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Al-Ramadhani R, Hect JL, Abel TJ. The changing landscape of palliative epilepsy surgery for Lennox Gastaut Syndrome. Front Neurol 2024; 15:1380423. [PMID: 38515452 PMCID: PMC10954786 DOI: 10.3389/fneur.2024.1380423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/21/2024] [Indexed: 03/23/2024] Open
Abstract
Lennox Gastaut Syndrome (LGS) is characterized by drug-resistant epilepsy that typically leads to decreased quality of life and deleterious neurodevelopmental comorbidities from medically refractory seizures. In recent years there has been a dramatic increase in the development and availability of novel treatment strategies for Lennox Gastaut Syndrome patient to improve seizure. Recent advances in neuromodulation and minimally invasive magnetic resonance guided laser interstitial thermal therapy (MRgLITT) have paved the way for new treatments strategies including deep brain stimulation (DBS), responsive neurostimulation (RNS), and MRgLITT corpus callosum ablation. These new strategies offer hope for children with drug-resistant generalized epilepsies, but important questions remain about the safety and effectiveness of these new approaches. In this review, we describe the opportunities presented by these new strategies and how each treatment strategy is currently being employed. Next, we will critically assess available evidence for these new approaches compared to traditional palliative epilepsy surgery approaches, such as vagus nerve stimulation (VNS) and open microsurgical corpus callosotomy (CC). Finally, we will describe future directions that would help define which of the available strategies should be employed and when.
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Affiliation(s)
- Ruba Al-Ramadhani
- Department of Pediatrics, Division of Child Neurology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jasmine L. Hect
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Taylor J. Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
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2
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Hansen D, Shandley S, Olaya J, Hauptman J, Auguste K, Ostendorf AP, Depositario-Cabacar DF, Wong-Kisiel LC, Reddy SB, McCormack MJ, Gonzalez-Giraldo E, Sullivan J, Pradeep J, Singh RK, Romanowski EF, McNamara NA, Ciliberto MA, Tatachar P, Shrey DW, Karakas C, Karia S, Kheder A, Gedela S, Alexander A, Eschbach K, Bolton J, Marashly A, Wolf S, McGoldrick P, Nangia S, Grinspan Z, Coryell J, Samanta D, Armstrong D, Perry MS. A multi-center comparison of surgical techniques for corpus Callosotomy in pediatric drug-resistant epilepsy. Epilepsia 2024; 65:422-429. [PMID: 38062633 DOI: 10.1111/epi.17853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 12/05/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES Corpus callosotomy (CC) is used to reduce seizures, primarily in patients with generalized drug-resistant epilepsy (DRE). The invasive nature of the procedure contributes to underutilization despite its potential superiority to other palliative procedures. The goal of this study was to use a multi-institutional epilepsy surgery database to characterize the use of CC across participating centers. METHODS Data were acquired from the Pediatric Epilepsy Research Consortium (PERC) Surgery Database, a prospective observational study collecting data on children 0-18 years referred for surgical evaluation of DRE across 22 U.S. pediatric epilepsy centers. Patient, epilepsy, and surgical characteristics were collected across multiple CC modalities. Outcomes and complications were recorded and analyzed statistically. RESULTS Eighty-three patients undergoing 85 CC procedures at 14 participating epilepsy centers met inclusion criteria. Mean age at seizure onset was 2.3 years (0-9.4); mean age for Phase I evaluation and surgical intervention were 9.45 (.1-20) and 10.46 (.2-20.6) years, respectively. Generalized seizure types were the most common (59%). Complete CC was performed in 88%. The majority of CC procedures (57%) were via open craniotomy, followed by laser interstitial thermal therapy (LiTT) (20%) and mini-craniotomy/endoscopic (mc/e) (22%). Mean operative times were significantly longer for LiTT, whereas mean estimated blood loss was greater in open cases. Complications occurred in 11 cases (13%) and differed significantly between surgical techniques (p < .001). There was no statistically significant difference in length of postoperative stay across approaches. Mean follow-up was 12.8 months (range 1-39). Favorable Engel outcomes were experienced by 37 (78.7%) of the patients who underwent craniotomy, 10 (58.8%) with LiTT, and 12 (63.2%) with mc/e; these differences were not statistically significant. SIGNIFICANCE CC is an effective surgical modality for children with DRE. Regardless of surgical modality, complication rates are acceptable and seizure outcomes generally favorable. Newer, less-invasive, surgical approaches may lead to increased adoption of this efficacious therapeutic option for pediatric DRE.
