1
|
Hinojosa J, Candela-Cantó S, Becerra V, Muchart J, Gómez-Chiari M, Rumia J, Aparicio J. Multimodal Approach for the Treatment of Complex Hypothalamic Hamartomas. Adv Tech Stand Neurosurg 2024; 50:119-145. [PMID: 38592529 DOI: 10.1007/978-3-031-53578-9_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Hypothalamic hamartomas (HHs) are rare congenital lesions formed by heterotopic neuronal and glial cells attached to the mammillary bodies, tuber cinereum, and hypothalamus.They often present with an intractable epilepsy typically characterized by gelastic seizures but commonly associated with other types of refractory seizures. The clinical course is progressive in most of the cases, starting with gelastic seizures in infancy and deteriorating into complex seizure disorders that result in catastrophic epilepsy associated with cognitive decline and behavioral disturbances.Hamartomas are known to be intrinsically epileptogenic and the site of origin for the gelastic seizures. As antiepileptic drugs are typically ineffective in controlling HH-related epilepsy, different surgical options have been proposed as a treatment to achieve seizure control. Resection or complete disconnection of the hamartoma from the mammillothalamic tract has proved to achieve a long-lasting control of the epileptic syndrome.Usually, symptoms and their severity are typically related to the size, localization, and type of attachment. Precocious puberty appears mostly in the pedunculated type, while epileptic syndrome and behavioral decline are frequently related to the sessile type. For this reason, different classifications of HHs have been developed based on their size, extension, and type of attachment to the hypothalamus.The bigger and more complex hypothalamic hamartomas typically present with severe refractory epilepsy, behavioral disturbances, and progressive cognitive decline posing a formidable challenge for the control of these symptoms.We present here our experience with the multimodal treatment for complex hypothalamic hamartomas. After an in-depth review of the literature, we systematize our approach for the different types of hypothalamic hamartomas.
Collapse
Affiliation(s)
- José Hinojosa
- Department of Neurosurgery, Hospital Sant Joan de Déu, Barcelona, Spain.
- Unit for Epilepsy Surgery, Hospital Sant Joan de Déu, Barcelona, Spain.
| | - Santiago Candela-Cantó
- Department of Neurosurgery, Hospital Sant Joan de Déu, Barcelona, Spain
- Unit for Epilepsy Surgery, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Victoria Becerra
- Department of Neurosurgery, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Jordi Muchart
- Unit for Epilepsy Surgery, Hospital Sant Joan de Déu, Barcelona, Spain
- Department of Diagnostic Imaging, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Marta Gómez-Chiari
- Unit for Epilepsy Surgery, Hospital Sant Joan de Déu, Barcelona, Spain
- Department of Diagnostic Imaging, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Jordi Rumia
- Department of Neurosurgery, Hospital Sant Joan de Déu, Barcelona, Spain
- Unit for Epilepsy Surgery, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Javier Aparicio
- Unit for Epilepsy Surgery, Hospital Sant Joan de Déu, Barcelona, Spain
- Department of Neurology, Hospital Sant Joan de Déu, Barcelona, Spain
| |
Collapse
|
2
|
Wang M, Zhou Y, Zhang Y, Shi W, Zhou S, Wang Y, Li H, Zhao R. One-Stage High-Density Focal Stereo-Array SEEG-Guided Radiofrequency Thermocoagulation for the Treatment of Pediatric Giant Hypothalamic Hamartomas. Front Neurol 2020; 11:965. [PMID: 32982954 PMCID: PMC7493627 DOI: 10.3389/fneur.2020.00965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/24/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Giant hypothalamic hamartomas (HHs) are extremely rare lesions, for which the treatment is challenging. While minimally invasive treatments such as radiofrequency thermal coagulation and laser ablation have improved seizure outcomes, multiple operations are often required. This study investigated the value of one-stage stereo-array radiofrequency thermocoagulation based on stereotactic electroencephalography (SEEG) for pediatric giant HHs. Methods: We analyzed the clinical data of six patients with giant HHs (masses with a maximum diameter >30 mm) who underwent stereotactic electrode implantation between November 2017 and April 2019. After a multidisciplinary discussion, we designed a high-density focal stereo-array electrode implantation strategy. SEEG-guided bipolar coagulations were performed between two contiguous contacts of the same electrode, or between two adjacent contacts of different electrodes. Results: Among the six patients, three were male and three were female, with an average age of 5.08 ± 4.73 years (range, 1.4–12 years); the average follow-up duration was 20.17 ± 5.49 months. One patient had previously undergone open surgery. Four patients had gelastic seizures, one had gelastic and tonic seizures, and one had gelastic and generalized tonic-clonic seizures. The number of implanted electrodes ranged from 3 to 7, with an average of 5.33. One patient had transient diabetes insipidus after the operation, and no child had fever or new hormone metabolisms disorder after surgery. Four patients had Engel I classification outcomes (free from disabling seizures), and two patients had Engel II classification outcomes. Conclusion: Although the exploration of epileptic activity and the extent of ablation are limited by the number of SEEG electrodes for the complete disconnection. One-stage high-density focal stereo-array SEEG-guided radiofrequency was safe and effective for treating pediatric giant HH patients. It can be an alternative method to treat giant HHs where LITT is unavailable.
