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Wang D, Lu D, Zhang M, Dai A, Jin G, Wang Q, Zhang Y, Kahane P. Advances in epileptic network findings of hypothalamic hamartomas. J Cent Nerv Syst Dis 2024; 16:11795735241237627. [PMID: 38449707 PMCID: PMC10916467 DOI: 10.1177/11795735241237627] [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: 12/29/2023] [Accepted: 01/16/2024] [Indexed: 03/08/2024] Open
Abstract
Hypothalamic hamartomas (HHs) are congenital developmental malformations located in the hypothalamus. They are associated with a characteristic clinical manifestation known as gelastic seizures (GS). However, the traditional understanding of HHs has been limited, resulting in insufficient treatment options and high recurrence rates of seizures after surgery. This is consistent with the network hypothesis of focal epilepsy that the epileptogenic zone is not only limited to HH but may also involve the distant cerebral cortex external to the HH mass. The epilepsy network theory, on the other hand, provides a new perspective. In this study, we aim to explore HH-related epilepsy as a network disease, challenging the conventional notion of being a focal lesional disease. We analyze various aspects of HHs, including genes and signaling pathways, local circuits, the whole-brain level, phenotypical expression in terms of seizure semiology, and comorbidities. By examining HHs through the lens of network theory, we can enhance our understanding of the condition and potentially identify novel approaches for more effective management and treatment of epilepsy associated with HHs.
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Affiliation(s)
- Di Wang
- School of Engineering Medicine, Beihang University, Beijing, China
| | - Di Lu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Mingtai Zhang
- School of Engineering Medicine, Beihang University, Beijing, China
| | - Anqi Dai
- School of Engineering Medicine, Beihang University, Beijing, China
| | - Guangyuan Jin
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qiao Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuyang Zhang
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Philippe Kahane
- Neurology Deparment, CHU Grenoble Alpes, University Grenoble Alpes, Grenoble Institute Neuroscience, Grenoble, France
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Wang X, Liu C, Zheng Z, Hu W, Zhang C, Yang X, Shao X, Zhang J, Zhang K. Epilepsy in hypothalamic hamartomas: semiology spectrum and predictor analyses of 78 patients. Ann Clin Transl Neurol 2023; 10:1365-1373. [PMID: 37366336 PMCID: PMC10424656 DOI: 10.1002/acn3.51827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 05/11/2023] [Accepted: 05/26/2023] [Indexed: 06/28/2023] Open
Abstract
OBJECTIVE To assess seizure semiology and disease evolution in a large number of hypothalamic hamartoma (HH) patients. METHODS Seizure semiology and associated medical records for 78 patients with HH-related epilepsy were retrospectively reviewed. Potential predictors of seizure types were assessed through univariate and binary logistic regression analyses. RESULTS 57 (73.1%) patients presented with gelastic seizures at the onset of epilepsy, of whole 39 (68.4%) experienced additional seizure types with a mean latency interval of 4.59 years. Automatism, version, and sGTCs were increasingly common with disease evolution. The intraventricular size of HH was significantly negatively correlated with the disease evolution interval (r = -0.445, p = 0.009). A significantly higher rate of patients with automatism in the DF-II group relative to the DF-III group was found in both χ2 (X = 6.07, p = 0.014) and logistic regression analyses (B = 3.196, p = 0.020). INTERPRETATION Gelastic seizures are the most common initial seizure type in HH patients, but variable semiologies occur with disease evolution. The intraventricular HH lesion size is an important determinant of epilepsy evolution. DF-II HH lesions contribute to a higher chance of automatism evolution. The present study furthers our understanding of the dynamic organization of the seizure network affected by HH.
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Affiliation(s)
- Xiu Wang
- Department of NeurosurgeryBeijing Tian Tan Hospital, Capital Medical UniversityBeijing100070China
| | - Chang Liu
- Department of NeurosurgeryBeijing Tian Tan Hospital, Capital Medical UniversityBeijing100070China
| | - Zhong Zheng
- Epilepsy CenterMedical Alliance of Beijing Tian Tan Hospital, Peking University First Hospital Fengtai HospitalBeijing100071China
| | - Wenhan Hu
- Stereotactic and Functional Neurosurgery LaboratoryBeijing Neurosurgical Institute, Capital Medical UniversityBeijing100070China
| | - Chao Zhang
- Department of NeurosurgeryBeijing Tian Tan Hospital, Capital Medical UniversityBeijing100070China
| | - Xiaoli Yang
- Epilepsy CenterMedical Alliance of Beijing Tian Tan Hospital, Peking University First Hospital Fengtai HospitalBeijing100071China
| | - Xiaoqiu Shao
- Department of NeurologyBeijing Tian Tan Hospital, Capital Medical UniversityBeijing100070China
| | - Jian‐Guo Zhang
- Department of NeurosurgeryBeijing Tian Tan Hospital, Capital Medical UniversityBeijing100070China
- Beijing Key Laboratory of NeurostimulationBeijing100070China
| | - Kai Zhang
- Department of NeurosurgeryBeijing Tian Tan Hospital, Capital Medical UniversityBeijing100070China
- Beijing Key Laboratory of NeurostimulationBeijing100070China
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Liu C, Hu W, Zhang C, Zheng Z, Yang X, Wang X, Mo J, Guo Z, Shao X, Zhang K. Anatomical features decide the atypical seizure manifestation of parahypothalamic hamartomas. Front Neurol 2022; 13:981488. [PMID: 36172032 PMCID: PMC9510781 DOI: 10.3389/fneur.2022.981488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/17/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe intrahypothalamic phenotype of hypothalamic hamartomas (HH) is associated with epilepsy, and the parahypothalamic phenotype usually leads to central precocious puberty but not neurological comorbidities or seizures. No study has confirmed the pathological role of parahypothalamic hamartomas in epileptogenesis, and the underlying mechanism is yet to be elucidated.ObjectiveWe aimed to investigate whether parahypothalamic hamartomas are intrinsically epileptogenic and elucidate the underlying pathway of epileptogenesis.MethodsWe reviewed 92 patients with HH-related epilepsy, categorized them by the classification system of Delalande and Fohlen, and further classified Type I (corresponding to parahypothalamic HH) into the following three groups based on the relationship between the lesion and mammillary bodies (MB): entirely invaded (Group 1), partially connected (Group 2), and not connected at all (Group 3). We examined different anatomical features with their relationship to clinical manifestations. Stereoelectroencephalography (SEEG) was implanted in both HH and extra-HH cortices in different groups to identify the epileptogenic zone. Corticocortical evoked potentials (CCEPs) were also used to determine the pathological correlation among different regions to determine the related epileptogenic network.ResultsA total of 13 patients presented with parahypothalamic HH and 10 (76.9%) presented with non-GS only, with late-onset age and normal cognitive development, which is different from classical clinical features. SEEG showed that HH is intrinsically epileptogenic in MB-involved parahypothalamic groups. No statistical difference was found in onset age (p = 0.213), and lesions horizontally oriented from the tuber cinereum without connection to MB were not involved in seizure genesis. CCEP indicated a pathological connection among HH, middle cingulate cortex, and insular cortex.ConclusionThe parahypothalamic HH can also cause epilepsy and is different from classic HH-related seizures, by non-GS only with the late-onset age and normal cognitive development. MB is proven to be related to non-GS by the mamillo-cingulate-cortex pathway.
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Affiliation(s)
- Chang Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenhan Hu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Stereotactic and Functional Neurosurgery Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Chao Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhong Zheng
- Epilepsy Center, Beijing Fengtai Hospital, Beijing, China
| | - Xiaoli Yang
- Epilepsy Center, Beijing Fengtai Hospital, Beijing, China
| | - Xiu Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiajie Mo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhihao Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoqiu Shao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kai Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Stereotactic and Functional Neurosurgery Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- *Correspondence: Kai Zhang
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Shirozu H, Masuda H, Kameyama S. A Special Approach for Stereotactic Radiofrequency Thermocoagulation of Hypothalamic Hamartomas With Bilateral Attachments to the Hypothalamus: The Transthird Ventricular Approach to the Contralateral Attachment. Neurosurgery 2022; 91:295-303. [PMID: 35394461 DOI: 10.1227/neu.0000000000001996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 02/12/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Disconnection surgery for the treatment of epileptic hypothalamic hamartomas (HHs) is strategically difficult in cases with complex-shaped HHs, especially with bilateral hypothalamic attachments, despite its effectiveness. OBJECTIVE To evaluate the feasibility of a new approach for stereotactic radiofrequency thermocoagulation (SRT) using penetration of the third ventricle (SRT-TT) aiming to disconnect bilateral hypothalamic attachments in a single-staged, unilateral procedure. METHODS Ninety patients (median age at surgery, 5.0 years) who had HHs with bilateral hypothalamic attachments and were followed for at least 1 year after their last SRT were retrospectively reviewed. RESULTS Thirty-three patients underwent SRT-TT as initial surgery. Of the 58 patients after mid-2013 when SRT-TT was introduced, 33 underwent SRT-TT and 12 (20.7%) required reoperation (ReSRT), whereas 20 of 57 patients (35.1%) without SRT-TT underwent reoperation. Reoperation was required in significantly fewer patients after mid-2013 (n = 12 of 58, 20.7%) than before mid-2013 (n = 15 of 32, 46.9%) (P = .01). Final seizure freedoms were not different between before and after mid-2013 (gelastic seizure freedom, n = 30 [93.8%] vs n = 49 [84.5%] and other types of seizure freedom, n = 21 of 31 [67.7%] vs n = 32 of 38 [84.2%]). Persistent complications were less in SRT-TT than in ReSRT using the bilateral approach, but not significantly. However, hormonal replacement was required significantly more often in ReSRT using the bilateral approach (4 of 9, 44.4%) than in SRT-TT (3 of 32, 9.4%) (P = .01). CONCLUSION SRT-TT enabled disconnection of bilateral attachments of HHs in a single-staged procedure, which reduced the additional invasiveness of reoperation. Moreover, SRT-TT reduced damage to the contralateral hypothalamus, with fewer endocrinological complications than the bilateral approach.
