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Luisi C, Salimbene L, Pietrafusa N, Trivisano M, Marras CE, De Benedictis A, Chiarello D, Mercier M, Pepi C, de Palma L, Specchio N. Hypothalamic Hamartoma related epilepsy: A systematic review exploring clinical, neuropsychological, and psychiatric outcome after surgery. Epilepsy Behav 2024; 157:109846. [PMID: 38820683 DOI: 10.1016/j.yebeh.2024.109846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 06/02/2024]
Abstract
The post-surgical outcome for Hypothalamic Hamartoma (HH) related epilepsy in terms of seizure freedom (SF) has been extensively studied, while cognitive and psychiatric outcome has been less frequently reported and defined. This is a systematic review of English language papers, analyzing the post-surgical outcome in series of patients with HH-related epilepsy (≥5 patients, at least 6 months follow-up), published within January 2002-December 2022. SF was measured using Engel scale/equivalent scales. We looked at the outcome related to different surgical techniques, and HH types according to Delalande classification. We evaluated the neuropsychological and neuropsychiatric status after surgery, and the occurrence of post-surgical complications. Forty-six articles reporting 1318 patients were included, of which ten pediatric series. SF was reported in 686/1222 patients (56,1%). Delalande classification was reported in 663 patients from 24 studies, of which 70 were type I HH (10%), 320 were type II HH (48%), 189 were type III HH (29%) and 84 were type IV HH (13%). The outcome in term of SF was reported in 243 out of 663 patients. SF was reported in 12 of 24 type I HH (50%), 80 of 132 type II HH (60,6%), 32 of 59 type III HH (54,2%) and 12 of 28 type IV HH (42,9%). SF was reached in 129/262 (49,2%) after microsurgery, 102/199 (51,3%) after endoscopic surgery, 46/114 (40,6%) after gamma knife surgery, 245/353 (69,4%) after radiofrequency thermocoagulation, and 107/152 (70,4%) after MRI-guided laser interstitial thermal therapy. Hyperphagia/weight gain were the most reported surgical complications. Others were electrolyte alterations, diabetes insipidus, hypotiroidism, transient hyperthermia/poikilothermia. The highest percentage of memory deficits was reported after microsurgery, while hemiparesis and cranial nerves palsy were reported after microsurgery or endoscopic surgery. Thirty studies reported developmental delay/intellectual disability in 424/819 (51,7%) patients. 248/346 patients obtained a global improvement (72%), 70/346 were stable (20%), 28/346 got worse (8%). 22 studies reported psychiatric disorders in 257/465 patients (55,3%). 78/98 patients improved (80%), 13/98 remained stable (13%), 7/98 got worse (7%). Most of the patients had non-structured cognitive/psychiatric assessments. Based on the available data, the surgical management in patients with HH related epilepsy should be individualized, aiming to reach not only the best epilepsy result, but also the optimal cognitive and psychiatric outcome.
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Affiliation(s)
- Concetta Luisi
- Neurology, Epilepsy and Movement Disorders Unit, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network on Rare and Complex Epilepsies, EpiCARE, Rome, Italy
| | - Licia Salimbene
- Neurology, Epilepsy and Movement Disorders Unit, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network on Rare and Complex Epilepsies, EpiCARE, Rome, Italy
| | - Nicola Pietrafusa
- Neurology, Epilepsy and Movement Disorders Unit, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network on Rare and Complex Epilepsies, EpiCARE, Rome, Italy
| | - Marina Trivisano
- Neurology, Epilepsy and Movement Disorders Unit, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network on Rare and Complex Epilepsies, EpiCARE, Rome, Italy
| | | | | | - Daniela Chiarello
- Neurology, Epilepsy and Movement Disorders Unit, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network on Rare and Complex Epilepsies, EpiCARE, Rome, Italy
| | - Mattia Mercier
- Neurology, Epilepsy and Movement Disorders Unit, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network on Rare and Complex Epilepsies, EpiCARE, Rome, Italy
| | - Chiara Pepi
- Neurology, Epilepsy and Movement Disorders Unit, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network on Rare and Complex Epilepsies, EpiCARE, Rome, Italy
| | - Luca de Palma
- Neurology, Epilepsy and Movement Disorders Unit, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network on Rare and Complex Epilepsies, EpiCARE, Rome, Italy
| | - Nicola Specchio
- Neurology, Epilepsy and Movement Disorders Unit, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network on Rare and Complex Epilepsies, EpiCARE, Rome, Italy.