Collapse
Affiliation(s)
- Min Wang
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Yuanfeng Zhou
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Yi Zhang
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Wei Shi
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Shuizhen Zhou
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Yi Wang
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Hao Li
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Rui Zhao
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| |
Collapse
|
3
|
Cristobal A, Vorona G, Ritter A, Lanni S, Urbine J. Pre- and postnatal MR imaging of an asymptomatic giant hypothalamic hamartoma. Radiol Case Rep 2020; 15:1250-1255. [PMID: 32577141 PMCID: PMC7303913 DOI: 10.1016/j.radcr.2020.05.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 11/29/2022] Open
Abstract
Hypothalamic hamartomas are rare tumors that are most often diagnosed in early childhood. These lesions are classified as giant hypothalamic hamartomas when they exceed 4 cm in any 1 dimension. The most common presenting symptoms associated with these lesions are precocious puberty, gelastic seizures, and (less commonly) syndromic conditions such as Pallister-Hall syndrome. We present a unique case of an asymptomatic giant hypothalamic hamartoma diagnosed prenatally by fetal magnetic resonance imaging and followed throughout infancy. This case demonstrates the utility of multimetric analysis using difference sequences, including diffuse-weighted imaging, to assess specific properties of intracranial lesions detected in utero and to aid in accurate diagnosis prior to birth.
Collapse
Affiliation(s)
- Alberto Cristobal
- Virginia Commonwealth University School of Medicine, 1201 E. Marshall St #4-100, Richmond, VA 23298
| | - Gregory Vorona
- Virginia Commonwealth University Medical Center, Richmond, VA
| | - Ann Ritter
- Virginia Commonwealth University Medical Center, Richmond, VA
| | - Susan Lanni
- Virginia Commonwealth University Medical Center, Richmond, VA
| | | |
Collapse
|
4
|
Kandregula S, Savardekar AR, Nandeesh BN, Arivazhagan A, Rao MB. Giant Hypothalamic Hamartoma in an Infant: A Case Report and Review of the Literature. Pediatr Neurosurg 2017; 52:55-61. [PMID: 27780163 DOI: 10.1159/000448738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 07/27/2016] [Indexed: 11/19/2022]
Abstract
Giant hypothalamic hamartomas (GHH) are extremely rare lesions in infants and usually intrinsically epileptogenic. We present the case of a 10-month-old girl child presenting with drug-resistant seizures and a giant hypothalamic lesion that was confirmed as hamartoma on histopathology. Surgical decompression and disconnection from the hypothalamus was performed with the intent of controlling her seizures. Unfortunately, the patient developed right middle cerebral artery and posterior cerebral artery territory infarction, possibly due to vasospasm or thrombosis of the vessels. The patient had a stormy postoperative course but has recovered well neurologically at the 18-month follow-up. Histopathological examination revealed abnormal clusters of NeuN-positive neurons, which was confirmatory of hypothalamic hamartoma. A review of the published literature on infantile GHH, its management and the postoperative complications is undertaken in this short report.