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Affiliation(s)
- Hiroshi Shirozu
- Department of Functional Neurosurgery, National Hospital Organization Nishiniigata Chuo Hospital, Niigata, Japan.,Hypothalamic Hamartoma Center, National Hospital Organization Nishiniigata Chuo Hospital, Niigata, Japan
| | - Hiroshi Masuda
- Department of Functional Neurosurgery, National Hospital Organization Nishiniigata Chuo Hospital, Niigata, Japan.,Hypothalamic Hamartoma Center, National Hospital Organization Nishiniigata Chuo Hospital, Niigata, Japan
| | - Shigeki Kameyama
- Department of Neurosurgery, Niigata Seiro Hospital, Seiro, Niigata, Japan
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Tuleasca C, Hamdi H, Daquin G, Villeneuve N, Chauvel P, Lepine A, Bartolomei F, Régis J. Increased Gray Matter Density in the Right Mesencephalic Tegmentum Is Associated With Better Engel Classes I and II After Radiosurgery for Hypothalamic Hamartomas. Neurosurgery 2022; 90:180-185. [PMID: 34995238 DOI: 10.1227/neu.0000000000001738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 08/21/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hypothalamic hamartomas (HHs) are disabling congenital lesions, responsible for gelastic seizures frequently associated with catastrophic epilepsies, epileptogenic encephalopathy, and cognitive and psychiatric severe comorbidities. Stereotactic radiosurgery (SRS) is a well-established minimally invasive therapeutic approach. OBJECTIVE To assess whether pretherapeutic gray matter density (GMD) correlates with seizure outcome. METHODS We used voxel-based morphometry at whole-brain level, as depicted on pretherapeutic standard structural magnetic resonance neuroimaging. We examined 24 patients (10 male patients, 14 female patients; mean age, 12.7 yr; median, 9; range, 5.9-50) treated in Marseille University Hospital, France, between May 2001 and August 2018. RESULTS Most relevant anatomic area predicting postoperative Engel classes I and II vs III and IV after SRS for HHs was mesencephalic tegmentum. Higher pretherapeutic GMD in this area was associated with better outcomes for seizure cessation. The only other statistically significant clusters were right cerebellar lobule VIIIb and VIIIa. Lower pretherapeutic GMD in both clusters correlated with better Engel class outcomes. GMD decreased with age in the left mediodorsal thalamus. CONCLUSION Seizure cessation after SRS for HHs was associated with higher GMD in mesencephalic tegmental area, acknowledged to be involved in the neural control of explosive vocal behavior in animals. This area is connected by the mamillotegmental bundle to the lateral tuberal nucleus area of the hypothalamus, where HHs are known to rise. In the future, the detection of more gray matter in this "laugh" tegmental area based on pretherapeutic routine structural neuroimaging might help in patient selection for minimally invasive radiosurgery for HH.
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Affiliation(s)
- Constantin Tuleasca
- Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (Unil), Lausanne, Switzerland
- Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Hussein Hamdi
- Aix-Marseille University, INSERM, UMR 1106, Marseille, France
- Functional and Stereotactic Neurosurgery and Gamma Knife Unit, Timone University Hospital, Marseille, France
- Functional Neurosurgery and Stereotaxy Unit, Neurological Surgery Department, Tanta University, Tanta, Egypt
| | - Géraldine Daquin
- Aix-Marseille University, INSERM, UMR 1106, Marseille, France
- Clinical Physiology Department, Timone University Hospital, Marseille, France
| | - Nathalie Villeneuve
- Clinical Physiology Department, Timone University Hospital, Marseille, France
| | - Patrick Chauvel
- Aix-Marseille University, INSERM, UMR 1106, Marseille, France
- Clinical Physiology Department, Timone University Hospital, Marseille, France
| | - Anne Lepine
- Clinical Physiology Department, Timone University Hospital, Marseille, France
| | - Fabrice Bartolomei
- Aix-Marseille University, INSERM, UMR 1106, Marseille, France
- Clinical Physiology Department, Timone University Hospital, Marseille, France
| | - Jean Régis
- Aix-Marseille University, INSERM, UMR 1106, Marseille, France
- Functional and Stereotactic Neurosurgery and Gamma Knife Unit, Timone University Hospital, Marseille, France
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Tripathi M, Maskara P, Sankhyan N, Sahu JK, Kumar R, Kumar N, Ahuja CK, Kaur P, Kaur R, Batish A, Mohindra S. Safety and Efficacy of Primary Hypofractionated Gamma Knife Radiosurgery for Giant Hypothalamic Hamartoma. Indian J Pediatr 2021; 88:1086-1091. [PMID: 33501606 DOI: 10.1007/s12098-020-03637-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 12/18/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe the feasibility, safety, efficacy, and complication profile of primary hypofractionated gamma knife radiosurgery (GKRS), and practical nuances of performing the same in pediatric patients. METHODS Three pediatric patients (age range 17-65 mo) underwent primary hypofractionated GKRS in 2-3 consecutive days with interfraction interval of 24 h. All patients had precocious puberty and were on GnRH analogue. Frame based GKRS done with 8.1-9.2 Gy radiation per fraction at 50% isodose in 2-3 fractions targeting the entire hamartoma volume. The mean target volume was 5.67 cc (4.45-7.39 cc). The authors followed these patients for clinical and endocrinological assessment at every 6 mo interval while the repeat MRI done at 6 mo and then annually. The seizure outcome analysis was done using Engel scale. RESULTS At a mean follow up of 27 mo (24-30 mo), 2 patients became Engel class 3 while one achieved Engel class 1 control. 2 patients showed halted pubertal growth with no additional hormonal aberration. 2 patients showed significant volumetric reduction (48% and 32%) and patchy necrosis inside the hypothalamic hamartoma (HH). There was no deficit in visual function, memory and cognition. One patient showed reduction in aggressiveness. CONCLUSION Giant HH are exceptionally difficult neurological diseases. Primary hypofractionated GKRS may be an alternative approach as mono/multitherapy with promising results and minimal complication.
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Affiliation(s)
- Manjul Tripathi
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India. .,National Institute of Health Research (NIHR) Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK.
| | - Prasant Maskara
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Naveen Sankhyan
- Department of Pediatric Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jitendra Kumar Sahu
- Department of Pediatric Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kumar
- Department of Pediatric Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Narendra Kumar
- Department of Radiotherapy, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Chirag K Ahuja
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Parwinder Kaur
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Rupinder Kaur
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Aman Batish
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Sandeep Mohindra
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
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Sbardella E, Puliani G, Feola T, Pofi R, Pirchio R, Sesti F, Verdecchia F, Gianfrilli D, Moffat D, Isidori AM, Grossman AB. A clinical approach to parasellar lesions in the transition age. J Neuroendocrinol 2021; 33:e12995. [PMID: 34138496 DOI: 10.1111/jne.12995] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/23/2021] [Accepted: 05/11/2021] [Indexed: 12/16/2022]
Abstract
Many reviews have summarised the pathology and management of the parasellar region in adult patients, although an analysis of these aspects in the transition years, from puberty onset to the age of peak bone mass, has been lacking. A comprehensive search of English-language original articles, published from 2000 to 2020, was conducted in the MEDLINE database (December 2019 to March 2020). We selected all studies regarding epidemiology, diagnosis and management of the following parasellar lesions: germinoma, craniopharyngioma, Langerhans cell histiocytosis, optic glioma, hypothalamic hamartoma, tuber cinereum hamartoma, cranial chordoma, Rathke cleft cyst, hypophysitis and hypothalamitis during the transition age from childhood to adulthood. In the present review, we provide an overview of the principal parasellar lesions occurring in the transition age. Symptoms are usually a result of the mass effect of the lesions on nearby structures, as well as anterior pituitary deficits. Diabetes insipidus occurs frequently in these patients. In this age group, pubertal developmental disorders may be more evident compared to other stages of life. Parasellar lesions in the transition age mostly include neoplastic lesions such as germinomas, hamartomas, optic gliomas, craniopharyngiomas Langerhans cell histiocytosis and chordomas, and rarely inflammatory lesions (hypophysitis, hypothalamitis). There are limited data on the management of parasellar lesions in the transition age. Endocrine evaluation is crucial for identifying conditions that require hormonal treatment so that they can be treated early to improve the quality of life of the individual patient in this complex age range. The clinical approach to parasellar lesions involves a multidisciplinary effort.
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Affiliation(s)
- Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Giulia Puliani
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
- Oncological Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Tiziana Feola
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
- Neuroendocrinology, Neuromed Institute, IRCCS, Pozzilli, Italy
| | - Riccardo Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Rosa Pirchio
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Franz Sesti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Federica Verdecchia
- Dipartimento Pediatrico Universitario Ospedaliero, Bambino Gesù Children Hospital, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Daniel Moffat
- Department of Neurosurgery, Barts and the London NHS Trust, London, UK
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Ashley B Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London, UK
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Hamdi H, Ferrante P, Spatola G, Clawson W, McGonigal A, Daquin G, Villeneuve N, Laguitton V, Bartolomei F, Regis J. Epileptic hypothalamic hamartomas impact of topography on clinical presentation and radiosurgical outcome. Epilepsy Res 2021; 173:106624. [PMID: 33839515 DOI: 10.1016/j.eplepsyres.2021.106624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 03/13/2021] [Accepted: 03/21/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Evidence exists for the role of the hypothalamic hamartoma's topography as a determinant for the clinical presentation. How the hamartoma relation to the hypothalamic structures can make clinical presentations, severity and surgery outcomes different from patient to patient is largely unknown. Our aim was to analyze the effect of fine anatomical topography on clinical spectrum and radiosurgery outcome. METHODS Forty-eight epileptic patients with hypothalamic hamartoma were treated by Gamma Knife Surgery and were reviewed for fine topography and morphology using magnetic resonance neuroimaging. We evaluated different topographic patterns; contact to prominent structures (the mammillary body, tuber cinereum and pituitary stalk), the degree of involvement within sagittally-oriented regions, (mammillary, tuberal, and supra optic) coronally-oriented zones (periventricular, medial, and lateral), lesion dimensions (length, width, and height),and volumes (total, intra-hypothalamic, and extra-hypothalamic volumes). This data were statistically analysed for correlation with all clinical variables and epilepsy surgery outcome. We reviewed all the classification protocols in the literature. RESULTS Focal onset impaired awareness seizures started at an earlier age of onset with larger hypothalamic hamartoma volume and dimensions. Lateral extension within the hypothalamus was associated with more severe epilepsy, higher seizure frequency, more severe psychiatric comorbidity, hetero-aggression, hyperkinesia, and school difficulties. Presence of precocious puberty was positively correlated to anterior-posterior extension; tuberal region involvement, hypothalamic hamartoma volume, and type III-VI. Larger hypothalamic hamartoma presented precocious puberty at an earlier age of onset. After Gamma Knife Surgery, epilepsy outcome was better and rapid when lesion is smaller. Post-radiosurgical transient increased seizures were present when the mammillary region was more involved. CONCLUSION Clinical presentation of epileptic hypothalamic hamartoma is significantly affected by fine topography patterns and invaded hypothalamic areas. Gamma Knife Radiosurgery effect is better and rapid in smaller hamartoma (Type I-III) and seizure outcome was not affected by the invaded hypothalamic areas.