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Ghatan S. Pediatric Neurostimulation and Practice Evolution. Neurosurg Clin N Am 2024; 35:1-15. [PMID: 38000833 DOI: 10.1016/j.nec.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Since the late nineteenth century, the prevailing view of epilepsy surgery has been to identify a seizure focus in a medically refractory patient and eradicate it. Sadly, only a select number of the many who suffer from uncontrolled seizures benefit from this approach. With the development of safe, efficient stereotactic methods and targeted surgical therapies that can affect deep structures and modulate broad networks in diverse disorders, epilepsy surgery in children has undergone a paradigmatic evolutionary change. With modern diagnostic techniques such as stereo electroencephalography combined with closed loop neuromodulatory systems, pediatric epilepsy surgery can reach a much broader population of underserved patients.
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Affiliation(s)
- Saadi Ghatan
- Neurological Surgery Icahn School of Medicine at Mt Sinai, New York, NY 10128, USA.
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Romanelli P, Tuniz F, Fabbro S, Beltramo G, Conti A. Image-guided LINAC radiosurgery in hypothalamic hamartomas. Front Neurol 2022; 13:909829. [PMID: 36119668 PMCID: PMC9475216 DOI: 10.3389/fneur.2022.909829] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 08/01/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Hypothalamic hamartomas (HH) are developmental malformations that are associated with mild to severe drug-refractory epilepsy. Stereotactic radiosurgery (SRS) is an emerging non-invasive option for the treatment of small and medium-sized HH, providing good seizure outcomes without neurological complications. Here, we report our experience treating HH with frameless LINAC SRS. Materials and methods We retrospectively collected clinical and neuroradiological data of ten subjects with HH-related epilepsy that underwent frameless image-guided SRS. Results All patients underwent single-fraction SRS using a mean prescribed dose of 16.27 Gy (range 16–18 Gy). The median prescription isodose was 79% (range 65–81 Gy). The mean target volume was 0.64 cc (range 0.26–1.16 cc). Eight patients experienced complete or near complete seizure freedom (Engel class I and II). Five patients achieved complete seizure control within 4 to 18 months after the treatment. Four patients achieved Engel class II outcome, with stable results. One patient had a reduction of seizure burden superior to 50% (Engel class III). One patient had no benefit at all (Engel class IV) and refused further treatments. Overall, at the last follow-up, three patients experience class I, five class II, one class III and one class IV outcome. No neurological complications were reported. Conclusions Frameless LINAC SRS provides good seizure and long-term neuropsychosocial outcome, without the risks of neurological complications inherently associated with microsurgical resection.