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Affiliation(s)
- Daniel Hansen
- Jane and John Justin Institute for Mind Health, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Sabrina Shandley
- Jane and John Justin Institute for Mind Health, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Joffre Olaya
- Children's Hospital of Orange County, Orange, California, USA
| | - Jason Hauptman
- Division of Pediatric Neurosurgery, University of Washington/Seattle Children's Hospital, Seattle, Washington, USA
| | - Kurtis Auguste
- University of California San Francisco Weill Institute for Neurosciences, Benioff Children's Hospital, San Francisco, California, USA
| | - Adam P Ostendorf
- Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Dewi F Depositario-Cabacar
- Center for Neuroscience, Children's National Hospital, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Lily C Wong-Kisiel
- Department of Neurology, Divisions of Child Neurology and Epilepsy, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Shilpa B Reddy
- Department of Pediatric Neurology, Vanderbilt University, Monroe Carell Jr Children's Hospital, Nashville, Tennessee, USA
| | - Michael J McCormack
- Department of Pediatric Neurology, Vanderbilt University, Monroe Carell Jr Children's Hospital, Nashville, Tennessee, USA
| | - Ernesto Gonzalez-Giraldo
- University of California San Francisco Weill Institute for Neurosciences, Benioff Children's Hospital, San Francisco, California, USA
| | - Joseph Sullivan
- University of California San Francisco Weill Institute for Neurosciences, Benioff Children's Hospital, San Francisco, California, USA
| | - Javarayee Pradeep
- Department of Pediatric Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Rani K Singh
- Division of Neurology, Department of Pediatrics, Atrium Health/Levine Children's Hospital, Charlotte, North Carolina, USA
| | - Erin Fedak Romanowski
- Department of Pediatrics, Division of Pediatric Neurology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nancy A McNamara
- Department of Pediatrics, Division of Pediatric Neurology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael A Ciliberto
- Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Priya Tatachar
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois, USA
| | - Daniel W Shrey
- Children's Hospital of Orange County, Orange, California, USA
| | - Cemal Karakas
- Department of Neurology, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Samir Karia
- Department of Neurology, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Ammar Kheder
- Department of Pediatrics, Emory University College of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Satyanarayana Gedela
- Department of Pediatrics, Emory University College of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Allyson Alexander
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Krista Eschbach
- Department of Neurology, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jeffrey Bolton
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ahmad Marashly
- Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Steven Wolf
- Boston Children's Health Physicians of New York and Connecticut, Maria Fareri Children's Hospital, New York Medical College, Valhalla, New York, USA
| | - Patricia McGoldrick
- Boston Children's Health Physicians of New York and Connecticut, Maria Fareri Children's Hospital, New York Medical College, Valhalla, New York, USA
| | | | | | - Jason Coryell
- Doernbecher Children's Hospital, Oregon Health and Sciences University, Oregon Health Science Center, Portland, Oregon, USA
| | - Debopam Samanta
- Department of Neurology, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Dallas Armstrong
- Department of Neurology, University of Texas Southwestern, Dallas, Texas, USA
| | - M Scott Perry
- Jane and John Justin Institute for Mind Health, Cook Children's Medical Center, Fort Worth, Texas, USA
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3
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Katlowitz KA, Curry DJ, Weiner HL. Novel Surgical Approaches in Childhood Epilepsy: Laser, Brain Stimulation, and Focused Ultrasound. Adv Tech Stand Neurosurg 2024; 49:291-306. [PMID: 38700689 DOI: 10.1007/978-3-031-42398-7_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Pediatric epilepsy has a worldwide prevalence of approximately 1% (Berg et al., Handb Clin Neurol 111:391-398, 2013) and is associated with not only lower quality of life but also long-term deficits in executive function, significant psychosocial stressors, poor cognitive outcomes, and developmental delays (Schraegle and Titus, Epilepsy Behav 62:20-26, 2016; Puka and Smith, Epilepsia 56:873-881, 2015). With approximately one-third of patients resistant to medical control, surgical intervention can offer a cure or palliation to decrease the disease burden and improve neurological development. Despite its potential, epilepsy surgery is drastically underutilized. Even today only 1% of the millions of epilepsy patients are referred annually for neurosurgical evaluation, and the average delay between diagnosis of Drug Resistant Epilepsy (DRE) and surgical intervention is approximately 20 years in adults and 5 years in children (Solli et al., Epilepsia 61:1352-1364, 2020). It is still estimated that only one-third of surgical candidates undergo operative intervention (Pestana Knight et al., Epilepsia 56:375, 2015). In contrast to the stable to declining rates of adult epilepsy surgery (Englot et al., Neurology 78:1200-1206, 2012; Neligan et al., Epilepsia 54:e62-e65, 2013), rates of pediatric surgery are rising (Pestana Knight et al., Epilepsia 56:375, 2015). Innovations in surgical approaches to epilepsy not only minimize potential complications but also expand the definition of a surgical candidate. In this chapter, three alternatives to classical resection are presented. First, laser ablation provides a minimally invasive approach to focal lesions. Next, both central and peripheral nervous system stimulation can interrupt seizure networks without creating permanent lesions. Lastly, focused ultrasound is discussed as a potential new avenue not only for ablation but also modulation of small, deep foci within seizure networks. A better understanding of the potential surgical options can guide patients and providers to explore all treatment avenues.