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Affiliation(s)
- Hussein Hamdi
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife, Timone University Hospital, Aix-Marseille University, Marseille, France; Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France; Functional Neurosurgery and Stereotaxy Unit, Neurological Surgery Department, Tanta University, Egypt.
| | - Patrizia Ferrante
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife, Timone University Hospital, Aix-Marseille University, Marseille, France; Department of Medicine and Surgery, University of Salerno, Baronissi, Italy
| | - Giorgio Spatola
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife, Timone University Hospital, Aix-Marseille University, Marseille, France; Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France
| | - Wesley Clawson
- Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France
| | - Aileen McGonigal
- Clinical Physiology Department, INSERM, UMR 1106 and Timone University Hospital, Aix-Marseille Université, Marseille, France
| | - Geraldine Daquin
- Clinical Physiology Department, INSERM, UMR 1106 and Timone University Hospital, Aix-Marseille Université, Marseille, France
| | - Nathalie Villeneuve
- Clinical Physiology Department, INSERM, UMR 1106 and Timone University Hospital, Aix-Marseille Université, Marseille, France
| | - Virginie Laguitton
- Clinical Physiology Department, INSERM, UMR 1106 and Timone University Hospital, Aix-Marseille Université, Marseille, France
| | - Fabrice Bartolomei
- Clinical Physiology Department, INSERM, UMR 1106 and Timone University Hospital, Aix-Marseille Université, Marseille, France
| | - Jean Regis
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife, Timone University Hospital, Aix-Marseille University, Marseille, France; Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France
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Mithani K, Neudorfer C, Boutet A, Germann J, Elias GJB, Weil AG, Donner E, Kalia S, Lozano AM, Drake JM, Widjaja E, Ibrahim GM. Surgical targeting of large hypothalamic hamartomas and seizure-freedom following MR-guided laser interstitial thermal therapy. Epilepsy Behav 2021; 116:107774. [PMID: 33549939 DOI: 10.1016/j.yebeh.2021.107774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Large hypothalamic hamartomas (HH) are often associated with difficult-to-treat, refractory seizures. Although magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) has emerged as a useful tool to treat these challenging lesions, postoperative outcomes are variable and potentially related to differences in surgical targeting. PURPOSE We sought to identify differences in the anatomic localization of laser ablations that either did or did not result in seizure freedom. METHODS Four children who underwent MRgLITT for large HH (3 seizure-free and 1 not seizure-free) were included in the analysis. Ablation volumes were segmented, normalized, and overlaid on a high-resolution hypothalamic atlas. For each lesion, the size, spatial extent, and degree of overlap with key hypothalamic nuclei and surrounding brain regions were computed and compared between ablations that did and did not result in seizure freedom. RESULTS Ablation masks that resulted in seizure freedom were smaller and located more centrally than the ablation mask that did not. In addition, ablation masks that resulted in seizure freedom overlapped with regions including the paraventricular nucleus, the posterior hypothalamus and the zona incerta, fornix, and mammillothalamic tract, whereas the single non-seizure-free ablation did not. CONCLUSION Differences in the size, position, and anatomical localization of ablation volumes may be a potential contributor to the variability in postoperative outcomes of large HH treated with MRgLITT. A novel, high-resolution MRI atlas of the hypothalamus identifies a number of regions at the interface of large HH that are preferentially disconnected in seizure-free patients. This method of anatomical localization not only serves as a potential clinical tool for surgical targeting but may also provide novel insights into the mechanisms of epileptogenesis in hypothalamic hamartomas.
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Affiliation(s)
- Karim Mithani
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Alexandre Boutet
- University Health Network, Toronto, ON, Canada; Joint Department of Medical Imaging, University of Toronto, ON, Canada
| | | | | | - Alexander G Weil
- Division of Neurosurgery, CHU-Ste Justine, Université de Montréal, Montréal, Canada
| | - Elizabeth Donner
- Division of Neurology, Hospital for Sick Children, Toronto, Canada
| | - Suneil Kalia
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - James M Drake
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada; Division of Neurosurgery, Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Canada
| | - Elysa Widjaja
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada
| | - George M Ibrahim
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada; Division of Neurosurgery, Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Canada.
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10
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Scholly J, Bartolomei F. Gelastic seizures and the hypothalamic hamartoma syndrome: Epileptogenesis beyond the lesion? HANDBOOK OF CLINICAL NEUROLOGY 2021; 182:143-154. [PMID: 34266589 DOI: 10.1016/b978-0-12-819973-2.00010-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The clinicoradiologic syndrome of hypothalamic hamartoma (HH) manifests with a variety of symptoms, including pharmacoresistant epilepsy with multiple seizure types, precocious puberty, behavioral disturbances, and cognitive impairment. Gelastic seizures are an early marker of epilepsy with HH in most of the cases. Despite a high variability, two major epilepsy phenotypes can be distinguished, based on electroclinical features: (i) focal seizures with epigastric or déjà-vu aura, loss of consciousness, and oroalimentary or gestural automatisms suggestive of temporal lobe involvement; and (ii) motor seizures with tonic, atonic, myoclonic, or versive phenomena, suggesting frontoparietal network involvement, with possible evolution toward an epileptic encephalopathy. The underlying physiopathologic mechanisms are not completely elucidated. The well-known intrinsic epileptogenicity of the HH represents the rationale for direct HH-aiming surgical procedures, with variable success in achieving seizure freedom. The concept of kindling-like secondary epileptogenesis has been suggested as a possible putative mechanism since the very beginnings of the hamartocentric era. Accordingly, a cortical area with enhanced epileptogenic properties due to an independent stage of secondary epileptogenesis would be responsible for seizures persisting after hamartoma ablation. However, recent intracerebral stereotactic EEG (SEEG) explorations demonstrated more complex, both reciprocal and hierarchical, relationships within the hypothalamo-cortical epileptogenic networks. Network formation may be due to either secondary epileptogenesis or widespread epileptogenicity present at the outset. A short time window from epilepsy onset to surgery seems to be crucial to cure epilepsy by direct surgery addressing a hamartoma. SEEG exploration may be reasonably proposed in cases where clinical data suggest an extension of the epileptogenic zone outside the limits of the HH, especially in focal seizures with impaired awareness and absence of gelastic seizures, or after a failure of the direct HH-aiming procedure.
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Affiliation(s)
- Julia Scholly
- Department of Epileptology and Cerebral Rhythmology, Aix Marseille University, Hôpital Timone, Marseille, France; Center for Magnetic Resonance in Biology and Medicine, Aix Marseille University, Hôpital Timone, Marseille, France
| | - Fabrice Bartolomei
- Department of Epileptology and Cerebral Rhythmology, Aix Marseille University, Hôpital Timone, Marseille, France; Institut de Neurosciences des Systèmes, Aix Marseille University, Marseille, France.
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11
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Fukuma K, Kajimoto K, Tanaka T, Takaya S, Kobayashi K, Shimotake A, Matsumoto R, Ikeda A, Toyoda K, Ihara M. Visualizing prolonged hyperperfusion in post-stroke epilepsy using postictal subtraction SPECT. J Cereb Blood Flow Metab 2021; 41:146-156. [PMID: 32065077 PMCID: PMC7747161 DOI: 10.1177/0271678x20902742] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Diagnosis of post-stroke epilepsy is often challenging because of a low incidence of epileptiform abnormalities on electroencephalography (EEG). Hence, this study evaluated whether postictal subtraction single-photon emission computed tomography (SPECT) could visualize epileptic activity and act as a diagnostic modality in post-stroke epilepsy. Fifty post-stroke epilepsy patients, who had undergone Tc-99m-ECD SPECT twice (postictal and interictal), were enrolled. The postictal hyperperfusion area was identified by subtraction (postictal-interictal) SPECT and classified into two distribution types: superficial or deep-seated. Laterality and distribution of postictal hyperperfusion on subtraction SPECT were compared with stroke lesions, seizure symptoms, and epileptiform EEG findings. Forty-three of the 50 patients (86%) had hyperperfusion on subtraction SPECT and 26 (52%) had epileptiform EEG findings. Subtraction SPECT showed prolonged postictal hyperperfusion despite the relatively long interval between seizure end and postictal SPECT (median: 19.1 h, range: 2.2-112.5 h). The laterality of the hyperperfusion area had a high concordance rate with the laterality of stroke lesions (97.7%), seizure symptoms (91.9%), and epileptiform EEG findings (100%). Scalp EEG identified epileptiform activity more frequently in superficial type of SPECT, but less frequently in deep-seated type (both, P = 0.03). Postictal SPECT can be complementary to scalp EEG in endorsing the diagnosis and location of post-stroke epilepsy.
