1
|
Viswanathan V, Rupp KM, Hect JL, Harford EE, Holt LL, Abel TJ. Intracranial Mapping of Response Latencies and Task Effects for Spoken Syllable Processing in the Human Brain. bioRxiv 2024:2024.04.05.588349. [PMID: 38617227 PMCID: PMC11014624 DOI: 10.1101/2024.04.05.588349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Prior lesion, noninvasive-imaging, and intracranial-electroencephalography (iEEG) studies have documented hierarchical, parallel, and distributed characteristics of human speech processing. Yet, there have not been direct, intracranial observations of the latency with which regions outside the temporal lobe respond to speech, or how these responses are impacted by task demands. We leveraged human intracranial recordings via stereo-EEG to measure responses from diverse forebrain sites during (i) passive listening to /bi/ and /pi/ syllables, and (ii) active listening requiring /bi/-versus-/pi/ categorization. We find that neural response latency increases from a few tens of ms in Heschl's gyrus (HG) to several tens of ms in superior temporal gyrus (STG), superior temporal sulcus (STS), and early parietal areas, and hundreds of ms in later parietal areas, insula, frontal cortex, hippocampus, and amygdala. These data also suggest parallel flow of speech information dorsally and ventrally, from HG to parietal areas and from HG to STG and STS, respectively. Latency data also reveal areas in parietal cortex, frontal cortex, hippocampus, and amygdala that are not responsive to the stimuli during passive listening but are responsive during categorization. Furthermore, multiple regions-spanning auditory, parietal, frontal, and insular cortices, and hippocampus and amygdala-show greater neural response amplitudes during active versus passive listening (a task-related effect). Overall, these results are consistent with hierarchical processing of speech at a macro level and parallel streams of information flow in temporal and parietal regions. These data also reveal regions where the speech code is stimulus-faithful and those that encode task-relevant representations.
Collapse
Affiliation(s)
- Vibha Viswanathan
- Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA 15213
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15260
| | - Kyle M. Rupp
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15260
| | - Jasmine L. Hect
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15260
| | - Emily E. Harford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15260
| | - Lori L. Holt
- Department of Psychology, The University of Texas at Austin, Austin, TX 78712
| | - Taylor J. Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15260
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15238
| |
Collapse
|
2
|
Joshi CN, Karakas C, Eschbach K, Samanta D, Auguste K, Desai V, Singh R, McGoldrick P, Wolf S, Abel TJ, Novotny E, Oluigbo C, Reddy SB, Alexander A, Price A, Reeders P, Mcnamara N, Romanowski EF, Mutchnick I, Ostendorf AP, Shaikhouni A, Knox A, Aungaroon G, Olaya J, Muh CR. Pediatric neuromodulation for drug-resistant epilepsy: Survey of current practices, techniques, and outcomes across US epilepsy centers. Epilepsia Open 2024; 9:785-792. [PMID: 38421143 PMCID: PMC10984294 DOI: 10.1002/epi4.12902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 12/26/2023] [Accepted: 01/11/2024] [Indexed: 03/02/2024] Open
Abstract
Neuromodulation via Responsive Neurostimulation (RNS) or Deep Brain Stimulation (DBS) is an emerging treatment strategy for pediatric drug-resistant epilepsy (DRE). Knowledge gaps exist in patient selection, surgical technique, and perioperative care. Here, we use an expert survey to clarify practices. Thirty-two members of the Pediatric Epilepsy Research Consortium were surveyed using REDCap. Respondents were from 17 pediatric epilepsy centers (missing data in one): Four centers implant RNS only while 13 implant both RNS and DBS. Thirteen RNS programs commenced in or before 2020, and 10 of 12 DBS programs began thereafter. The busiest six centers implant 6-10 new RNS devices per year; all DBS programs implant <5 annually. The youngest RNS patient was 3 years old. Most centers (11/12) utilize MP2RAGE and/or FGATIR sequences for planning. Centromedian thalamic nuclei were the unanimous target for Lennox-Gastaut syndrome. Surgeon exposure to neuromodulation occurred mostly in clinical practice (14/17). Clinically significant hemorrhage (n = 2) or infection (n = 3) were rare. Meaningful seizure reduction (>50%) was reported by 81% (13/16) of centers. RNS and DBS are rapidly evolving treatment modalities for safe and effective treatment of pediatric DRE. There is increasing interest in multicenter collaboration to gain knowledge and facilitate dialogue. PLAIN LANGUAGE SUMMARY: We surveyed 32 pediatric epilepsy centers in USA to highlight current practices of intracranial neuromodulation. Of the 17 that replied, we found that most centers are implanting thalamic targets in pediatric drug-resistant epilepsy using the RNS device. DBS device is starting to be used in pediatric epilepsy, especially after 2020. Different strategies for target identification are enumerated. This study serves as a starting point for future collaborative research.
Collapse
Affiliation(s)
- Charuta N Joshi
- Children's Health, University of Texas Southwest, Dallas, Texas, USA
| | - Cemal Karakas
- Department of Neurology, Division of Child Neurology, Norton Neuroscience Institute, University of Louisville, Louisville, Kentucky, USA
| | - Krista Eschbach
- Department of Pediatrics, Children's Hospital Colorado, Section of Neurology, University of Colorado, Aurora, Colorado, USA
| | - Debopam Samanta
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Kurtis Auguste
- Department of Pediatric Neurosurgery, Benioff Children's Hospital, UCSF Weill Institute for Neurosciences, San Francisco, California, USA
| | - Virendra Desai
- Department of Neurosurgery, Section of Pediatric Neurosurgery, Oklahoma Children's Hospital, University of Oklahoma School of Medicine, Oklahoma City, Oklahoma, USA
| | - Rani Singh
- Division of Neurology, Department of Pediatrics, Atrium Health/Levine Children's Hospital, Charlotte, North Carolina, USA
| | - Patricia McGoldrick
- Department of Pediatric Neurology, Maria Fareri Children's Hospital, Valhalla, New York, USA
| | - Steven Wolf
- Department of Pediatric Neurology, Boston Children's Health Physicians, New York Medical Center, Valhalla, New York, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Edward Novotny
- Department of Neurology and Pediatrics, University of Washington, Seattle, Washington, USA
- Center for Integrative Brain Research Seattle Children's Research Institute, Seattle, Washington, USA
| | - Chima Oluigbo
- Department of Neurosurgery, Children's National Hospital, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Shilpa B Reddy
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Allyson Alexander
- Department of Pediatrics, Children's Hospital Colorado, Section of Neurology, University of Colorado, Aurora, Colorado, USA
- Division of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Angela Price
- Division of Pediatric Neurosurgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Puck Reeders
- Department of Neuroscience, Brain Institute, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Nancy Mcnamara
- Department of Pediatrics, Division of Pediatric Neurology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Erin Fedak Romanowski
- Department of Pediatrics, Division of Pediatric Neurology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ian Mutchnick
- Norton Neuroscience Institute, Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Adam P Ostendorf
- Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Ammar Shaikhouni
- Department Neurosurgery, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Andrew Knox
- Department of Neurology, University of Wisconsin, Madison, Wisconsin, USA
| | - Gewalin Aungaroon
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Joffre Olaya
- Division of Neurosurgery, Children's Hospital Orange County, Orange, California, USA
| | - Carrie R Muh
- Department of Neurosurgery, Maria Fareri Children's Hospital, New York Medical Center, Valhalla, New York, USA
| |
Collapse
|
3
|
Harford EE, Holt LL, Abel TJ. Unveiling the development of human voice perception: Neurobiological mechanisms and pathophysiology. Curr Res Neurobiol 2024; 6:100127. [PMID: 38511174 PMCID: PMC10950757 DOI: 10.1016/j.crneur.2024.100127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 02/22/2024] [Accepted: 02/26/2024] [Indexed: 03/22/2024] Open
Abstract
The human voice is a critical stimulus for the auditory system that promotes social connection, informs the listener about identity and emotion, and acts as the carrier for spoken language. Research on voice processing in adults has informed our understanding of the unique status of the human voice in the mature auditory cortex and provided potential explanations for mechanisms that underly voice selectivity and identity processing. There is evidence that voice perception undergoes developmental change starting in infancy and extending through early adolescence. While even young infants recognize the voice of their mother, there is an apparent protracted course of development to reach adult-like selectivity for human voice over other sound categories and recognition of other talkers by voice. Gaps in the literature do not allow for an exact mapping of this trajectory or an adequate description of how voice processing and its neural underpinnings abilities evolve. This review provides a comprehensive account of developmental voice processing research published to date and discusses how this evidence fits with and contributes to current theoretical models proposed in the adult literature. We discuss how factors such as cognitive development, neural plasticity, perceptual narrowing, and language acquisition may contribute to the development of voice processing and its investigation in children. We also review evidence of voice processing abilities in premature birth, autism spectrum disorder, and phonagnosia to examine where and how deviations from the typical trajectory of development may manifest.
Collapse
Affiliation(s)
- Emily E. Harford
- Department of Neurological Surgery, University of Pittsburgh, USA
| | - Lori L. Holt
- Department of Psychology, The University of Texas at Austin, USA
| | - Taylor J. Abel
- Department of Neurological Surgery, University of Pittsburgh, USA
- Department of Bioengineering, University of Pittsburgh, USA
| |
Collapse
|
4
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
5
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
6
|
Nascimento MA, Biagiotti S, Herranz-Pérez V, Santiago S, Bueno R, Ye CJ, Abel TJ, Zhang Z, Rubio-Moll JS, Kriegstein AR, Yang Z, Garcia-Verdugo JM, Huang EJ, Alvarez-Buylla A, Sorrells SF. Protracted neuronal recruitment in the temporal lobes of young children. Nature 2024; 626:1056-1065. [PMID: 38122823 PMCID: PMC10901738 DOI: 10.1038/s41586-023-06981-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 12/07/2023] [Indexed: 12/23/2023]
Abstract
The temporal lobe of the human brain contains the entorhinal cortex (EC). This region of the brain is a highly interconnected integrative hub for sensory and spatial information; it also has a key role in episodic memory formation and is the main source of cortical hippocampal inputs1-4. The human EC continues to develop during childhood5, but neurogenesis and neuronal migration to the EC are widely considered to be complete by birth. Here we show that the human temporal lobe contains many young neurons migrating into the postnatal EC and adjacent regions, with a large tangential stream persisting until the age of around one year and radial dispersal continuing until around two to three years of age. By contrast, we found no equivalent postnatal migration in rhesus macaques (Macaca mulatta). Immunostaining and single-nucleus RNA sequencing of ganglionic eminence germinal zones, the EC stream and the postnatal EC revealed that most migrating cells in the EC stream are derived from the caudal ganglionic eminence and become LAMP5+RELN+ inhibitory interneurons. These late-arriving interneurons could continue to shape the processing of sensory and spatial information well into postnatal life, when children are actively interacting with their environment. The EC is one of the first regions of the brain to be affected in Alzheimer's disease, and previous work has linked cognitive decline to the loss of LAMP5+RELN+ cells6,7. Our investigation reveals that many of these cells arrive in the EC through a major postnatal migratory stream in early childhood.
Collapse
Affiliation(s)
- Marcos Assis Nascimento
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.
- Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California, San Francisco, CA, USA.
| | - Sean Biagiotti
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, PA, USA
| | - Vicente Herranz-Pérez
- Laboratory of Comparative Neurobiology, Institute Cavanilles, University of Valencia, CIBERNED, Valencia, Spain
- Department of Cell Biology, Functional Biology and Physical Anthropology, University of Valencia, Burjassot, Spain
| | - Samara Santiago
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Neuroscience Graduate Training Program, University of Pittsburgh, Pittsburgh, PA, USA
- Center for the Neural Basis of Cognition at the University of Pittsburgh, Pittsburgh, PA, USA
| | - Raymund Bueno
- Institute of Human Genetics, University of California, San Francisco, CA, USA
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, CA, USA
| | - Chun J Ye
- Institute of Human Genetics, University of California, San Francisco, CA, USA
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
- Institute of Computational Health Sciences, University of California, San Francisco, CA, USA
- Parker Institute for Cancer Immunotherapy, San Francisco, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Zhuangzhi Zhang
- State Key Laboratory of Medical Neurobiology and Institutes of Brain Science, Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Juan S Rubio-Moll
- Servicio de Obstetricia, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Arnold R Kriegstein
- Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Zhengang Yang
- State Key Laboratory of Medical Neurobiology and Institutes of Brain Science, Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jose Manuel Garcia-Verdugo
- Laboratory of Comparative Neurobiology, Institute Cavanilles, University of Valencia, CIBERNED, Valencia, Spain
| | - Eric J Huang
- Department of Pathology, University of California, San Francisco, CA, USA
| | - Arturo Alvarez-Buylla
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.
- Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California, San Francisco, CA, USA.
| | - Shawn F Sorrells
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, PA, USA.
- Center for Neuroscience Graduate Training Program, University of Pittsburgh, Pittsburgh, PA, USA.
- Center for the Neural Basis of Cognition at the University of Pittsburgh, Pittsburgh, PA, USA.
| |
Collapse
|
7
|
Gatesman TA, Hect JL, Phillips HW, Johnson BJ, Wald AI, McClung C, Nikiforova MN, Skaugen JM, Pollack IF, Abel TJ, Agnihotri S. Characterization of low-grade epilepsy-associated tumor from implanted stereoelectroencephalography electrodes. Epilepsia Open 2024; 9:409-416. [PMID: 37798921 PMCID: PMC10839351 DOI: 10.1002/epi4.12840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 09/29/2023] [Indexed: 10/07/2023] Open
Abstract
Low-grade epilepsy-associated tumors (LEATs) are a common cause of drug-resistant epilepsy in children. Herein, we demonstrate the feasibility of using tumor tissue derived from stereoelectroencephalography (sEEG) electrodes upon removal to molecularly characterize tumors and aid in diagnosis. An 18-year-old male with focal epilepsy and MRI suggestive of a dysembryoplastic neuroepithelial tumor (DNET) in the left posterior temporal lobe underwent implantation of seven peri-tumoral sEEG electrodes for peri-operative language mapping and demarcation of the peri-tumoral ictal zone prior to DNET resection. Using electrodes that passed through tumor tissue, we show successful isolation of tumor DNA and subsequent analysis using standard methods for tumor classification by DNA, including Glioseq targeted sequencing and DNA methylation array analysis. This study provides preliminary evidence for the feasibility of molecular diagnosis of LEATs or other lesions using a minimally invasive method with microscopic tissue volumes. The implications of sEEG electrodes in tumor characterization are broad but would aid in diagnosis and subsequent targeted therapeutic strategies.
Collapse
Affiliation(s)
- Taylor A. Gatesman
- Department of Neurological SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- Department of Cellular and Molecular PathologyUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- John G. Rangos Sr. Research CenterChildren's Hospital of PittsburghPittsburghPennsylvaniaUSA
| | - Jasmine L. Hect
- Department of Neurological SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- John G. Rangos Sr. Research CenterChildren's Hospital of PittsburghPittsburghPennsylvaniaUSA
| | - H. Westley Phillips
- Department of Neurological SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Brenden J. Johnson
- Department of Neurological SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- John G. Rangos Sr. Research CenterChildren's Hospital of PittsburghPittsburghPennsylvaniaUSA
| | - Abigail I. Wald
- Molecular and Genomic PathologyUniversity of Pittsburgh Medical Center Health SystemPittsburghPennsylvaniaUSA
| | - Colleen McClung
- Department of PsychiatryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Marina N. Nikiforova
- Molecular and Genomic PathologyUniversity of Pittsburgh Medical Center Health SystemPittsburghPennsylvaniaUSA
| | - John M. Skaugen
- Molecular and Genomic PathologyUniversity of Pittsburgh Medical Center Health SystemPittsburghPennsylvaniaUSA
| | - Ian F. Pollack
- Department of Neurological SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- John G. Rangos Sr. Research CenterChildren's Hospital of PittsburghPittsburghPennsylvaniaUSA
| | - Taylor J. Abel
- Department of Neurological SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- Department of PsychiatryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Sameer Agnihotri
- Department of Neurological SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- Department of Cellular and Molecular PathologyUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- John G. Rangos Sr. Research CenterChildren's Hospital of PittsburghPittsburghPennsylvaniaUSA
- Department of NeurobiologyUniversity of PittsburghPittsburghPennsylvaniaUSA
| |
Collapse
|
8
|
Casillo SM, Gatesman TA, Chilukuri A, Varadharajan S, Johnson BJ, David Premkumar DR, Jane EP, Plute TJ, Koncar RF, Stanton ACJ, Biagi-Junior CAO, Barber CS, Halbert ME, Golbourn BJ, Halligan K, Cruz AF, Mansi NM, Cheney A, Mullett SJ, Land CV, Perez JL, Myers MI, Agrawal N, Michel JJ, Chang YF, Vaske OM, MichaelRaj A, Lieberman FS, Felker J, Shiva S, Bertrand KC, Amankulor N, Hadjipanayis CG, Abdullah KG, Zinn PO, Friedlander RM, Abel TJ, Nazarian J, Venneti S, Filbin MG, Gelhaus SL, Mack SC, Pollack IF, Agnihotri S. An ERK5-PFKFB3 axis regulates glycolysis and represents a therapeutic vulnerability in pediatric diffuse midline glioma. Cell Rep 2024; 43:113557. [PMID: 38113141 DOI: 10.1016/j.celrep.2023.113557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 07/28/2023] [Accepted: 11/22/2023] [Indexed: 12/21/2023] Open
Abstract
Metabolic reprogramming in pediatric diffuse midline glioma is driven by gene expression changes induced by the hallmark histone mutation H3K27M, which results in aberrantly permissive activation of oncogenic signaling pathways. Previous studies of diffuse midline glioma with altered H3K27 (DMG-H3K27a) have shown that the RAS pathway, specifically through its downstream kinase, extracellular-signal-related kinase 5 (ERK5), is critical for tumor growth. Further downstream effectors of ERK5 and their role in DMG-H3K27a metabolic reprogramming have not been explored. We establish that ERK5 is a critical regulator of cell proliferation and glycolysis in DMG-H3K27a. We demonstrate that ERK5 mediates glycolysis through activation of transcription factor MEF2A, which subsequently modulates expression of glycolytic enzyme PFKFB3. We show that in vitro and mouse models of DMG-H3K27a are sensitive to the loss of PFKFB3. Multi-targeted drug therapy against the ERK5-PFKFB3 axis, such as with small-molecule inhibitors, may represent a promising therapeutic approach in patients with pediatric diffuse midline glioma.
Collapse
Affiliation(s)
- Stephanie M Casillo
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Taylor A Gatesman
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Akanksha Chilukuri
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Srinidhi Varadharajan
- Department of Pediatric Hematology and Oncology, St Jude Children's Research Hospital, Memphis, TN 38105, USA; Department of Developmental Neurobiology, St Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Brenden J Johnson
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Daniel R David Premkumar
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Esther P Jane
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Tritan J Plute
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Robert F Koncar
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Ann-Catherine J Stanton
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Carlos A O Biagi-Junior
- Department of Pediatric Oncology, Dana-Farber Boston Children's Cancer and Blood Disorders Center, Boston, MA 02115, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Callie S Barber
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Matthew E Halbert
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Brian J Golbourn
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Katharine Halligan
- Division of Hematology Oncology, University of Pittsburgh School of Medicine, Pittsburgh, Pittsburgh, PA 15261, USA; Division of Hematology Oncology, Department of Pediatrics, Albany Medical College, Albany, NY 12208, USA
| | - Andrea F Cruz
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Neveen M Mansi
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Allison Cheney
- Department of Molecular, Cell, and Developmental Biology, University of California, Santa Cruz, Santa Cruz, CA 95064, USA; University of California, Santa Cruz Genomics Institute, Santa Cruz, CA 95064, USA
| | - Steven J Mullett
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
| | - Clinton Van't Land
- Division of Genetic and Genomic Medicine, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA 15261, USA; Rangos Metabolic Core Facility, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Jennifer L Perez
- Department of Neurological Surgery, Mayo Clinic Alix School of Medicine, Rochester, MN 55905, USA
| | - Max I Myers
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Nishant Agrawal
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Joshua J Michel
- Rangos Flow Cytometry Core Laboratory, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Yue-Fang Chang
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Olena M Vaske
- Department of Molecular, Cell, and Developmental Biology, University of California, Santa Cruz, Santa Cruz, CA 95064, USA; University of California, Santa Cruz Genomics Institute, Santa Cruz, CA 95064, USA
| | - Antony MichaelRaj
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Frank S Lieberman
- Adult Neuro-Oncology Program, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
| | - James Felker
- Pediatric Neuro-Oncology Program, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Sruti Shiva
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA; Heart, Lung, Blood, and Vascular Medicine Institute, Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
| | - Kelsey C Bertrand
- Department of Pediatric Hematology and Oncology, St Jude Children's Research Hospital, Memphis, TN 38105, USA; Department of Developmental Neurobiology, St Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Nduka Amankulor
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Costas G Hadjipanayis
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Kalil G Abdullah
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Pascal O Zinn
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Robert M Friedlander
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Javad Nazarian
- Brain Tumor Institute, Children's National Hospital, Washington, DC 20010, USA
| | - Sriram Venneti
- Laboratory of Brain Tumor Metabolism and Epigenetics, Department of Pathology, University of Michigan Medical School, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Mariella G Filbin
- Department of Pediatric Oncology, Dana-Farber Boston Children's Cancer and Blood Disorders Center, Boston, MA 02115, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Stacy L Gelhaus
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA; Health Sciences Mass Spectrometry Core, University of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Stephen C Mack
- Department of Pediatric Hematology and Oncology, St Jude Children's Research Hospital, Memphis, TN 38105, USA; Department of Developmental Neurobiology, St Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Ian F Pollack
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Sameer Agnihotri
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; Pediatric Neuro-Oncology Program, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA.
| |
Collapse
|
9
|
Hect JL, Harford E, Maroufi SF, Klem ML, Mansouri A, Abel TJ. Clinical outcomes of MR-guided laser interstitial thermal therapy corpus callosum ablation in drug-resistant epilepsy: a systematic review and meta-analysis. J Neurosurg Pediatr 2024; 33:12-21. [PMID: 37856385 DOI: 10.3171/2023.9.peds23326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/15/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE The goal of this systematic review and meta-analysis was to provide an updated analysis of studies investigating outcomes, morbidity, and mortality associated with MR-guided laser interstitial thermal therapy (MRgLITT) corpus callosum ablation (CCA). METHODS Study inclusion criteria for screening required that studies report on human subjects only, including patients aged 1-52 years diagnosed with drug-resistant epilepsy who underwent CCA. Sixteen articles published between 2016 and 2023 were included for the systematic review and analysis, including 4 case reports, 11 case series, and 1 case-control study. Altogether, 85 pediatric and adult patients undergoing CCA were included in the systematic review (46 patients younger and 39 patients older than 21 years). The main outcome of seizure freedom was measured using the decrease in the frequency of atonic seizures following surgery, percentage of atonic seizure freedom following surgery, and percentage of overall seizure freedom following surgery. These measurements were made using data from the last follow-up for patients with at least 6 months of follow-up post-CCA. RESULTS The extent of CCA differed across the pooled cohorts, including anterior two-thirds CCA (38.89%, n = 35) and posterior one-third CCA for completion of a prior partial CCA (22.22%, n = 20), complete CCA (27.78%, n = 25), or CCA of residual white matter in the case of subtotal initial ablation (5.56%, n = 5). Overall, 12.94% of the patients undergoing CCA experienced operational complications. The most common operative complications across 90 CCA operations were probe malpositioning (n = 6), hemorrhage (n = 5), off-target extension of splenium ablation to the thalamus (n = 1), infection (n = 1), and postoperative CSF leak (n = 1). Neurological deficits following CCA were reported as transient in 18.82% and permanent in 4.71% of patients across all studies. The most common neurological deficits were disconnection syndrome (n = 4) or transient hemiplegia (supplementary motor area-like syndrome; n = 4). The 6-month overall seizure freedom rate was 18.87% of 53 patients, and the atonic seizure freedom rate was 46.28% of 52 patients postoperatively. CCA resulted in an average decrease in atonic seizure rate from 8.30 to 1.65 atonic seizures per day (average decrease 80.12%). CONCLUSIONS CCA is associated with an acceptable complication profile, and most patients experience a meaningful reduction in target seizure semiologies. Accurate MRgLITT probe placement is likely important for maximizing CCA while avoiding collateral damage. Avoidable complications of CCA include off-target ablation (and associated deficits), hemorrhage, and future surgery for residual CCA to palliate continued seizures.