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Affiliation(s)
- Kalman A Katlowitz
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Department of Neurosurgery, Texas Children's Hospital, Houston, TX, USA
| | - Daniel J Curry
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Department of Neurosurgery, Texas Children's Hospital, Houston, TX, USA
| | - Howard L Weiner
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA.
- Department of Neurosurgery, Texas Children's Hospital, Houston, TX, USA.
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Hale AT, Barkley AS, Blount JP. Corpus Callosotomy Is a Safe and Effective Procedure for Medically Resistant Epilepsy. Adv Tech Stand Neurosurg 2023; 48:355-369. [PMID: 37770691 DOI: 10.1007/978-3-031-36785-4_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Corpus callosotomy (CC) is an effective surgical treatment for medically resistant generalized or multifocal epilepsy (MRE). The premise of CC extrapolates from the observation that the corpus callosum is the predominant commissural pathway that allows spread and synchroneity of epileptogenic activity between the hemispheres. Candidacy for CC is typically reserved for patients seeking palliative epilepsy treatment with the goal of reducing the frequency of drop attacks, although reduction of other seizure semiologies (absence, complex partial seizures, and tonic-clonic) has been observed. A reduction in morbidity affiliated with evolution of surgical techniques to perform CC has improved the safety profile of the procedure without necessarily sacrificing efficacy.
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Affiliation(s)
- Andrew T Hale
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Ariana S Barkley
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Jeffrey P Blount
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA.
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Candela-Cantó S, Muchart J, Valera C, Jou C, Culebras D, Alamar M, Becerra V, Artés D, Armero G, Aparicio J, Hinojosa J, Rumià J. Completion of disconnective surgery for refractory epilepsy in pediatric patients using robot-assisted MRI-guided laser interstitial thermal therapy. J Neurosurg Pediatr 2023; 31:61-70. [PMID: 36272116 DOI: 10.3171/2022.9.peds22258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/08/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Since 2007, the authors have performed 34 hemispherotomies and 17 posterior quadrant disconnections (temporoparietooccipital [TPO] disconnections) for refractory epilepsy at Sant Joan de Déu Barcelona Children's Hospital. Incomplete disconnection is the main cause of surgical failure in disconnective surgery, and reoperation is the treatment of choice. In this study, 6 patients previously treated with hemispherotomy required reoperation through open surgery. After the authors' initial experience with real-time MRI-guided laser interstitial thermal therapy (MRIgLITT) for hypothalamic hamartomas, they decided to use this technique instead of open surgery to complete disconnective surgeries. The objective was to report the feasibility, safety, and efficacy of MRIgLITT to complete hemispherotomies and TPO disconnections for refractory epilepsy in pediatric patients. METHODS Eight procedures were performed on 6 patients with drug-resistant epilepsy. Patient ages ranged between 4 and 18 years (mean 10 ± 4.4 years). The patients had previously undergone hemispherotomy (4 patients) and TPO disconnection (2 patients) at the hospital. The Visualase system assisted by a Neuromate robotic arm was used. The ablation trajectory was planned along the residual connection. The demographic and epilepsy characteristics of the patients, precision of the robot, details of the laser ablation, complications, and results were prospectively collected. RESULTS Four patients underwent hemispherotomy and 2 underwent TPO disconnection. Two patients, including 1 who underwent hemispherotomy and 1 who underwent TPO disconnection, received a second laser ablation because of persistent seizures and connections after the first treatment. The average precision of the system (target point localization error) was 1.7 ± 1.4 mm. The average power used was 6.58 ± 1.53 J. No complications were noted. Currently, 5 of the 6 patients are seizure free (Engel class I) after a mean follow-up of 20.2 ± 5.6 months. CONCLUSIONS According to this preliminary experience, laser ablation is a safe method for complete disconnective surgeries and allowed epilepsy control in 5 of the 6 patients treated. A larger sample size and longer follow-up periods are necessary to better assess the efficacy of MRIgLITT to complete hemispherotomy and TPO disconnection, but the initial results are encouraging.