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Affiliation(s)
- Kazuki Fukuma
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Katsufumi Kajimoto
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tomotaka Tanaka
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shigetoshi Takaya
- Department of Neurology, Senri Rehabilitation Hospital, Osaka, Japan.,Department of Rehabilitation Medicine, Senri Rehabilitation Hospital, Osaka, Japan
| | - Katsuya Kobayashi
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akihiro Shimotake
- Department of Epilepsy, Movement Disorders and Physiology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Riki Matsumoto
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Division of Neurology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Akio Ikeda
- Department of Epilepsy, Movement Disorders and Physiology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
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12
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Roodakker KR, Ezra B, Gauffin H, Latini F, Zetterling M, Berntsson S, Landtblom AM. Ecstatic and gelastic seizures related to the hypothalamus. Epilepsy Behav Rep 2020; 16:100400. [PMID: 35028554 PMCID: PMC8714766 DOI: 10.1016/j.ebr.2020.100400] [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] [Indexed: 11/25/2022] Open
Abstract
Ecstatic seizures constitute a rare form of epilepsy, and the semiology is diverse. Previously, brain areas including the temporal lobe and the insula have been identified to be involved in clinical expression. The aim of this report is to review changes in ecstatic seizures in a patient before and after operation for a hypothalamic hamartoma, and to scrutinize the relation to gelastic seizures. In this case, the ecstatic seizures disappeared after surgery of the hamartoma but reappeared eleven years later. Clinical information was retrospectively obtained from medical records, interviews, and a questionnaire covering seizure semiology that pertained to ecstatic and gelastic seizures. Our findings imply a possible connection between gelastic and ecstatic seizures, originating from a hypothalamic hamartoma. To our knowledge, this location has not previously been described in ecstatic seizures. Gelastic seizures may in this case be associated with ecstatic seizures. We speculate that patients with ecstatic seizures may have an ictal activation of neuronal networks that involve the insula. Our case may add information to the knowledge concerning ecstatic seizures.
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Affiliation(s)
- Kenney Roy Roodakker
- Department of Neuroscience, Neurology, Uppsala University, University Hospital, Uppsala, Sweden
| | - Bisrat Ezra
- Department of Neuroscience, Neurology, Uppsala University, University Hospital, Uppsala, Sweden
| | - Helena Gauffin
- Department of Neurology and Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Francesco Latini
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Maria Zetterling
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Shala Berntsson
- Department of Neuroscience, Neurology, Uppsala University, University Hospital, Uppsala, Sweden
| | - Anne-Marie Landtblom
- Department of Neuroscience, Neurology, Uppsala University, University Hospital, Uppsala, Sweden
- Department of Neurology and Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Neurology Division, Clinic of Medical Specialist, Motala General Hospital, Motala, Sweden
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13
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Togo M, Inouchi M, Matsumoto R, Sawamoto N, Ikeda A, Takahashi R. [A case of refractory generalized atonic seizure and hemifacial spasm with the possible causative pontocerebellar lesion]. Rinsho Shinkeigaku 2020; 60:362-366. [PMID: 32307394 DOI: 10.5692/clinicalneurol.cn-001368] [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: 11/05/2022]
Abstract
The patient was a 35-year-old woman. At the age of 1, she had undergone resection and radiation therapy for neoplastic lesions in the pons. She had a history of gelastic seizures when she was in elementary school, and brief lapses of the neck and truncal muscular tone and convulsions on the left face occurred at the age of 23. After a generalized sharp wave in the ictal electroencephalogram and electromyogram recording, left orbicularis oris muscle contraction was observed followed by sudden cervical extensor atonia. Seizure propagation was noted in the cerebral cortex, left facial nerve nucleus, and brainstem reticular formation. In a simultaneous electroencephalography with functional MRI, the blood oxygen level-dependent effect related to generalized sharp waves was observed in the vicinity of brainstem lesions in addition to a decrease in bilateral frontal and parietal lobes signals, as detected in generalized seizures. These findings suggest that the lesion could be a part of the epilepsy network. Although most epileptic seizures are derived from the cerebral cortex, it is important to note that brainstem lesions are involved in seizures in the patient presented in this study.
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Affiliation(s)
- Masaya Togo
- Department of Neurology, Kyoto University Graduate School of Medicine
| | | | - Riki Matsumoto
- Department of Neurology, Kobe University Graduate School of Medicine
| | - Nobukatsu Sawamoto
- Department of Human Health Sciences, Kyoto University Graduate School of Medicine
| | - Akio Ikeda
- Department of Epilepsy, Movement Disorders and Physiology, Kyoto University Graduate School of Medicine
| | - Ryosuke Takahashi
- Department of Neurology, Kyoto University Graduate School of Medicine
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14
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Roodakker KR, Ezra B, Gauffin H, Latini F, Zetterling M, Berntsson S, Landtblom AM. Ecstatic and gelastic seizures relate to the hypothalamus. Epilepsy Behav Rep 2020; 14:100358. [PMID: 32368731 PMCID: PMC7186513 DOI: 10.1016/j.ebr.2020.100358] [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: 08/21/2019] [Revised: 01/21/2020] [Accepted: 02/28/2020] [Indexed: 11/27/2022] Open
Abstract
Ecstatic seizures constitute a rare form of epilepsy, and the semiology is diverse. Previously, brain areas including the temporal lobe and the insula have been identified to be involved in clinical expression. The aim of this report is to review changes in ecstatic seizures in a patient before and after operation of a hypothalamic hamartoma, and to scrutinize the relation to gelastic seizures. In this case, the ecstatic seizures disappeared after surgery of the hamartoma but reappeared eleven years later. Clinical information was retrospectively obtained from medical records, interviews, and a questionnaire covering seizure semiology that pertained to ecstatic and gelastic seizures. Our findings imply a possible connection between gelastic and ecstatic seizures, originating from a hypothalamic hamartoma. To our knowledge, this location has not previously been described in ecstatic seizures. Gelastic seizures may in this case were associated with ecstatic seizures. We speclate patients with ecstatic seizures may have an ictal activation of neuronal networks that involves the insula. Our case may add information to the growing knowledge concerning ecstatic seizures.
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Affiliation(s)
- Kenney Roy Roodakker
- Department of Neuroscience, Neurology, Uppsala University, University Hospital, Uppsala, Sweden
| | - Bisrat Ezra
- Department of Neuroscience, Neurology, Uppsala University, University Hospital, Uppsala, Sweden
| | - Helena Gauffin
- Department of Neurology, Department of Clinical and Experimental Medicine, Linköping University, Sweden
| | - Francesco Latini
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Maria Zetterling
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Shala Berntsson
- Department of Neuroscience, Neurology, Uppsala University, University Hospital, Uppsala, Sweden
| | - Anne-Marie Landtblom
- Department of Neuroscience, Neurology, Uppsala University, University Hospital, Uppsala, Sweden.,Department of Neurology, Department of Clinical and Experimental Medicine, Linköping University, Sweden.,Neurology division, Clinic of Medical Specialist, Motala General Hospital, Motala, Sweden
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15
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Wang D, Shan Y, Bartolomei F, Kahane P, An Y, Li M, Zhang H, Fan X, Ou S, Yang Y, Wei P, Lu C, Wang Y, Du J, Ren L, Wang Y, Zhao G. Electrophysiological properties and seizure networks in hypothalamic hamartoma. Ann Clin Transl Neurol 2020; 7:653-666. [PMID: 32298053 PMCID: PMC7261749 DOI: 10.1002/acn3.51033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/11/2020] [Indexed: 12/14/2022] Open
Abstract
Objective Little is known about the intrinsic electrophysiological properties of hypothalamic hamartoma (HH) in vivo and seizure network since only few cases using stereoelectroencephalography (SEEG) electrodes exploring both cortex and HH have been published. To elucidate these issues, we analyzed simultaneous SEEG recordings in HH and cortex systematically. Methods We retrospectively investigated data from 15 consecutive patients with SEEG electrodes into the HH for the treatment purpose of radiofrequency thermocoagulation treatment. Additional SEEG electrodes were placed into the cortex in 11 patients to assess extra‐HH involvement. Interictal discharges within the HH and anatomo‐electroclinical correlations during seizures of each patient were qualitatively and quantitatively analyzed. Results Overall, 77 electrodes with 719 contacts were implanted, and 33 spontaneous seizures were recorded during long‐term SEEG monitoring. Interictally, distinct electrophysiological patterns, including isolated intermittent spikes/sharp waves, burst spike and wave trains, paroxysmal fast discharges, periodic discharges, and high‐frequency oscillations, were identified within the HH. Notably, synchronized or independent interictal discharges in the cortex were observed. Regarding the ictal discharges, the electrical onset pattern within the HH always started with abrupt giant shifts superimposed on low‐voltage fast activity across patients. The gelastic seizure network mainly involved the HH, orbitofrontal areas, and cingulate gyrus. Seizures with automatisms and impaired awareness primarily propagated to mesial temporal lobes. Moreover, independent ictal discharges arising from the mesial temporal lobe were detected in three out of nine patients. Interpretation This study comprehensively reveals intrinsic electrophysiological patterns and epileptogenic networks in vivo, providing new insights into the mechanisms underlying cortical and subcortical epileptogenesis.