Collapse
Affiliation(s)
- Jasmine L Hect
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Emily Harford
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Seyed Farzad Maroufi
- 2Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Mary Lou Klem
- 3Health Sciences Library System, University of Pittsburgh, Pennsylvania
| | - Alireza Mansouri
- 4Department of Neurosurgery, Penn State University, Hershey, Pennsylvania; and
| | - Taylor J Abel
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- 5Department of Bioengineering, University of Pittsburgh, Pennsylvania
| |
Collapse
|
10
|
Muthiah N, Rothenberger S, Abel TJ. Socioeconomic status and healthcare utilization disparities among children with epilepsy in the United States: Results from a nationally representative sample. Sci Rep 2023; 13:21776. [PMID: 38066038 PMCID: PMC10709331 DOI: 10.1038/s41598-023-48668-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023] Open
Abstract
Epilepsy affects 1% of the US population. Healthcare disparities are well-studied among adults with epilepsy but less so among children. We examined whether children with epilepsy (1) have lower income than or (2) utilize the emergency department (ED) differently from children without epilepsy, and (3) if income moderates ED utilization. Data from the 2016-2019 National Survey of Children's Health were used to identify children with active "epilepsy or seizure disorder". Children with versus without epilepsy were compared. Income and ED visits were modeled with logistic and Poisson regressions. This analysis included 131,326 children; 835 were diagnosed with epilepsy. Estimated population prevalence of epilepsy was 0.6%. Children from higher-income-households were less likely to have epilepsy (aOR: 0.7). Children with epilepsy were more likely to visit EDs (aOR = 10.2), see healthcare professionals (aOR: 2.7), and receive care from specialists (aOR: 10.3). Income moderated the relationship between having epilepsy and ED visits. 7.7% of children with epilepsy did not receive needed healthcare. Some barriers were acquiring appointments (aOR: 3.9) and transportation (aOR: 4.7). In conclusion, children with epilepsy were more likely than children without epilepsy to live in lower-income-households, visit EDs, see healthcare professionals, and not receive needed healthcare. Barrier-specific policy interventions may improve medical access for children with epilepsy.
Collapse
Affiliation(s)
- Nallammai Muthiah
- Department of Neurological Surgery, Washington University in Saint Louis School of Medicine, Saint Louis, USA
| | - Scott Rothenberger
- Department of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Taylor J Abel
- Department of Neurological Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA, 15224, USA.
| |
Collapse
|
11
|
Fields DP, Lavadi RS, Hudson JS, McCarthy DJ, Hect J, Wawrose R, Capuk O, Agarwal N, McDowell MM, Simon D, Abel TJ, Greene S. Patterns in Follow-Up Imaging Usage for Pediatric Patients with Whiplash-Associated Disorder. World Neurosurg 2023; 180:e786-e790. [PMID: 37852474 DOI: 10.1016/j.wneu.2023.10.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/06/2023] [Accepted: 10/07/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND A clinical concern exists that pediatric patients with whiplash-associated disorder (WAD) might have missed structural injuries or, alternatively, subsequently develop structural injuries over time, despite initially negative imaging findings. The primary objective of this study is to assess follow-up imaging usage for pediatric patients presenting with WAD. METHODS A retrospective review of 444 pediatric patients presenting to a level 1 pediatric trauma hospital from January 1, 2010 to December 31, 2019 was performed. Imaging was reviewed at the initial encounter and the 3- and 6-month follow-up appointments. RESULTS At the initial evaluation, children aged <6 years were more likely to receive radiographs (P = 0.007) and magnetic resonance imaging (P = 0.048) than were children aged 6-11 and 12-18 years. At the 3- and 6-month follow-up appointments, persistent neck pain was rare, representing <15% of patients at either time. Regardless of pain persistence, 80.2% of patients seen at the 3-month follow-up and 100% of patients at the 6-month follow-up underwent additional imaging studies. At the 3-month follow-up, children with persistent neck pain were more likely to undergo magnetic resonance imaging than were patients without persistent pain (P < 0.001). Also, patients with persistent neck pain were also more likely to not undergo any imaging evaluation (P = 0.002). Follow-up imaging studies did not reveal new structural injuries at either time point. CONCLUSIONS Follow-up imaging for pediatric patients with low-grade WAD did not identify new structural pathology-in patients with or without persistent neck pain.
Collapse
Affiliation(s)
- Daryl P Fields
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Raj Swaroop Lavadi
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Joseph S Hudson
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David J McCarthy
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jasmine Hect
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Richard Wawrose
- Department of Orthopedics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Okan Capuk
- Department of Neurology, University of Pittsburgh Institute for Neurodegenerative Diseases, Pittsburgh, Pennsylvania, USA
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael M McDowell
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Department of Neurological Surgery, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dennis Simon
- Department of Neurological Surgery, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Department of Neurological Surgery, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Stephanie Greene
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Department of Neurological Surgery, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
12
|
Phillips HW, Miller TA, Liu HY, Abel TJ, McDowell MM. Utility of minimally invasive endoscopic skull base approaches for the treatment of drug-resistant mesial temporal lobe epilepsy: a review of current techniques and trends. J Neurosurg 2023; 139:1604-1612. [PMID: 37347658 DOI: 10.3171/2023.4.jns221889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 04/21/2023] [Indexed: 06/24/2023]
Abstract
Mesial temporal lobe epilepsy (mTLE) is an important cause of drug-resistant epilepsy (DRE) in adults and children. Traditionally, the surgical option of choice for mTLE includes a frontotemporal craniotomy and open resection of the anterior temporal cortex and mesial temporal structures. Although this technique is effective and durable, the neuropsychological morbidity resulting from temporal neocortical resections has resulted in the investigation of alternative approaches to resect the mesial temporal structures to achieve seizure freedom while minimizing postoperative cognitive deficits. Outcomes supporting the use of selective temporal resections have resulted in alternative approaches to directly access the mesial temporal structures via endoscopic approaches whose direct trajectory to the epileptogenic zone minimizes retraction, resection, and manipulation of surrounding cortex. The authors reviewed the utility of the endoscopic transmaxillary, endoscopic endonasal, endoscopic transorbital, and endoscopic supracerebellar transtentorial approaches for the treatment of drug-resistant mesial temporal lobe epilepsy. First, a review of the literature demonstrated the anatomical feasibility of each approach, including the limits of exposure provided by each trajectory. Next, clinical data assessing the safety and effectiveness of these techniques in the treatment of DRE were analyzed. An outline of the surgical techniques is provided to highlight the technical nuances of each approach. The direct access to mesial temporal structures and avoidance of lateral temporal manipulation makes endoscopic approaches promising alternatives to traditional methods for the treatment of DRE arising from the temporal pole and mesial temporal lobe. A dearth of literature outlining clinical outcomes, a need for qualified cosurgeons, and a lack of experience with endoscopic approaches remain major barriers to widespread application of the aforementioned techniques. Future studies are warranted to define the utility of these approaches moving forward.
Collapse
|
13
|
Piazza MG, Smith KJ, Abel TJ. Influence of New Technologies on the Cost-Effectiveness of Invasive Monitoring in Epilepsy Surgery. World Neurosurg 2023; 180:231-232. [PMID: 37838164 DOI: 10.1016/j.wneu.2023.10.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Affiliation(s)
- Martin G Piazza
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kenneth J Smith
- Department of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
14
|
Piazza MG, Varga G, Welch W, Abel TJ. The Utility of Responsive Neurostimulation for the Treatment of Pediatric Drug-Resistant Epilepsy. Brain Sci 2023; 13:1455. [PMID: 37891823 PMCID: PMC10605851 DOI: 10.3390/brainsci13101455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/07/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
Drug-resistant epilepsy (DRE) has a strongly negative impact on quality of life, as well as the development of pediatric patients. Surgical treatments have evolved over time, including more invasive craniotomies for resection or disconnection. More recently, neuromodulation techniques have been employed as a less invasive option for patients. Responsive neurostimulation (RNS) is the first closed-loop technology that allows for both treatment and device data collection, which allows for an internal assessment of the efficacy of treatment. This novel technology has been approved in adults and has been used off label in pediatrics. This review seeks to describe this technology, its history, and future directions.
Collapse
Affiliation(s)
- Martin G. Piazza
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.G.P.); (G.V.)
| | - Gregory Varga
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.G.P.); (G.V.)
| | - William Welch
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Taylor J. Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.G.P.); (G.V.)
| |
Collapse
|
15
|
Alreja A, Ward MJ, Ma Q, Russ BE, Bickel S, Van Wouwe NC, González-Martínez JA, Neimat JS, Abel TJ, Bagić A, Parker LS, Richardson RM, Schroeder CE, Morency LP, Ghuman AS. A new paradigm for investigating real-world social behavior and its neural underpinnings. Behav Res Methods 2023; 55:2333-2352. [PMID: 35877024 PMCID: PMC10841340 DOI: 10.3758/s13428-022-01882-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2022] [Indexed: 11/08/2022]
Abstract
Eye tracking and other behavioral measurements collected from patient-participants in their hospital rooms afford a unique opportunity to study natural behavior for basic and clinical translational research. We describe an immersive social and behavioral paradigm implemented in patients undergoing evaluation for surgical treatment of epilepsy, with electrodes implanted in the brain to determine the source of their seizures. Our studies entail collecting eye tracking with other behavioral and psychophysiological measurements from patient-participants during unscripted behavior, including social interactions with clinical staff, friends, and family in the hospital room. This approach affords a unique opportunity to study the neurobiology of natural social behavior, though it requires carefully addressing distinct logistical, technical, and ethical challenges. Collecting neurophysiological data synchronized to behavioral and psychophysiological measures helps us to study the relationship between behavior and physiology. Combining across these rich data sources while participants eat, read, converse with friends and family, etc., enables clinical-translational research aimed at understanding the participants' disorders and clinician-patient interactions, as well as basic research into natural, real-world behavior. We discuss data acquisition, quality control, annotation, and analysis pipelines that are required for our studies. We also discuss the clinical, logistical, and ethical and privacy considerations critical to working in the hospital setting.
Collapse
Affiliation(s)
- Arish Alreja
- Center for the Neural Basis of Cognition, Carnegie Mellon University and University of Pittsburgh, Pittsburgh, USA.
- Neuroscience Institute, Carnegie Mellon University, Pittsburgh, USA.
- Machine Learning Department, Carnegie Mellon University, Pittsburgh, USA.