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Affiliation(s)
- Santiago Candela-Cantó
- Departments of1Neurosurgery
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
| | - Jordi Muchart
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
- 3Diagnostic Imaging
| | - Carlos Valera
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
| | - Cristina Jou
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
- 4Pathology, and
| | - Diego Culebras
- Departments of1Neurosurgery
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
| | | | | | | | | | - Javier Aparicio
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
| | - José Hinojosa
- Departments of1Neurosurgery
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
| | - Jordi Rumià
- Departments of1Neurosurgery
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
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Best BJ, Kim I, Lew SM. Magnetic resonance imaging-guided laser interstitial thermal therapy for complete corpus callosotomy: technique and 1-year outcomes. Patient series. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22364. [PMID: 36536524 PMCID: PMC9764374 DOI: 10.3171/case22364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/27/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI)-guided stereotactic laser interstitial thermal therapy (LITT) is a minimally invasive technique that has been described for the treatment of certain forms of epilepsy through partial or complete callosotomy, with few cases describing single-stage complete LITT callosotomy. The authors aimed to demonstrate this technique's feasibility and efficacy through description of the technique and 1-year outcomes in 3 cases of single-stage complete LITT callosotomy in patients with anatomically normal corpa callosa (CCs). OBSERVATIONS The patients were aged 14-27 years and experienced atonic seizures. Completeness of callosotomy was determined from MRI scans obtained >3 months after LITT procedures. The estimated ablations of the CC were 94%, 89%, and 100%, respectively. The second patient had a catheter breach the lateral ventricle, resulting in the lowest estimated percentage of ablation in this series (89%), with minimal atonic seizure reduction. The first patient had significant reduction in atonic seizure frequency, and the third patient had complete resolution of atonic seizures. None of the patients experienced any long-term complications. Intensive care length of stay was 1 night for each patient, and total length of stay was between 2 and 7 nights. Postoperative follow-up was between 14 and 18 months. LESSONS Complete laser callosotomy is achievable and is a safe alternative to microsurgical or endoscopic approaches.
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Affiliation(s)
- Benjamin J. Best
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin; and ,Division of Pediatric Neurosurgery, Children’s Wisconsin, Milwaukee, Wisconsin
| | - Irene Kim
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin; and ,Division of Pediatric Neurosurgery, Children’s Wisconsin, Milwaukee, Wisconsin
| | - Sean M. Lew
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin; and ,Division of Pediatric Neurosurgery, Children’s Wisconsin, Milwaukee, Wisconsin
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Miller KJ, Fine AL. Decision-making in stereotactic epilepsy surgery. Epilepsia 2022; 63:2782-2801. [PMID: 35908245 PMCID: PMC9669234 DOI: 10.1111/epi.17381] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 11/27/2022]
Abstract
Surgery can cure or significantly improve both the frequency and the intensity of seizures in patients with medication-refractory epilepsy. The set of diagnostic and therapeutic interventions involved in the path from initial consultation to definitive surgery is complex and includes a multidisciplinary team of neurologists, neurosurgeons, neuroradiologists, and neuropsychologists, supported by a very large epilepsy-dedicated clinical architecture. In recent years, new practices and technologies have emerged that dramatically expand the scope of interventions performed. Stereoelectroencephalography has become widely adopted for seizure localization; stereotactic laser ablation has enabled more focal, less invasive, and less destructive interventions; and new brain stimulation devices have unlocked treatment of eloquent foci and multifocal onset etiologies. This article articulates and illustrates the full framework for how epilepsy patients are considered for surgical intervention, with particular attention given to stereotactic approaches.