Collapse
|
5
|
Lee JY, Yoon HK, Khang SK. Giant hypothalamic hamartoma associated with an intracranial cyst in a newborn. Ultrasonography 2016; 35:353-8. [PMID: 27101982 PMCID: PMC5040142 DOI: 10.14366/usg.15080] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 03/22/2016] [Accepted: 03/23/2016] [Indexed: 11/16/2022] Open
Abstract
We report the case of a giant hypothalamic hamartoma with a large intracranial cyst
in a neonate. On ultrasonography, the lesion presented as a lobulated, mass-like
lesion with similar echogenicity to the adjacent brain parenchyma, located anterior
to the underdeveloped and compressed left temporal lobe, and presenting as an
intracranial cyst in the left cerebral convexity without definite internal
echogenicity or septa. The presence of a hypothalamic hamartoma and intracranial
neurenteric cyst were confirmed by surgical biopsy. The association of a giant
hypothalamic hamartoma and a neurenteric cyst is rare. Due to the rarity of this
association, the large size of the intracranial cyst, and the resulting distortion in
the regional anatomy, the diagnosis of the solid mass was not made correctly on
prenatal high-resolution ultrasonography.
Collapse
Affiliation(s)
- Joo Yeon Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Kyung Yoon
- Department of Radiology, Kangwon National University Hospital, Chuncheon, Korea
| | - Shin Kwang Khang
- Department of Pathology, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
6
|
Alves C, Barbosa V, Machado M. Giant hypothalamic hamartoma: case report and literature review. Childs Nerv Syst 2013; 29:513-6. [PMID: 23314738 DOI: 10.1007/s00381-013-2022-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Accepted: 01/03/2013] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Hypothalamic hamartomas are very rare (1:200,000) and range in size from 17.9 to 18 mm. When their dimensions exceed 30-40 mm, they are classified as giant hypothalamic hamartomas. METHODS We present a 14-month-old boy with central precocious puberty and gelastic seizures in whom a magnetic resonance imaging scan revealed a giant hypothalamic hamartoma measuring 50 × 50 × 40 mm. RESULTS In the 11 cases described so far, we found that in comparison to the average-size lesion, giant hypothalamic hamartomas had a lower frequency of precocious puberty, but a similar frequency of seizures. The mean age at diagnosis was younger, and males were more affected than females. Magnetic resonance imaging results were similar with the exception of mass effect. CONCLUSIONS Giant hypothalamic hamartomas had a higher tendency to adhere to surrounding structures. Their invasiveness and cystic degeneration were frequent findings among the 11 studies. Surgical removal was ineffective in controlling refractory epilepsy and caused postoperative morbidity in all patients.
Collapse
Affiliation(s)
- Cresio Alves
- Pediatric Endocrinology Unit, Hospital Universitario Prof. Edgard Santos, Faculty of Medicine, Federal University of Bahia, Salvador, Bahia, Brazil.
| | | | | |
Collapse
|
7
|
Miranda P, Esparza J, Cabrera A, Hinojosa J. Giant hypothalamic hamartoma operated through subfrontal approach with orbitary rim osteotomy. Pediatr Neurosurg 2006; 42:254-7. [PMID: 16714869 DOI: 10.1159/000092365] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2005] [Accepted: 10/02/2005] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Hypothalamic hamartomas are associated with precocious puberty, gelastic seizures and severe refractory epilepsy. Treatment options include surgical resection, radiofrequency and radiosurgery. CASE REPORT A 7-month-old girl presented with gelastic seizures and developmental delay related to a giant hypothalamic hamartoma. The patient was operated through a subfrontal approach. Intraoperatively the lesion appeared intimately adherent to the right internal carotid artery. Seizure control was improved after tumoral decompression. CONCLUSIONS Treatment of giant hypothalamic hamartomas should always include surgical resection, given the mass effect over surrounding vital structures. Subfrontal approach with orbitary rim osteotomy provides a wide exposure with minimal frontal lobe retraction. Close adherence of hypothalamic hamartoma to vascular structures may be present, requiring careful surgical manipulation.
Collapse
Affiliation(s)
- Pablo Miranda
- Department of Pediatric Neurosurgery, Hospital 12 de Octubre, Valencia, Spain.
| | | | | | | |
Collapse
|