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Affiliation(s)
- Di Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,The Beijing Key Laboratory of Neuromodulation, Beijing, China.,Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongzhi Shan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Fabrice Bartolomei
- Institut de Neurosciences des Systèmes, Aix-Marseille University, Marseille, France.,Service de Neurophysiologie Clinique, Hôpital de la Timone, AP-HM, Marseille, France
| | - Philippe Kahane
- Inserm U836, Grenoble, France.,University Grenoble Alpes, GIN, Grenoble, France.,Neurology Department, CHU de Grenoble, Hospital Michallon, Grenoble, France
| | - Yang An
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Muyang Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Huaqiang Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaotong Fan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Siqi Ou
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yanfeng Yang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Penghu Wei
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chao Lu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yihe Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jialin Du
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,The Beijing Key Laboratory of Neuromodulation, Beijing, China
| | - Liankun Ren
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,The Beijing Key Laboratory of Neuromodulation, Beijing, China
| | - Yuping Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,The Beijing Key Laboratory of Neuromodulation, Beijing, China.,Beijing Institute for Brain Disorder, Beijing, China.,Department of Pediatrics, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Guoguang Zhao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Institute for Brain Disorder, Beijing, China
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16
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Wang S, Zhao M, Li T, Zhang C, Zhou J, Wang M, Wang X, Liu Z, Ma K, Luan G, Guan Y. Stereotactic radiofrequency thermocoagulation and resective surgery for patients with hypothalamic hamartoma. J Neurosurg 2020; 134:1019-1026. [PMID: 32302977 DOI: 10.3171/2020.2.jns193423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 02/13/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE In this study, the authors compared the efficacy and safety of stereotactic radiofrequency thermocoagulation (SRT) and resective surgery (RS) for patients with hypothalamic hamartoma (HH). METHODS The authors included all patients with HHs who were treated by SRT or hamartoma resection. Seizure outcomes were assessed by blinded observers according to the International League Against Epilepsy (ILAE) classification. Favorable seizure outcomes were defined as ILAE classes 1 and 2, and unfavorable seizure outcomes were defined as ILAE classes 3-6. RESULTS Twenty-nine patients who underwent SRT or RS met the inclusion criteria; 3 were excluded because they had completed less than 12 months of follow-up. Most of the patients (20 of 26; 76.9%) had small HHs (i.e., maximum HH diameter less than 20 mm). The patients' follow-up time ranged from 12 to 66 months (median 60 months). At the last follow-up, favorable outcomes were observed in 9 patients (69.2%) who had undergone SRT and 10 patients (76.9%) who had undergone HH resection. No significant difference was found in seizure outcomes between SRT and RS recipients. Patients with giant HHs were more likely than patients with smaller tumors to undergo multiple resections (p = 0.043, univariate logistic regression; significant). However, no significant difference was found between SRT and RS recipients in terms of the number of procedures per patient. SRT recipients had fewer and less-severe adverse events than RS recipients. CONCLUSIONS For patients with small HHs, SRT provides similar seizure outcomes to RS with a less invasive procedure. Patients who underwent SRT experienced fewer and lighter adverse effects than patients who had RS. Patients with giant HHs were more likely to undergo multiple HH resections.
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Affiliation(s)
| | | | - Tianfu Li
- 2Neurology, SanBo Brain Hospital, Capital Medical University, Beijing.,3Beijing Key Laboratory of Epilepsy, Beijing; and.,4Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | | | - Jian Zhou
- Departments of1Neurosurgery and.,3Beijing Key Laboratory of Epilepsy, Beijing; and.,4Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | - Mengyang Wang
- 2Neurology, SanBo Brain Hospital, Capital Medical University, Beijing
| | - Xiongfei Wang
- Departments of1Neurosurgery and.,3Beijing Key Laboratory of Epilepsy, Beijing; and.,4Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | | | | | - Guoming Luan
- Departments of1Neurosurgery and.,3Beijing Key Laboratory of Epilepsy, Beijing; and.,4Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | - Yuguang Guan
- Departments of1Neurosurgery and.,3Beijing Key Laboratory of Epilepsy, Beijing; and.,4Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
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17
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Shirozu H, Masuda H, Kameyama S. Repeat stereotactic radiofrequency thermocoagulation in patients with hypothalamic hamartoma and seizure recurrence. Epilepsia Open 2020; 5:107-120. [PMID: 32140649 PMCID: PMC7049799 DOI: 10.1002/epi4.12378] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 01/02/2020] [Accepted: 01/04/2020] [Indexed: 11/09/2022] Open
Abstract
Objective To evaluate the feasibility of repeat stereotactic radiofrequency thermocoagulation (re‐SRT) for patients with hypothalamic hamartoma (HH) and to clarify clinical and surgical factors for seizure outcomes. Methods Hypothalamic hamartoma patients with gelastic seizures (GSs) who underwent SRT were retrospectively reviewed. Seizure outcomes were evaluated separately for GS and other types of seizures (non‐GS). Surgical complications were compared between re‐SRT and first SRT. Clinical and surgical factors related to both seizure recurrences after first SRT and final seizure outcomes were analyzed. Results Participants comprised 150 patients (92 males; median age at surgery, 8 years; range, 1.7‐50 years). Of those, 122 (81.3%) had non‐GS. Forty‐three patients (28.7%) underwent re‐SRT. Freedom from GS was achieved by first SRT in 103 patients (68.7%), second SRT in 30/40 (67.5%), third SRT in 3/10 (30.0%), and fourth SRT in 2/3 (66.7%). Finally, 135 patients (90.0%) became GS‐free. Ninety patients (73.8%) achieved non‐GS freedom, with first SRT in all except one case. Transient complications were more frequent with first SRT (118/150, 78.7%) than re‐SRT (35/56, 62.5%), whereas persistent complications were more frequent with re‐SRT (7/56, 12.5%) than with first SRT (3/150, 2.0%). Multivariate analyses revealed only younger age at surgery (≤1 year) as related to GS recurrence after first SRT, with no variables affecting final GS outcomes. Meanwhile, seizure type (tonic seizure), intellectual disability, and genetic syndromes were significant factors for both non‐GS recurrence and final outcomes. Multiple previous treatments were significantly related to final non‐GS outcomes as well. Size and subtype of HH and surgical factors were unrelated to seizure outcomes. Significance Repeat stereotactic radiofrequency thermocoagulation provides potential opportunities to achieve freedom from recurrent GS, albeit with increased risks of persistent complications. Non‐GS and intellectual disability could offer early surgical indications, and repeated ineffective treatments should be avoided.
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Affiliation(s)
- Hiroshi Shirozu
- Department of Functional Neurosurgery National Hospital Organization Nishiniigata Chuo Hospital Niigata Japan.,Hypothalamic Hamartoma Center National Hospital Organization Nishiniigata Chuo Hospital Niigata Japan
| | - Hiroshi Masuda
- Department of Functional Neurosurgery National Hospital Organization Nishiniigata Chuo Hospital Niigata Japan.,Hypothalamic Hamartoma Center National Hospital Organization Nishiniigata Chuo Hospital Niigata Japan
| | - Shigeki Kameyama
- Department of Functional Neurosurgery National Hospital Organization Nishiniigata Chuo Hospital Niigata Japan.,Hypothalamic Hamartoma Center National Hospital Organization Nishiniigata Chuo Hospital Niigata Japan.,Department of Neurosurgery Saiseikai Niigata Hospital Niigata Japan
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18
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Conde Blanco E, Anciones Martín C, Manzanares I, Gil López F, Roldán P, Donaire A, Rumiá J, Carreño M. Hypothalamic hamartomas in adulthood: Clinical spectrum and treatment outcome-A unicenter experience. Brain Behav 2019; 9:e01412. [PMID: 31578831 PMCID: PMC6851795 DOI: 10.1002/brb3.1412] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/01/2019] [Accepted: 07/28/2019] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Clinical manifestations of the hypothalamic hamartoma-epilepsy syndrome (HH-ES) in adulthood are variable. Efficacy of therapeutic options and outcome are diverse. METHODS Retrospective study of adult patients diagnosed with a HH in magnetic resonance imaging and epilepsy who attended our tertiary Epilepsy Unit between 2003 and 2018. We report the clinical and electroencephalographic features of a series of adult patients with HH and related epilepsy seen in our center together with the treatments and seizure outcome. RESULTS We describe a series of eight patients. Five males (62.5%), median age at evaluation was 28.5 years (IQR: 15.5). Clinical manifestations included focal with preserved and impaired awareness emotional seizures (gelastic seizures [GS]) in six patients (75%), focal tonic, atonic with impaired awareness and focal to bilateral tonic-clonic seizures. Mild GS were the only symptom in one patient. Three patients (37.5%) had endocrinological disturbances such as obesity and hypothyroidism. Fifty percent of the patients showed psychiatric comorbidity such as anxiety disorder and aggressiveness, and two patients had psychomotor delay. Seven patients (87.7%) had drug-resistant seizures and three of them were treated with radiosurgery. Out of the treated group, only one (33.3%) became seizure-free 2 years after surgery but developed psychiatric problems. The other two patients had an Engel IV outcome and received a vagal nerve stimulation (VNS) implant. VNS did not lead to changes either in intensity nor in seizure frequency. CONCLUSIONS Hypothalamic hamartoma-epilepsy syndrome clinical manifestations in adult patients are as variable as at pediatric age. Outcome of therapeutic options such as radiosurgery or VNS may be poorer at this stage.
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Affiliation(s)
| | | | - Isabel Manzanares
- Epilepsy Unit, Department of Neurology, Hospital Clinic, Barcelona, Spain
| | | | - Pedro Roldán
- Epilepsy Unit, Department of Neurology, Hospital Clinic, Barcelona, Spain
| | - Antonio Donaire
- Epilepsy Unit, Department of Neurology, Hospital Clinic, Barcelona, Spain
| | - Jordi Rumiá
- Epilepsy Unit, Department of Neurology, Hospital Clinic, Barcelona, Spain
| | - Mar Carreño
- Epilepsy Unit, Department of Neurology, Hospital Clinic, Barcelona, Spain
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19
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Asymmetric gelastic seizure as a lateralizing sign in patients with hypothalamic hamartoma. Epilepsy Behav 2019; 94:35-40. [PMID: 30884405 DOI: 10.1016/j.yebeh.2019.02.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 02/19/2019] [Accepted: 02/21/2019] [Indexed: 10/27/2022]
Abstract
Gelastic seizure (GS) is a cardinal symptom of hypothalamic hamartoma (HH), which is intractable but surgically remediable. Although facial asymmetry with GS has not been extensively discussed, asymmetric GS has been frequently recognized in our large series. We hypothesized that asymmetric GS represents a lateralizing sign caused by the epileptic propagation from the attachment of the HH. To examine this hypothesis, the positive predictive value (PPV) and diagnostic odds ratio (DOR) of asymmetric GS were validated to predict the side of HH attachment. In 103 cases registered to the present analysis, asymmetric GS was recognized in 71 patients and symmetric GS in 32. Asymmetric GS with a lopsided grimace was exclusively observed on the side contralateral to unilateral HH in 39 patients and to the dominant attachment of 23 HHs with bilateral attachment (true positive, n = 62). In contrast, asymmetric GS was exhibited independently on both sides in 4 patients with bilaterally attached HH and on the side ipsilateral to the dominant attachment in the other 4. Symmetric HH attachments were identified in 1 patient (false negative, n = 9). Asymmetric GS was a reliable lateralizing sign with high DOR (6.08) and PPV (78%) to predict the side of epileptic propagation. Furthermore, the present study demonstrated the probability of seizure propagation from bilateral attachment, and this evidence provides a new rationale to the surgical strategy of bilateral disconnection for HH with bilateral attachment.