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, USA.
| | - Michael J Ward
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, USA
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Qianli Ma
- Language Technologies Institute, Carnegie Mellon University, Pittsburgh, USA
| | - Brian E Russ
- Nathan Kline Institute for Psychiatric Research, Orangeburg, USA
| | - Stephan Bickel
- Department of Neurosurgery and Neurology, Northwell Health, The Feinstein Institutes for Medical Research, Manhasset, USA
| | - Nelleke C Van Wouwe
- Department of Neurological Surgery, University of Louisville, Louisville, USA
| | | | - Joseph S Neimat
- Department of Neurological Surgery, University of Louisville, Louisville, USA
| | - Taylor J Abel
- Center for the Neural Basis of Cognition, Carnegie Mellon University and University of Pittsburgh, Pittsburgh, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, USA
- Brain Institute, University of Pittsburgh, Pittsburgh, USA
| | - Anto Bagić
- Department of Neurology, University of Pittsburgh, Pittsburgh, USA
| | - Lisa S Parker
- School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - R Mark Richardson
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, USA
- Department of Neurosurgery, Harvard Medical School and Massachusetts General Hospital, Boston, USA
| | - Charles E Schroeder
- Nathan Kline Institute for Psychiatric Research, Orangeburg, USA
- Departments of Neurosurgery and Psychiatry, Columbia University, New York, USA
| | | | - Avniel Singh Ghuman
- Center for the Neural Basis of Cognition, Carnegie Mellon University and University of Pittsburgh, Pittsburgh, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, USA
- Brain Institute, University of Pittsburgh, Pittsburgh, USA
- Departments of Psychology, Neurobiology, and Psychiatry, University of Pittsburgh, Pittsburgh, USA
| |
Collapse
|
16
|
Muthiah N, Abel TJ. Letter to the Editor. The importance of vagus nerve stimulation for young children. J Neurosurg Pediatr 2023; 32:522-523. [PMID: 37503927 DOI: 10.3171/2023.5.peds23216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
|
17
|
Muthiah N, Mallela AN, Vodovotz L, Sharma N, Akwayena E, Pan E, Welch W, Ibrahim GM, Abel TJ. Development of a clinical model to predict vagus nerve stimulation response in pediatric patients with drug-resistant epilepsy. J Neurosurg Pediatr 2023; 31:476-483. [PMID: 36805960 DOI: 10.3171/2023.1.peds22312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 01/13/2023] [Indexed: 02/19/2023]
Abstract
OBJECTIVE Epilepsy impacts 470,000 children in the United States. For patients with drug-resistant epilepsy (DRE) and unresectable seizure foci, vagus nerve stimulation (VNS) is a treatment option. Predicting response to VNS has been historically challenging. The objective of this study was to create a clinical VNS prediction tool for use in an outpatient setting. METHODS The authors performed an 11-year retrospective cohort analysis with 1-year follow-up. Patients < 21 years of age with DRE who underwent VNS (n = 365) were included. Logistic regressions were performed to assess clinical factors associated with VNS response (≥ 50% seizure frequency reduction after 1 year); 70% and 30% of the sample were used to train and validate the multivariable model, respectively. A prediction score was subsequently developed. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) were calculated. RESULTS Variables associated with VNS response were < 4-year epilepsy duration before VNS (p = 0.008) and focal motor seizures (p = 0.037). The variables included in the clinical prediction score were epilepsy duration before VNS, age at seizure onset, number of pre-VNS antiseizure medications, if VNS was the patient's first therapeutic epilepsy surgery, and predominant seizure semiology. The final AUCs were 0.7013 for the "fitted" sample and 0.6159 for the "validation" sample. CONCLUSIONS The authors developed a clinical model to predict VNS response in a large sample of pediatric patients treated with VNS. Despite the large sample size, clinical variables alone were not able to accurately predict VNS response. This score may be useful after further validation, although its predictive ability underscores the need for more robust biomarkers to predict treatment response.
Collapse
Affiliation(s)
| | - Arka N Mallela
- 1Department of Neurological Surgery, University of Pittsburgh
| | - Lena Vodovotz
- 1Department of Neurological Surgery, University of Pittsburgh
| | - Nikhil Sharma
- 1Department of Neurological Surgery, University of Pittsburgh
| | - Emefa Akwayena
- 1Department of Neurological Surgery, University of Pittsburgh
| | - Evelyn Pan
- 1Department of Neurological Surgery, University of Pittsburgh
| | - William Welch
- 2Department of Pediatrics, Division of Child Neurology, University of Pittsburgh, Pennsylvania
| | - George M Ibrahim
- 3Department of Surgery, Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada; and
| | - Taylor J Abel
- 1Department of Neurological Surgery, University of Pittsburgh.,4Department of Bioengineering, University of Pittsburgh, Pennsylvania
| |
Collapse
|
18
|
Rhone AE, Rupp K, Hect JL, Harford E, Tranel D, Howard MA, Abel TJ. Electrocorticography reveals the dynamics of famous voice responses in human fusiform gyrus. J Neurophysiol 2023; 129:342-346. [PMID: 36576268 PMCID: PMC9886354 DOI: 10.1152/jn.00459.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/14/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022] Open
Abstract
Voice and face processing occur through convergent neural systems that facilitate speaker recognition. Neuroimaging studies suggest that familiar voice processing engages early visual cortex, including the bilateral fusiform gyrus (FG) on the basal temporal lobe. However, what role the FG plays in voice processing and whether it is driven by bottom-up or top-down mechanisms is unresolved. In this study we directly examined neural responses to famous voices and faces in human FG with direct cortical surface recordings (electrocorticography) in epilepsy surgery patients. We tested the hypothesis that neural populations in human FG respond to famous voices and investigated the temporal properties of voice responses in FG. Recordings were acquired from five adult participants during a person identification task using visual and auditory stimuli from famous speakers (U.S. Presidents Barack Obama, George W. Bush, and Bill Clinton). Patients were presented with images of presidents or clips of their voices and asked to identify the portrait/speaker. Our results demonstrate that a subset of face-responsive sites in and near FG also exhibit voice responses that are both lower in magnitude and delayed (300-600 ms) compared with visual responses. The dynamics of voice processing revealed by direct cortical recordings suggests a top-down feedback-mediated response to famous voices in FG that may facilitate speaker identification.NEW & NOTEWORTHY Interactions between auditory and visual cortices play an important role in person identification, but the dynamics of these interactions remain poorly understood. We performed direct brain recordings of fusiform face cortex in human epilepsy patients performing a famous voice naming task, revealing the dynamics of famous voice processing in human fusiform face cortex. The findings support a model of top-down interactions from auditory to visual cortex to facilitate famous voice recognition.
Collapse
Affiliation(s)
- Ariane E Rhone
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa
| | - Kyle Rupp
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jasmine L Hect
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Emily Harford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daniel Tranel
- Department of Psychology, University of Iowa, Iowa City, Iowa
| | | | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
19
|
Muthiah N, Joseph B, Varga G, Vodovotz L, Sharma N, Abel TJ. Investigation of the effectiveness of vagus nerve stimulation for pediatric drug-resistant epilepsies secondary to nonaccidental trauma. Childs Nerv Syst 2023; 39:1201-1206. [PMID: 36602582 DOI: 10.1007/s00381-022-05817-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/25/2022] [Indexed: 01/06/2023]
Abstract
PURPOSE Epilepsy following non-accidental trauma (NAT) occurs in 18% of pediatric patients. About 33% of patients with epilepsy develop drug-resistant epilepsy. For these patients, vagus nerve stimulation (VNS) is a palliative treatment option. We aimed to investigate the effectiveness of VNS among pediatric NAT-related epilepsy patients compared to those with non-NAT-related epilepsy. METHODS We performed an 11-year retrospective analysis of VNS implantations for drug-resistant epilepsy at UPMC Children's Hospital of Pittsburgh. Patients were split into two groups: NAT vs. non-NAT. The primary outcome was the attainment of ≥ 50% seizure frequency reduction at 1-year post-VNS implantation. Fisher's exact tests and Wilcoxon rank-sum tests were used to compare groups. Significance was assessed at the alpha = 0.05 level. RESULTS This analysis included data from 370 pediatric VNS patients, of whom 9 had NAT-related epilepsy. NAT patients had a significantly younger age of epilepsy onset than non-NAT patients (0.3 years vs. 3.3 years). Otherwise, there were no statistically significant baseline differences between groups, including patient sex and quantity of antiseizure medications pre-VNS. Overall, 71% of NAT patients experienced ≥ 50% seizure frequency reduction compared to 48% of non-NAT patients (p = 0.269). CONCLUSION VNS may allow a higher proportion of pediatric patients with NAT-related epilepsy to achieve ≥ 50% seizure frequency reduction compared to other epilepsy etiologies. While the results of this study were not statistically significant, the effect size was large. Our results underscore the need for larger, multi-center studies to validate the effectiveness of VNS for this patient population.
Collapse
Affiliation(s)
| | - Brigit Joseph
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Gregory Varga
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lena Vodovotz
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nikhil Sharma
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
| |
Collapse
|
20
|
Abel TJ, Muthiah N, Hect JL, Gonzalez-Martinez J, Salehi A, Smyth MD, Smith KJ. Cost-effectiveness of invasive monitoring strategies in epilepsy surgery. J Neurosurg 2022:1-7. [PMID: 36585866 DOI: 10.3171/2022.11.jns221744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/17/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Drug-resistant epilepsy occurs in up to 40% of patients with epilepsy who may be considered for epilepsy surgery. For drug-resistant focal epilepsy, up to 50% of patients require invasive monitoring prior to surgery. Of the most common invasive monitoring strategies (subdural electrodes [SDEs] and stereo-electroencephalography [sEEG]), the most cost-effective strategy is unknown despite substantial differences in morbidity profiles. METHODS Using data collected from an internationally representative sample published in available systematic reviews and meta-analyses, this economic evaluation study employs a decision analysis model to simulate the risks and benefits of SDE and sEEG invasive monitoring strategies. In this model, patients faced differing risks of morbidity, mortality, resection, and seizure freedom depending on which invasive monitoring strategy they underwent. A range of cost values was obtained from a recently published single-center cost-utility analysis. The model considers a base case simulation of a characteristic patient with drug-resistant epilepsy using clinical parameters obtained from systematic reviews of invasive monitoring available in the literature. The main outcome measure was the probability of a positive outcome after invasive monitoring, which was defined as improvement in seizures without a complication. Cost-effectiveness was measured using an incremental cost-effectiveness ratio (ICER). RESULTS Invasive monitoring with sEEG had an increased cost of $274 and increased probability of effectiveness of 0.02 compared with SDEs, yielding an ICER of $12,630 per positive outcome obtained. Sensitivity analyses varied parameters widely and revealed consistent model results across the range of clinical parameters reported in the literature. One-way sensitivity analyses revealed that invasive monitoring strategy costs were the most influential parameter for model outcome. CONCLUSIONS In this analysis, based on available observational data and estimates of complication costs, invasive monitoring with either SDEs or sEEG was nearly equivalent in terms of cost-effectiveness.
Collapse
Affiliation(s)
- Taylor J Abel
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh.,Departments of2Bioengineering and
| | - Nallammai Muthiah
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh
| | - Jasmine L Hect
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh
| | - Jorge Gonzalez-Martinez
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh
| | - Afshin Salehi
- 3Department of Neurosurgery, University of Nebraska, Omaha, Nebraska; and
| | - Matthew D Smyth
- 4Department of Neurosurgery, Johns Hopkins All Children's Hospital, Tampa, Florida
| | | |
Collapse
|
21
|
Chilukuri AS, Awkwayena E, Abel TJ. Insulo-opercular stereoelectroencephalography exploration in children and young adults: Indications, techniques, and safety. Epilepsia Open 2022; 7:729-736. [PMID: 36161288 PMCID: PMC9712468 DOI: 10.1002/epi4.12651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/21/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Sampling the insulo-opercular region with invasive recordings is crucial given the importance of this region in epileptic networks and a variety of electroclinical presentations. However, implantation of the insulo-opercular region via stereoelectroencephalography (sEEG) is considered technically challenging given complex vascular and gray matter relationships in this region. We investigated the safety of insulo-opercular sEEG exploration in children and young adults using standard sEEG approaches: (1) orthogonal insulo-opercular (including the pseudo-orthogonal insulo-opercular approach) and (2) medial-lateral insular oblique approach. METHODS We performed a retrospective cohort study of 30 consecutive patients who underwent 33 sEEG implantations. All patients had drug-resistant focal epilepsy, were between the ages of 4 and 21, and were operated at one institution between January 2019 and March 2021. Medical records and neuroimaging were reviewed. Hemorrhage, infection, and other complications were considered as outcome variables. RESULTS A total of 519 electrodes were placed. Eighty-one were placed orthogonally into the temporal operculum, 53 orthogonally into the frontal operculum, and 19 obliquely into the insula. sEEG electrodes localized seizure onset to the insulo-opercular region in eight patients, leading to a resection three times, an ablation four times, and one peri-insular hemispherectomy. Of the 519 electrodes placed, none of them exhibited hemorrhage or serious complications. Of the 153 electrodes placed into the insula, none had any permanent deficits or complications and one had minor bleeding due to the electrode breaking. SIGNIFICANCE These results demonstrate that the orthogonal (including pseudo-orthogonal) and medial approaches to sampling the insula are safe.