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Affiliation(s)
- Pantaleo Romanelli
- Cyberknife Center, Italian Diagnostic Center (CDI), Milan, Italy
- *Correspondence: Pantaleo Romanelli
| | - Francesco Tuniz
- Department of Neurosurgery, ASUFC “Santa Maria della Misericordia”, Udine, Italy
| | - Sara Fabbro
- Department of Neurosurgery, ASUFC “Santa Maria della Misericordia”, Udine, Italy
| | | | - Alfredo Conti
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), IRCCS Istituto delle Scienze Neurologiche di Bologna, Alma Mater Studiorum-Università di Bologna, Bologna, Italy
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Wang M, Zhou Y, Zhang Y, Shi W, Zhou S, Wang Y, Li H, Zhao R. One-Stage High-Density Focal Stereo-Array SEEG-Guided Radiofrequency Thermocoagulation for the Treatment of Pediatric Giant Hypothalamic Hamartomas. Front Neurol 2020; 11:965. [PMID: 32982954 PMCID: PMC7493627 DOI: 10.3389/fneur.2020.00965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/24/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Giant hypothalamic hamartomas (HHs) are extremely rare lesions, for which the treatment is challenging. While minimally invasive treatments such as radiofrequency thermal coagulation and laser ablation have improved seizure outcomes, multiple operations are often required. This study investigated the value of one-stage stereo-array radiofrequency thermocoagulation based on stereotactic electroencephalography (SEEG) for pediatric giant HHs. Methods: We analyzed the clinical data of six patients with giant HHs (masses with a maximum diameter >30 mm) who underwent stereotactic electrode implantation between November 2017 and April 2019. After a multidisciplinary discussion, we designed a high-density focal stereo-array electrode implantation strategy. SEEG-guided bipolar coagulations were performed between two contiguous contacts of the same electrode, or between two adjacent contacts of different electrodes. Results: Among the six patients, three were male and three were female, with an average age of 5.08 ± 4.73 years (range, 1.4–12 years); the average follow-up duration was 20.17 ± 5.49 months. One patient had previously undergone open surgery. Four patients had gelastic seizures, one had gelastic and tonic seizures, and one had gelastic and generalized tonic-clonic seizures. The number of implanted electrodes ranged from 3 to 7, with an average of 5.33. One patient had transient diabetes insipidus after the operation, and no child had fever or new hormone metabolisms disorder after surgery. Four patients had Engel I classification outcomes (free from disabling seizures), and two patients had Engel II classification outcomes. Conclusion: Although the exploration of epileptic activity and the extent of ablation are limited by the number of SEEG electrodes for the complete disconnection. One-stage high-density focal stereo-array SEEG-guided radiofrequency was safe and effective for treating pediatric giant HH patients. It can be an alternative method to treat giant HHs where LITT is unavailable.
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Affiliation(s)
- Min Wang
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Yuanfeng Zhou
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Yi Zhang
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Wei Shi
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Shuizhen Zhou
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Yi Wang
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Hao Li
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Rui Zhao
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
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Wang D, Wei P, Shan Y, Ren L, Wang Y, Zhao G. Optimized stereoelectroencephalography-guided radiofrequency thermocoagulation in the treatment of patients with focal epilepsy. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:15. [PMID: 32055606 DOI: 10.21037/atm.2019.10.112] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Epilepsy is a severe health disorder affecting people of all ages with high prevalence worldwide. The introduction of new antiepileptic drugs has yielded notable effects in recent decades, yet there are still approximately 30% of patients with seizures refractory to medical therapy. Open surgical resection is widely accepted as a highly effective approach for the treatment of drug-resistant focal epilepsy if the epileptogenic zone can be precisely delineated. However, concerns about the impact of open surgery on brain function have driven considerable interest in less invasive techniques. Clinically, stereoelectroencephalography (SEEG) offers a unique means of exploring the pathophysiologic process and accurately mapping the epileptogenic network in presurgical evaluations for patients with epilepsy because of insufficient information from other noninvasive investigations. Moreover, SEEG-guided radiofrequency thermocoagulation (SEEG-guided RF-TC), which ablates lesions directly through the recording electrodes according to electroclinical evidence, has emerged as a promising, minimally invasive modality with notable preservation of neurocognitive functions. This critical review summarizes the technical details of the parameters and the selection of patients for SEEG-guided RF-TC based on the literature as well as our experiences. With respect to the parameters, the power and duration of RF-TC are discussed. In particular, an optimized SEEG-guided RF-TC modality that integrates more contacts from multiple different electrodes to create a confluent lesioning field is proposed for a more curative effect in comparison to the current protocol of palliative treatment in which RF-TC selectively disrupts critical hubs in the epileptic network through contiguous contacts within the range of a single electrode. Currently, SEEG-guided RF-TC is indicated for a variety of small, deeply seeded and well-demarcated epileptogenic foci, such as deep heterotopic nodules and hypothalamic hamartoma. The efficacy of treating patients with focal cortical dysplasias in the eloquent cortex and with mesial temporal lobe epilepsy associated with hippocampal sclerosis needs to be further determined. Given the small number of patients reported, randomized controlled trials are necessary to compare the efficacy of SEEG-guided RF-TC with conventional methods in the future.
