood of seizure-free outcomes.
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Affiliation(s)
- Kalman A Katlowitz
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Prazwal Athukuri
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Himanshu Sharma
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Huy Dang
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Astitva Soni
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - A Basit Khan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Fatema Malbari
- Department of Pediatrics, Division of Child Neurology and Neurodevelopmental Disabilities, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Nisha Gadgil
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Howard L Weiner
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA.
- Department of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
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Huisman TAGM, Patel R, Kralik S, Desai NK, Meoded A, Chen K, Weiner HL, Curry DJ, Lequin M, Kranendonk M, Orman G, Jallo G. Advances in Imaging Modalities for Pediatric Brain and Spinal Cord Tumors. Pediatr Neurosurg 2023; 58:240-258. [PMID: 37604135 DOI: 10.1159/000531998] [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: 05/20/2022] [Accepted: 07/05/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Neuroimaging has evolved from anatomical imaging toward a multi-modality comprehensive anatomical and functional imaging in the past decades, important functional data like perfusion-weighted imaging, permeability imaging, diffusion-weighted imaging (DWI), and diffusion tensor imaging (DTI), tractography, metabolic imaging, connectomics, event-related functional imaging, resting state functional imaging, and much more is now being offered. SUMMARY Precision diagnostics has proven to be essential for precision treatment. Many minimal invasive techniques have been developed, taking advantage of digital subtraction angiography and interventional neuroradiology. Furthermore, intraoperative CT and/or MRI and more recently MR-guided focused ultrasound have complemented the diagnostic and therapeutic armamentarium. KEY MESSAGES In the current manuscript, we discuss standard imaging sequences including advanced techniques like DWI, DTI, susceptibility-weighted imaging, and 1H magnetic resonance spectroscopy, various perfusion weighted imaging approaches including arterial spin labeling, dynamic contrast enhanced imaging, and dynamic susceptibility contrast imaging. Pre-, intra, and postoperative surgical imaging including visualize imaging will be discussed. The value of connectomics will be presented for its value in neuro-oncology. Minimal invasive therapeutic possibilities of interventional neuroradiology and image-guided laser ablation and MR-guided high-intensity-focused ultrasound will be presented for treatment of pediatric brain and spinal cord tumors. Finally, a comprehensive review of spinal cord tumors and matching neuropathology has been included.
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Affiliation(s)
- Thierry A G M Huisman
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Rajan Patel
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Stephen Kralik
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Nilesh K Desai
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Avner Meoded
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Karen Chen
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Howard L Weiner
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel J Curry
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Maarten Lequin
- Department of Radiology, Wilhelmina Children's Hospital and Princess Maxima Center for Pediatric Oncology University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mariette Kranendonk
- Department of Pathobiology, Princess Maxima Center for Pediatric Oncology University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gunes Orman
- Divisions of Neuroradiology and Interventional Radiology, Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA,
| | - George Jallo
- Department of Neurosurgery, Institute for Brain Protection Sciences, Johns Hopkins University School of Medicine, Johns Hopkins All Children's Hospital, Saint Petersburg, Florida, USA
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12
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Kim SA, Ivanov AO, Halepa AA, Sysoeva AA, Gunenko GA. Surgical treatment of epilepsy in a patient with bilateral periventricular nodular heterotopia: A case report. Surg Neurol Int 2023; 14:283. [PMID: 37680926 PMCID: PMC10481799 DOI: 10.25259/sni_478_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/20/2023] [Indexed: 09/09/2023] Open
Abstract
Background Periventricular nodular heterotopia (PNH) is a rare pathological condition characterized by the presence of nodules of gray matter located along the lateral ventricles of the brain. The condition typically presents with seizures and other neurological symptoms, and various methods of surgical treatment and postoperative outcomes have been described in the literature. Case Description We present a case study of a 17-year-old patient who has been experiencing seizures since the age of 13. The patient reported episodes of loss of consciousness and periodic freezing with preservation of posture. Two years later, the patient experienced his first generalized tonic-clonic seizure during nocturnal sleep and was subsequently admitted to a neurological department. A magnetic resonance imaging scan of the brain with an epilepsy protocol (3 Tesla) confirmed the presence of an extended bilateral subependymal nodular heterotopy at the level of the temporal and occipital horns of the lateral ventricles, which was larger on the left side, and a focal subcortical heterotopy of the right cerebellar hemisphere. The patient underwent a posterior quadrant disconnection surgery, which aimed to isolate the extensive epileptogenic zone in the left temporal, parietal, and occipital lobes using standard techniques. As of today, 6 months have passed since the surgery and there have been no registered epileptic seizures during this period following the surgical treatment. Conclusion Although PNHs can be extensive and located bilaterally, surgical intervention may still be an effective way to achieve seizure control in selected cases.
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Affiliation(s)
- Sergey Afanasievich Kim
- Department of Pediatric Neurosurgery, Federal Center of Neurosurgery, Novosibirsk, Russian Federation
- Research Institute of Clinical and Experimental Lymphology - Branch of the Federal State Budgetary Scientific Institution “Federal Research Center Institute of Cytology and Genetics of the Siberian Branch of the Russian Academy of Sciences”, Novosibirsk, Russia
| | - Anton Olegovich Ivanov
- Department of Pediatric Neurosurgery, Federal Center of Neurosurgery, Novosibirsk, Russian Federation
| | | | - Anna Alexeevna Sysoeva
- Department of Pediatric Neurosurgery, Federal Center of Neurosurgery, Novosibirsk, Russian Federation
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13
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Chen JS, Lamoureux AA, Shlobin NA, Elkaim LM, Wang A, Ibrahim GM, Obaid S, Harroud A, Guadagno E, Dimentberg E, Bouthillier A, Bernhardt BC, Nguyen DK, Fallah A, Weil AG. Magnetic resonance-guided laser interstitial thermal therapy for drug-resistant epilepsy: A systematic review and individual participant data meta-analysis. Epilepsia 2023; 64:1957-1974. [PMID: 36824029 DOI: 10.1111/epi.17560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/30/2023] [Accepted: 02/22/2023] [Indexed: 02/25/2023]
Abstract
Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) has emerged as a popular minimally invasive alternative to open resective surgery for drug-resistant epilepsy (DRE). We sought to perform a systematic review and individual participant data meta-analysis to identify independent predictors of seizure outcome and complications following MRgLITT for DRE. Eleven databases were searched from January 1, 2010 to February 6, 2021 using the terms "MR-guided ablation therapy" and "epilepsy". Multivariable mixed-effects Cox and logistic regression identified predictors of time to seizure recurrence, seizure freedom, operative complications, and postoperative neurological deficits. From 8705 citations, 46 studies reporting on 450 MRgLITT DRE patients (mean age = 29.5 ± 18.1 years, 49.6% female) were included. Median postoperative seizure freedom and follow-up duration were 15.5 and 19.0 months, respectively. Overall, 240 (57.8%) of 415 patients (excluding palliative corpus callosotomy) were seizure-free at last follow-up. Generalized seizure semiology (hazard ratio [HR] = 1.78, p = .020) and nonlesional magnetic resonance imaging (MRI) findings (HR = 1.50, p = .032) independently predicted shorter time to seizure recurrence. Cerebral cavernous malformation (CCM; odds ratio [OR] = 7.97, p < .001) and mesial temporal sclerosis/atrophy (MTS/A; OR = 2.21, p = .011) were independently associated with greater odds of seizure freedom at last follow-up. Operative complications occurred in 28 (8.5%) of 330 patients and were independently associated with extratemporal ablations (OR = 5.40, p = .012) and nonlesional MRI studies (OR = 3.25, p = .017). Postoperative neurological deficits were observed in 53 (15.1%) of 352 patients and were independently predicted by hypothalamic hamartoma etiology (OR = 5.93, p = .006) and invasive electroencephalographic monitoring (OR = 4.83, p = .003). Overall, MRgLITT is particularly effective in treating patients with well-circumscribed lesional DRE, such as CCM and MTS/A, but less effective in nonlesional cases or lesional cases with a more diffuse epileptogenic network associated with generalized seizures. This study identifies independent predictors of seizure freedom and complications following MRgLITT that may help further guide patient selection.
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Affiliation(s)
- Jia-Shu Chen
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Audrey-Anne Lamoureux
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Nathan A Shlobin
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Lior M Elkaim
- Division of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Andrew Wang
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - George M Ibrahim
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Sami Obaid
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Montreal, Quebec, Canada
- Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Adil Harroud
- Division of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
- Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Elena Guadagno
- Harvey E. Beardmore Division of Pediatric Surgery, McGill University Health Center, Montreal, Quebec, Canada
| | - Evan Dimentberg
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Montreal, Quebec, Canada
- Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Alain Bouthillier
- Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Boris C Bernhardt
- McConnell Brain Imaging Center, Montreal Neurological Institute and Hospital, McGill University, Quebec, Canada
| | - Dang K Nguyen
- Division of Neurology, University of Montreal Medical Center, Montreal, Quebec, Canada
| | - Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Alexander G Weil
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Montreal, Quebec, Canada
- Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
- Brain and Child Development Axis, Sainte Justine Research Center, Montreal, Quebec, Canada
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14
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Gong M, Xu K, Shan Y, Wang Y, Zhang C, Wang X, Zhou J, Guan Y, Li T, Luan G. Protocol of a prospective multicenter randomized controlled trial of robot-assisted stereotactic lesioning in the treatment of focal drug-resistant epilepsy. Trials 2023; 24:387. [PMID: 37296479 DOI: 10.1186/s13063-023-07334-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/29/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND This protocol describes the design of a multicenter randomized controlled trial of robot-assisted stereotactic lesioning versus epileptogenic foci resection. Typical causes of focal epilepsy include hippocampal sclerosis and focal cortical dysplasia. These patients usually present with drug resistance and require surgical treatment. Although epileptogenic foci resection is still the most commonly used treatment for such focal epilepsy, there is increasing evidence that epileptogenic focus resection may lead to neurological impairment. The treatment of epilepsy with a robot-assisted stereotactic lesioning mainly includes two new minimally invasive surgical methods: radiofrequency thermocoagulation (RF-TC) and laser interstitial thermal therapy (LITT). Seizure-free is less likely to be achieved by these two procedures, but neurologic preservation is better. In this study, we aimed to compare the safety and efficacy of RF-TC, LITT, and epileptogenic foci resection for focal drug-resistant epilepsy. METHODS This is a multicenter, three-arm, randomized controlled clinical trial. The study will include patients older than 3 years of age with epilepsy who have had medically refractory seizures for at least 2 years and are eligible for surgical treatment with an epileptogenic focus as determined by multidisciplinary evaluation prior to randomization. The primary outcome measure is seizure outcome (quantified by seizure remission rate) at 3-month, 6-month, and 1-year follow-up after treatment. Postoperative neurologic impairment, spectrum distribution change of video electroencephalogram, quality of life, and medical costs will also be assessed as secondary outcomes. TRIAL REGISTRATION Chinese Clinical Trials Registry ChiCTR2200060974. Registered on June 14, 2022. The status of the trial is recruiting, and the estimated study completion date is December 31, 2024.