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Affiliation(s)
- Kai J. Miller
- Neurosurgery, Mayo Clinic, 200 First St., Rochester, MN, 55902
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8
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Surgical Treatment of Drug-Resistant Generalized Epilepsy. Curr Neurol Neurosci Rep 2022; 22:459-465. [PMID: 35713776 DOI: 10.1007/s11910-022-01210-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To summarize current evidence and recent developments in the surgical treatment of drug-resistant generalized epilepsy. RECENT FINDINGS Current surgical treatments of drug-resistant generalized epilepsy include vagus nerve stimulation (VNS), deep brain stimulation (DBS) and corpus callosotomy (CC). Neurostimulation with VNS and/or DBS has been shown to be effective in reducing seizure frequency in patients with generalized epilepsy. DBS for generalized epilepsy is primarily consisted of open-loop stimulation directed at the centromedian (CM) nucleus in the thalamus, though closed-loop stimulation and additional targets are being explored. CC can be effective in treating some seizure types and can be performed using traditional surgical techniques or with the less invasive methods of laser ablation and radiosurgery. This current literature supports the use of VNS, DBS and CC, alone or in combination, as palliative treatments of drug-resistant generalized epilepsy.
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9
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Stereotactic laser interstitial thermal therapy for the treatment of pediatric drug-resistant epilepsy: indications, techniques, and safety. Childs Nerv Syst 2022; 38:961-970. [PMID: 35274185 DOI: 10.1007/s00381-022-05491-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 03/03/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND MRI-guided laser interstitial thermal therapy (MRgLITT) is a promising alternative to open surgery for treatment of drug-resistant epilepsy, offering significant advantages over traditional approaches for candidate patients, including minimally invasive approach, shorter hospitalization, and decreased patient post-operative discomfort. LITT uses a stereotactically placed fiber optic laser probe to ablate tissue under real-time MR thermometry. METHODS Retrospective chart review of intraoperative and perioperative characteristics was performed for 28 cases of MRgLITT in 25 pediatric patients, ages 4-21 years old, at our institution between 2019 and 2021. MRgLITT ablation of the mesial temporal lobe was performed in 8 cases, extratemporal epileptogenic foci in 9 cases, and for corpus callosotomy in 11 cases. RESULTS At 1 year of follow-up, 53% of all patients experienced improvement in seizure frequency (Engel I or II) (class I: 38%, class II: 15%, class III: 17%, class IV: 31%), including 37% of MTL ablations and 80% extratemporal SOZ ablations. After MRgLITT corpus callosotomy, 71% of patients were free from atonic seizures at most recent follow-up. Median length of hospitalization was 2 days (1-3), including a median ICU stay of 1 day (1-2). CONCLUSION This series demonstrates the safety of MRgLITT as an approach for seizure control in drug-resistant epilepsy. We provide additional evidence that MRgLITT is an effective procedure that is well-tolerated by pediatric patients and is accompanied by an acceptable rate of complications and relatively short hospital stay.
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10
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Darwish A, Radwan H, Fayed Z, Mounir SM, Hamada S. Surgical nuances in corpus callosotomy as a palliative epilepsy surgery. Surg Neurol Int 2022; 13:110. [PMID: 35399875 PMCID: PMC8986757 DOI: 10.25259/sni_7_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 03/15/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Corpus callosotomy is a well-established palliative procedure in selected patients with drug resistant epilepsy (DRE). It has a beneficial role in ameliorating generalized seizures mainly drop attacks. Here, we present some technical tips for performing callosotomy depending on the anatomical basis, to minimize craniotomy size and guard against inadvertently entering the lateral ventricles. Methods: This study was a retrospective review of patients who received corpus callosotomy at our institute as a palliative epilepsy surgery. We present our experience and surgical tips with the extraventricular technique of corpus callosotomy with comparison of surgery-related complications and operative time between extraventricular and conventional techniques in selected patients with DRE. Results: Our study included 34 patients. First group of patients included 14 patients who received conventional approach, while the extraventricular approach was done in 20 patients. Extraventricular approach showed significantly lower wound complications rate of 10% compared to 78% in intraventricular approach (P < 0.001). Mean operative time was significantly lower in extraventricular versus conventional technique with 52 min versus 94 min, respectively (P < 0.001). Planned extent of corpus callosotomy resection was achieved in all our patients using both approaches. Conclusion: The cleft of the septum pellucidum offers a natural pursuit to section corpus callosum strictly midline and completely extraventricular in well selected patients of DRE candidate for callosotomy. Performing corpus callosotomy in extraventricular approach provided better patients outcomes regarding surgery and wound-related complications when compared to conventional approach.