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Affiliation(s)
- Di Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China.,The Beijing Key Laboratory of Neuromodulation, Beijing 100053, China
| | - Penghu Wei
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Yongzhi Shan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Liankun Ren
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China.,The Beijing Key Laboratory of Neuromodulation, Beijing 100053, China
| | - Yuping Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China.,The Beijing Key Laboratory of Neuromodulation, Beijing 100053, China
| | - Guoguang Zhao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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Romanelli P. CyberKnife® Radiosurgery as First-line Treatment for Catastrophic Epilepsy Caused by Hypothalamic Hamartoma. Cureus 2018; 10:e2968. [PMID: 30221096 PMCID: PMC6136885 DOI: 10.7759/cureus.2968] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Hypothalamic hamartomas (HH) are deep-seated lesions often associated with catastrophic epilepsy (an epileptic syndrome characterized by severe, drug-refractory seizures eventually leading to mental retardation and death). Radical microsurgical resection is not feasible for lesions located within the wall of the third ventricle inside the hypothalamus. Frame-based stereotactic radiosurgery has been reported as an effective treatment modality for small- to medium-size intrahypothalamic hamartomas, providing excellent seizure outcomes without lasting complications. This report describes the use of frameless image-guided robotic radiosurgery (CyberKnife® Radiosurgery System) as a first-line treatment in two children with catastrophic epilepsy induced by HH. Both patients experienced multiple-daily complex partial and gelastic seizures, as well as almost daily generalized seizures. The prescribed dose was 16 Gy (to the 65% isodose for case I; to the 70% isodose for case II). Lesional volume was 11.5 cc (case I) and 8.9 cc (case II). A steady reduction of the seizure frequency and severity was achieved after the treatment, starting about three months after the treatment. The generalized seizures disappeared within one year, while complete resolution of the gelastic seizures required up to 18 months. No seizure recurrence and no radiation-induced side effects or complications were witnessed over a follow-up period of ten years and eight months (case I) and nine years and seven months (case II) since the treatment. CyberKnife radiosurgery proved to be a safe and effective non-invasive first-line treatment in these two children with catastrophic epilepsy caused by HH.
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Wei PH, An Y, Fan XT, Wang YH, Yang YF, Ren LK, Shan YZ, Zhao GG. Stereoelectroencephalography-Guided Radiofrequency Thermocoagulation for Hypothalamic Hamartomas: Preliminary Evidence. World Neurosurg 2018; 114:e1073-e1078. [DOI: 10.1016/j.wneu.2018.03.148] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 03/21/2018] [Accepted: 03/21/2018] [Indexed: 11/15/2022]
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Killeen Z, Bunch R, Kerrigan JF. Psychiatric comorbidity with hypothalamic hamartoma: Systematic review for predictive clinical features. Epilepsy Behav 2017. [PMID: 28636978 DOI: 10.1016/j.yebeh.2017.05.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE We conducted a systematic review of the English-language literature to identify clinical features associated with a higher risk of psychiatric symptoms (aggression and rage behaviors) in patients with hypothalamic hamartoma (HH) and epilepsy. METHODS Two publicly-accessible databases (PubMed and Cochrane Library) were searched for Hypothalamic Hamartoma AND Epilepsy. We identified peer-reviewed original research publications (case reports or clinical series; N=19) in which clinical data was provided on an individual basis. Subjects were cohorted into those with (N=51) and without (N=68) behavioral aggression. Multiple clinical features were collated and subjected to univariate analysis to determine possible differences between these two cohorts. RESULTS The presence of aggression significantly correlated with 1) male gender, 2) younger age at time of first seizure onset, 3) the presence of intellectual disability, and 4) the presence of multiple seizure types (versus gelastic seizures only). For those patients undergoing surgical treatment, aggression also correlated with younger age at the time of surgical intervention. CONCLUSION Possible predictive clinical features for the presence of aggression and rage behaviors in patients with hypothalamic hamartoma and epilepsy are identified. These results may contribute to the complex treatment decisions that are unique to this population.
