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Candela-Cantó S, Hinojosa J, Muchart J, Jou C, Palau L, Valera C, Flores C, Palacio-Navarro A, Climent MA, Pascual A, González A, Culebras D, Alamar M, Becerra V, Aparicio J, Rumià J. Temporo-Parieto-Occipital Disconnection by Robot-Assisted Magnetic Resonance Imaging-Guided Laser Interstitial Thermal Therapy for Refractory Epilepsy in a Pediatric Patient: Proof-of-Principle Case Report and Surgical Nuances. World Neurosurg 2024; 187:124-132. [PMID: 38641246 DOI: 10.1016/j.wneu.2024.04.064] [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: 12/05/2023] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVE Magnetic resonance imaging-guided laser interstitial thermal therapy (MRIgLITT) has been proven safe and effective for the treatment of focal epilepsy of different etiologies. It has also been used to disconnect brain tissue in more extensive or diffuse epilepsy, such as corpus callosotomy and hemispherotomy. METHODS In this study, we report a case of temporo-parieto-occipital disconnection surgery performed using MRIgLITT assisted by a robotic arm for refractory epilepsy of the posterior quadrant. A highly realistic cadaver simulation was performed before the actual surgery. RESULTS The patient was a 14-year-old boy whose seizures began at the age of 8. The epilepsy was a result of a left perinatal ischemic event that caused a porencephalic cyst, and despite receiving multiple antiepileptic drugs, the patient continued to experience daily seizures which led to the recommendation of surgery. CONCLUSIONS A Wada test lateralized language in the right hemisphere. Motor and sensory function was confirmed in the left hemisphere through magnetic resonance imaging functional studies and NexStim. The left MRIgLITT temporo-parieto-occipital disconnection disconnection was achieved using 5 laser fibers. The patient followed an excellent postoperative course and was seizure-free, with no additional neurological deficits 24 months after the surgery.
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Affiliation(s)
- Santiago Candela-Cantó
- Neurosurgery Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain; Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain.
| | - José Hinojosa
- Neurosurgery Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain; Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - Jordi Muchart
- Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain; Diagnostic Imaging Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - Cristina Jou
- Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain; Pathlogy Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - Laura Palau
- Bioengineering Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - Carlos Valera
- Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - Cecilia Flores
- Intraoperative Neurophisiology Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - Andrea Palacio-Navarro
- Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - María Alejandra Climent
- Intraoperative Neurophisiology Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - Anna Pascual
- Anesthesiology Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - Adrià González
- Pathlogy Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - Diego Culebras
- Neurosurgery Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain; Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - Mariana Alamar
- Neurosurgery Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - Victoria Becerra
- Neurosurgery Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - Javier Aparicio
- Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
| | - Jordi Rumià
- Neurosurgery Department, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain; Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Barcelona, Spain
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Phillips HW, Hect JL, Harford E, Pan E, Abel TJ. Comparison of magnetic resonance-guided laser interstitial thermal therapy corpus callosum ablation to open microsurgical corpus callosotomy: A single-center retrospective cohort study. Epilepsia Open 2024; 9:96-105. [PMID: 37766507 PMCID: PMC10839368 DOI: 10.1002/epi4.12835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
OBJECTIVE Corpus callosotomy (CC) is an important treatment for atonic seizures in patients with generalized or multifocal drug-resistant epilepsy (DRE). Traditionally, CC is performed via an open microsurgical approach, but more recently, MR-guided stereotactic laser interstitial thermal therapy (LITT) corpus callosum ablation (CCA) has been developed to leverage the safety and minimally invasive nature of LITT. Given the recent adoption of CCA at select centers, how CCA compares to CC is unknown. We aim to compare the clinical seizure outcomes of CCA and CC after extended follow-up. METHODS We performed a retrospective cohort study to compare the effectiveness and safety of CC to CCA from 1994 to 2022. The primary outcome was a 50% reduction in target seizure. Secondary outcome measures were postoperative length of stay, adverse events, and other effectiveness metrics. Comparative statistics were executed using Stata. Normality for continuous variables was assessed, and parametric statistics were utilized as needed. Frequency was compared with chi-squared or Fischer's exact tests, when applicable. RESULTS Data from 47 operations performed on 36 patients were included in this study, of which 13 (36%) patients underwent 17 CCA. Patients who received CCA had similar rates of meaningful reduction (>50%) of atonic seizures as their CC counterparts (55% vs 70% P = 0.15). Patients undergoing CCA had significantly shorter hospitalizations than those receiving CC (2.5 vs 6.0 days P < 0.001). There was no significant difference in rates of postoperative complications between the groups, although the magnitude of the complication rates was lower in the CCA cohort (12% vs 28%). SIGNIFICANCE This early experience suggests CCA has similar outcomes to traditional CC, albeit with a shorter hospital stay. However, future studies are necessary to investigate the noninferiority between these two approaches. Large multicenter studies are necessary to investigate differences in adverse events and whether these findings generalize across other centers.