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Affiliation(s)
- Ahmed Darwish
- Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo,
| | - Hesham Radwan
- Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo,
| | - Zeiad Fayed
- Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo,
| | - Samir M. Mounir
- Department of Pediatrics, Faculty of Medicine, Minia University, El Minia, Egypt
| | - Salah Hamada
- Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo,
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11
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Singh R, Bendok BR, Zimmerman RS. Commentary: Completion Posterior Quadrant Disconnection After Failed Temporal Lobectomy: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 22:e175-e176. [PMID: 34989708 DOI: 10.1227/ons.0000000000000088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 10/29/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Rohin Singh
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, USA
| | - Bernard R Bendok
- Department of Neurosurgery, Mayo Clinic Arizona, Phoenix, Arizona, USA.,Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA.,Department of Radiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
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12
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Mallela AN, Hect JL, Abou-Al-Shaar H, Akwayena E, Abel TJ. Stereotactic laser interstitial thermal therapy corpus callosotomy for the treatment of pediatric drug-resistant epilepsy. Epilepsia Open 2021; 7:75-84. [PMID: 34758204 PMCID: PMC8886067 DOI: 10.1002/epi4.12559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/21/2021] [Accepted: 10/31/2021] [Indexed: 11/14/2022] Open
Abstract
Objective Corpus callosotomy is a safe and effective procedure for reducing the frequency of drop attacks. MR‐guided laser interstitial thermal therapy (MRgLITT) offers a minimally invasive alternative to conventional open craniotomy for callosotomy. We hypothesized that MRgLITT callosotomy could be safely performed in pediatric patients with similar seizure control. Methods We present an institutional case series of 11 procedures in 10 patients for the treatment of drop attacks in drug‐refractory primary generalized epilepsy. MRgLITT was used for complete callosotomy, anterior two‐thirds, posterior, or ablation of residual callosal fibers following prior callosotomy (open or MRgLITT). We retrospectively reviewed clinical course, operative details, radiographic imaging, clinical outcomes, and complications. Results Operative time ranged from 4‐8 hours, and median hospitalization was 2 days. No complications were encountered. Among the 7 patients with at least 3 months of follow‐up, 71% experienced freedom from drop attacks at longest follow‐up and 57% of cases showed improvement in their other seizure semiologies as well (Engel Class II: 28%, Class III: 28%, Class IV: 43%). Significance MR‐guided LITT callosotomy is safe and effective modality in the management of pediatric patients with medically intractable epilepsy characterized by drop attacks. While this is among the largest pediatric series to date, further studies are required to delineate its safety and efficacy among such patients.
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Affiliation(s)
- Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jasmine L Hect
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Emefa Akwayena
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
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13
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Ung TH, Kahn L, Hirt L, Chatain G, Humes E, David-Gerecht P, Drees C, Thompson JA, Ojemann S, Abosch A. Using a Robotic-Assisted Approach for Stereotactic Laser Ablation Corpus Callosotomy: A Technical Report. Stereotact Funct Neurosurg 2021; 100:61-66. [PMID: 34515241 DOI: 10.1159/000518109] [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: 04/21/2021] [Accepted: 06/26/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Corpus callosotomy for medically intractable epilepsy is an effective ablative procedure traditionally achieved using either standard open craniotomy or with less-invasive approaches. Advances in robotic-assisted stereotactic guidance for neurosurgery can be applied for LITT for corpus callosotomy. CLINICAL PRESENTATIONS Two patients were included in this study. One was a 25-year-old female patient with extensive bi-hemispheric malformations of cortical development and medically refractory epilepsy, and the other was an 18-year-old male with medically refractory epilepsy and atonic seizures, who underwent a complete corpus callosotomy using robotic-assisted stereotactic guidance for LITT. RESULTS Both patients underwent successful intended corpus callosotomy with volumetric analysis demonstrating a length disconnection of 74% and a volume disconnection of 55% for patient 1 and a length disconnection of 83% and a volume disconnection of 33% for patient 2. Postoperatively, both patients had clinical reductions in seizure. CONCLUSION Our experience demonstrates that robotic guidance systems can safely and effectively be adapted for minimally invasive LITT corpus callosotomy.