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Affiliation(s)
- Zachary Killeen
- University of Arizona College of Medicine, Phoenix, AZ, United States
| | - Raymond Bunch
- Division of Psychiatry and Hypothalamic Hamartoma Program, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States
| | - John F Kerrigan
- Division of Pediatric Neurology and Hypothalamic Hamartoma Program, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States.
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Pure endoscopic management of epileptogenic hypothalamic hamartomas. Neurosurg Rev 2017; 40:647-653. [PMID: 28168619 DOI: 10.1007/s10143-017-0822-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 01/09/2017] [Accepted: 01/22/2017] [Indexed: 10/20/2022]
Abstract
Hypothalamic hamartomas (HH) are rare congenital malformations located in the region of the tuber cinereum and third ventricle. Their usual clinical presentation is characterized by gelastic/dacrystic seizures which often become pharmaco-resistant and progress to secondary focal/generalized intractable epilepsy causing mostly in children cognitive and behavioral problems (particularly in cases of progressive epileptic encephalopathy) and precocious puberty. Whereas gelastic seizures can be surgically controlled either by resection of the lesion or disconnection (tissue-destructive) procedures, aimed at functionally prevent the spreading of the epileptic burst; generalized seizures tend to respond better to HH excision rather than isolated neocortical resections, which generally fail to control them. Prospective analysis of 14 consecutive patients harboring HH treated in an 8-year period; 12 patients had unilateral and two bilateral HH. All patients were managed by pure endoscopic excision of the HH. The mean operative time was 48 min and mean hospital stay was 2 days; perioperative blood loss was negligible in all cases. Two patients showed a transient diabetes insipidus (DI); no transient or permanent postoperative neurological deficit or memory impairment was recorded. Complete HH excision was achieved in 10/14 patients. At a mean follow-up of 48 months, no wound infection, meningitis, postoperative hydrocephalus, and/or mortality were recorded in this series of patients. Eight patients became seizure free (Engel class I), 2 other experienced worthwhile improvement of disabling seizures (Engel class II); 2 patients were cured from gelastic attacks while still experiencing focal dyscognitive seizures; and 2, having bilateral HH (both undergoing unilateral HH excision), did not experience significant improvement and required later on a temporal lobectomy coupled to amygdalohyppocampectomy. Overall, the followings resulted to be predictive factors for better outcomes in terms of seizure control: (1) cases of unilateral, Delalande class B, HH, (2) shorter history of epilepsy. Endoscopic resection of HH proved, in our series, to be effective in achieving complete control or in reducing the frequency of seizures. Furthermore, this approach has confirmed its minimally invasive nature with a very low morbidity rate: of note, it allowed to better preserve short-term memory and hypothalamic function.
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Udayakumaran S, Ayiramuthu P, Panikar D. Extradural temporopolar approach for parahypothalamic hypothalamic hamartoma and use of posterior communicating artery as resection margin pointer. Childs Nerv Syst 2015; 31:603-8. [PMID: 25700614 DOI: 10.1007/s00381-015-2631-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 02/03/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hypothalamic hamartomas (HH) are malformations originating from the hypothalamus and are associated with seizures, hormonal and behavioral abnormalities. METHOD Most patients, especially those with a typical syndrome characterized by gelastic seizures, precocious puberty, cognitive decline, and behavior problems, are diagnosed in childhood. Pedunculated and parahypothalamic types of hamartomas are attached to the floor by a narrow or wide peduncle in the absence of distortion of the overlying hypothalamus. This location is most commonly associated with a clinical presentation of precocious puberty, and surgical removal has proved curative in small case series. Enthusiastic resection of hypothalamic lesions are known to produce severe hypothalamic disturbance while under resection might mean inadequate response to surgery. CONCLUSIONS In this article, the authors describe the use of extradural temporopolar approach to hypothalamic hamartoma as an improvisation to improve access with reduced morbidity and describe a surgical nuance of using posterior communicating artery to determine a safe but maximal resection margin.