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Affiliation(s)
- Mingkun Gong
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Haidian District, No. 50, Yikesong Road, Beijing, 100093, China
| | - Ke Xu
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Haidian District, No. 50, Yikesong Road, Beijing, 100093, China
| | - Yongzhi Shan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, 100053, China
| | - Yihe Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, 100053, China
| | - Chao Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 10007, China
| | - Xiongfei Wang
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Haidian District, No. 50, Yikesong Road, Beijing, 100093, China
| | - Jian Zhou
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Haidian District, No. 50, Yikesong Road, Beijing, 100093, China
| | - Yuguang Guan
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Haidian District, No. 50, Yikesong Road, Beijing, 100093, China
| | - Tianfu Li
- Department of Neurology, Sanbo Brain Hospital, Capital Medical University, Haidian District, No. 50, Yikesong Road, Beijing, 100093, China
| | - Guoming Luan
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Haidian District, No. 50, Yikesong Road, Beijing, 100093, China.
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15
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Lawrence JD, Marsh R. Feasibility and Morbidity for the Use of MR-Guided Laser-Induced Thermotherapy for the Treatment of Skull Base Tumors: A Report of Three Cases. J Neurol Surg Rep 2023; 84:e46-e50. [PMID: 37090943 PMCID: PMC10121370 DOI: 10.1055/a-2061-3075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 12/23/2022] [Indexed: 04/25/2023] Open
Abstract
Background Laser-induced thermotherapy (LITT) is a minimally invasive technique that has been demonstrated as an effective treatment of many pathologies; however, it has never been investigated for the use in skull base tumors. Case Series Three patients underwent LITT for treatment of skull base meningiomas. All three patients were determined to be poor candidates for open resection. Each patient was treated with a single laser fiber. Postoperative imaging confirmed ablation zones along the tract of the catheter in all three patients. Ablation zones were estimated to be 9 to 20% of the intended to treat tumor volume. Two of three treated patients suffered cranial nerve injury following the procedure with one patient diagnosed with neurotrophic keratitis and one patient with symptoms consistent with anesthesia dolorosa. Conclusion LITT is a technically feasible, minimally invasive treatment modality for skull base lesions. Significant risk to cranial nerves and small ablation zones afforded by a single cannula placement proposes serious obstacles. Further investigation is warranted prior to using this technique outside of a palliative indication.
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Affiliation(s)
- Jesse D. Lawrence
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, United States
- Address for correspondence Jesse D. Lawrence, MD Department of Neurosurgery, West Virginia University, 1 Medical Center DriveMorgantown, WV 26505United States
| | - Robert Marsh
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, United States
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16
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Obaid S, Chen JS, Ibrahim GM, Bouthillier A, Dimentberg E, Surbeck W, Guadagno E, Brunette-Clément T, Shlobin NA, Shulkin A, Hale AT, Tomycz LD, Von Lehe M, Perry MS, Chassoux F, Bouilleret V, Taussig D, Fohlen M, Dorfmuller G, Hagiwara K, Isnard J, Oluigbo CO, Ikegaya N, Nguyen DK, Fallah A, Weil AG. Predictors of outcomes after surgery for medically intractable insular epilepsy: A systematic review and individual participant data meta-analysis. Epilepsia Open 2023; 8:12-31. [PMID: 36263454 PMCID: PMC9978079 DOI: 10.1002/epi4.12663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 09/28/2022] [Indexed: 11/11/2022] Open
Abstract
Insular epilepsy (IE) is an increasingly recognized cause of drug-resistant epilepsy amenable to surgery. However, concerns of suboptimal seizure control and permanent neurological morbidity hamper widespread adoption of surgery for IE. We performed a systematic review and individual participant data meta-analysis to determine the efficacy and safety profile of surgery for IE and identify predictors of outcomes. Of 2483 unique citations, 24 retrospective studies reporting on 312 participants were eligible for inclusion. The median follow-up duration was 2.58 years (range, 0-17 years), and 206 (66.7%) patients were seizure-free at last follow-up. Younger age at surgery (≤18 years; HR = 1.70, 95% CI = 1.09-2.66, P = .022) and invasive EEG monitoring (HR = 1.97, 95% CI = 1.04-3.74, P = .039) were significantly associated with shorter time to seizure recurrence. Performing MR-guided laser ablation or radiofrequency ablation instead of open resection (OR = 2.05, 95% CI = 1.08-3.89, P = .028) was independently associated with suboptimal or poor seizure outcome (Engel II-IV) at last follow-up. Postoperative neurological complications occurred in 42.5% of patients, most commonly motor deficits (29.9%). Permanent neurological complications occurred in 7.8% of surgeries, including 5% and 1.4% rate of permanent motor deficits and dysphasia, respectively. Resection of the frontal operculum was independently associated with greater odds of motor deficits (OR = 2.75, 95% CI = 1.46-5.15, P = .002). Dominant-hemisphere resections were independently associated with dysphasia (OR = 13.09, 95% CI = 2.22-77.14, P = .005) albeit none of the observed language deficits were permanent. Surgery for IE is associated with a good efficacy/safety profile. Most patients experience seizure freedom, and neurological deficits are predominantly transient. Pediatric patients and those requiring invasive monitoring or undergoing stereotactic ablation procedures experience lower rates of seizure freedom. Transgression of the frontal operculum should be avoided if it is not deemed part of the epileptogenic zone. Well-selected candidates undergoing dominant-hemisphere resection are more likely to exhibit transient language deficits; however, the risk of permanent deficit is very low.
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Affiliation(s)
- Sami Obaid
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada.,Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Jia-Shu Chen
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - George M Ibrahim
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Alain Bouthillier
- Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Evan Dimentberg
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada.,Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Werner Surbeck
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital of the University of Zurich, Zurich, Switzerland
| | - Elena Guadagno
- Harvey E. Beardmore Division of Pediatric Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tristan Brunette-Clément
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada.,Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Nathan A Shlobin
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Aidan Shulkin
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada
| | - Andrew T Hale
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Luke D Tomycz
- The Epilepsy Institute of New Jersey, Jersey City, New Jersey, USA
| | - Marec Von Lehe
- Department of Neurosurgery, Brandenburg Medical School, Neuruppin, Germany
| | - Michael Scott Perry
- Comprehensive Epilepsy Program, Jane and John Justin Neuroscience Center, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Francine Chassoux
- Service de Neurochirurgie, GHU Paris Psychiatrie et Neurosciences, Université Paris-Descartes Paris, Paris, France
| | - Viviane Bouilleret
- Université Paris Saclay-APHP, Unité de Neurophysiologie Clinique et d'Épileptologie(UNCE), Le Kremlin Bicêtre, France
| | - Delphine Taussig
- Université Paris Saclay-APHP, Unité de Neurophysiologie Clinique et d'Épileptologie(UNCE), Le Kremlin Bicêtre, France.,Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France
| | - Martine Fohlen
- Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France
| | - Georg Dorfmuller
- Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France
| | - Koichi Hagiwara
- Epilepsy and Sleep Center, Fukuoka Sanno Hospital, Fukuoka, Japan
| | - Jean Isnard
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon, Hospital for Neurology and Neurosurgery, Lyon, France
| | - Chima O Oluigbo
- Department of Neurosurgery, Children's National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Naoki Ikegaya
- Departments of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Dang K Nguyen
- Division of Neurology, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Aria Fallah
- Department of Neurosurgery and Pediatrics, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Alexander G Weil
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada.,Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada.,Department of Neuroscience, University of Montreal, Montreal, Quebec, Canada
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17
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The use of stereotactic MRI-guided laser interstitial thermal therapy for the treatment of pediatric cavernous malformations: the SUNY Upstate Golisano Children's Hospital experience. Childs Nerv Syst 2023; 39:417-424. [PMID: 36416952 DOI: 10.1007/s00381-022-05701-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 10/03/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Cavernous malformations (CM) are central nervous system lesions characterized by interlaced vascular sinusoids coated with endothelial cells without intervening parenchyma. Magnetic resonance imaging-guided laser interstitial thermal therapy (MRIgLITT) is a minimally invasive treatment modality that can precisely treat pathologic cerebral tissue, making it an effective alternative for the management of cavernomas. We describe the outcomes of a series of pediatric patients with cavernous brain malformations treated with MRIgLITT between 2014 and 2018 at our institution. METHODS We retrospectively analyzed 11 cavernomas in 6 pediatric patients treated with MRIgLITT. Both the Visualase System® and/or Neuroblate® systems were used. A variation of the surgical technique on the application of the laser was developed. Post-ablation MRIs were obtained to assess ablated areas. RESULTS A total of 11 cavernomas in 6 patients were treated with MRIgLITT. Median age was 15 years (12 to 17 years); 75% were males. Presenting symptoms were headache (75%) and seizures (25%). Two patients presented with multiple CMs. All lesions in this study were supratentorial (cerebral hemispheres 81.8%, corpus callosum 9.1%, basal ganglia 9.1%). Our surgical technique was well-tolerated, with no significant adverse events observed. Hospital stay for all patients was less than 48 hours. CONCLUSION MRIgLITT is an effective minimally invasive technique for the treatment of pediatric CMs. It represents a useful and safe tool, when other therapeutic alternatives may represent a greater risk of surgical morbidity.