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Affiliation(s)
- H. Westley Phillips
- Department of NeurosurgeryStanford University School of MedicinePalo AltoCaliforniaUSA
| | - Jasmine L. Hect
- Department of Neurological SurgeryUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Emily Harford
- Department of Neurological SurgeryUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Evelyn Pan
- Department of Neurological SurgeryUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Taylor J. Abel
- Department of Neurological SurgeryUniversity of PittsburghPittsburghPennsylvaniaUSA
- Department of BioengineeringUniversity of PittsburghPittsburghPennsylvaniaUSA
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Schijns OE. Functional hemispheric disconnection procedures for chronic epilepsy: history, indications, techniques, complications and current practice in Europe. A consensus statement on behalf of the EANS functional neurosurgery section. BRAIN & SPINE 2024; 4:102754. [PMID: 38510638 PMCID: PMC10951757 DOI: 10.1016/j.bas.2024.102754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/08/2024] [Accepted: 01/21/2024] [Indexed: 03/22/2024]
Abstract
Introduction The surgical procedure for severe, drug-resistant, unilateral hemispheric epilepsy is challenging. Over the last decades the surgical landscape for hemispheric disconnection procedures changed from anatomical hemispherectomy to functional hemispherotomy with a reduction of complications and stable good seizure outcome. Here, a task force of European epilepsy surgeons prepared, on behalf of the EANS Section for Functional Neurosurgery, a consensus statement on different aspects of the hemispheric disconnection procedure. Research question To determine history, indication, timing, techniques, complications and current practice in Europe for hemispheric disconnection procedures in drug-resistant epilepsy. Material and methods Relevant literature on the topic was collected by a literature search based on the PRISMA 2020 guidelines. Results A comprehensive overview on the historical development of hemispheric disconnection procedures for epilepsy is presented, while discussing indications, timing, surgical techniques and complications. Current practice for this procedure in European epilepsy surgery centers is provided. At present, our knowledge of long-term seizure outcomes primarily stems from open surgical disconnection procedures. Although minimal invasive surgical techniques in epilepsy are rapidly developing and reported in case reports or small case series, long-term seizure outcome remain uncertain and needs to be reported. Discussion and conclusion This is the first paper presenting a European consensus statement regarding history, indications, techniques and complications of hemispheric disconnection procedures for different causes of chronic, drug-resistant epilepsy. Furthermore, it serves as the pioneering document to report a comprehensive overview of the current surgical practices regarding this type of surgery employed in renowned epilepsy surgery centers across Europe.
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Affiliation(s)
- Olaf E.M.G. Schijns
- Corresponding author. Department of Neurosurgery, Maastricht University Medical Center, Maastricht, the Netherlands.
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Mendoza-Elias N, Satzer D, Henry J, Nordli DR, Warnke PC. Tailored Hemispherotomy Using Tractography-Guided Laser Interstitial Thermal Therapy. Oper Neurosurg (Hagerstown) 2023; 24:e407-e413. [PMID: 36807222 DOI: 10.1227/ons.0000000000000650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 12/06/2022] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Medically refractory hemispheric epilepsy is a devastating disease with significant lifetime costs and social burden. Functional hemispherotomy is a highly effective treatment for hemispheric epilepsy but is associated with significant complication rates. Percutaneous hemispherotomy through laser interstitial thermal therapy (LITT) based on morphological MRI has been recently described in a single patient but not replicated in the literature. OBJECTIVE To describe the first 2 cases of tractography-guided interstitial laser hemispherotomy and their short-term outcomes. METHODS Two 11-year-old male patients with medically refractory epilepsy secondary to perinatal large vessel infarcts were referred for hemispherotomy. Both patients underwent multitrajectory LITT to disconnect the remaining pathological hemisphere, using tractography to define targets and assess structural outcomes. RESULTS Both cases had minor complication of small intraventricular/subarachnoid hemorrhage not requiring additional intervention. Both patients remain seizure-free at all follow-up visits. CONCLUSION LITT hemispherotomy can produce seizure freedom with short hospitalization and recovery. Tractography allows surgical planning to be tailored according to individual patient anatomy, which often is distorted in perinatal stroke. Minimally invasive procedures offer the greatest potential for seizure freedom without the risks of an open hemispherotomy.