Collapse
Affiliation(s)
| | - Emefa Awkwayena
- Department of Neurological SurgeryUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Taylor J. Abel
- Department of Neurological SurgeryUniversity of PittsburghPittsburghPennsylvaniaUSA,Department of BioengineeringUniversity of PittsburghPittsburghPennsylvaniaUSA
| |
Collapse
|
22
|
Curtis K, Hect JL, Harford E, Welch WP, Abel TJ. Responsive neurostimulation for pediatric patients with drug-resistant epilepsy: a case series and review of the literature. Neurosurg Focus 2022; 53:E10. [PMID: 36183183 DOI: 10.3171/2022.7.focus22331] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/21/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Responsive neurostimulation (RNS) is a promising treatment for pediatric patients with drug-resistant epilepsy for whom resective surgery is not an option. The relative indications and risk for pediatric patients undergoing RNS therapy require further investigation. Here, the authors report their experience with RNS implantation and therapy in pediatric patients. METHODS The authors performed a retrospective chart review to identify patients implanted with RNS depth or strip electrodes for the treatment of drug-resistant epilepsy at their institution between 2020 and 2022. Patient demographics, surgical variables, and patient seizure outcomes (Engel class and International League Against Epilepsy [ILAE] reporting) were evaluated. RESULTS The authors identified 20 pediatric patients ranging in age from 8 to 21 years (mean 15 [SD 4] years), who underwent RNS implantation, including depth electrodes (n = 15), strip electrodes (n = 2), or both (n = 3). Patient seizure semiology, onset, and implantation strategy were heterogeneous, including bilateral centromedian nucleus (n = 5), mesial temporal lobe (n = 4), motor cortex or supplementary motor area (n = 7), or within an extratemporal epileptogenic zone (n = 4). There were no acute complications of RNS implantation (hemorrhage or stroke) or device malfunctions. One patient required rehospitalization for postoperative infection. At the longest follow-up (mean 10 [SD 7] months), 13% patients had Engel class IIB, 38% had Engel class IIIA, 6% had Engel class IIIB, 19% had Engel class IVA, 19% had Engel class IVB, and 6% had Engel class IVC outcomes. Using ILAE metrics, 6% were ILAE class 3, 25% were ILAE class 4, and 69% were ILAE class 5. CONCLUSIONS This case series supports current literature suggesting that RNS is a safe and potentially effective surgical intervention for pediatric patients with drug-resistant epilepsy. The authors report comparable rates of serious adverse events to current RNS literature in pediatric and adult populations. Seizure outcomes may continue to improve with follow-up as stimulation strategy is refined and the chronic neuromodulatory effect evolves, as previously described in patients with RNS. Further large-scale, multicenter case series of RNS in pediatric patients with drug-resistant epilepsy are required to determine long-term pediatric safety and effectiveness.
Collapse
Affiliation(s)
- Kendall Curtis
- 1Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh
| | - Jasmine L Hect
- 1Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh
| | - Emily Harford
- 1Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh
| | - William P Welch
- 2Division of Child Neurology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh; and
| | - Taylor J Abel
- 1Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh
- 3Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pennsylvania
| |
Collapse
|
23
|
Remick M, Akwayena E, Harford E, Chilukuri A, White GE, Abel TJ. Subdural electrodes versus stereoelectroencephalography for pediatric epileptogenic zone localization: a retrospective cohort study. Neurosurg Focus 2022; 53:E4. [DOI: 10.3171/2022.7.focus2269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/19/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE
The objective of this study was to compare the relative safety and effectiveness of invasive monitoring with subdural electrodes (SDEs) and stereoelectroencephalography (sEEG) in pediatric patients with drug-resistant epilepsy.
METHODS
A retrospective cohort study was performed in 176 patients who underwent invasive monitoring evaluations at UPMC Children’s Hospital of Pittsburgh between January 2000 and September 2021. To examine differences between SDE and sEEG groups, independent-samples t-tests for continuous variables and Pearson chi-square tests for categorical variables were performed. A p value < 0.1 was considered statistically significant.
RESULTS
There were 134 patients (76%) in the SDE group and 42 (24%) in the sEEG group. There was a difference in the proportion with complications (17.9% in the SDE group vs 7.1% in the sEEG group, p = 0.09) and resection (75.4% SDE vs 21.4% sEEG, p < 0.01) between SDE and sEEG patients. However, there was no observable difference in the rates of postresection seizure freedom at 1-year clinical follow-up (60.2% SDE vs 75.0% sEEG, p = 0.55).
CONCLUSIONS
These findings reveal a difference in rates of surgical complications and resection between SDEs and sEEG. Larger prospective, multi-institutional pediatric comparative effectiveness studies may further explore these associations.
Collapse
Affiliation(s)
| | | | | | | | | | - Taylor J. Abel
- Departments of Neurological Surgery,
- Bioengineering, University of Pittsburgh, Pennsylvania
| |
Collapse
|
24
|
Muthiah N, Sharma N, Vodovotz L, White GE, Abel TJ. Predictors of vagus nerve stimulation complications among pediatric patients with drug-resistant epilepsy. J Neurosurg Pediatr 2022; 30:284-291. [PMID: 35901694 DOI: 10.3171/2022.6.peds2289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/02/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Complications from vagus nerve stimulator (VNS) procedures are common and can have important implications for morbidity and seizure control, yet predictors of complications are poorly understood. The objective of this study was to assess clinical factors associated with minor and major complications from VNS procedures among pediatric patients with drug-resistant epilepsy. METHODS The authors performed an 11-year retrospective review of patients who underwent VNS procedures for drug-resistant epilepsy at age < 21 years. The primary outcome was complications (minor or major) following VNS surgery. Preoperative and surgery characteristics were compared between patients who developed versus those who did not develop complications. Multivariable Poisson regression was performed to determine the association between preoperative characteristics and infection. RESULTS Of 686 surgeries, 48 complications (7.0%) developed; there were 7 minor complications (1.0%) and 41 major complications (6.0%). Surgeries with minor complications were an average of 68 minutes longer than those without minor complications (p < 0.001). The incidence rate of infection was 1 per 100 person-years, with 3% of procedures complicated by infection. Poisson regression revealed that after adjusting for age at surgery, duration of surgery, and primarily motor seizure semiology, the incident rate of infection for revision surgeries preceded by ≥ 2 procedures was 19 times that of first-time revisions. CONCLUSIONS The overall minor complication rate was 1% and the overall major complication rate was 6% for VNS procedures. Longer surgery duration was associated with the development of minor complications but not major complications. Repeat incisions to the VNS pocket may be associated with higher incident rate of infection, highlighting a need for longer-lasting VNS pulse generator models.
Collapse
Affiliation(s)
| | - Nikhil Sharma
- 1Department of Neurological Surgery, University of Pittsburgh
| | - Lena Vodovotz
- 1Department of Neurological Surgery, University of Pittsburgh
| | - Gretchen E White
- 2Institute for Clinical Research Education, University of Pittsburgh; and
| | - Taylor J Abel
- 1Department of Neurological Surgery, University of Pittsburgh
- 3Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
25
|
Rupp K, Hect JL, Remick M, Ghuman A, Chandrasekaran B, Holt LL, Abel TJ. Neural responses in human superior temporal cortex support coding of voice representations. PLoS Biol 2022; 20:e3001675. [PMID: 35900975 PMCID: PMC9333263 DOI: 10.1371/journal.pbio.3001675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/13/2022] [Indexed: 11/19/2022] Open
Abstract
The ability to recognize abstract features of voice during auditory perception is an intricate feat of human audition. For the listener, this occurs in near-automatic fashion to seamlessly extract complex cues from a highly variable auditory signal. Voice perception depends on specialized regions of auditory cortex, including superior temporal gyrus (STG) and superior temporal sulcus (STS). However, the nature of voice encoding at the cortical level remains poorly understood. We leverage intracerebral recordings across human auditory cortex during presentation of voice and nonvoice acoustic stimuli to examine voice encoding at the cortical level in 8 patient-participants undergoing epilepsy surgery evaluation. We show that voice selectivity increases along the auditory hierarchy from supratemporal plane (STP) to the STG and STS. Results show accurate decoding of vocalizations from human auditory cortical activity even in the complete absence of linguistic content. These findings show an early, less-selective temporal window of neural activity in the STG and STS followed by a sustained, strongly voice-selective window. Encoding models demonstrate divergence in the encoding of acoustic features along the auditory hierarchy, wherein STG/STS responses are best explained by voice category and acoustics, as opposed to acoustic features of voice stimuli alone. This is in contrast to neural activity recorded from STP, in which responses were accounted for by acoustic features. These findings support a model of voice perception that engages categorical encoding mechanisms within STG and STS to facilitate feature extraction. Voice perception occurs via specialized networks in higher order auditory cortex, but how voice features are encoded remains a central unanswered question. Using human intracerebral recordings of auditory cortex, this study provides evidence for categorical encoding of voice.
Collapse
Affiliation(s)
- Kyle Rupp
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Jasmine L. Hect
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Madison Remick
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Avniel Ghuman
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Bharath Chandrasekaran
- Department of Communication Science and Disorders, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Lori L. Holt
- Department of Psychology, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
| | - Taylor J. Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- * E-mail:
| |
Collapse
|
26
|
Didato G, Chiesa V, Losito E, Amorim Leite R, Abel TJ. Editorial: Complex Scenarios of Drug-Resistant Epilepsies: Diagnostic Challenges and Novel Therapeutic Options. Front Neurol 2022; 13:908163. [PMID: 35572920 PMCID: PMC9100954 DOI: 10.3389/fneur.2022.908163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/11/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Giuseppe Didato
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- *Correspondence: Giuseppe Didato
| | - Valentina Chiesa
- Epilepsy Center, San Paolo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
| | - Emma Losito
- Department of Clinical Neurophysiology, Assistance Publique - Hôpitaux de Paris, Necker-Enfants Malades Hospital, Paris, France
| | - Ricardo Amorim Leite
- Video-EEG Unit, Psychiatry Institute of São Paulo University—USP, São Paulo, Brazil
| | - Taylor J. Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
| |
Collapse
|
27
|
Abel TJ, Remick M, Welch WC, Smith KJ. One-Year Cost-Effectiveness of Callosotomy Versus Vagus Nerve Stimulation for Drug-Resistant Seizures in Lennox-Gastaut Syndrome: A Decision Analytic Model. Epilepsia Open 2021; 7:124-130. [PMID: 34890113 PMCID: PMC8886071 DOI: 10.1002/epi4.12570] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/22/2021] [Accepted: 11/27/2021] [Indexed: 11/12/2022] Open
Abstract
Objective Palliative epilepsy surgery via corpus callosotomy (CC) or vagus nerve stimulation (VNS) is commonly employed for drug‐resistant seizures in Lennox‐Gastaut Syndrome (LGS). VNS is less effective at reducing seizures but has fewer adverse events, CC is more effective for seizure control, particularly atonic seizures, but can be associated with serious adverse events, and yet their relative cost‐effectiveness remains unknown. Methods To determine which option is most cost‐effective, a decision analytic model was developed to evaluate the risks and benefits of CC and VNS at 1 year based on costs in the United States. Our primary outcome measure was positive seizure outcomes, defined as >50% seizure reduction without procedural complications. Results CC had a 15% greater likelihood of a positive seizure outcome, but per patient costs were $68 147 more than VNS, or $451 952 per positive seizure outcome gained. One‐way sensitivity analyses demonstrate that probabilities of seizure freedom or reduction by VNS or CC and CC cost were most influential on results. When considering atonic seizures, CC had a 27% greater positive outcome likelihood than VNS, the same incremental cost, and cost $250 556 per positive seizure outcome gained. Significance This exploratory model suggests that VNS is more cost‐effective relative to CC at 1 year.