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18
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A novel technique for frame-based MR-guided laser ablation in an infant. Childs Nerv Syst 2023; 39:497-503. [PMID: 35925382 DOI: 10.1007/s00381-022-05616-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 07/23/2022] [Indexed: 11/03/2022]
Abstract
Hypothalamic hamartomata (HH) not only are usually associated with drug-resistant epilepsy but can also cause precocious puberty and developmental delay. Gelastic seizures are the most common type of seizures. Magnetic resonance image (MRI)-guided laser interstitial thermal therapy (LiTT) is a technique whereby a laser fibre is stereotactically implanted into a target lesion and heat is used to ablate whilst tissue temperature is monitored using MRI thermography. MRI-guided LiTT has proven to be an effective and safe method to treat HH. To use the LiTT system, highly accurate stereotactic fibre implantation is required. This can be achieved by the use of frame-based or frameless neuronavigation techniques. However, these techniques generally involve rigid head immobilisation using cranial pin fixation. Patients need sufficient skull thickness to safely secure the pins and sufficient skull rigidity to prevent deformation. Hence, most of the clinical reports on the use of LiTT for children describe patients aged 2 years or older. We report a novel and practical technique of using a paste cast helmet to securely place a stereotactic frame in a 5-month-old infant with HH and drug-resistant epilepsy that allowed the successful application of MRI-guided LiTT.
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19
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Ravindra VM, Karas PJ, Lazaro TT, Coorg R, Awad AW, Patino I, McClernon EE, Clarke D, Cairampoma Whitehead L, Anderson A, Diaz-Medina G, Houck K, Katyayan A, Masters L, Nath A, Quach M, Riviello J, Seto ES, Sully K, Agurs L, Sen S, Handoko M, LoPresti M, Ali I, Curry DJ, Weiner HL. Epilepsy Surgery in Young Children With Tuberous Sclerosis Complex: A Novel Hybrid Multimodal Surgical Approach. Neurosurgery 2023; 92:398-406. [PMID: 36637274 DOI: 10.1227/neu.0000000000002214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 08/31/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Surgery has become integral in treating children with tuberous sclerosis complex (TSC)-related drug-resistant epilepsy (DRE). OBJECTIVE To describe outcomes of a multimodal diagnostic and therapeutic approach comprising invasive intracranial monitoring and surgical treatment and compare the complementary techniques of open resection and magnetic resonance-guided laser interstitial thermal therapy. METHODS Clinical and radiographic data were prospectively collected for pediatric patients undergoing surgical evaluation for TSC-related DRE at our tertiary academic hospital. Seizure freedom, developmental improvement, and Engel class were compared. RESULTS Thirty-eight patients (20 females) underwent treatment in January 2016 to April 2019. Thirty-five underwent phase II invasive monitoring with intracranial electrodes: 24 stereoencephalography, 9 craniotomy for grid/electrode placement, and 2 grids + stereoencephalography. With the multimodal approach, 33/38 patients (87%) achieved >50% seizure freedom of the targeted seizure type after initial treatment; 6/9 requiring secondary treatment and 2/2 requiring a third treatment achieved >50% freedom. The median Engel class was II at last follow-up (1.65 years), and 55% of patients were Engel class I/II. The mean age was lower for children undergoing open resection (2.4 vs 4.9 years, P = .04). Rates of >50% reduction in seizures (86% open resection vs 88% laser interstitial thermal therapy) and developmental improvement (86% open resection vs 83% magnetic resonance-guided laser interstitial thermal therapy) were similar. CONCLUSION This hybrid approach of using both open surgical and minimally invasive techniques is safe and effective in treating DRE secondary to TSC. Clinical trials focused on treatment method with longer follow-up are needed to determine the optimal candidates for each approach and compare the treatment modalities more effectively.
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Affiliation(s)
- Vijay M Ravindra
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Patrick J Karas
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Tyler T Lazaro
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Rohini Coorg
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Al-Wala Awad
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Ilana Patino
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Emily E McClernon
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Dave Clarke
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Laura Cairampoma Whitehead
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Anne Anderson
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Gloria Diaz-Medina
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Kimberly Houck
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Akshat Katyayan
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Laura Masters
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Audrey Nath
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Michael Quach
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - James Riviello
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Elaine S Seto
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Krystal Sully
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Latanya Agurs
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Sonali Sen
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Maureen Handoko
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Melissa LoPresti
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Irfan Ali
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel J Curry
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Howard L Weiner
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
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20
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Vetkas A, Germann J, Boutet A, Samuel N, Sarica C, Yamamoto K, Santyr B, Cheyuo C, Conner CR, Lang SM, Lozano AM, Ibrahim GM, Valiante T, Kongkham PN, Kalia SK. Laser interstitial thermal therapy for the treatment of insular lesions: A systematic review. Front Neurol 2023; 13:1024075. [PMID: 36686528 PMCID: PMC9845884 DOI: 10.3389/fneur.2022.1024075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 12/02/2022] [Indexed: 01/06/2023] Open
Abstract
Background The surgical treatment of insular lesions has been historically associated with high morbidity. Laser interstitial thermal therapy (LITT) has been increasingly used in the treatment of insular lesions, commonly neoplastic or epileptogenic. Stereotaxis is used to guide laser probes to the insula where real-time magnetic resonance thermometry defines lesion creation. There is an absence of previously published reviews on insular LITT, despite a rapid uptake in use, making further study imperative. Methods Here we present a systematic review of the PubMed and Scopus databases, examining the reported clinical indications, outcomes, and adverse effects of insular LITT. Results A review of the literature revealed 10 retrospective studies reporting on 53 patients (43 pediatric and 10 adults) that were treated with insular LITT. 87% of cases were for the treatment of epilepsy, with 89% of patients achieving seizure outcomes of Engle I-III following treatment. The other 13% of cases reported on insular tumors and radiological improvement was seen in all cases following treatment. All but one study reported adverse events following LITT with a rate of 37%. The most common adverse events were transient hemiparesis (29%) and transient aphasia (6%). One patient experienced an intracerebral hemorrhage, which required a decompressive hemicraniectomy, with subsequent full recovery. Conclusion This systematic review highlights the suitability of LITT for the treatment of both insular seizure foci and insular tumors. Despite the growing use of this technique, prospective studies remain absent in the literature. Future work should directly evaluate the efficacy of LITT with randomized and controlled trials.
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Affiliation(s)
- Artur Vetkas
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada,Neurology Clinic, Department of Neurosurgery, Tartu University Hospital, University of Tartu, Tartu, Estonia,*Correspondence: Artur Vetkas ✉
| | - Jürgen Germann
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Alexandre Boutet
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada,Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Nardin Samuel
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Can Sarica
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Kazuaki Yamamoto
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Brendan Santyr
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada,Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Cletus Cheyuo
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Christopher R. Conner
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Stefan M. Lang
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Andres M. Lozano
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada,Krembil Research Institute, Toronto, ON, Canada
| | - George M. Ibrahim
- Division of Pediatric Neurosurgery, Sick Kids Toronto, University of Toronto, Toronto, ON, Canada
| | - Taufik Valiante
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada,CRANIA, University Health Network and University of Toronto, Toronto, ON, Canada,The KITE Research Institute, University Health Network, Toronto, ON, Canada
| | - Paul N. Kongkham
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Suneil K. Kalia
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada,CRANIA, University Health Network and University of Toronto, Toronto, ON, Canada,The KITE Research Institute, University Health Network, Toronto, ON, Canada
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21
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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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22
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Candela-Cantó S, Muchart J, Valera C, Jou C, Culebras D, Alamar M, Becerra V, Artés D, Armero G, Aparicio J, Hinojosa J, Rumià J. Completion of disconnective surgery for refractory epilepsy in pediatric patients using robot-assisted MRI-guided laser interstitial thermal therapy. J Neurosurg Pediatr 2023; 31:61-70. [PMID: 36272116 DOI: 10.3171/2022.9.peds22258] [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: 06/22/2022] [Accepted: 09/08/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Since 2007, the authors have performed 34 hemispherotomies and 17 posterior quadrant disconnections (temporoparietooccipital [TPO] disconnections) for refractory epilepsy at Sant Joan de Déu Barcelona Children's Hospital. Incomplete disconnection is the main cause of surgical failure in disconnective surgery, and reoperation is the treatment of choice. In this study, 6 patients previously treated with hemispherotomy required reoperation through open surgery. After the authors' initial experience with real-time MRI-guided laser interstitial thermal therapy (MRIgLITT) for hypothalamic hamartomas, they decided to use this technique instead of open surgery to complete disconnective surgeries. The objective was to report the feasibility, safety, and efficacy of MRIgLITT to complete hemispherotomies and TPO disconnections for refractory epilepsy in pediatric patients. METHODS Eight procedures were performed on 6 patients with drug-resistant epilepsy. Patient ages ranged between 4 and 18 years (mean 10 ± 4.4 years). The patients had previously undergone hemispherotomy (4 patients) and TPO disconnection (2 patients) at the hospital. The Visualase system assisted by a Neuromate robotic arm was used. The ablation trajectory was planned along the residual connection. The demographic and epilepsy characteristics of the patients, precision of the robot, details of the laser ablation, complications, and results were prospectively collected. RESULTS Four patients underwent hemispherotomy and 2 underwent TPO disconnection. Two patients, including 1 who underwent hemispherotomy and 1 who underwent TPO disconnection, received a second laser ablation because of persistent seizures and connections after the first treatment. The average precision of the system (target point localization error) was 1.7 ± 1.4 mm. The average power used was 6.58 ± 1.53 J. No complications were noted. Currently, 5 of the 6 patients are seizure free (Engel class I) after a mean follow-up of 20.2 ± 5.6 months. CONCLUSIONS According to this preliminary experience, laser ablation is a safe method for complete disconnective surgeries and allowed epilepsy control in 5 of the 6 patients treated. A larger sample size and longer follow-up periods are necessary to better assess the efficacy of MRIgLITT to complete hemispherotomy and TPO disconnection, but the initial results are encouraging.