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Affiliation(s)
- Suhas Udayakumaran
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Amrita Institute of Medical Sciences and Research Centre, Ponekkara, Kochi, 682041, India,
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Shim KW, Park EK, Kim JS, Kim DS. How would we deal with hypothalamic hamartomas? World J Surg Proced 2015; 5:65-74. [DOI: 10.5412/wjsp.v5.i1.65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 12/26/2014] [Accepted: 01/19/2015] [Indexed: 02/06/2023] Open
Abstract
Hypothalamic hamartoma (HH) is usually associated with refractory epilepsy, cognitive impairment, and behavioral disturbance. There is now increasing evidence that HH can be treated effectively with a variety of neurosurgical approaches. Treatment options for intractable gelastic seizure in HH patients include direct open surgery with craniotomy, endoscopic surgery, radiosurgery with gamma knife and stereotactic radiofrequency thermocoagulation. Selection of treatment modalities depends on type and size of the HH and the surgeon’s preference. Two surgical techniques, resection and disconnection, had been described with favorable outcomes. Pretreatment evaluation, patient selection, surgical techniques, complications, and possible selection of treatment are discussed.
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Graziano F, Ganau M, Meccio F, Iacopino DG, Ulm AJ. The Transcallosal Anterior Interfoniceal Approach: A Microsurgical Anatomy Study. J Neurol Surg B Skull Base 2014. [PMID: 26225299 DOI: 10.1055/s-0034-1396595] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Objectives A plethora of surgical strategies have been described to reach deep-seated lesions situated within the third ventricle including the Rosenfeld, or transcallosal anterior interfoniceal (TAIF), approach. First introduced in 2001, it consists of a small callosotomy followed by the midline transseptal dissection of fornices to enter the roof of the third ventricle. The aim of this microsurgical anatomy study is to describe and show each stage of the surgical procedure, focusing on the possible trajectories to anatomical landmarks. Participants A total of 20 adult cadaveric specimens were used in this study. Using ×3 to ×40 magnifications, the surgical dissection was performed in a stepwise fashion, and the transcallosal anterior interforniceal approach was performed, analyzed, and described. Results In 5 specimens of 10, a cavum septum pellucidum was depicted. In 5 cases of 20 after the callosotomy ,the lateral ventricular cavities were reached. Different orientation of the microscope allowed us to define three surgical trajectories to visualize the region of interest without exposing important functional areas. Conclusion The TAIF represents a minimally invasive approach to the third ventricle; its tricky surgical steps make appropriate anatomical dissection training essential to become confident and skilled in performing this approach.
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Affiliation(s)
- F Graziano
- Department of Experimental Biomedicine and Clinical Neurosciences, Neurosurgical Clinic, AOPU "P. Giaccone" Universita' degli Studi di Palermo, Italy ; Department of Neurosurgery, Louisiana State University, New Orleans, Louisiana, United States
| | - M Ganau
- Harvard Medical School, Cambridge, Massachusetts, United States ; Department of Biomedical Engineering, University of Cagliari, Italy
| | - F Meccio
- Department of Experimental Biomedicine and Clinical Neurosciences, Neurosurgical Clinic, AOPU "P. Giaccone" Universita' degli Studi di Palermo, Italy
| | - D G Iacopino
- Department of Experimental Biomedicine and Clinical Neurosciences, Neurosurgical Clinic, AOPU "P. Giaccone" Universita' degli Studi di Palermo, Italy
| | - A J Ulm
- Department of Neurosurgery, Louisiana State University, New Orleans, Louisiana, United States
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Jayalakshmi S, Panigrahi M, Reddy R, Somayajula S. Clinical characteristics and long-term outcome of surgery for hypothalamic hamartoma in children with refractory epilepsy. Ann Indian Acad Neurol 2014; 17:43-7. [PMID: 24753658 PMCID: PMC3992768 DOI: 10.4103/0972-2327.128547] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 06/23/2013] [Accepted: 10/06/2013] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Hypothalamic hamartomas (HH) are ectopic masses of neuronal and glial tissue most commonly presenting with medically refractory gelastic seizures with evolution to other seizure types. They are also associated with cognitive and behavioral problems to varying extent. Surgery has been found to improve quality of life in more than 50% of patients. AIM To evaluate the clinical characteristics and long-term outcome of surgery in children with HH and refractory epilepsy. MATERIALS AND METHODS A retrospective analysis of presurgical, surgical, and postsurgical data of six children