Collapse
Affiliation(s)
- Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Madison Remick
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - William C Welch
- Division of Pediatric Neurology, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kenneth J Smith
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
28
|
Hect JL, Fernandez LD, Welch WP, Abel TJ. Deep brain stimulation of the centromedian thalamic nucleus for the treatment of FIRES. Epilepsia Open 2021; 7:187-193. [PMID: 34862854 PMCID: PMC8886094 DOI: 10.1002/epi4.12568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/16/2021] [Accepted: 11/28/2021] [Indexed: 11/10/2022] Open
Abstract
Febrile infection‐related epilepsy syndrome (FIRES) is a rare, life‐threatening complication of febrile illness in previously healthy individuals followed by super‐refractory status epilepticus. Deep brain stimulation (DBS) has been demonstrated to be a promising therapy for the treatment of intractable epilepsy. Here, we present a pediatric patient with FIRES whose seizures were mitigated by acute DBS of the bilateral centromedian thalamic nucleus (CMTN). This is a previously healthy 11‐year‐old female who presented emergently with altered mental status, fever, and malaise after 1 week of lethargy, anorexia, fever, and abdominal pain. The patient began having seizures shortly after admission. After thorough workup for encephalitis and other potential etiologies, this patient was diagnosed with FIRES due to super‐refractory status epilepticus. Status epilepticus persisted despite pharmacologic management, immunotherapy, and vagus nerve stimulation. DBS of the bilateral CMTN (CM‐DBS) was pursued after 56 days of hospitalization, and she demonstrated considerable improvement in baseline mental status 30 days after DBS insertion. This report highlights application of CM‐DBS for super‐refractory status epilepticus in FIRES. This region is a diffusely connected brain region and has been shown to modulate neural networks contributing to seizure propagation and consciousness; therefore, neurostimulation is a potential therapeutic intervention for patients with super‐refractory status epilepticus.
Collapse
Affiliation(s)
- Jasmine L Hect
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Luis D Fernandez
- Division of Pediatric Neurology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - William P Welch
- Division of Pediatric Neurology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Bioengineering, University of Pittsburgh Swanson School of Engineering, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
29
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
30
|
Gnanateja GN, Rupp K, Llanos F, Remick M, Pernia M, Sadagopan S, Teichert T, Abel TJ, Chandrasekaran B. Frequency-Following Responses to Speech Sounds Are Highly Conserved across Species and Contain Cortical Contributions. eNeuro 2021; 8:ENEURO.0451-21.2021. [PMID: 34799409 PMCID: PMC8704423 DOI: 10.1523/eneuro.0451-21.2021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 11/02/2021] [Indexed: 11/21/2022] Open
Abstract
Time-varying pitch is a vital cue for human speech perception. Neural processing of time-varying pitch has been extensively assayed using scalp-recorded frequency-following responses (FFRs), an electrophysiological signal thought to reflect integrated phase-locked neural ensemble activity from subcortical auditory areas. Emerging evidence increasingly points to a putative contribution of auditory cortical ensembles to the scalp-recorded FFRs. However, the properties of cortical FFRs and precise characterization of laminar sources are still unclear. Here we used direct human intracortical recordings as well as extracranial and intracranial recordings from macaques and guinea pigs to characterize the properties of cortical sources of FFRs to time-varying pitch patterns. We found robust FFRs in the auditory cortex across all species. We leveraged representational similarity analysis as a translational bridge to characterize similarities between the human and animal models. Laminar recordings in animal models showed FFRs emerging primarily from the thalamorecipient layers of the auditory cortex. FFRs arising from these cortical sources significantly contributed to the scalp-recorded FFRs via volume conduction. Our research paves the way for a wide array of studies to investigate the role of cortical FFRs in auditory perception and plasticity.
Collapse
Affiliation(s)
- G Nike Gnanateja
- Department of Communication Sciences and Disorders, University of Pittsburgh, Pittsburgh, Pennsylvania 15260
| | - Kyle Rupp
- Department of Neurological Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Fernando Llanos
- Department of Linguistics, The University of Texas at Austin, Austin, Texas 78712
| | - Madison Remick
- Department of Neurological Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Marianny Pernia
- Center for Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania 15261
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, Pennsylvania 15260
| | - Srivatsun Sadagopan
- Department of Communication Sciences and Disorders, University of Pittsburgh, Pittsburgh, Pennsylvania 15260
- Center for Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania 15261
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15260
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, Pennsylvania 15260
- Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, Pennsylvania 15261
| | - Tobias Teichert
- Center for Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania 15261
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15260
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Taylor J Abel
- Department of Neurological Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15213
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15260
| | - Bharath Chandrasekaran
- Department of Communication Sciences and Disorders, University of Pittsburgh, Pittsburgh, Pennsylvania 15260
- Center for Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania 15261
| |
Collapse
|
31
|
Hudson JS, Jeong S, Zhang X, Abel TJ. Spontaneous epidural pneumorrhachis in 14 years old. Surg Neurol Int 2021; 12:329. [PMID: 34345470 PMCID: PMC8326144 DOI: 10.25259/sni_414_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 06/04/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Pneumorrhachis is an exceedingly rare complication of pneumomediastinum as air tracks through tissue planes into the epidural (or subdural space). The majority of these patients present with a clear history of trauma, iatrogenic injury, pneumothorax, vomiting, or retching. Case Description: A 14-year-old male presented with the asymptomatic spontaneous onset of pneumorrhachis associated with significant pneumomediastinum of unclear etiology. Conclusion: Most patients with pneumorrhachis present with nonfocal neurological examinations. For these patients, it is critical to rule out infection as the cause of epidural gas. If other systemic signs are present, then urgent contrast-enhanced magnetic resonance imaging should be obtained. The majority of patients will demonstrate spontaneous radiographic resolution of pneumorrhachis within several days.
Collapse
Affiliation(s)
| | - Seung Jeong
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, United States
| | - Xiaoran Zhang
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, United States
| | - Taylor J Abel
- Department of Neurosurgery, UPMC, Pittsburgh, Pennsylvania, United States
| |
Collapse
|
32
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
33
|
Welch WP, Hect JL, Abel TJ. Case Report: Responsive Neurostimulation of the Centromedian Thalamic Nucleus for the Detection and Treatment of Seizures in Pediatric Primary Generalized Epilepsy. Front Neurol 2021; 12:656585. [PMID: 33995254 PMCID: PMC8113700 DOI: 10.3389/fneur.2021.656585] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/22/2021] [Indexed: 11/13/2022] Open
Abstract
Up to 20% of pediatric patients with primary generalized epilepsy (PGE) will not respond effectively to medication for seizure control. Responsive neurostimulation (RNS) is a promising therapy for pediatric patients with drug-resistant epilepsy and has been shown to be an effective therapy for reducing seizure frequency and severity in adult patients. RNS of the centromedian nucleus of the thalamus may help to prevent loss of awareness during seizure activity in PGE patients with absence seizures. Here we present a 16-year-old male, with drug-resistant PGE with absence seizures, characterized by 3 Hz spike-and-slow-wave discharges on EEG, who achieved a 75% reduction in seizure frequency following bilateral RNS of the centromedian nuclei. At 6-months post-implant, this patient reported complete resolution of the baseline daily absence seizure activity, and decrease from 3-4 generalized convulsive seizures per month to 1 per month. RNS recordings showed well-formed 3 Hz spike-wave discharges in bilateral CM nuclei, further supporting the notion that clinically relevant ictal discharges in PGE can be detected in CM. This report demonstrates that CM RNS can detect PGE-related seizures in the CM nucleus and deliver therapeutic stimulation.
Collapse
Affiliation(s)
- William P Welch
- Division of Pediatric Neurology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Jasmine L Hect
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Department of Bioengineering, University of Pittsburgh Swanson School of Engineering, Pittsburgh, PA, United States
| |
Collapse
|
34
|
Wang R, Beg U, Padmanaban V, Abel TJ, Lipsman N, Ibrahim GM, Mansouri A. A Systematic Review of Minimally Invasive Procedures for Mesial Temporal Lobe Epilepsy: Too Minimal, Too Fast? Neurosurgery 2021; 89:164-176. [PMID: 33862622 DOI: 10.1093/neuros/nyab125] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/13/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cortico-amygdalohippocampectomy (CAH) is effective for mesial temporal lobe epilepsy (mTLE). Concerns regarding surgical morbidity have generated enthusiasm for more minimally invasive interventions. A careful analysis of current data is warranted before widespread adoption of these techniques. OBJECTIVE To systematically review the use of laser interstitial thermal therapy (LITT), stereotactic radiosurgery (SRS), radiofrequency thermocoagulation (RF-TC), and focused ultrasound for mTLE. METHODS Major online databases were searched for prospective observational studies, randomized clinical trials, and retrospective studies (>50 patients), including mTLE patients. Outcomes of interest were seizure freedom (Engel I), complications and re-operation rates, and neuropsychological and quality-of-life (QoL) data. RESULTS Nineteen publications were identified. At ≥6 mo postoperatively, LITT (9/19) Engel I outcomes ranged from 52% to 80%. SRS (3/19) has a latency period (52%-67%, 24-36 mo postoperatively) and the radiosurgery vs. open surgery for epilepsy (ROSE) trial reported inferiority of SRS compared to CAH. RF-TC (7/19) demonstrated variable seizure freedom rates (0%-79%) and high re-operation rates (0%-90%). Twelve studies reported neuropsychological outcomes but QoL (4/19) was not widely reported, and few studies (3/19) assessed both. Study quality ranged from fair to good. CONCLUSION Based on nonrandomized data, LITT has compelling evidence of efficacy; however, comparisons to surgical resection are lacking. SRS has a latency period and is inferior to CAH (ROSE trial). RF-TC is a less resource-intensive alternative to LITT; however, comparisons of efficacy are limited. Additional studies are needed before minimally invasive procedures can supplant standard surgery.
Collapse
Affiliation(s)
- Ryan Wang
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Usman Beg
- Midwestern University Arizona College of Osteopathic Medicine, Glendale, Arizona, USA
| | - Varun Padmanaban
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Bioengineering, University of Pittsburgh, Pennsylvania, USA
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Harquail Centre for Neuromodulation, Sunnybrook Research Institute, Hurvitz Brain Sciences Program, Toronto, Ontario, Canada
| | - George M Ibrahim
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Alireza Mansouri
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA.,Penn State Cancer Institute, Hershey, Pennsylvania, USA
| |
Collapse
|
35
|
McDowell MM, Kellogg R, Goldstein JA, Abel TJ. Endoscope-assisted right coronal suturectomy. Neurosurgical Focus: Video 2021; 4:V11. [PMID: 36284851 PMCID: PMC9542232 DOI: 10.3171/2021.1.focvid20130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/20/2021] [Indexed: 11/10/2022]
Abstract
Endoscopic suturectomy combined with supplementary techniques such as spring-assisted expansion and cranial molding helmets for the correction of craniosynostosis is growing in popularity due to the reduced scar burdened, decreased morbidity, and reduced overall cost. The authors present their technique for the correction of isolated coronal craniosynostosis. The use of dedicated endoscopic tools and lit endoscopes permits enhanced visualization and technical ability, particularly at the distal portions of the suturectomy, and may reduce operative time and cerebrospinal fluid leak risk. The video can be found here: https://vimeo.com/515401366.
Collapse
|
36
|
Barrash J, Abel TJ, Okerstrom-Jezewski KL, Zanaty M, Bruss JE, Manzel K, Howard M, Tranel D. Acquired Personality Disturbances After Meningioma Resection Are Strongly Associated With Impaired Quality of Life. Neurosurgery 2020; 87:276-284. [PMID: 31642509 DOI: 10.1093/neuros/nyz440] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 08/18/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Some patients experience long-term declines in quality of life following meningioma resection, but associated factors are not well understood. OBJECTIVE To investigate whether long-term declines in quality of life (specifically impaired adaptive functioning) after meningioma resection are associated with specific personality disturbances that often develop with lesions in ventromedial prefrontal cortex (vmPFC). METHODS We studied 38 patients who underwent resection of meningioma, 18 of whom had vmPFC lesions and 20 with lesions elsewhere (non-vmPFC). A total of 30 personality characteristics were rated by spouse or family, and a neuropsychologist blindly rated adaptive functioning an average of 3.8 yr postresection. Relevant personality disturbance was defined by a priori process: the presence of "conjoint personality disturbance" required specific disturbances in at least 2 of 4 types of disturbance: executive disorders, disturbed social behavior, emotional dysregulation, and hypoemotionality. RESULTS Fourteen patients had impaired adaptive functioning: 12 had vmPFC lesions and 2 had non-vmPFC lesions. Fourteen patients had conjoint personality disturbance, and 12 of them had impaired adaptive functioning. By contrast, among the 24 patients who did not have conjoint personality disturbance, only 2 had impaired adaptive functioning. Mediation analysis showed that the association between vmPFC lesions and impaired adaptive functioning was mediated by the negative impact of acquired personality disturbance on adaptive functioning. CONCLUSION Anterior skull base meningiomas plus resection surgery may result in specific personality disturbances that are highly associated with impaired adaptive functioning at long-term follow-up. These patients may benefit from early counseling regarding potential personality changes and their implications for adaptive functioning.