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Affiliation(s)
- Timothy H Ung
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado, USA.,School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Lora Kahn
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado, USA.,School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Lisa Hirt
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado, USA
| | - Gregoire Chatain
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado, USA.,School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Elizabeth Humes
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado, USA.,School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Pamela David-Gerecht
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado, USA.,School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Cornelia Drees
- School of Medicine, University of Colorado, Aurora, Colorado, USA.,Department of Neurology, University of Colorado Hospital, Aurora, Colorado, USA
| | - John A Thompson
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado, USA.,School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Steven Ojemann
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado, USA.,School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Aviva Abosch
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado, USA.,School of Medicine, University of Colorado, Aurora, Colorado, USA
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14
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Remick M, McDowell MM, Gupta K, Felker J, Abel TJ. Emerging indications for stereotactic laser interstitial thermal therapy in pediatric neurosurgery. Int J Hyperthermia 2021; 37:84-93. [PMID: 32672117 DOI: 10.1080/02656736.2020.1769868] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Surgical treatment of deep or difficult to access lesions represents a unique and significant challenge for pediatric neurosurgeons. The introduction of stereotactic magnetic resonance-guided laser interstitial thermal therapy (LITT) over the last decade has had a dramatic impact on the landscape of pediatric neurosurgery. LITT provides a safe and effective option for children with epilepsy from hypothalamic hamartoma that represents a ground-breaking new therapy for a condition which was historically very difficult to treat with previous neurosurgical techniques. LITT has also been used as an alternative surgical technique for mesial temporal sclerosis, focal cortical dysplasia, MR-negative epilepsy, cavernoma-related epilepsy, insular epilepsy, and corpus callosotomy among other epilepsy etiologies. In some cases, LITT has been associated with improved cognitive outcomes compared to standard techniques, as in mesial temporal lobe epilepsy. Initial experiences with LITT for neuro-oncologic processes are also promising. LITT is often attractive to patients and providers as a minimally invasive approach, but the differences in safety and clinical outcome between LITT and traditional approaches are still being studied. In this review, we examine the emerging indications and clinical evidence for LITT in pediatric neurosurgery.
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Affiliation(s)
- Madison Remick
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael M McDowell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kanupriya Gupta
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - James Felker
- Department of Pediatric Neuro-Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
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15
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Caruso JP, Janjua MB, Dolce A, Price AV. Retrospective analysis of open surgical versus laser interstitial thermal therapy callosotomy in pediatric patients with refractory epilepsy. J Neurosurg Pediatr 2021; 27:420-428. [PMID: 33482643 DOI: 10.3171/2020.7.peds20167] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 07/28/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Corpus callosotomy remains an established surgical treatment for certain types of medically refractory epilepsy in pediatric patients. While the traditional surgical approach is often well tolerated, the advent of MR-guided laser interstitial thermal therapy (LITT) provides a new opportunity to ablate the callosal body in a minimally invasive fashion and minimize the risks associated with an open interhemispheric approach. However, the literature is sparse regarding the comparative efficacy and safety profiles of open corpus callosotomy (OCC) and LITT callosotomy. To this end, the authors present a novel retrospective analysis comparing the efficacy and safety of these methods. METHODS Patients who underwent OCC and LITT callosotomy during the period from 2005 to 2018 were included in a single-center retrospective analysis. Patient demographic and procedural variables were collected, including length of stay, procedural blood loss, corticosteroid requirements, postsurgical complications, and postoperative disposition. Pre- and postoperative seizure frequency (according to seizure type) were recorded. RESULTS In total, 19 patients, who underwent 24 interventions (16 OCC and 8 LITT), were included in the analysis. The mean follow-up durations for the OCC and LITT cohorts were 83.5 months and 12.3 months, respectively. Both groups experienced reduced frequencies of seizure and drop attack frequency postoperatively. Additionally, LITT callosotomy was associated with a significant decrease in estimated blood loss and decreased length of pediatric ICU stay, with a trend of shorter length of hospitalization. CONCLUSIONS Longer-term follow-up and a larger population are required to further delineate the comparative efficacies of LITT callosotomy and OCC for the treatment of pediatric medically refractory epilepsy. However, the authors' data demonstrate that LITT shows promise as a safe and effective alternative to OCC.