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Affiliation(s)
- Santiago Candela-Cantó
- Departments of1Neurosurgery
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
| | - Jordi Muchart
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
- 3Diagnostic Imaging
| | - Carlos Valera
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
| | - Cristina Jou
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
- 4Pathology, and
| | - Diego Culebras
- Departments of1Neurosurgery
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
| | | | | | | | | | - Javier Aparicio
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
| | - José Hinojosa
- Departments of1Neurosurgery
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
| | - Jordi Rumià
- Departments of1Neurosurgery
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
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23
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Melikyan AG, Kozlova AB, Vlasov PA, Dorofeeva MY, Shishkina LV, Agrba SB. [Epilepsy surgery in children with tuberous sclerosis]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:5-16. [PMID: 37011323 DOI: 10.17116/neiro2023870215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Most children with tuberous sclerosis (TS) present with intractable seizures. Various factors including demography, clinical data and surgery option are mentioned to affect the outcome after epilepsy surgery in these cases. OBJECTIVE To evaluate some demographic and clinical variables probably related to seizure outcome. MATERIAL AND METHODS Thirty-three children, median age 4.2 ys (7.5 mths-16 ys), with TS and DR-epilepsy underwent surgery. Within overall 38 procedures (redo surgery was needed in 5 cases), tuberectomy (with or without perituberal cortectomy) was performed in 21 cases, lobectomy - 8, callosotomy - 3, various disconnections (anterior frontal, TPO and hemispherotomy) - 6 patients. Standard preoperative evaluation included MRI and video-EEG. Invasive recordings were used in 8 cases, coupled by MEG and SISCOM SPECT in some cases. ECOG and neuronavigation were used routinely during tuberectomies, and stimulation and mapping were employed in cases with lesions overlapping or near to eloquent cortex. Surgical complications: wound CSF leak (n=1) and hydrocephalus (n=2) were noted in 7.5% of cases. Postoperative neurological deficit (most frequently hemiparesis) developed in 12 patients, being temporary in majority of them. At the last FU (med 5.4 ys) favorable outcome (Engel I) has been achieved in 18 cases (54%), while 7 patients (15%) with persisting seizures reported less common attacks and their milder form (Engel Ib-III). Six patients were able to discontinue AED-treatment and 15 children resumed development and markedly improved in cognition and behavior. RESULTS AND CONCLUSION Among different variables potentially influencing the outcome after epilepsy surgery in cases with TS, the most important one is seizure type. If prevalent, focal type may be a biomarker of favorable outcomes and probability to become free of seizures.
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Affiliation(s)
| | - A B Kozlova
- Burdenko Neurosurgical Center, Moscow, Russia
| | - P A Vlasov
- Burdenko Neurosurgical Center, Moscow, Russia
| | - M Yu Dorofeeva
- Veltishchev Research and Clinical Institute for Pediatrics and Pediatric Surgery, Moscow, Russia
| | | | - S B Agrba
- Burdenko Neurosurgical Center, Moscow, Russia
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24
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Belal A, Allmen GV, Kommuru I, Lankford J, Mosher JC, Shah M, Funke M, Watkins M, Patel R. Complete corpus callosotomy using a frameless navigation probe through a minicraniotomy in children with medically refractory epilepsy: A case series and technical note. Surg Neurol Int 2022; 13:585. [PMID: 36600777 PMCID: PMC9805650 DOI: 10.25259/sni_1188_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 09/13/2022] [Indexed: 12/24/2022] Open
Abstract
Background Medically refractory epilepsy constitutes up to one-third of the epilepsy pediatric patients. Corpus callosotomy (CC) has been used for the treatment of medically refractory epilepsy in children with atonic seizures and generalized tonic-clonic (GTC) seizures. In this case series study, we are describing a novel technique for CC using the frameless navigation probe through a minicraniotomy. Methods Thirteen pediatric patients with the diagnosis of medically refractory epilepsy predominantly GTC with drop attack who underwent extensive Phase I. An L-shape was done, then through a 4 × 3 cm craniotomy, we were able to open the interhemispheric fissure until the corpus callosum is visualized. The Stealth probe is then used to go down to the midline raphe which is followed anteriorly then traced posteriorly to the anterior border of the vein of Galen. Finally, the Stealth probe is used to confirm the completeness of the callosotomy. Results The procedure was accomplished successfully with no intraoperative complications; mean surgical time is 3 h:07 m. The mean follow-up was 31.5 months. All patients achieved significant seizure control. No patients experienced worsening of their atonic seizures after surgery compared with their preoperative state; however, six patients achieved Engel Class I, four patients achieved Engel Class II, and three patients achieved Engel Class III. Conclusion Complete CC using a frameless navigation probe is a novel and effective technique for the treatment of medically refractory epilepsy with a very good surgical and seizure outcomes, minimal neurological morbidity, minimal blood loss, and short OR time.
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Affiliation(s)
- Ahmed Belal
- Department of Pediatric Neurosurgery, McGovern Medical School, University of Texas, Houston and Children’s Memorial Hermann Hospital, Texas, United States.,Department of Neurosurgery, Indiana University, Texas, United States.,Corresponding author: Ahmed Belal, Department of Pediatric Neurosurgery, McGovern Medical School, University of Texas, Houston and Children’s Memorial Hermann Hospital, Houston, Texas, United States.
| | - Gretchen Von Allmen
- Department of Pediatric Neurology, McGovern Medical School at UTHouston and Children’s Memorial Hermann Hospital, Texas, United States
| | - Indira Kommuru
- Department of Pediatric Neurology, McGovern Medical School at UTHouston and Children’s Memorial Hermann Hospital, Texas, United States
| | - Jeremy Lankford
- Department of Pediatric Neurology, McGovern Medical School at UTHouston and Children’s Memorial Hermann Hospital, Texas, United States
| | - John C. Mosher
- Department of Neurology, University of Texas Health Science Center at Houston, Texas, United States
| | - Manish Shah
- Department of Pediatric Neurosurgery, McGovern Medical School, University of Texas, Houston and Children’s Memorial Hermann Hospital, Texas, United States
| | - Michael Funke
- Department of Pediatric Neurology, McGovern Medical School at UTHouston and Children’s Memorial Hermann Hospital, Texas, United States
| | - Michael Watkins
- Department of Pediatric Neurology, McGovern Medical School at UTHouston and Children’s Memorial Hermann Hospital, Texas, United States
| | - Rajan Patel
- Department of Radiology, McGovern Medical School at UTHouston and Children’s Memorial Hermann Hospital, Houston, Texas, United States
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25
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Best BJ, Kim I, Lew SM. Magnetic resonance imaging-guided laser interstitial thermal therapy for complete corpus callosotomy: technique and 1-year outcomes. Patient series. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22364. [PMID: 36536524 PMCID: PMC9764374 DOI: 10.3171/case22364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/27/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI)-guided stereotactic laser interstitial thermal therapy (LITT) is a minimally invasive technique that has been described for the treatment of certain forms of epilepsy through partial or complete callosotomy, with few cases describing single-stage complete LITT callosotomy. The authors aimed to demonstrate this technique's feasibility and efficacy through description of the technique and 1-year outcomes in 3 cases of single-stage complete LITT callosotomy in patients with anatomically normal corpa callosa (CCs). OBSERVATIONS The patients were aged 14-27 years and experienced atonic seizures. Completeness of callosotomy was determined from MRI scans obtained >3 months after LITT procedures. The estimated ablations of the CC were 94%, 89%, and 100%, respectively. The second patient had a catheter breach the lateral ventricle, resulting in the lowest estimated percentage of ablation in this series (89%), with minimal atonic seizure reduction. The first patient had significant reduction in atonic seizure frequency, and the third patient had complete resolution of atonic seizures. None of the patients experienced any long-term complications. Intensive care length of stay was 1 night for each patient, and total length of stay was between 2 and 7 nights. Postoperative follow-up was between 14 and 18 months. LESSONS Complete laser callosotomy is achievable and is a safe alternative to microsurgical or endoscopic approaches.
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Affiliation(s)
- Benjamin J. Best
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin; and ,Division of Pediatric Neurosurgery, Children’s Wisconsin, Milwaukee, Wisconsin
| | - Irene Kim
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin; and ,Division of Pediatric Neurosurgery, Children’s Wisconsin, Milwaukee, Wisconsin
| | - Sean M. Lew
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin; and ,Division of Pediatric Neurosurgery, Children’s Wisconsin, Milwaukee, Wisconsin
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26
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Yao Y, Wang X, Hu W, Zhang C, Sang L, Zheng Z, Mo J, Liu C, Qiu J, Shao X, Zhang J, Zhang K. Magnetic Resonance-Guided Laser Interstitial Thermal Therapy for Hypothalamic Hamartoma: Surgical Approach and Treatment Outcomes. J Clin Med 2022; 11:6579. [PMID: 36362807 PMCID: PMC9658093 DOI: 10.3390/jcm11216579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 10/31/2022] [Accepted: 11/04/2022] [Indexed: 09/18/2023] Open
Abstract
Hypothalamic hamartoma (HH) is a rare lesion consisting of normal neurons and neuroglia arranged in an abnormal pattern which usually causes gelastic seizures (GS). Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) has been developed as a minimally invasive approach to treat HH and gradually become a first-line treatment. In total, this study enrolled 47 consecutive HH patients that underwent one round of ablation. Patients were followed for at least one year. Patients' medical records and surgical information were carefully reviewed, and univariate analyses were performed. Of the treated patients, 72.3% remained GS-free in this study, with an overall Engel class I rate of 68.1%. Long-term postoperative complications occurred in six patients. Factors associated with GS prognosis included Delalande classification (p = 0.033), HH volume (p = 0.01), and the ablation rate of the HH body (p = 0.035). The disconnection rate was 0.73 ± 0.14 in the Engel class Ia group as compared to 0.62 ± 0.13 in the Engel Ib-Engel IV group (p = 0.046). MRgLITT represents a safe and effective surgical procedure. Patients with larger or Delalande type IV HH may require multiple rounds of ablation. In addition to assessing the degree of disconnection, ablation volume should also be carefully considered for patients undergoing this procedure.