Collapse
Affiliation(s)
- Joseph Barrash
- Department of Neurology, University of Iowa, Iowa City, Iowa.,Department of Psychological and Brain Sciences, University of Iowa, Iowa City, Iowa
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Mario Zanaty
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa
| | - Joel E Bruss
- Department of Neurology, University of Iowa, Iowa City, Iowa
| | - Kenneth Manzel
- Department of Neurology, University of Iowa, Iowa City, Iowa
| | - Matthew Howard
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa
| | - Daniel Tranel
- Department of Neurology, University of Iowa, Iowa City, Iowa.,Department of Psychological and Brain Sciences, University of Iowa, Iowa City, Iowa
| |
Collapse
|
37
|
Faraji AH, Remick M, Abel TJ. Contributions of Robotics to the Safety and Efficacy of Invasive Monitoring With Stereoelectroencephalography. Front Neurol 2020; 11:570010. [PMID: 33391145 PMCID: PMC7772229 DOI: 10.3389/fneur.2020.570010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 11/09/2020] [Indexed: 12/19/2022] Open
Abstract
The purpose of this review is to provide a discussion of the history and utility of robotics in invasive monitoring for epilepsy surgery using stereoelectroencephalography (sEEG). The authors conducted a literature review of available sources to describe how the advent of surgical robotics has improved the efficacy and ease of performing sEEG surgery. The sEEG method integrates anatomic, electrographic, and clinical information to test hypotheses regarding the localization of the epileptogenic zone (EZ) and has been used in Europe since the 1950s. One of the primary benefits of robot-assisted sEEG implantation techniques is the ability to seamlessly transition between both orthogonal and oblique trajectory types using a single technique. Based on available information, it is our view that, when applied appropriately, robotic sEEG can have a low rate of complications and many advantages over both non-robotic sEEG implantation and traditional craniotomy-based invasive monitoring methods.
Collapse
Affiliation(s)
- Amir H Faraji
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, TX, United States.,Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Madison Remick
- 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
| |
Collapse
|
38
|
Gupta K, Grover P, Abel TJ. Current Conceptual Understanding of the Epileptogenic Network From Stereoelectroencephalography-Based Connectivity Inferences. Front Neurol 2020; 11:569699. [PMID: 33324320 PMCID: PMC7724044 DOI: 10.3389/fneur.2020.569699] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/13/2020] [Indexed: 11/13/2022] Open
Abstract
Localization of the epileptogenic zone (EZ) is crucial in the surgical treatment of focal epilepsy. Recently, EEG studies have revealed that the EZ exhibits abnormal connectivity, which has led investigators to now consider connectivity as a biomarker to localize the EZ. Further, abnormal connectivity of the EZ may provide an explanation for the impact of focal epilepsy on more widespread brain networks involved in typical cognition and development. Stereo-electroencephalography (sEEG) is a well-established method for localizing the EZ that has recently been applied to examine altered brain connectivity in epilepsy. In this manuscript, we review recent computational methods for identifying the EZ using sEEG connectivity. Findings from previous sEEG studies indicate that during interictal periods, the EZ is prone to seizure generation but concurrently receives inward connectivity preventing seizures. At seizure onset, this control is lost, allowing seizure activity to spread from the EZ. Regulatory areas within the EZ may be important for subsequently ending the seizure. After the seizure, the EZ appears to regain its influence on the network, which may be how it is able to regenerate epileptiform activity. However, more research is needed on the dynamic connectivity of the EZ in order to build a biomarker for EZ localization. Such a biomarker would allow for patients undergoing sEEG to have electrode implantation, localization of the EZ, and resection in a fraction of the time currently needed, preventing patients from having to endure long hospital stays and induced seizures.
Collapse
Affiliation(s)
- Kanupriya Gupta
- University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Pulkit Grover
- Center for the Neural Basis of Cognition, Carnegie Mellon University/University of Pittsburgh, Pittsburgh, PA, United States.,Department of Electrical and Computer Engineering, Carnegie Mellon University, Pittsburgh, PA, United States
| | - Taylor J Abel
- University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States.,Center for the Neural Basis of Cognition, Carnegie Mellon University/University of Pittsburgh, Pittsburgh, PA, United States.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
| |
Collapse
|
39
|
Muthiah N, Zhang J, Remick M, Welch W, Sogawa Y, Jeong JH, Abel TJ. Efficacy of vagus nerve stimulation for drug-resistant epilepsy in children age six and younger. Epilepsy Behav 2020; 112:107373. [PMID: 32942207 DOI: 10.1016/j.yebeh.2020.107373] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/15/2020] [Accepted: 07/22/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The objective of the study were to examine the safety and efficacy of vagus nerve stimulation (VNS) for reducing seizure frequency and antiepileptic drugs (AEDs) in children younger than six years and to examine long-term VNS efficacy for children who receive the device at ages 1-3 and at ages 4-6. METHODS We conducted a 10-year retrospective analysis of VNS implantations at UPMC Children's Hospital of Pittsburgh. Relevant data were collected within 12 months of VNS implantation and at six months, one, two, and four years after VNS implantation. RESULTS This analysis included 99 patients ages 0-3 (n = 40) and 4-6 (n = 59) at first VNS implantation. Eighty-six patients followed up for ≥4 years. There were no significant differences between age at VNS implant (0-3 vs. 4-6) and seizure etiology or most seizure semiologies. Patients took an average of 3.01 ± 1.29 AEDs prior to VNS and 3.84 ± 1.68 AEDs at their latest follow-up. The overall response to VNS therapy (≥50% seizure reduction) at one year, two years, and four years after VNS implantation was 55%, 60%, and 52%, respectively. At two years, 59% of 0- to 3-year-old patients responded to VNS and 52% of 4- to 6-year-old patients responded to VNS. The overall major complication rate was 5.6%, consistent with VNS use for older age groups. SIGNIFICANCE This study demonstrates the safety and efficacy of VNS for children with drug-resistant epilepsy (DRE) younger than six. One, two, and four years after VNS implantation, 55%, 60%, and 52% of these patients, respectively, achieved ≥50% reduction in seizure frequency. The safety of VNS is also comparable with older, better studied, age groups. Based on these data, VNS therapy should be considered for children younger than six.
Collapse
Affiliation(s)
| | - Jun Zhang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Madison Remick
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - William Welch
- Division of Pediatric Neurology, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yoshimi Sogawa
- Division of Pediatric Neurology, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jong-Hyeon Jeong
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA; Clinical and Translational Science Institute (CTSI), 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.
| |
Collapse
|
40
|
Gale JR, Nowicki KW, Wolfe RM, Sefcik RK, Abel TJ. Infection of arachnoid cyst associated with vasospasm and stroke in a pediatric patient: case report. J Neurosurg Pediatr 2020; 26:594-598. [PMID: 32858508 DOI: 10.3171/2020.5.peds20419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 05/22/2020] [Indexed: 11/06/2022]
Abstract
Arachnoid cysts are relatively common and benign intraarachnoid membrane outpouchings containing CSF-like fluid. The majority of arachnoid cysts remain stable and asymptomatic and do not require intervention in the pediatric population. Here, the authors present the first reported case of an infected arachnoid cyst in a pediatric patient resulting in severe vasospasm of the left terminal internal carotid artery, left A1 segment, and left M1 branches with a left middle cerebral artery infarct. Their experience suggests that close monitoring is warranted for this condition and that the pediatric population may be at higher risk for vasospasm.
Collapse
Affiliation(s)
- Jenna R. Gale
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kamil W. Nowicki
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Rachel M. Wolfe
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Roberta K. Sefcik
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Taylor J. Abel
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
41
|
Remick M, Ibrahim GM, Mansouri A, Abel TJ. Cross-national disparities contribute to heterogeneity in patient outcomes following invasive monitoring: A hierarchical mixed-effects analysis. Epilepsia 2020; 61:e116-e123. [PMID: 33460067 DOI: 10.1111/epi.16647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 11/30/2022]
Abstract
There is substantial variability in outcomes following invasive monitoring and surgical treatment of drug-resistant epilepsy (DRE). Patients with DRE are uniquely vulnerable to cross-national health care disparities, as their epilepsy is difficult to treat and requires extensive resources. In a large cross-national database of patients undergoing invasive monitoring for epilepsy surgery, we sought to evaluate the association between social, economic, and educational indicators of the country of treatment and patient outcomes following invasive monitoring. We performed a mixed-effects analysis of an individual patient database of 595 subjects enrolled in 33 studies encompassing 25 neurosurgical centers in 10 countries of invasive monitoring for epilepsy from 1996 to 2019. Upon preliminary univariate analysis, significant nation-level predictors of seizure outcome following either stereoelectroencephalography or subdural electrodes were hospital beds per 100,000 population, physician density, gross domestic product (GDP) growth, male and female educational attainment, and unemployment rate. On multivariate mixed-effects logistic regression, physician density (β = -0.5112, P<.00697) and GDP growth (β = 0.53822, P<.00404) were the only nation-level covariates of significance associated with seizure outcome. A higher physician density was associated with lesser seizure freedom rates, whereas higher GDP growth was associated with greater seizure freedom rates. Although patient-specific variables were the primary determinant of seizure outcomes, cross-national disparities also contribute to heterogeneities. Our findings highlight the importance of a systems-level dialogue to improve surgical outcomes for DRE patients.
Collapse
Affiliation(s)
- Madison Remick
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - George M Ibrahim
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada.,Division of Neurosurgery, Hospital for Sick Children, Program in Neuroscience and Mental Health, Hospital for Sick Children Research Institute, Toronto, Canada
| | - Alireza Mansouri
- Department of Neurosurgery, Penn State University, Hershey, PA, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
42
|
Abstract
We provide a history and overview of the network approach to epilepsy surgery. Models of the epileptogenic zone (EZ) have evolved considerably over the years with more recent models accounting for the connectivity and network properties of epileptic foci. Next, we describe several examples of network phenotypes of focal epilepsy and how these have the potential to influence surgical decision-making and patient outcome. Future research will provide new insight into how network models of the EZ can determine optimal surgical interventions that improve seizure outcomes and optimize cognitive outcomes.
Collapse
Affiliation(s)
- Ricardo Amorim-Leite
- Department of Neurology, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Madison Remick
- Department of Neurological Surgery, University of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
| | - William Welch
- Division of Pediatric Neurology, Department of Pediatrics, University of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
| |
Collapse
|
43
|
Mallela AN, Abel TJ. Commentary: Endoscopic Interhemispheric Disconnection for Intractable Multifocal Epilepsy: Surgical Technique and Functional Neuroanatomy. Oper Neurosurg (Hagerstown) 2020; 18:E30-E31. [PMID: 31384942 DOI: 10.1093/ons/opz211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 05/28/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
44
|
McDowell MM, Ortega Peraza D, Abel TJ. Development and implementation of a novel child life protocol to enhance psychosocial support for pediatric awake craniotomies: technical note. Neurosurg Focus 2020; 48:E5. [PMID: 32006942 DOI: 10.3171/2019.11.focus19774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 11/13/2019] [Indexed: 11/06/2022]
Abstract
Awake craniotomies are a crucial tool for identifying eloquent cortex, but significant limitations frequently related to patient tolerance have limited their applicability in pediatric cases. The authors describe a comprehensive, longitudinal protocol developed in collaboration with a certified child life specialist (CCLS) in order to enhance patient experiences and develop resiliency related to the intraoperative portion of cases. This protocol includes preoperative conditioning, intraoperative support, and postoperative positive reinforcement and debriefing. A unique coping plan is developed for each prospective patient. With appropriate support, awake craniotomy may be applicable in a wider array of preadolescent and adolescent patients than has previously been possible. Future prospective studies are needed to validate this approach.