who underwent surgery for HH and had at least 3 years follow-up was performed. RESULTS SIX CHILDREN (MALE: female = 5:1) aged 3-16 years (at the time of surgery) underwent surgical resection of HH for refractory epilepsy. At last follow-up (range 3-9 years), three children were in Engel's class I, two in Class II, and one in class III outcome. Significant improvement in behavior, quality of life was noted in four children; while the change in intelligence quotient (IQ) was marginal. CONCLUSIONS Medically refractory epilepsy associated with behavioral and cognitive dysfunction is the most common presentation of HH. Open surgical resection is safe with favorable outcome of epilepsy in 50% with significant improvement in behavior and marginal change in cognitive functions.
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Affiliation(s)
- Sita Jayalakshmi
- Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Andhra Pradesh, India
| | - Manas Panigrahi
- Department of Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, Andhra Pradesh, India
| | - Rajesh Reddy
- Department of Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, Andhra Pradesh, India
| | - Shanmukhi Somayajula
- Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Andhra Pradesh, India
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Bateman LM, Latchaw R, Seyal M. Dental hardware complicating diagnosis in refractory gelastic epilepsy secondary to hypothalamic hamartoma. Clin EEG Neurosci 2010; 41:151-4. [PMID: 20722350 DOI: 10.1177/155005941004100309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hypothalamic hamartomas (HH) are developmental malformations of the hypothalamus associated with a potentially treatable epileptic encephalopathy, characterized by early onset gelastic seizures, the later development of multiple seizure types and progressive cognitive and behavioral decline. Surgical treatment of HH can lead to seizure control and improvement in the cognitive-behavioral syndrome. Video-EEG telemetry (VET) is often necessary to characterize the semiology of the seizures, but there are no specific interictal or ictal EEG pattems that will confirm the diagnosis. Magnetic resonance imaging (MRI) can identify HH and define their anatomy, but the imaging findings may be subtle and susceptible to artifactual contamination. We present a patient with intractable gelastic epilepsy in whom the diagnosis of HH was initially missed due to failure to recognize the clinical syndrome and contamination of the MRI images with dental hardware artifact. VET confirmed the clinical diagnosis and the HH was identified on MRI after the dental hardware was removed. VET should be performed to confirm seizure semiology in patients with suspected gelastic epilepsy. Establishing this diagnosis can subsequently direct the appropriate neuroradiological evaluation for HH and surgical treatment of these lesions.
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Affiliation(s)
- Lisa M Bateman
- Department of Neurology, University of California Davis, Sacramento, California, USA.
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Téllez-Zenteno JF, Serrano-Almeida C, Moien-Afshari F. Gelastic seizures associated with hypothalamic hamartomas. An update in the clinical presentation, diagnosis and treatment. Neuropsychiatr Dis Treat 2008; 4:1021-31. [PMID: 19337448 PMCID: PMC2646637 DOI: 10.2147/ndt.s2173] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Gelastic seizures are epileptic events characterized by bouts of laughter. Laughter-like vocalization is usually combined with facial contraction in the form of a smile. Autonomic features such as flushing, tachycardia, and altered respiration are widely recognized. Conscious state may not be impaired, although this is often difficult to asses particularly in young children. Gelastic seizures have been associated classically to hypothalamic hamartomas, although different extrahypothalamic localizations have been described. Hypothalamic hamartomas are rare congenital lesions presenting with the classic triad of gelastic epilepsy, precocious puberty and developmental delay. The clinical course of patients with gelastic seizures associated with hypothalamic hamartomas is progressive, commencing with gelastic seizures in infancy, deteriorating into more complex seizure disorder resulting in intractable epilepsy. Electrophysiological, radiological, and pathophysiological studies have confirmed the intrinsic epileptogenicity of the hypothalamic hamartoma. Currently the most effective surgical approach is the trancallosal anterior interforniceal approach, however newer approaches including the endoscopic and other treatment such as radiosurgery and gamma knife have been used with success. This review focuses on the syndrome of gelastic seizures associated with hypothalamic hamartomas, but it also reviews other concepts such as status gelasticus and some aspects of gelastic seizures in other locations.