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Affiliation(s)
- Yuan Yao
- Department of Neurosurgery, Beijing TianTan Hospital, Capital Medical University, Beijing 100070, China
| | - Xiu Wang
- Department of Neurosurgery, Beijing TianTan Hospital, Capital Medical University, Beijing 100070, China
| | - Wenhan Hu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing 100070, China
| | - Chao Zhang
- Department of Neurosurgery, Beijing TianTan Hospital, Capital Medical University, Beijing 100070, China
| | - Lin Sang
- Department of Neurosurgery, Beijing FengTai Hospital, Beijing 100070, China
| | - Zhong Zheng
- Department of Neurosurgery, Beijing FengTai Hospital, Beijing 100070, China
| | - Jiajie Mo
- Department of Neurosurgery, Beijing TianTan Hospital, Capital Medical University, Beijing 100070, China
| | - Chang Liu
- Department of Neurosurgery, Beijing TianTan Hospital, Capital Medical University, Beijing 100070, China
| | - Jiaji Qiu
- Department of Neurosurgery, Beijing TianTan Hospital, Capital Medical University, Beijing 100070, China
| | - Xiaoqiu Shao
- Department of Neurosurgery, Beijing TianTan Hospital, Capital Medical University, Beijing 100070, China
| | - Jianguo Zhang
- Department of Neurosurgery, Beijing TianTan Hospital, Capital Medical University, Beijing 100070, China
| | - Kai Zhang
- Department of Neurosurgery, Beijing TianTan Hospital, Capital Medical University, Beijing 100070, China
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27
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Muacevic A, Adler JR, Jimenez MJD, Budnick HC, Raskin J. Thermal Damage Estimate Artifact Following Antecedent Biopsy: A Case Report. Cureus 2022; 14:e31913. [PMID: 36579245 PMCID: PMC9792349 DOI: 10.7759/cureus.31913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2022] [Indexed: 11/27/2022] Open
Abstract
MR-guided laser interstitial therapy (MRgLITT) is becoming more commonly used for minimal access approaches to intracranial lesions of all etiologies. The short-term safety profile of MRgLITT is favorable compared with sweeping incisions and open craniotomies, especially for lesions located in deep, periventricular, and highly eloquent areas. The Visualase software (Medtronic Inc., Minneapolis, MN, USA) has multiple adaptations to assist with this safety margin, including the thermal damage estimate (TDE), which applies predictive mathematical modeling to a two-dimensional (2D) graphical representation. TDE has been shown to highly correlate with actual tissue destruction in a priori MRgLITT cases and to anecdotally be imprecise when MRgLITT is combined with biopsy. We present a case regarding a 17-year-old male patient with intractable focal epilepsy. He underwent stereotactic biopsy and then ablation where it was shown that TDE is ~35% larger in the coronal plane than in the actual ablation zone. Air may have caused this artifact in the biopsy cavity, which affected the proton resonance frequency (PRF) and caused TDE pigment deposition. We believe in the need for a more comprehensive understanding and investigation regarding this TDE artifact. Future prospective studies into MRgLITT should attend carefully in cases where it is combined with biopsy.
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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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Paulo DL, Ball TJ, Englot DJ. Emerging Technologies for Epilepsy Surgery. Neurol Clin 2022; 40:849-867. [DOI: 10.1016/j.ncl.2022.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Barkley AS, Sullivan LT, Gibson AW, Zalewski K, Mac Donald CL, Barber JK, Hakimian S, Ko AL, Ojemann JG, Hauptman JS. Acute Postoperative Seizures and Engel Class Outcome at 1 Year Postselective Laser Amygdalohippocampal Ablation for Mesial Temporal Lobe Epilepsy. Neurosurgery 2022; 91:347-354. [PMID: 35506941 DOI: 10.1227/neu.0000000000002023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 03/05/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND MRI-guided laser interstitial thermal therapy (MRgLITT) for mesial temporal lobe epilepsy is a safe, minimally invasive alternative to traditional surgical approaches. Prognostic factors associated with efficacy are debated; preoperative epilepsy duration and semiology seem to be important variables. OBJECTIVE To determine whether acute postoperative seizure (APOS) after MRgLITT for mesial temporal lobe epilepsy is associated with seizure freedom/Engel class outcome at 1 year. METHODS A single-institution retrospective study including adults undergoing first time MRgLITT for mesial temporal lobe epilepsy (2010-2019) with ≥1-year follow-up. Preoperative data included sex, epilepsy duration, number of antiepileptics attempted, weekly seizure frequency, seizure semiology, and radiographically verified anatomic lesion at seizure focus. Postoperative data included clinical detection of APOS within 7 days postoperatively, and immediate amygdala, hippocampal, entorhinal, and parahippocampal residual volumes determined using quantitative imaging postprocessing. Primary outcome was seizure freedom/Engel classification 1 year postoperatively. RESULTS Of 116 patients, 53% (n = 61) were female, with an average epilepsy duration of 21 (±14) years, average 6 failed antiepileptics (±3), and weekly seizure frequency of 5. APOS was associated with worse Engel class (P = .010), conferring 6.3 times greater odds of having no improvement vs achieving seizure freedom at 1 year. Residual amygdala, hippocampal, entorhinal, and parahippocampal volumes were not statistically significant prognostic factors. CONCLUSION APOS was associated with a lower chance of seizure freedom at 1 year post-MRgLITT for mesial temporal lobe epilepsy. Amygdala, hippocampal, entorhinal, and parahippocampal residual volumes after ablation were not significant prognostic factors.
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Affiliation(s)
- Ariana S Barkley
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Liam T Sullivan
- Department of Biology, University of Washington, Seattle, Washington, USA
| | - Alec W Gibson
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Kody Zalewski
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | | | - Jason K Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Shahin Hakimian
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Andrew L Ko
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Jeffrey G Ojemann
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.,Department of Neurosurgery, Seattle Children's Hospital, Seattle, Washington, USA.,Division of Neurosurgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jason S Hauptman
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.,Department of Neurosurgery, Seattle Children's Hospital, Seattle, Washington, USA.,Division of Neurosurgery, Seattle Children's Hospital, Seattle, Washington, USA
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Stereotactic laser interstitial thermal therapy for the treatment of pediatric drug-resistant epilepsy: indications, techniques, and safety. Childs Nerv Syst 2022; 38:961-970. [PMID: 35274185 DOI: 10.1007/s00381-022-05491-x] [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: 09/23/2021] [Accepted: 03/03/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND MRI-guided laser interstitial thermal therapy (MRgLITT) is a promising alternative to open surgery for treatment of drug-resistant epilepsy, offering significant advantages over traditional approaches for candidate patients, including minimally invasive approach, shorter hospitalization, and decreased patient post-operative discomfort. LITT uses a stereotactically placed fiber optic laser probe to ablate tissue under real-time MR thermometry. METHODS Retrospective chart review of intraoperative and perioperative characteristics was performed for 28 cases of MRgLITT in 25 pediatric patients, ages 4-21 years old, at our institution between 2019 and 2021. MRgLITT ablation of the mesial temporal lobe was performed in 8 cases, extratemporal epileptogenic foci in 9 cases, and for corpus callosotomy in 11 cases. RESULTS At 1 year of follow-up, 53% of all patients experienced improvement in seizure frequency (Engel I or II) (class I: 38%, class II: 15%, class III: 17%, class IV: 31%), including 37% of MTL ablations and 80% extratemporal SOZ ablations. After MRgLITT corpus callosotomy, 71% of patients were free from atonic seizures at most recent follow-up. Median length of hospitalization was 2 days (1-3), including a median ICU stay of 1 day (1-2). CONCLUSION This series demonstrates the safety of MRgLITT as an approach for seizure control in drug-resistant epilepsy. We provide additional evidence that MRgLITT is an effective procedure that is well-tolerated by pediatric patients and is accompanied by an acceptable rate of complications and relatively short hospital stay.
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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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Granna J, Pitt EB, McKay ME, Ball TJ, Neimat JS, Englot DJ, Naftel RP, Barth EJ, Webster RJ. Targeting Epilepsy Through the Foremen Ovale: How Many Helical Needles are Needed? Ann Biomed Eng 2022; 50:499-506. [PMID: 35244812 PMCID: PMC9007910 DOI: 10.1007/s10439-022-02929-w] [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: 10/22/2021] [Accepted: 02/08/2022] [Indexed: 11/25/2022]
Abstract
Laser ablation of the hippocampus offers medically refractory epilepsy patients an alternative to invasive surgeries. Emerging commercial solutions deliver the ablator through a burr hole in the back of the head. We recently introduced a new access path through the foremen ovale, using a helical needle, which minimizes the amount of healthy brain tissue the needle must pass through on its way to the hippocampus, and also enables the needle to follow the medial axis of the hippocampus more closely. In this paper, we investigate whether helical needles should be designed and fabricated on a patient-specific basis as we had previously proposed, or whether a small collection of pre-defined needle shapes can apply across many patients. We propose a new optimization strategy to determine this needle set using patient data, and investigate the accuracy with which these needles can reach the the medial axis of the hippocampus. We find that three basic tube shapes (mirrored as necessary for left vs. right hippocampi) are all that is required, across 20 patient datasets (obtained from 10 patient CT scans), to reduce worst-case maximum error below 2 mm.
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Affiliation(s)
- J Granna
- Mechanical Engineering Department, Vanderbilt University, Nashville, TN, USA
- Vanderbilt Institute for Surgery and Engineering (VISE), Nashville, TN, USA
| | - E B Pitt
- Mechanical Engineering Department, Vanderbilt University, Nashville, TN, USA
- Vanderbilt Institute for Surgery and Engineering (VISE), Nashville, TN, USA
| | - M E McKay
- Mechanical Engineering Department, Vanderbilt University, Nashville, TN, USA
- Vanderbilt Institute for Surgery and Engineering (VISE), Nashville, TN, USA
| | - T J Ball
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - J S Neimat
- University of Louisville School of Medicine, Louisville, KT, USA
| | - D J Englot
- Vanderbilt Institute for Surgery and Engineering (VISE), Nashville, TN, USA
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - R P Naftel
- Vanderbilt Institute for Surgery and Engineering (VISE), Nashville, TN, USA
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - E J Barth
- Mechanical Engineering Department, Vanderbilt University, Nashville, TN, USA
- Vanderbilt Institute for Surgery and Engineering (VISE), Nashville, TN, USA
| | - R J Webster
- Mechanical Engineering Department, Vanderbilt University, Nashville, TN, USA.
- Vanderbilt Institute for Surgery and Engineering (VISE), Nashville, TN, USA.
- Vanderbilt University Medical Center, Nashville, TN, USA.