Collapse
Affiliation(s)
- Michael M McDowell
- 1Division of Neurological Surgery, UPMC Children's Hospital of Pittsburgh.,2Department of Neurological Surgery, University of Pittsburgh
| | | | - Taylor J Abel
- 1Division of Neurological Surgery, UPMC Children's Hospital of Pittsburgh.,2Department of Neurological Surgery, University of Pittsburgh.,4Department of Bioengineering, University of Pittsburgh, Pennsylvania
| |
Collapse
|
45
|
Remick M, Ibrahim GM, Mansouri A, Abel TJ. Patient phenotypes and clinical outcomes in invasive monitoring for epilepsy: An individual patient data meta-analysis. Epilepsy Behav 2020; 102:106652. [PMID: 31770717 DOI: 10.1016/j.yebeh.2019.106652] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 10/16/2019] [Accepted: 10/17/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Invasive monitoring provides valuable clinical information in patients with drug-resistant epilepsy (DRE). However, there is no clear evidence indicating either stereoelectroencephalography (SEEG) or subdural electrodes (SDE) as the optimal method. Our goal was to examine differences in postresection seizure freedom rates between SEEG- and SDE-informed resective epilepsy surgeries. Additionally, we aimed to determine potential clinical indicators for SEEG or SDE monitoring in patients with drug-resistant epilepsy. METHODS A systematic literature review was performed in which we searched for primary articles using keywords such as "electroencephalography", "intracranial grid", and "epilepsy." Only studies containing individual patient data (IPD) were included for analysis. A one-stage IPD meta-analysis was performed to determine differences in rates of seizure freedom (International League Against Epilepsy (ILAE) guidelines and Engel classification) and resection status between SEEG and SDE patients. A Cox proportional-hazards regression was performed to determine the effect of time on seizure freedom status. Additionally, a principal component analysis was performed to investigate primary drivers of variance between these two groups. RESULTS This IPD meta-analysis compared differences between SEEG and SDE invasive monitoring techniques in 595 patients from 33 studies. Our results demonstrate that while there was no difference in seizure freedom rates regardless of resection (p = 0.0565), SEEG was associated with a lower rate of resection compared with SDE (82.00% SEEG, 92.74% SDE, p = 0.0002). Additionally, while SDE was associated with a higher rate of postresection seizure freedom (54.04% SEEG, 64.32% SDE, p = 0.0247), the difference between seizure freedom rates following SEEG- or SDE-informed resection decreased with long-term follow-up. A principal component analysis showed that cases resulting in SEEG were associated with lower risk of morbidity than SDE cases, which were strongly collinear with multiple subpial transections, anterior temporal lobectomy, amygdalectomy, and hippocampectomy. SIGNIFICANCE In this IPD meta-analysis of SEEG and SDE invasive monitoring techniques, SEEG and SDE were associated with similar rates of seizure freedom at latest follow-up. The former was associated with lower rates of resection. Furthermore, the clinical phenotypes of patients undergoing SEEG monitoring was associated with lower rates of complications. Future long-term prospective registries of IPD are promising options for clarifying the differences in these intracranial monitoring techniques as well as the unique patient phenotypes that may be associated with their indication.
Collapse
Affiliation(s)
- Madison Remick
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - George M Ibrahim
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada; Division of Neurosurgery, Hospital for Sick Children, Program in Neuroscience and Mental Health, Hospital for Sick Children Research Institute, Toronto, Canada
| | - Alireza Mansouri
- Department of Neurosurgery, Penn State University, Hershey, PA, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA.
| |
Collapse
|
46
|
McDowell MM, Abel TJ. Commentary: Image Guidance for Ventricular Shunt Surgery: An Analysis of Hospital Charges. Neurosurgery 2019; 85:E771-E772. [PMID: 31149716 DOI: 10.1093/neuros/nyz184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/06/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Michael M McDowell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
47
|
Yan H, Katz JS, Anderson M, Mansouri A, Remick M, Ibrahim GM, Abel TJ. Method of invasive monitoring in epilepsy surgery and seizure freedom and morbidity: A systematic review. Epilepsia 2019; 60:1960-1972. [PMID: 31423575 DOI: 10.1111/epi.16315] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 07/23/2019] [Accepted: 07/23/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Invasive monitoring is sometimes necessary to guide resective surgery in epilepsy patients, but the ideal method is unknown. In this systematic review, we assess the association of postresection seizure freedom and adverse events in stereoelectroencephalography (SEEG) and subdural electrodes (SDE). METHODS We searched three electronic databases (MEDLINE, Embase, and CENTRAL [Cochrane Central Register of Controlled Trials]) from their inception to January 2018 with the keywords "electroencephalography," "intracranial grid," and "epilepsy." Studies that presented primary quantitative patient data for postresection seizure freedom with at least 1 year of follow-up or complication rates of SEEG- or SDE-monitored patients were included. Two trained investigators independently collected data from eligible studies. Weighted mean differences (WMDs) with 95% confidence interval (CIs) were used as a measure of the association of SEEG or SDE with seizure freedom and with adverse event outcomes. RESULTS Of 11 462 screened records, 48 studies met inclusion criteria. These studies reported on 1973 SEEG patients and 2036 SDE patients. Our systematic review revealed SEEG was associated with 61.0% and SDE was associated with 56.4% seizure freedom after resection (WMD = +5.8%, 95% CI = 4.7-6.9%, P = .001). Furthermore, SEEG was associated with 4.8% and SDE was associated with 15.5% morbidity (WMD = -10.6%, 95% CI = -11.6 to -9.6%, P = .001). SEEG was associated with 0.2% mortality and SDE was associated with 0.4% mortality (WMD = -0.2%, 95% CI = -0.3 to -0.1%, P = .001). SIGNIFICANCE In this systematic review of SEEG and SDE invasive monitoring techniques, SEEG was associated with fewer surgical resections yet better seizure freedom outcomes in those undergoing resections. SEEG was also associated with lower mortality and morbidity than SDE. Clinical studies directly comparing these modalities are necessary to understand the relative rates of seizure freedom, morbidity, and mortality associated with these techniques.
Collapse
Affiliation(s)
- Han Yan
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Joel S Katz
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Melanie Anderson
- Library and Information Services, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Alireza Mansouri
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Madison Remick
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - George M Ibrahim
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Hospital for Sick Children, Program in Neuroscience and Mental Health, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
48
|
Stewart E, Abel TJ, Davidson B, Smith ML. Behaviour outcomes in children with epilepsy 1 year after surgical resection of the ventromedial prefrontal cortex. Neuropsychologia 2019; 133:107155. [PMID: 31398427 DOI: 10.1016/j.neuropsychologia.2019.107155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 07/01/2019] [Accepted: 08/01/2019] [Indexed: 10/26/2022]
Abstract
Early damage to the ventromedial prefrontal cortex (VM) has been associated with impaired behavioural functioning in children without epilepsy, yet behaviour in children with epilepsy and VM lesions has not been investigated. The primary aim of this study was to examine behavioural outcomes in children with epilepsy emanating from the VM preoperatively and one year after epilepsy surgery compared to the general population and matched epilepsy controls. Behavioural outcomes were defined as comprising both problems and competencies (i.e. social, school and co-curricular performance). A secondary aim was to examine whether seizure outcome, number of antiepileptic drugs (AEDs), or age at surgery related to behavioural outcomes. Ratings on the Child Behavior Checklist were examined preoperatively and 1 year after surgery for 20 children with epilepsy who had undergone surgical resection of the VM (N = 10) or temporal lobe (TL, N = 10). VM and TL groups were comparable on Full Scale IQ (40-101), age of seizure onset (0.5-9.0 years), age at surgery (3.1-16.9 years), seizure laterality (5 left in each group), age at assessments, sex (3 female in VM group, 2 female in TL group) and seizure outcome (7 seizure free in VM group, 6 seizure free in TL group). The VM group had significantly elevated behaviour problems (i.e. withdrawn, thought, social and attention problems) and reduced competencies (i.e. social and school) compared to the general population before and after surgery. VM and TL cases did not differ on any behaviour problem scales pre or postoperatively and neither group showed significant change in functioning over time; however, VM patients had significantly lower total competence than TL patients postoperatively. A significant seizure outcome × time interaction was observed: children who were seizure free following surgery (collapsed across surgical site) showed an improvement in total behaviour problems and aggression at 1 year follow-up, whereas children with ongoing seizures showed a deterioration in these domains. In conclusion, VM lesions in children with epilepsy are associated with behavioural problems but their profile does not differ from that of children with temporal lobe epilepsy. These results are consistent with the concept that seizures arise from epileptogenic networks that may affect multiple cortical areas, even when onset is in a focal site.
Collapse
Affiliation(s)
- Elizabeth Stewart
- School of Psychology, The University of Sydney, Camperdown, NSW, 2007, Australia
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, 15238, USA
| | - Benjamin Davidson
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Mary Lou Smith
- Department of Psychology, University of Toronto Mississauga, Mississauga ON, L5L 1C6, Canada; Neurosciences and Mental Health Program, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada.
| |
Collapse
|
49
|
Affiliation(s)
- R Mark Richardson
- Center for the Neural Basis of Cognition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Epilepsy and Movement Disorders Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Taylor J Abel
- Center for the Neural Basis of Cognition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Pediatric Epilepsy Surgery, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
50
|
White MD, Zollman J, McDowell MM, Agarwal N, Abel TJ, Hamilton DK. Neurosurgical Resident Exposure to Pediatric Neurosurgery: An Analysis of Resident Case Logs. Pediatr Neurosurg 2019; 54:181-187. [PMID: 31112956 DOI: 10.1159/000500299] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 04/11/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The purpose of this study is to identify the national trends of exposure to pediatric procedures during neurosurgical residency and to subsequently evaluate how neurosurgery residents' experiences correlate with the minimum requirements set forth by the American College of Graduate Medical Education (ACGME). METHODS ACGME resident case logs from residents graduating between 2013 and 2017 were retrospectively reviewed. These reports were analyzed to determine trends in resident operative experience in pediatric procedures. The number of cases performed by residents was compared to the required minimums set by the ACGME within each pediatric surgical category. A linear regression analysis and t tests were utilized to analyze the change in cases performed over the study period. RESULTS A mean of 98.8 procedures were performed for each of the 877 residents graduating between 2013 and 2017. The total number of pediatric procedures declined at a rate of 1.7 cases/year (r2 = 0.77, p = 0.05). Spine and cerebrospinal fluid diversion procedures showed decreasing trends at rates of 1.9 (r2 = 0.70, p = 0.08) and 1.2 (r2 = 0.70, p = 0.08) cases/year, respectively. The number of trauma and brain tumor cases were shown to have increasing rates at 1.0 (r2 = 0.86, p = 0.02) and 0.3 (r2 = 0.69, p = 0.08) cases/year, respectively, with trauma cases showing significant increases. There was also a trend of increasing cases logged as the lead resident surgeon by 12.9 cases/year (r2 = 0.99, p < 0.001). The number of cases performed by the average graduating resident was also significantly higher than the minimums required by the ACGME; residents, on average, performed 3 times the required minimum number of pediatric cases. CONCLUSION Neurosurgical residents graduating from 2013 to 2017 reported significantly higher volumes of pediatric neurosurgery cases than the standards set for by the ACGME. During this time, there was also a significant trend of increasing cases logged as the lead resident surgeon, suggesting more involvement in the critical portions of pediatric cases. There was also a significant, but not clinically impactful, decrease in pediatric case volumes during this time. However, the overall data indicate that residents are continuing to gain valuable pediatric experience during residency training.
Collapse
Affiliation(s)
- Michael D White
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Joshua Zollman
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael M McDowell
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA,
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David K Hamilton
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|