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20
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Warren AEL, Abbott DF, Jackson GD, Archer JS. Thalamocortical functional connectivity in Lennox-Gastaut syndrome is abnormally enhanced in executive-control and default-mode networks. Epilepsia 2017; 58:2085-2097. [PMID: 29098688 DOI: 10.1111/epi.13932] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To identify abnormal thalamocortical circuits in the severe epilepsy of Lennox-Gastaut syndrome (LGS) that may explain the shared electroclinical phenotype and provide potential treatment targets. METHODS Twenty patients with a diagnosis of LGS (mean age = 28.5 years) and 26 healthy controls (mean age = 27.6 years) were compared using task-free functional magnetic resonance imaging (MRI). The thalamus was parcellated according to functional connectivity with 10 cortical networks derived using group-level independent component analysis. For each cortical network, we assessed between-group differences in thalamic functional connectivity strength using nonparametric permutation-based tests. Anatomical locations were identified by quantifying spatial overlap with a histologically informed thalamic MRI atlas. RESULTS In both groups, posterior thalamic regions showed functional connectivity with visual, auditory, and sensorimotor networks, whereas anterior, medial, and dorsal thalamic regions were connected with networks of distributed association cortex (including the default-mode, anterior-salience, and executive-control networks). Four cortical networks (left and right executive-control network; ventral and dorsal default-mode network) showed significantly enhanced thalamic functional connectivity strength in patients relative to controls. Abnormal connectivity was maximal in mediodorsal and ventrolateral thalamic nuclei. SIGNIFICANCE Specific thalamocortical circuits are affected in LGS. Functional connectivity is abnormally enhanced between the mediodorsal and ventrolateral thalamus and the default-mode and executive-control networks, thalamocortical circuits that normally support diverse cognitive processes. In contrast, thalamic regions connecting with primary and sensory cortical networks appear to be less affected. Our previous neuroimaging studies show that epileptic activity in LGS is expressed via the default-mode and executive-control networks. Results of the present study suggest that the mediodorsal and ventrolateral thalamus may be candidate targets for modulating abnormal network behavior underlying LGS, potentially via emerging thalamic neurostimulation therapies.
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Affiliation(s)
- Aaron E L Warren
- Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - David F Abbott
- Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - Graeme D Jackson
- Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia.,Department of Neurology, Austin Health, Heidelberg, Victoria, Australia
| | - John S Archer
- Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia.,Department of Neurology, Austin Health, Heidelberg, Victoria, Australia
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21
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Shimogori K, Doden T, Oguchi K, Hashimoto T. Thalamic and cerebellar hypermetabolism and cortical hypometabolism during absence status epilepticus. BMJ Case Rep 2017; 2017:bcr-2017-220139. [PMID: 28756378 DOI: 10.1136/bcr-2017-220139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report on a 17-year-old girl with absence status epilepticus who developed recurrent motionless confusional state and continuous generalised 3-4 Hz rhythmic delta waves on electroencephalogram (EEG). The patient had no history of absence, myoclonus or generalised convulsion. Her seizure was resistant to a combination of antiepileptic drugs including carbamazepine. Ictal positron emission tomography using [18F]fluorodeoxyglucose ([18F]FDG-PET) revealed hypermetabolism of the bilateral thalamus and cerebellum and hypometabolism of the frontal, parietal and posterior cingulate cortices. We diagnosed her seizure as absence status and obtained remission by changing medication. The findings of ictal metabolic alteration in previous studies and in our case confirm the pathogenic importance of the thalamus in absence status and that associated cortical deactivation and cerebellar activation may be related to the generation or maintenance of epileptic EEG discharges.
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Affiliation(s)
- Kei Shimogori
- Department of Neurology, Aizawa Hospital, Matsumoto, Japan
| | - Tadashi Doden
- Department of Neurology, Aizawa Hospital, Matsumoto, Japan
| | | | - Takao Hashimoto
- Center for Neurological Diseases, Aizawa Hospital, Matsumoto, Japan
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22
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Sonoda M, Masuda H, Shirozu H, Ito Y, Akazawa K, Asano E, Kameyama S. Predictors of cognitive function in patients with hypothalamic hamartoma following stereotactic radiofrequency thermocoagulation surgery. Epilepsia 2017; 58:1556-1565. [DOI: 10.1111/epi.13838] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2017] [Indexed: 01/04/2023]
Affiliation(s)
- Masaki Sonoda
- Hypothalamic Hamartoma Center; Department of Functional Neurosurgery; Nishi-Niigata Chuo National Hospital; Niigata Japan
- Department of Neurosurgery; Graduate School of Medicine; Yokohama City University; Yokohama Kanagawa Japan
| | - Hiroshi Masuda
- Hypothalamic Hamartoma Center; Department of Functional Neurosurgery; Nishi-Niigata Chuo National Hospital; Niigata Japan
| | - Hiroshi Shirozu
- Hypothalamic Hamartoma Center; Department of Functional Neurosurgery; Nishi-Niigata Chuo National Hospital; Niigata Japan
| | - Yosuke Ito
- Hypothalamic Hamartoma Center; Department of Functional Neurosurgery; Nishi-Niigata Chuo National Hospital; Niigata Japan
| | - Kohei Akazawa
- Department of Medical Informatics; Niigata University Medical and Dental Hospital; Niigata Japan
| | - Eishi Asano
- Department of Pediatrics; Children's Hospital of Michigan; Detroit Medical Center; Wayne State University; Detroit Michigan U.S.A
- Department of Neurology; Children's Hospital of Michigan; Detroit Medical Center; Wayne State University; Detroit Michigan U.S.A
| | - Shigeki Kameyama
- Hypothalamic Hamartoma Center; Department of Functional Neurosurgery; Nishi-Niigata Chuo National Hospital; Niigata Japan
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23
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Scholly J, Staack AM, Kahane P, Scavarda D, Régis J, Hirsch E, Bartolomei F. Hypothalamic hamartoma: Epileptogenesis beyond the lesion? Epilepsia 2017; 58 Suppl 2:32-40. [PMID: 28591482 DOI: 10.1111/epi.13755] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2016] [Indexed: 11/30/2022]
Abstract
The discovery of intrinsic epileptogenicity of the hypothalamic hamartoma (HH) marked a new area in understanding the associated clinical syndrome, often manifesting as progressive epileptic encephalopathy. However, therapeutic procedures targeting the HH proved to be inefficient to cure seizures in up to 50% of cases, whereas in cases with partial improvement, the electroclinical patterns of persisting seizures suggest an involvement of distant cortical regions. The concept of kindling-like secondary epileptogenesis has been suggested as a possible underlying mechanism. Yet the role of the hypothalamic lesion in the pathophysiology of the syndrome remains debatable. In the Strasbourg-Kork series, the best outcomes were obtained when the duration of epilepsy before endoscopic HH surgery did not exceed 10 years. In two patients with HH ablation followed at a later time by a temporal lobectomy, only this second surgical step allowed complete seizure freedom. These findings suggest the existence of an independent, third stage of secondary epileptogenesis in human. In the Grenoble series, stereotactic intracerebral recordings (stereo electroencephalography [SEEG]) of five HH cases demonstrated that gelastic/dacrystic seizures were correlated with discharges within the HH, whereas other seizure types were related to discharges affecting cortical regions, which sometimes seemed to be triggered by HH. In the Marseille series, two cases explored by SEEG provided evidence of extended epileptogenicity outside the limits of the HH, forming complex epileptogenic networks, with HH still triggering clusters of neocortical seizures in the first, but not obligatory involved in spontaneous seizures in the second case. Taken together, our data argue for the existence of dynamic ictal network organization, with possible "kindling-like" relationships between the HH and the neocortex or widespread epileptogenesis. Despite the existence of secondary epileptogenesis, the epileptogenic zone could still be limited to the hamartoma, for which early surgical treatment should be pragmatically considered as a first surgical step.
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Affiliation(s)
- Julia Scholly
- Medical and Surgical Epilepsy Unit, Hautepierre Hospital, University of Strasbourg, Strasbourg, France.,Kork Epilepsy Center, Kehl-Kork, Germany
| | | | - Philippe Kahane
- Inserm U836, Grenoble, France.,University Grenoble Alpes, GIN, Grenoble, France.,Neurology Department, CHU de Grenoble, Hospital Michallon, Grenoble, France
| | - Didier Scavarda
- Aix Marseille Univ, Inserm, INS, Systems Neurosciences Institute, Marseille, France
| | - Jean Régis
- Aix Marseille Univ, Inserm, INS, Systems Neurosciences Institute, Marseille, France
| | - Edouard Hirsch
- Medical and Surgical Epilepsy Unit, Hautepierre Hospital, University of Strasbourg, Strasbourg, France.,IDEE, Institute of Epilepsies of Childhood and Adolescence, Lyon, France
| | - Fabrice Bartolomei
- Aix Marseille Univ, Inserm, INS, Systems Neurosciences Institute, Marseille, France
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24
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Striano S, Striano P. Clinical features and evolution of the gelastic seizures-hypothalamic hamartoma syndrome. Epilepsia 2017; 58 Suppl 2:12-15. [DOI: 10.1111/epi.13753] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Salvatore Striano
- Department of Neurosciences, Reproductive and Odontostomatological Sciences; Epilepsy Center; School of Medicine; Federico II University; Napoli Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health; Institute “G. Gaslini”; University of Genova; Genova Italy
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25
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Shim KW, Park EK, Kim DS. Endoscopic Treatment of Hypothalamic Hamartomas. J Korean Neurosurg Soc 2017; 60:294-300. [PMID: 28490155 PMCID: PMC5426443 DOI: 10.3340/jkns.2017.0101.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/05/2017] [Accepted: 03/08/2017] [Indexed: 11/27/2022] Open
Abstract
Hypothalamic hamartoma (HH) is a benign indolent lesion despite the presentation of refractory epilepsy. Behavioral disturbances and endocrine problems are additional critical symptoms that arise along with HHs. Due to its nature of generating epileptiform discharge and spreading to cortical region, various management strategies have been proposed and combined. Surgical approaches with open craniotomy or endoscopy, stereotactic approaches with radiosurgery and gamma knife surgery or radiofrequency thermos-coagulation, and laser ablation have been introduced. Topographical dimension and the surgeon’s preference are key factors for treatment modalities. Endoscopic disconnection has been one of the most favorable options performed in treating HHs. Here we discuss presurgical evaluation, patient selection, surgical procedures, and complications.