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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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Savateev AN, Golanov AV, Saushev DA, Osinov IK, Kostyuchenko VV, Dalechina AV, Melikian AG, Vlasov PA, Mazerkina NA, Makashova ES. [Stereotactic radiosurgery for epilepsy related to hypothalamic hamartoma]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:14-24. [PMID: 35942833 DOI: 10.17116/neiro20228604114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
UNLABELLED Hypothalamic hamartoma (HH) is a dysplastic lesion fused with hypothalamus and followed by epilepsy, precocious puberty and behavioral disorders. Up to 50% of patients become free of seizures after surgery, but various complications occur in 1/4 of cases. Radiofrequency thermocoagulation, laser interstitial thermal therapy and stereotactic radiosurgery (SRS) are alternative treatment options. OBJECTIVE To define the indications for SRS in patients with HH and to clarify the irradiation parameters. MATERIAL AND METHODS Twenty-two patients with HH and epilepsy underwent SRS at the Moscow Gamma-knife Center. A retrospective analysis included 19 patients with sufficient follow-up data. Median age of patients was 11.5 years (range 1.3-25.8). The diameter of irradiated HHs ranged between 5.5 and 40.9 mm. In 8 (36%) cases, the volume of hamartoma exceeded 3 cm3. Mean prescribed dose was 18±2.0 Gy, mean prescribed isodose - 48±4.2%. Median follow-up period was 14.8 months (range 3.4 - 96.1). RESULTS Three (15.8%) patients were free of seizures. One patient (5.3%) improved dramatically after treatment with compete resolution of generalized seizures and experienced only rare emotional seizures (Engel IB). Eleven (57.8%) patients reported lower incidence of seizures. Severity and incidence of seizures were the same in 4 patients (21.1%). The best results were achieved in mean target dose over 20-22 Gy, minimal target dose over 7-10 Gy, covering by the prescribed dose of at least 70-80% of hamartoma volume, as well as in patients with the prescribed dose of 12 Gy delivered to almost entire volume of tumor. None patient had any complications after SRS. CONCLUSION SRS is safe regarding neurological, endocrine or visual disturbances. Careful patient selection for SRS makes it an effective option for HH-related epilepsy. The best candidates for SRS are children with seizures aged over 1 year, hamartoma <3 cm3 and area of fusion with hypothalamus <150 mm2.
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Affiliation(s)
| | - A V Golanov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - I K Osinov
- Moscow Gamma-knife Center, Moscow, Russia
| | | | | | | | - P A Vlasov
- Burdenko Neurosurgical Center, Moscow, Russia
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Consales A, Cognolato E, Pacetti M, Mancardi MM, Tortora D, Di Perna G, Piatelli G, Nobili L. Magnetic Resonance-Guided Laser Interstitial Thermal Therapy (MR-gLiTT) in Pediatric Epilepsy Surgery: State of the Art and Presentation of Giannina Gaslini Children's Hospital (Genoa, Italy) Series. Front Neurol 2021; 12:739034. [PMID: 34764929 PMCID: PMC8577648 DOI: 10.3389/fneur.2021.739034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/27/2021] [Indexed: 11/13/2022] Open
Abstract
Magnetic resonance-guided laser interstitial thermal therapy (MR-gLiTT) is a novel minimally invasive treatment approach for drug-resistant focal epilepsy and brain tumors. Using thermal ablation induced by a laser diode implanted intracranially in a stereotactic manner, the technique is highly effective and safe, reducing the risk associated with more traditional open surgical approaches that could lead to increased neurological morbidity. Indications for MR-gLiTT in pediatric epilepsy surgery include hypothalamic hamartoma, tuberous sclerosis complex, cavernoma-related epilepsy, SEEG-guided seizure onset zone ablation, corpus callosotomy, periventricular nodular heterotopia, mesial temporal lobe epilepsy, and insular epilepsy. We review the available literature on the topic and present our series of patients with drug-resistant epilepsy treated by MR-gLiTT. Our experience, represented by six cases of hypothalamic hamartomas, one case of tuberous sclerosis, and one case of dysembryoplastic neuroepithelial tumor, helps to confirm that MR-gLiTT is a highly safe and effective procedure for several epilepsy conditions in children.
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Affiliation(s)
- Alessandro Consales
- Unit of Neurosurgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Erica Cognolato
- DINOGMI, University of Genoa, Genoa, Italy.,Unit of Child Neuropsychiatry, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Mattia Pacetti
- Unit of Neurosurgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy.,DINOGMI, University of Genoa, Genoa, Italy
| | - Maria Margherita Mancardi
- Unit of Child Neuropsychiatry, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Domenico Tortora
- Unit of Neuroradiology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Giuseppe Di Perna
- Unit of Neurosurgery, Azienda Ospedaliera Universitaria (AOU) Città della Scienza e della Salute, University of Turin, Turin, Italy
| | - Gianluca Piatelli
- Unit of Neurosurgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Lino Nobili
- DINOGMI, University of Genoa, Genoa, Italy.,Unit of Child Neuropsychiatry, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
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Shofty B, Bergman L, Berger A, Aizenstein O, Ben-Valid S, Gurovich D, Tankus A, Attias M, Fahoum F, Strauss I. Adopting MR-guided stereotactic laser ablations for epileptic lesions: initial clinical experience and lessons learned. Acta Neurochir (Wien) 2021; 163:2797-2803. [PMID: 34269876 DOI: 10.1007/s00701-021-04903-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/07/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE MR-guided laser interstitial thermal therapy (MRgLITT) is a minimally invasive technique for ablating brain lesions under real-time MRI feedback and control of the ablation process. The Medtronic Visualase system was recently approved for use in Europe and Israel. We report our initial technical experience using the system in the first 16 cases in which the system was used to ablate focal epileptogenic lesions. METHODS We included all consecutive patients with intractable epilepsy who underwent MRgLITT procedures between 2018 and 2020. We reviewed medical charts and imaging studies of patients. Post-ablation MRIs were used to calculate ablation volumes. RESULTS Seventeen MRgLITT procedures were performed in 16 patients. One cooling catheter/laser fiber assemblies were placed per patient. Indications for surgery were intractable epilepsy due to TLE (n = 7), suspected low-grade glioma (n = 4), radiological cortical dysplasia (n = 1), hypothalamic hamartoma (n = 1), and MR-negative foci (n = 3). Ablations were made using 30 to 70% of the maximal energy of the Visualase system. We used serial ablations as needed along the tract of the catheter by pulling back the optic fiber; the length of the lesion ranged between 7.4 and 38.1 mm. Ablation volume ranged between 0.27 and 6.78 mm3. Immediate post-ablation MRI demonstrated good ablation of the epileptic lesion in 16/17 cases. In one case with mesial temporal sclerosis, no ablation was performed due to suboptimal position of the catheter. That patient was successfully reoperated at a later date. Mean follow-up was 14.9 months (± 11.6 months). Eleven patients had follow-up longer than 12 months. Good seizure control (Engel I, A) was achieved in 7/11 patients (63%) and 1/11 (9%) had significant improvement in seizure frequency (Angle IIIa). Three patients (27%) did not experience improvement in their seizure frequency (Engel IV, B), and one of these patients died during the follow-up period from sudden unexpected death of epilepsy (SUDEP). No immediate or delayed neurological complications were documented in any of the cases during the follow-up period. CONCLUSIONS MRgLITT is a promising technique and can be used safely as an alternative to open resection in both lesional and non-lesional intractable epilepsy cases. In our local series, the success rate of epilepsy surgery was comparable to recent publications.
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Guglielmi G, Eschbach KL, Alexander AL. Smaller Knife, Fewer Seizures? Recent Advances in Minimally Invasive Techniques in Pediatric Epilepsy Surgery. Semin Pediatr Neurol 2021; 39:100913. [PMID: 34620456 DOI: 10.1016/j.spen.2021.100913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 02/02/2023]
Abstract
Children with drug-resistant epilepsy are at high risk for developmental delay, increased mortality, psychiatric comorbidities, and requiring assistance with activities of daily living. Despite the advent of new and effective pharmacologic therapies, about one in 5 children will develop drug-resistant epilepsy, and most of these children continue to have seizures despite trials of other medication. Epilepsy surgery is often a safe and effective option which may offer seizure freedom or at least a significant reduction in seizure burden in many children. However, despite published evidence of safety and efficacy, epilepsy surgery remains underutilized in the pediatric population. Patient and family fears about the risks of surgery may contribute to this gap. Less invasive surgical techniques may be more palatable to children with epilepsy and their caregivers. In this review, we present recent advances in minimally invasive techniques for the surgical treatment of epilepsy as well as intriguing possibilities for the future. We describe the indications for, benefits of, and limits to minimally-invasive techniques including Stereo-encephalography, laser interstitial thermal ablation, deep brain stimulation, focused ultrasound, stereo-encephalography-guided radiofrequency ablation, endoscopic disconnections, and responsive neurostimulation.
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Affiliation(s)
- Gina Guglielmi
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO
| | - Krista L Eschbach
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO
| | - Allyson L Alexander
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO.
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Malcolm JG, Douglas JM, Greven A, Rich C, Dawoud RA, Hu R, Reisner A, Barrow DL, Gross RE, Willie JT. Feasibility and Morbidity of Magnetic Resonance Imaging-Guided Stereotactic Laser Ablation of Deep Cerebral Cavernous Malformations: A Report of 4 Cases. Neurosurgery 2021; 89:635-644. [PMID: 34270738 DOI: 10.1093/neuros/nyab241] [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] [Received: 03/07/2020] [Accepted: 05/08/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Magnetic resonance imaging (MRI)-guided laser interstitial thermal therapy (MRgLITT) has been used successfully to treat epileptogenic cortical cerebral cavernous malformations (CCM). It is unclear whether MRgLITT would be as feasible or safe for deep CCMs. OBJECTIVE To describe our experience with MRgLITT for symptomatic deep CCMs. METHODS Patients' records were reviewed retrospectively. MRgLITT was carried out using a commercially available system in an interventional MRI suite with efforts to protect adjacent brain structures. Immediate postoperative imaging was used to judge ablation adequacy. Delayed postoperative MRI was used to measure lesion volume changes during follow-up. RESULTS Four patients with CCM in the thalamus, putamen, midbrain, or subthalamus presented with persistent and disabling neurological symptoms. A total of 2 patients presented with disabling headaches and sensory disturbances and 2 with recurrent symptomatic hemorrhages, of which 1 had familial CCM. Patients were considered by vascular neurosurgeons to be poor candidates for open surgery or had refused it. Multiple trajectories were used in most cases. Adverse events included device malfunction with leakage of saline causing transient mass effect in one patient, and asymptomatic tract hemorrhage in another. One patient suffered an expected mild but persistent exacerbation of baseline deficits. All patients showed improvement from a previously aggressive clinical course with lesion volume decreased by 20% to 73% in follow-up. CONCLUSION MRgLITT is feasible in the treatment of symptomatic deep CCM but may carry a high risk of complications without the benefit of definitive resection. We recommend cautious patient selection, low laser power settings, and conservative temperature monitoring in surrounding brain parenchyma.