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Affiliation(s)
- José F Téllez-Zenteno
- Division of Neurology, University of Saskatchewan, Department of Medicine, Royal University Hospital 103, Hospital Drive. BOX 26, Room 1622, Saskatoon SK S7N OW8, Canada.
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Rosenfeld JV, Feiz-Erfan I. Hypothalamic hamartoma treatment: surgical resection with the transcallosal approach. Semin Pediatr Neurol 2007; 14:88-98. [PMID: 17544952 DOI: 10.1016/j.spen.2007.03.007] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Multiple treatment options are available for patients with hypothalamic hamartoma (HH) including the frontotemporal approaches, the anterior transcallosal transseptal interforniceal approach, the transventricular endoscopic approach, and stereotactic radiosurgery. Relatively large patient series of the transcallosal resection/disconnection from Royal Children's Hospital in Melbourne and the Barrow Neurological Institute in Phoenix, AZ, show, respectively, that 52% to 54% are 100% seizure free, and 24% to 35% have >90% seizure reduction. However, there appears to be an 8% to 14% risk of persisting memory problems. The surgery should ideally be performed in the early years of childhood before secondary generalized epilepsy develops and developmental delay and behavioral problems are established. Radiosurgery may be a preferable option for higher-functioning adolescent or adult patients with HH. The choice of treatment must be individualized depending on the age and clinical circumstances of the patient and the size and anatomic relationships of the hamartoma. The transcallosal resection of HH is an effective and safe treatment, but there is a small risk of short-term memory impairment. The endoscopic approach is an alternative to the transcallosal approach for smaller HH.
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Affiliation(s)
- Jeffrey V Rosenfeld
- Department of Neurosurgery, The Alfred Hospital and Monash University, Victoria, Australia.
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Rekate HL, Feiz-Erfan I, Ng YT, Gonzalez LF, Kerrigan JF. Endoscopic surgery for hypothalamic hamartomas causing medically refractory gelastic epilepsy. Childs Nerv Syst 2006; 22:874-80. [PMID: 16770620 DOI: 10.1007/s00381-006-0125-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Indexed: 01/23/2023]
Abstract
INTRODUCTION There is increasing evidence that removal or disconnection of hypothalamic hamartomas can lead to seizure control and improvement in behavior. The purpose of this study is to report our experiences with endoscopic removal of these hamartomas. METHODS This is a prospective review of the early outcome of 44 patients undergoing endoscopic resection utilizing frameless stereotaxis and a micromanipulator. RESULTS All patients had normal-sized ventricles. Complete removal was possible in 14 patients, 13 of whom were seizure free at follow-up. Four patients suffered complications that have persisted for more than 3 months: One had significant hemiparesis and three had persistent difficulties with short-term memory. Postoperatively, no patient suffered a permanent hormonal deficiency. In one patient who had undergone a previous attempt at transcallosal resection, the procedure was abandoned because of the lack of internal anatomic landmarks. In a second patient, insufficient mass could be removed due to the size of the lesion and the distorted anatomy. Consequently, 1 week later, the patient underwent a transcallosal approach. CONCLUSION In appropriately selected patients, sessile hypothalamic hamartomas can be removed completely or they can be completely disconnected from the hypothalamus with an acceptable risk. At least a year after surgery is needed to evaluate the efficacy of the procedure in terms of control of seizures and improvements in behavior and emotional ability.
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Affiliation(s)
- Harold L Rekate
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
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