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Affiliation(s)
| | | | - Alison Dolce
- 2Neurology, Children's Medical Center, University of Texas Southwestern, Dallas, Texas
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16
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Abstract
Lennox-Gastaut syndrome (LGS), a childhood-onset severe developmental and epileptic encephalopathy (DEE), is an entity that encompasses a heterogenous group of aetiologies, with no single genetic cause. It is characterised by multiple seizure types, an abnormal EEG with generalised slow spike and wave discharges and cognitive impairment, associated with high morbidity and profound effects on the quality of life of patients and their families. Drug-refractory seizures are a hallmark and treatment is further complicated by its multiple morbidities, which evolve over the patient's lifetime. This review provides a comprehensive overview of the current and future options for the treatment of seizures associated with LGS. Six treatments are specifically indicated as adjunct therapies for the treatment of seizures associated with LGS in the US: lamotrigine, clobazam, rufinamide, topiramate, felbamate and most recently cannabidiol. These therapies have demonstrated reductions in drop seizures in 15%-68% of patients across trials, with responder rates (≥ 50% reduction in drop seizures) of 37%-78%. Valproate is still the preferred first-line treatment, generally in combination with lamotrigine or clobazam. Other treatments frequently used off-label include the broad spectrum anti-epileptic drugs (AED) levetiracetam, zonisamide and perampanel, while recent evidence from observational studies has indicated that a newer AED, the levetiracetam analogue brivaracetam, may be effective and well tolerated in LGS patients. Other treatments in clinical development include fenfluramine in late phase III, perampanel, soticlestat-OV953/TAK-953, carisbamate and ganaxolone. Non-pharmacologic interventions include the ketogenic diet, vagus nerve stimulation and surgical interventions; these are also expanding, with the potential for less invasive techniques for corpus callosotomy that have promise for reducing complications. However, despite these advancements, patients continue to experience a significant burden. Because LGS is not a single entity, tailoring of treatment is needed as opposed to a 'one size fits all' approach. Further research is needed into the underlying aetiologies and pathophysiology of LGS, together with advancements in treatments that encompass the spectrum of seizures associated with this complex syndrome.
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17
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O’Connor KP, Palejwala AH, Milton CK, Lu VM, Glenn CA, Sughrue ME, Conner AK. Laser Interstitial Thermal Therapy Case Series: Choosing the Correct Number of Fibers Depending on Lesion Size. Oper Neurosurg (Hagerstown) 2020; 20:18-23. [DOI: 10.1093/ons/opaa264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/18/2020] [Indexed: 12/21/2022] Open
Abstract
Abstract
BACKGROUND
Laser interstitial thermal therapy (LITT) is being used for the treatment of recurrent glioblastoma multiforme (GBM). Lesions can be treated using 1 or multiple LITT fibers depending on the preference of surgeons. Usually, more fibers are needed for coverage of larger tumors.
OBJECTIVE
To investigate and analyze how tumor size affected the number of LITT fibers used.
METHODS
This is a retrospective review of patients undergoing treatment of recurrent GBM. Patients were treated with up to 4 LITT fibers for adequate tumor coverage. Patient demographics, tumor characteristics, length of stay, complications, and biopsy results were recorded.
RESULTS
A total of 43 cases were treated using LITT, and of these cases, 31 consisted of contiguous lesions. We used more fibers to treat larger tumor volumes. On average, for each 5 cc of tumor volume, a fiber was added for proper coverage (P = .554). Complications and length of stay were similar across the groups (P = .378, P = .941).
CONCLUSION
LITT can be used for the treatment of recurrent GBM. For each 5 cc of tumor volume, a LITT fiber can be added to the treatment plan.
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Affiliation(s)
- Kyle P O’Connor
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Ali H Palejwala
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Camille K Milton
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Victor M Lu
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Chad A Glenn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Michael E Sughrue
- Department of Neurosurgery, Prince of Wales Hospital, Randwick, Australia
| | - Andrew K Conner
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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