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Affiliation(s)
- James G Malcolm
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Alex Greven
- Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Reem A Dawoud
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ranliang Hu
- Department of Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Andrew Reisner
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Neurosurgery, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Daniel L Barrow
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Robert E Gross
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jon T Willie
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Munier SM, Desai AN, Patel NV, Danish SF. Effects of Intraoperative Magnetic Resonance Thermal Imaging Signal Artifact During Laser Interstitial Thermal Therapy on Thermal Damage Estimate and Postoperative Magnetic Resonance Imaging Ablative Area Concordance. Oper Neurosurg (Hagerstown) 2021; 18:524-530. [PMID: 31313811 DOI: 10.1093/ons/opz182] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 04/11/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a minimally invasive procedure that utilizes intraoperative magnetic resonance thermal imaging (MRTI) to generate a thermal damage estimate (TDE) of the ablative area. In select cases, the MRTI contains a signal artifact or defect that distorts the ablative region. No study has considered the impact of this artifact on TDE accuracy. OBJECTIVE To determine the effect of intraoperative MRTI signal artifact on postoperative magnetic resonance imaging (MRI)-predicted ablative area. METHODS All ablations were performed using the Visualase MRI-Guided Laser Ablation System (Medtronic). Patients were grouped based on whether the intraoperative MRTI contained signal artifact that distorted the ablative region. Cross-sectional area of the ablative lesion from the MRI image was measured, and the difference between intraoperative TDE and postoperative MRI cross-sectional area was calculated and compared between groups with and without intraoperative MRTI artifact. RESULTS A total of 91 patients undergoing MRgLITT for various surgical indications were examined. MRTI artifact was observed in 43.9% of cases overall. The mean absolute difference between TDE and the postoperative MRI cross-sectional area was 94.8 mm2 (SEM = 11.6) in the group with intraoperative MRTI artifact and 54.4 mm2 (SEM = 5.5) in the nonartifact group. CONCLUSION MRTI signal artifact is common during LITT. The presence of signal artifact during intraoperative MRTI results in higher variation between intraoperative TDE and postoperative MRI cross-sectional ablative area. In cases in which intraoperative MRTI artifact is observed, there may be a larger degree of variation between observed intraoperative TDE and measured postoperative MRTI ablative area.
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Affiliation(s)
- Sean M Munier
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Akshay N Desai
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Nitesh V Patel
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Shabbar F Danish
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
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Seto ES, Coorg R. Epilepsy Surgery: Monitoring and Novel Surgical Techniques. Neurol Clin 2021; 39:723-742. [PMID: 34215384 DOI: 10.1016/j.ncl.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Drug-resistant epilepsy warrants referral to an epilepsy surgery center for consideration of alternative treatments including epilepsy surgery. Advances in technology now allow for minimally invasive neurophysiologic monitoring and surgical interventions, approaches that are attractive to families because large craniotomies and associated morbidity are avoided. This work reviews the presurgical evaluation process and discusses the use of invasive stereo-electroencephalography monitoring to localize seizure onset zones. Minimally invasive surgical techniques are described for the treatment of focal and generalized epilepsies. These approaches have expanded our capacity to palliate and cure epilepsy in the pediatric population.
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Affiliation(s)
- Elaine S Seto
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Department of Neurology and Developmental Neuroscience, Texas Children's Hospital, 6701 Fannin Street, Suite 1250, Houston, TX 77030, USA.
| | - Rohini Coorg
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Department of Neurology and Developmental Neuroscience, Texas Children's Hospital, 6701 Fannin Street, Suite 1250, Houston, TX 77030, USA
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42
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Shan W, Mao X, Wang X, Hogan RE, Wang Q. Potential surgical therapies for drug-resistant focal epilepsy. CNS Neurosci Ther 2021; 27:994-1011. [PMID: 34101365 PMCID: PMC8339538 DOI: 10.1111/cns.13690] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/07/2021] [Accepted: 05/18/2021] [Indexed: 12/19/2022] Open
Abstract
Drug-resistant focal epilepsy (DRFE), defined by failure of two antiepileptic drugs, affects 30% of epileptic patients. Epilepsy surgeries are alternative options for this population. Preoperative evaluation is critical to include potential candidates, and to choose the most appropriate procedure to maximize efficacy and simultaneously minimize side effects. Traditional procedures involve open skull surgeries and epileptic focus resection. Alternatively, neuromodulation surgeries use peripheral nerve or deep brain stimulation to reduce the activities of epileptogenic focus. With the advanced improvement of laser-induced thermal therapy (LITT) technique and its utilization in neurosurgery, magnetic resonance-guided LITT (MRgLITT) emerges as a minimal invasive approach for drug-resistant focal epilepsy. In the present review, we first introduce drug-resistant focal epilepsy and summarize the indications, pros and cons of traditional surgical procedures and neuromodulation procedures. And then, focusing on MRgLITT, we thoroughly discuss its history, its technical details, its safety issues, and current evidence on its clinical applications. A case report on MRgLITT is also included to illustrate the preoperational evaluation. We believe that MRgLITT is a promising approach in selected patients with drug-resistant focal epilepsy, although large prospective studies are required to evaluate its efficacy and side effects, as well as to implement a standardized protocol for its application.
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Affiliation(s)
- Wei Shan
- Department of NeurologyBeijing Tiantan HospitalCapital Medical UniversityBeijingChina
- National Center for Clinical Medicine of Neurological DiseasesBeijingChina
- Beijing Institute for Brain DisordersBeijingChina
- Beijing Key Laboratory of Neuro‐modulationBeijingChina
| | - Xuewei Mao
- Shandong Key Laboratory of Industrial Control TechnologySchool of AutomationQingdao UniversityQingdaoChina
| | - Xiu Wang
- National Center for Clinical Medicine of Neurological DiseasesBeijingChina
| | - Robert E. Hogan
- Departments of Neurology and NeurosurgerySchool of MedicineWashington University in St. LouisSt. LouisMOUSA
| | - Qun Wang
- Department of NeurologyBeijing Tiantan HospitalCapital Medical UniversityBeijingChina
- National Center for Clinical Medicine of Neurological DiseasesBeijingChina
- Beijing Institute for Brain DisordersBeijingChina
- Beijing Key Laboratory of Neuro‐modulationBeijingChina
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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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44
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Pruitt R, Bonda D, Kakare S, Kothare S, Rodgers S. Laser interstitial thermal therapy for gyrus rectus cortical dysplasia in a child: a technical note. Childs Nerv Syst 2021; 37:1747-1751. [PMID: 33825977 DOI: 10.1007/s00381-021-05147-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/23/2021] [Indexed: 11/29/2022]
Abstract
Laser interstitial thermal therapy (LITT) has become a popular tool in the treatment of tumors and epilepsy. While most commonly used for the treatment of mesial temporal lobe epilepsy, it can be used as a minimally invasive option for the treatment of any seizure focus but has very rarely been discussed in the setting of cortical dysplasia. Here, we discuss the case of a 5-year-old girl with medically refractory epilepsy secondary to a right medial orbital gyrus and gyrus rectus cortical dysplasia successfully treated with LITT. After confirmation of seizure focus using stereo electroencephalography (SEEG), the patient underwent thermal ablation of the focus through an eyebrow incision with use of a single laser fiber. She has been seizure-free 6 months postoperatively, only on one anti-seizure medication, with normal EEG. The use of LITT in this case was successful because of the cylindrical shape of the cortical dysplasia, making it easily accessible via a single laser fiber in the absence of a yet to develop fontal sinus. While open resection would have also been appropriate, the use of LITT provided a minimally invasive alternative approach that allowed for an excellent outcome with limited risks.
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Affiliation(s)
- Rachel Pruitt
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - David Bonda
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Shefali Kakare
- Division of Neurology, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Sanjeev Kothare
- Division of Neurology, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Shaun Rodgers
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA. .,Division of Neurosurgery, Cohen Children's Medical Center, MD 410 Lakeville Rd, New Hyde Park, NY, 11042, USA.
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45
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Brotis AG, Giannis T, Paschalis T, Kapsalaki E, Dardiotis E, Fountas KN. A meta-analysis on potential modifiers of LITT efficacy for mesial temporal lobe epilepsy: Seizure-freedom seems to fade with time. Clin Neurol Neurosurg 2021; 205:106644. [PMID: 33962146 DOI: 10.1016/j.clineuro.2021.106644] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The efficacy of laser interstitial thermal therapy (LITT) in mesial temporal lobe epilepsy (MTLE) has not been clearly established yet. OBJECTIVE We conducted a meta-analysis to estimate the efficacy of LITT for TLE (Q1). We also examined the effect of the patient's age (Q2), the total ablation volume (TAV) (Q3), the strength of the MRI unit (Q4), the type of the utilized stereotactic platform (Q5), and the follow up period (Q6) on the patient's outcome. METHODS Fixed- and random-effects model meta-analysis was conducted to assess the proportion estimate for each parameter individually. Kaplan-Meier survival-analysis was performed on the available individual patient time-to-first seizure data. RESULTS Sixteen studies with 575 patients fulfilled our eligibility criteria. The efficacy of LITT was 0.547 (95%CI: 0.506-0.588). Our statistical analysis had robust results after stratification according to the study population (Q2; p = 0.3418), and the type of the utilized stereotactic platform (Q5; p = 0.286), whereas the role of the TAV (Q3; p = 0.058) and strength of the magnetic field (Q4; p = 0.062) in seizure control remained unclear. The median seizure-free period (Q6) was 0.643 (0.569-0.726) and 0.467 (0.385-0.566) for the one- and the two-year follow up. CONCLUSIONS LITT seems to offer a viable alternative to resective surgery, with a moderate efficacy and enduring results. Higher ablation volumes may be associated with improved seizure control, although our current study provided no statistically significant data. More high-quality studies are required to highlight the role of LITT in epilepsy surgery, particularly in the pediatric population.
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Affiliation(s)
- Alexandros G Brotis
- Departments of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece.
| | - Theofanis Giannis
- Departments of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Thanos Paschalis
- Departments of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Eftychia Kapsalaki
- Departments of Radiology, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Efthymios Dardiotis
- Departments of Neurology, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Konstantinos N Fountas
- Departments of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
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46
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Feroze AH, McGrath M, Williams JR, Young CC, Ene CI, Buckley RT, Cole BL, Ojemann JG, Hauptman JS. Laser interstitial thermal therapy for pediatric atypical teratoid/rhabdoid tumor: case report. Neurosurg Focus 2021; 48:E11. [PMID: 31896085 DOI: 10.3171/2019.10.focus19746] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 10/16/2019] [Indexed: 11/06/2022]
Abstract
Herein, the authors describe the successful use of laser interstitial thermal therapy (LITT) for management of metastatic craniospinal disease for biopsy-proven atypical teratoid/rhabdoid tumor in a 16-month-old boy presenting to their care. Specifically, LITT was administered to lesions of the right insula and left caudate. The patient tolerated 2 stages of LITT to the aforementioned lesions without complication and with evidence of radiographic improvement of lesions at the 2- and 6-month follow-up appointments. To the authors' knowledge, this represents the first such published report of LITT for management of atypical teratoid/rhabdoid tumor.