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Affiliation(s)
- Kyu Won Shim
- Department of Pediatric Neurosurgery, Severance Children's Hospital, Yonsei University College of Medicine, Brain Korea 21 Project for Medical Science, Seoul, Korea
| | - Eun Kyung Park
- Department of Pediatric Neurosurgery, Severance Children's Hospital, Yonsei University College of Medicine, Brain Korea 21 Project for Medical Science, Seoul, Korea
| | - Dong-Seok Kim
- Department of Pediatric Neurosurgery, Severance Children's Hospital, Yonsei University College of Medicine, Brain Korea 21 Project for Medical Science, Seoul, Korea
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26
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Shirozu H, Masuda H, Ito Y, Sonoda M, Kameyama S. Stereotactic radiofrequency thermocoagulation for giant hypothalamic hamartoma. J Neurosurg 2016; 125:812-821. [DOI: 10.3171/2015.6.jns15200] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE
The authors undertook this study to validate the feasibility and safety of stereotactic radiofrequency thermocoagulation (SRT) for the surgical treatment of giant hypothalamic hamartoma (HH).
METHODS
Of the 109 patients who underwent SRT for hypothalamic hamartoma (HH) at the authors' institution between 1997 and 2013, 16 patients (9 female, 7 male) had giant HHs (maximum diameter ≥ 30 mm). The clinical records of these 16 patients were retrospectively reviewed.
RESULTS
The patients' age at first SRT ranged from 1 to 22 years (median 5 years). The maximum diameter of their HHs was 30–80 mm (mean 38.5 mm). Eleven HHs had bilateral attachments to the hypothalamus. All patients had gelastic seizures (GS), and 12 had types of seizures other than GS. Some of these patients also had mental retardation (n = 10, 62.5%), behavioral disorders (n = 8, 50.0%), and precocious puberty (n = 11, 68.8%). A total of 22 SRT procedures were performed; 5 patients underwent repeat SRT procedures. There was no mortality or permanent morbidity. After 17 of the 22 procedures, the patients experienced transient complications, including high fever (n = 7), hyperphagia (n = 3), hyponatremia (n = 6), disturbance of consciousness (n = 1), cyst enlargement (n = 1), and epidural hematoma (n = 1). Thirteen patients (81.3%) achieved freedom from GS after the final SRT procedure during a follow-up period ranging from 6 to 60 months (mean 23 months). Twelve patients had nongelastic seizures in addition to GS, and 7 (58.3%) of these 12 patients experienced freedom from their nongelastic seizures.
CONCLUSIONS
SRT provided minimal invasiveness and excellent seizure outcomes even in patients with giant HHs. Repeat SRT is safe for residual GS. SRT is a feasible single surgical strategy for HH regardless of the tumor's size or shape.
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Affiliation(s)
- Hiroshi Shirozu
- 1Department of Functional Neurosurgery and
- 2Hypothalamic Hamartoma Center, Nishi-Niigata Chuo National Hospital, Niigata, Japan
| | - Hiroshi Masuda
- 1Department of Functional Neurosurgery and
- 2Hypothalamic Hamartoma Center, Nishi-Niigata Chuo National Hospital, Niigata, Japan
| | - Yosuke Ito
- 1Department of Functional Neurosurgery and
- 2Hypothalamic Hamartoma Center, Nishi-Niigata Chuo National Hospital, Niigata, Japan
| | - Masaki Sonoda
- 1Department of Functional Neurosurgery and
- 2Hypothalamic Hamartoma Center, Nishi-Niigata Chuo National Hospital, Niigata, Japan
| | - Shigeki Kameyama
- 1Department of Functional Neurosurgery and
- 2Hypothalamic Hamartoma Center, Nishi-Niigata Chuo National Hospital, Niigata, Japan
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27
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Lesional cerebellar epilepsy: a review of the evidence. J Neurol 2016; 264:1-10. [PMID: 27260293 DOI: 10.1007/s00415-016-8161-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/03/2016] [Accepted: 05/04/2016] [Indexed: 10/21/2022]
Abstract
Classical teaching in epileptology localizes the origins of focal seizures solely in the cerebral cortex, with only inhibitory effects attributed to subcortical structures. However, electrophysiological and neuroimaging studies over the last decades now provide evidence for an initiation of epileptic seizures within subcortical structures. Intrinsic epileptogenicity of hypothalamic hamartoma has already been established in recognition of subcortical epilepsy, whereas a seizure-generating impact of dysplastic cerebellar lesions remains to be clarified. Herein, we examine the supportive evidence and clinical presentation of cerebellar seizures and review therapy options.
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28
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Usami K, Matsumoto R, Sawamoto N, Murakami H, Inouchi M, Fumuro T, Shimotake A, Kato T, Mima T, Shirozu H, Masuda H, Fukuyama H, Takahashi R, Kameyama S, Ikeda A. Epileptic network of hypothalamic hamartoma: An EEG-fMRI study. Epilepsy Res 2016; 125:1-9. [PMID: 27295078 DOI: 10.1016/j.eplepsyres.2016.05.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 04/20/2016] [Accepted: 05/27/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate the brain networks involved in epileptogenesis/encephalopathy associated with hypothalamic hamartoma (HH) by EEG with functional MRI (EEG-fMRI), and evaluate its efficacy in locating the HH interface in comparison with subtraction ictal SPECT coregistered to MRI (SISCOM). METHODS Eight HH patients underwent EEG-fMRI. All had gelastic seizures (GS) and 7 developed other seizure types. Using a general linear model, spike-related activation/deactivation was analyzed individually by applying a hemodynamic response function before, at, and after spike onset (time-shift model=-8-+4s). Group analysis was also performed. The sensitivity of EEG-fMRI in identifying the HH interface was compared with SISCOM in HH patients having unilateral hypothalamic attachment. RESULTS EEG-fMRI revealed activation and/or deactivation in subcortical structures and neocortices in all patients. 6/8 patients showed activation in or around the hypothalamus with the HH interface with time-shift model before spike onset. Group analysis showed common activation in the ipsilateral hypothalamus, brainstem tegmentum, and contralateral cerebellum. Deactivation occurred in the default mode network (DMN) and bilateral hippocampi. Among 5 patients with unilateral hypothalamic attachment, activation in or around the ipsilateral hypothalamus was seen in 3 using EEG-fMRI, whereas hyperperfusion was seen in 1 by SISCOM. SIGNIFICANCE Group analysis of this preliminary study may suggest that the commonly activated subcortical network is related to generation of GS and that frequent spikes lead to deactivation of the DMN and hippocampi, and eventually to a form of epileptic encephalopathy. Inter-individual variance in neocortex activation explains various seizure types among patients. EEG-fMRI enhances sensitivity in detecting the HH interface compared with SISCOM.
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Affiliation(s)
- Kiyohide Usami
- Department of Neurology, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Riki Matsumoto
- Department of Epilepsy, Movement Disorders and Physiology, Kyoto University, Graduate School of Medicine, Kyoto, Japan.
| | - Nobukatsu Sawamoto
- Department of Neurology, Kyoto University, Graduate School of Medicine, Kyoto, Japan; Human Brain Research Center, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Hiroatsu Murakami
- Department of Neurosurgery, Nishi-Niigata Chuo National Hospital, Niigata, Japan
| | - Morito Inouchi
- Department of Neurology, Kyoto University, Graduate School of Medicine, Kyoto, Japan; Department of Respiratory Medicine, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Tomoyuki Fumuro
- Research and Educational Unit of Leaders for Integrated Medical System, Kyoto University, Kyoto, Japan
| | - Akihiro Shimotake
- Department of Neurology, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Takeo Kato
- Department of Pediatrics, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Tatsuya Mima
- Human Brain Research Center, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Hiroshi Shirozu
- Department of Neurosurgery, Nishi-Niigata Chuo National Hospital, Niigata, Japan
| | - Hiroshi Masuda
- Department of Neurosurgery, Nishi-Niigata Chuo National Hospital, Niigata, Japan
| | - Hidenao Fukuyama
- Human Brain Research Center, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Ryosuke Takahashi
- Department of Neurology, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Shigeki Kameyama
- Department of Neurosurgery, Nishi-Niigata Chuo National Hospital, Niigata, Japan
| | - Akio Ikeda
- Department of Epilepsy, Movement Disorders and Physiology, Kyoto University, Graduate School of Medicine, Kyoto, Japan.
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29
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Kameyama S, Shirozu H, Masuda H, Ito Y, Sonoda M, Akazawa K. MRI-guided stereotactic radiofrequency thermocoagulation for 100 hypothalamic hamartomas. J Neurosurg 2016; 124:1503-12. [DOI: 10.3171/2015.4.jns1582] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECT
The aim of this study was to elucidate the invasiveness, effectiveness, and feasibility of MRI-guided stereotactic radiofrequency thermocoagulation (SRT) for hypothalamic hamartoma (HH).
METHODS
The authors examined the clinical records of 100 consecutive patients (66 male and 34 female) with intractable gelastic seizures (GS) caused by HH, who underwent SRT as a sole surgical treatment between 1997 and 2013.
The median duration of follow-up was 3 years (range 1–17 years). Seventy cases involved pediatric patients. Ninety percent of patients also had other types of seizures (non-GS). The maximum diameter of the HHs ranged from 5 to 80 mm (median 15 mm), and 15 of the tumors were giant HHs with a diameter of 30 mm or more. Comorbidities included precocious puberty (33.0%), behavioral disorder (49.0%), and mental retardation (50.0%).