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Affiliation(s)
- Nasya Mendoza-Elias
- Department of Neurological Surgery, University of Chicago, Chicago, Illinois, USA
| | - David Satzer
- Department of Neurological Surgery, University of Chicago, Chicago, Illinois, USA
| | - Julia Henry
- Department of Pediatrics, University of Chicago, Chicago, Illinois, USA
| | - Douglas R Nordli
- Department of Pediatrics, University of Chicago, Chicago, Illinois, USA
| | - Peter C Warnke
- Department of Neurological Surgery, University of Chicago, Chicago, Illinois, USA
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Treiber JM, Bayley JC, Curry D. Minimally Invasive Destructive, Ablative, and Disconnective Epilepsy Surgery. JOURNAL OF PEDIATRIC EPILEPSY 2023. [DOI: 10.1055/s-0042-1760106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
AbstractConventional epilepsy surgery performed by microsurgical dissection typically requires large cranial working windows created with high-speed drills and lengthy incisions. In the past few decades, minimally invasive techniques have been developed with smaller incisions, comparable efficacy, shorter hospitalizations, and better safety profiles. These minimally invasive alternatives utilize stereotactic, ultrasonic, radiotherapeutic, and endoscopic techniques. Although not able to completely replace conventional surgery for all etiologies of epilepsy, these minimally invasive techniques have revolutionized modern epilepsy surgery and have been an invaluable asset to the neurosurgeon's repertoire. The endoscope has allowed for surgeons to have adequate visualization during resective and disconnective epilepsy surgeries using keyhole or miniature craniotomies. Modern stereotactic techniques such as laser interstitial thermal therapy and radiofrequency ablation can be used as viable alternatives for mesial temporal lobe epilepsy and can destroy lesional tissue deep areas without the approach-related morbidity of microsurgery such as with hypothalamic hamartomas. These stereotactic techniques do not preclude future surgery in the settings of treatment failure and have been used successfully after failed conventional surgery. Multiple ablation corridors can be performed in a single procedure that can be used for lesioning of large targets or to simplify treating multifocal epilepsies. These stereotactic techniques have even been used successfully to perform disconnective procedures such as hemispherotomies and corpus callosotomies. In patients unable to tolerate surgery, stereotactic radiosurgery is a minimally invasive option that can result in improved seizure control with minimal procedural risks. Advances in minimally invasive neurosurgery provide viable treatment options for drug-resistant epilepsy with quicker recovery, less injury to functional brain, and for patients that may otherwise not choose conventional surgery.
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Affiliation(s)
- Jeffrey M. Treiber
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - James C. Bayley
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Daniel Curry
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, United States
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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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Carter LM, Desai VR. Commentary: Midline Brain Shift After Hemispheric Surgery: Natural History, Clinical Significance, and Association With Cerebrospinal Fluid Diversion. Oper Neurosurg (Hagerstown) 2022; 23:e191-e192. [PMID: 35972111 DOI: 10.1227/ons.0000000000000327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/05/2022] [Indexed: 02/04/2023] Open
Affiliation(s)
- Lacey M Carter
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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A simulation study to investigate the use of concentric tube robots for epilepsy surgery. Childs Nerv Syst 2022; 38:1349-1356. [PMID: 35084537 DOI: 10.1007/s00381-022-05449-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/06/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Patients with pharmacoresistant refractory epilepsy may require epilepsy surgery to prevent future seizure occurrences. Conventional surgery consists of a large craniotomy with straight rigid tools with associated outcomes of morbidity, large tissue resections, and long post-operative recovery times. Concentric tube robots have recently been developed as a promising application to neurosurgery due to their nonlinear form and small diameter. The authors present a concept study to explore the feasibility of performing minimally invasive hemispherotomy with concentric tube robots. METHODS A model simulation was used to achieve the optimal design and surgical path planning parameters of the concentric tube robot for corpus callosotomy and temporal lobectomy. A single medial burr hole was chosen to access the lateral ventricles for both white matter disconnections. RESULTS The concentric tube robot was able to accurately reach the designated surgical paths on the corpus callosum and the temporal lobe. CONCLUSION In a model simulation, the authors demonstrated the feasibility of performing corpus callosotomy and temporal lobectomy using concentric tube robots. Further advancements in the technology may increase the applicability of this technique for epilepsy surgery to better patient outcomes.
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