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Affiliation(s)
| | - Margaret McGrath
- 1Department of Neurological Surgery, University of Washington; and
| | - John R Williams
- 1Department of Neurological Surgery, University of Washington; and
| | | | - Chibawanye I Ene
- 1Department of Neurological Surgery, University of Washington; and
| | - Robert T Buckley
- 1Department of Neurological Surgery, University of Washington; and
| | - Bonnie L Cole
- 3Pathology, Seattle Children's Hospital, Seattle, Washington
| | - Jeffrey G Ojemann
- 1Department of Neurological Surgery, University of Washington; and.,Departments of2Neurological Surgery and
| | - Jason S Hauptman
- 1Department of Neurological Surgery, University of Washington; and.,Departments of2Neurological Surgery and
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47
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Bakr SM, Patel A, Zaazoue MA, Wagner K, Lam SK, Curry DJ, Raskin JS. Standard work tools for dynamic stereoelectroencephalography using ROSA: naming convention and perioperative planning. J Neurosurg Pediatr 2021; 27:411-419. [PMID: 33482632 DOI: 10.3171/2020.8.peds20420] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The grid-based orthogonal placement of depth electrodes (DEs), initially defined by Jean Talairach and Jean Bancaud, is known as stereo-electroencephalography (sEEG). Although acceptance in the United States was initially slow, advances in imaging and technology have spawned a proliferation of North American epilepsy centers offering sEEG. Despite publications highlighting minimal access techniques and varied indications, standard work for phase I targeted DE has not been defined. In this article, the authors propose the term "dynamic sEEG" and define standard work tools and related common data elements to promote uniformity in the field. METHODS A multidisciplinary approach from July to August 2016 resulted in the production of 4 standard work tools for dynamic sEEG using ROSA: 1) a 34-page illustrated manual depicting a detailed workflow; 2) a planning form to collocate all the phase I data; 3) a naming convention for DEs that encodes the data defining it; and 4) a reusable portable perioperative planning and documentation board. A retrospective review of sEEG case efficiency was performed comparing those using standard work tools (between July 2016 and April 2017) with historical controls (between March 2015 and June 2016). The standard work tools were then instituted at another epilepsy surgery center, and the results were recorded. RESULTS The process for dynamic sEEG was formally reviewed, including anesthesia, positioning, perioperative nursing guidelines, surgical steps, and postoperative care for the workflow using cranial fixation and ROSA-guided placement. There was a 40% improvement in time per electrode, from 44.7 ± 9.0 minutes to 26.9 ± 6.5 minutes (p = 0.0007) following the development and use of the manual, the naming convention, and the reusable portable perioperative planning and documentation board. This standardized protocol was implemented at another institution and yielded a time per electrode of 22.3 ± 4.4 minutes. CONCLUSIONS The authors propose the term dynamic sEEG for stereotactic depth electrodes placed according to phase I workup data with the intention of converting to ablation. This workflow efficiency can be optimized using the standard work tools presented. The authors also propose a novel naming convention that encodes critical data and allows portability among providers. Use of a planning form for common data elements optimizes research, and global adoption could facilitate multicenter studies correlating phase I modality and seizure onset zone identification.
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Affiliation(s)
- Salma M Bakr
- 1Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana.,2Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ajay Patel
- 1Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mohamed A Zaazoue
- 1Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kathryn Wagner
- 3Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sandi K Lam
- 4Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital, Chicago; and.,5Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Daniel J Curry
- 3Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Jeffrey S Raskin
- 1Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Mirza FA, Mitha R, Shamim MS. Current Role of Laser Interstitial Thermal Therapy in the Treatment of Intracranial Tumors. Asian J Neurosurg 2020; 15:800-808. [PMID: 33708647 PMCID: PMC7869293 DOI: 10.4103/ajns.ajns_185_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/18/2020] [Accepted: 07/24/2020] [Indexed: 12/19/2022] Open
Abstract
Laser interstitial thermal therapy (LITT) is gaining popularity in the treatment of both primary and secondary intracranial tumors. The goal of LITT is to deliver thermal energy in a predictable, controlled, and minimally invasive fashion. It can be particularly valuable in patients with recurrent tumors who, due to previous radiation or surgery, may have a potentially higher risk of wound breakdown or infection with repeat craniotomy. Deep-seated lesions that are often inaccessible through open approaches (thalamus, hypothalamus, mesial basal temporal lobe, brainstem) may also be suitable targets. The experience and data published thus far on this modality is limited but growing. This review highlights the use of LITT as a primary treatment method in a variety of intracranial tumors, as well as its application as an adjunct to established surgical techniques.
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Affiliation(s)
- Farhan A Mirza
- Department of Neurosurgery, The Montreal Neurological Institute, McGill University, Montreal, QC, Canada.,Department of Neurosurgery, Kentucky Neuroscience Institute, University of Kentucky, Lexington, KY, USA
| | - Rida Mitha
- Department of Surgery, Section of Neurosurgery, The Aga Khan University Hospital, Karachi, Pakistan
| | - Muhammad Shahzad Shamim
- Department of Surgery, Section of Neurosurgery, The Aga Khan University Hospital, Karachi, Pakistan
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49
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Hajtovic S, Mogilner A, Ard J, Gautreaux JE, Britton H, Fatterpekar G, Young MG, Placantonakis DG. Awake Laser Ablation for Patients With Tumors in Eloquent Brain Areas: Operative Technique and Case Series. Cureus 2020; 12:e12186. [PMID: 33489596 PMCID: PMC7815262 DOI: 10.7759/cureus.12186] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Magnetic resonance imaging (MRI)-guided laser interstitial thermal therapy (LITT) is a minimally invasive treatment modality that has been gaining traction in neuro-oncology. Laser ablation is a particularly appealing treatment option when eloquent neurologic function at the tumor location precludes conventional surgical excision. Although typically performed under general anesthesia, LITT in awake patients may help monitor and preserve critical neurologic functions. Objective To describe intraoperative workflow and clinical outcomes in patients undergoing awake laser ablation of brain tumors. Methods We present a cohort of six patients with tumors located in eloquent brain areas that were treated with awake LITT and report three different workflow paradigms involving diagnostic or intraoperative MRI. In all cases, we used NeuroBlate® (Monteris Medical, Plymouth, MN) fiberoptic laser probes for stereotactic laser ablation of tumors. The neurologic status of patients was intermittently assessed every few minutes during the ablation. Results The mean preoperative tumor volume that was targeted was 12.09 ± 3.20 cm3, and the estimated ablation volume was 12.06 ± 2.75 cm3. Performing the procedure in awake patients allowed us close monitoring of neurologic function intraoperatively. There were no surgical complications. The length of stay was one day for all patients except one. Three patients experienced acute or delayed worsening of pre-existing neurologic deficits that responded to corticosteroids. Conclusion We propose that awake LITT is a safe approach when tumors in eloquent brain areas are considered for laser ablation.
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Affiliation(s)
- Sabastian Hajtovic
- Neurosurgery, City University of New York (CUNY) School of Medicine, New York, USA
| | - Alon Mogilner
- Neurological Surgery, New York University (NYU) Grossman School of Medicine, New York, USA
| | - John Ard
- Anesthesiology, New York University (NYU) Grossman School of Medicine, New York, USA
| | | | | | - Girish Fatterpekar
- Radiology, New York University (NYU) Grossman School of Medicine, New York, USA
| | - Matthew G Young
- Radiology, New York University (NYU) Grossman School of Medicine, New York, USA
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50
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Gadgil N, Lam S, Pan IW, LoPresti M, Wagner K, Ali I, Wilfong A, Curry DJ. Staged Magnetic Resonance-Guided Laser Interstitial Thermal Therapy for Hypothalamic Hamartoma: Analysis of Ablation Volumes and Morphological Considerations. Neurosurgery 2020; 86:808-816. [PMID: 31990344 DOI: 10.1093/neuros/nyz378] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 06/27/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Hypothalamic hamartomas (HH) are a challenging pathology that cause gelastic seizures. Magnetic Resonance Imaging-guided Laser Interstitial Thermal Therapy (MRgLITT) offers a safe and effective treatment for HHs via a minimally invasive technique. OBJECTIVE To determine how clinical outcome correlates to residual tumor volume and surgical strategy by analyzing radiographic data and reconstructing volumetric imaging. METHODS Clinical and radiographic information of 58 pediatric patients who underwent MRgLITT for HH with at least 6 mo of follow-up were retrospectively reviewed. MR imaging was volumetrically reconstructed to analyze the impact of hamartoma and ablation volumes on outcome. Primary outcome measure was freedom from gelastic seizures. RESULTS Eighty-one percent of patients were completely free of gelastic seizures at last follow-up; of 22 patients with secondary nongelastic epilepsy, 15 were free of additional seizures. Postoperative complication rate was low. There was no significant difference in gelastic seizure outcome related to pre- or postoperative hamartoma size. Residual hamartoma percentage in those free of gelastic seizures was 43% compared to 71% in those with continued seizures (P = .021). Larger hamartomas required multiple ablations to achieve seizure freedom. CONCLUSION This large series of patients confirms the safety and efficacy of MRgLITT for pediatric HH and describes morphological considerations that predict success. Our data suggest that complete ablation of the lesion is not necessary, and that the focus should be on appropriate disconnection of the epileptogenic network. We have found that a staged approach to hamartoma ablation allows adequate disconnection of the hamartoma while mitigating risk to surrounding structures.
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Affiliation(s)
- Nisha Gadgil
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Sandi Lam
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - I-Wen Pan
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Melissa LoPresti
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Kathryn Wagner
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Irfan Ali
- Department of Neurology and Developmental Neuroscience, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Angus Wilfong
- Department of Pediatric Neurology, Phoenix Children's Hospital, Phoenix, Arizona
| | - Daniel J Curry
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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