RESULTS
A total of 140 SRT procedures were performed. There was no adaptive restriction for the giant or the subtype of HH, regardless of any prior history of surgical treatment or comorbidities. Patients in this case series exhibited delayed precocious puberty (9.0%), pituitary dysfunction (2.0%), and weight gain (7.0%), besides the transient hypothalamic symptoms after SRT. Freedom from GS was achieved in 86.0% of patients, freedom from other types of seizures in 78.9%, and freedom from all seizures in 71.0%. Repeat surgeries were not effective for non-GS. Seizure freedom led to disappearance of behavioral disorders and to intellectual improvement.
CONCLUSIONS
The present SRT procedure is a minimally invasive and highly effective surgical procedure without adaptive limitations. SRT involves only a single surgical procedure appropriate for all forms of epileptogenic HH and should be considered in patients with an early history of GS.
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Affiliation(s)
- Shigeki Kameyama
- 1Hypothalamic Hamartoma Center, Department of Functional Neurosurgery, Nishi-Niigata Chuo National Hospital; and
| | - Hiroshi Shirozu
- 1Hypothalamic Hamartoma Center, Department of Functional Neurosurgery, Nishi-Niigata Chuo National Hospital; and
| | - Hiroshi Masuda
- 1Hypothalamic Hamartoma Center, Department of Functional Neurosurgery, Nishi-Niigata Chuo National Hospital; and
| | - Yosuke Ito
- 1Hypothalamic Hamartoma Center, Department of Functional Neurosurgery, Nishi-Niigata Chuo National Hospital; and
| | - Masaki Sonoda
- 1Hypothalamic Hamartoma Center, Department of Functional Neurosurgery, Nishi-Niigata Chuo National Hospital; and
| | - Kohei Akazawa
- 2Department of Medical Informatics, Niigata University Medical and Dental Hospital, Niigata, Japan
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30
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Weiner HL. Editorial: Hypothalamic hamartomas. J Neurosurg 2015; 124:1501-2. [PMID: 26587659 DOI: 10.3171/2015.5.jns15785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Howard L Weiner
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
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31
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Scholly J, Valenti MP, Staack AM, Strobl K, Bast T, Kehrli P, Steinhoff BJ, Hirsch E. Hypothalamic hamartoma: Is the epileptogenic zone always hypothalamic? Arguments for independent (third stage) secondary epileptogenesis. Epilepsia 2013; 54 Suppl 9:123-8. [DOI: 10.1111/epi.12456] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Julia Scholly
- Medical and Surgical Epilepsy Unit; University of Strasbourg; Strasbourg France
- Kork; Epilepsy Center; Kehl-Kork Germany
| | - Maria-Paola Valenti
- Medical and Surgical Epilepsy Unit; University of Strasbourg; Strasbourg France
| | | | | | | | - Pierre Kehrli
- Medical and Surgical Epilepsy Unit; University of Strasbourg; Strasbourg France
| | | | - Edouard Hirsch
- Medical and Surgical Epilepsy Unit; University of Strasbourg; Strasbourg France
- Federation of Translational Medicine; Epilepsy Center; Strasbourg France
- IDEE; Institute of Epilepsies of Childhood and Adolescence; Lyon France
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32
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Mittal S, Mittal M, Montes JL, Farmer JP, Andermann F. Hypothalamic hamartomas. Part 1. Clinical, neuroimaging, and neurophysiological characteristics. Neurosurg Focus 2013; 34:E6. [DOI: 10.3171/2013.3.focus1355] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Hypothalamic hamartomas are uncommon but well-recognized developmental malformations that are classically associated with gelastic seizures and other refractory seizure types. The clinical course is often progressive and, in addition to the catastrophic epileptic syndrome, patients commonly exhibit debilitating cognitive, behavioral, and psychiatric disturbances. Over the past decade, investigators have gained considerable knowledge into the pathobiological and neurophysiological properties of these rare lesions. In this review, the authors examine the causes and molecular biology of hypothalamic hamartomas as well as the principal clinical features, neuroimaging findings, and electrophysiological characteristics. The diverse surgical modalities and strategies used to manage these difficult lesions are outlined in the second article of this 2-part review.
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Affiliation(s)
- Sandeep Mittal
- 1Department of Neurosurgery, Comprehensive Epilepsy Center, Wayne State University, Detroit Medical Center, Detroit, Michigan
| | - Monika Mittal
- 1Department of Neurosurgery, Comprehensive Epilepsy Center, Wayne State University, Detroit Medical Center, Detroit, Michigan
| | | | | | - Frederick Andermann
- 3Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
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Chaudhary UJ, Carmichael DW, Rodionov R, Thornton RC, Bartlett P, Vulliemoz S, Micallef C, McEvoy AW, Diehl B, Walker MC, Duncan JS, Lemieux L. Mapping preictal and ictal haemodynamic networks using video-electroencephalography and functional imaging. ACTA ACUST UNITED AC 2013; 135:3645-63. [PMID: 23250884 DOI: 10.1093/brain/aws302] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Ictal patterns on scalp-electroencephalography are often visible only after propagation, therefore rendering localization of the seizure onset zone challenging. We hypothesized that mapping haemodynamic changes before and during seizures using simultaneous video-electroencephalography and functional imaging will improve the localization of the seizure onset zone. Fifty-five patients with ≥2 refractory focal seizures/day, and who had undergone long-term video-electroencephalography monitoring were included in the study. 'Preictal' (30 s immediately preceding the electrographic seizure onset) and ictal phases, 'ictal-onset'; 'ictalestablished' and 'late ictal', were defined based on the evolution of the electrographic pattern and clinical semiology. The functional imaging data were analysed using statistical parametric mapping to map ictal phase-related haemodynamic changes consistent across seizures. The resulting haemodynamic maps were overlaid on co-registered anatomical scans, and the spatial concordance with the presumed and invasively defined seizure onset zone was determined. Twenty patients had typical seizures during functional imaging. Seizures were identified on video-electroencephalography in 15 of 20, on electroencephalography alone in two and on video alone in three patients. All patients showed significant ictal-related haemodynamic changes. In the six cases that underwent invasive evaluation, the ictal-onset phase-related maps had a degree of concordance with the presumed seizure onset zone for all patients. The most statistically significant haemodynamic cluster within the presumed seizure onset zone was between 1.1 and 3.5 cm from the invasively defined seizure onset zone, which was resected in two of three patients undergoing surgery (Class I post-surgical outcome) and was not resected in one patient (Class III post-surgical outcome). In the remaining 14 cases, the ictal-onset phase-related maps had a degree of concordance with the presumed seizure onset zone in six of eight patients with structural-lesions and five of six non-lesional patients. The most statistically significant haemodynamic cluster was localizable at sub-lobar level within the presumed seizure onset zone in six patients. The degree of concordance of haemodynamic maps was significantly better (P < 0.05) for the ictal-onset phase [entirely concordant/concordant plus (13/20; 65%) + some concordance (4/20; 20%) = 17/20; 85%] than ictal-established [entirely concordant/concordant plus (5/13; 38%) + some concordance (4/13; 31%) = 9/13; 69%] and late ictal [concordant plus (1/9; 11%) + some concordance (4/9; 44%) = 5/9; 55%] phases. Ictal propagation-related haemodynamic changes were also seen in symptomatogenic areas (9/20; 45%) and the default mode network (13/20; 65%). A common pattern of preictal changes was seen in 15 patients, starting between 98 and 14 s before electrographic seizure onset, and the maps had a degree of concordance with the presumed seizure onset zone in 10 patients. In conclusion, preictal and ictal haemodynamic changes in refractory focal seizures can non-invasively localize seizure onset at sub-lobar/gyral level when ictal scalp-electroencephalography is not helpful.
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Striano S, Santulli L, Ianniciello M, Ferretti M, Romanelli P, Striano P. The gelastic seizures-hypothalamic hamartoma syndrome: facts, hypotheses, and perspectives. Epilepsy Behav 2012; 24:7-13. [PMID: 22503469 DOI: 10.1016/j.yebeh.2012.02.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 02/12/2012] [Accepted: 02/14/2012] [Indexed: 11/15/2022]
Abstract
Hypothalamic hamartoma (HH) can be associated with a wide spectrum of epileptic conditions, ranging from a mild form with seizures characterized by urge to laugh and no cognitive involvement up to a catastrophic encephalopathy with early onset gelastic seizures (GS), precocious puberty, and mental retardation. Moreover, a refractory, either focal or generalized, epilepsy develops during the clinical course in nearly all the cases. Neurophysiologic and neuroimaging studies have demonstrated that HH itself generates GS and starts a process of secondary epileptogenesis responsible for refractory focal or generalized epilepsy. The intrinsic epileptogenicity of HH may be explained by the neurophysiological properties of small GABAergic, spontaneously firing HH neurons. Surgical ablation of HH can reverse epilepsy and encephalopathy. Gamma-knife radiosurgery and image-guided robotic radiosurgery seem to be useful and safe approaches for treatment, in particular of small HH. Here, we review this topic, based on literature reports and our personal observations. In addition, we discuss pathogenetic hypotheses and suggest new approaches to this intriguing issue.
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Affiliation(s)
- Salvatore Striano
- Epilepsy Center, Department of Neurological Sciences, Federico II University, Napoli, Italy.
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Kokkinos V, Zountsas B, Kontogiannis K, Garganis K. Epileptogenic Networks in Two Patients with Hypothalamic Hamartoma. Brain Topogr 2011; 25:327-31. [DOI: 10.1007/s10548-011-0214-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Accepted: 12/12/2011] [Indexed: 10/14/2022]
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Parvizi J, Le S, Foster BL, Bourgeois B, Riviello JJ, Prenger E, Saper C, Kerrigan JF. Gelastic epilepsy and hypothalamic hamartomas: neuroanatomical analysis of brain lesions in 100 patients. Brain 2011; 134:2960-8. [DOI: 10.1093/brain/awr235] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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