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Hwang BY, Eremiev A, Palla A, Mampre D, Negoita S, Tsehay YK, Kim MJ, Coogan C, Kang JY, Anderson WS. Association of intraoperative end-tidal carbon dioxide level with ablation volume during magnetic resonance-guided laser interstitial thermal therapy for mesial temporal lobe epilepsy. J Neurosurg 2022; 137:427-433. [PMID: 34891139 DOI: 10.3171/2021.9.jns211554] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/03/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Maximal safe ablation of target structures during magnetic resonance-guided laser interstitial thermal therapy (MRgLiTT) is critical to achieving good seizure outcome in patients with mesial temporal lobe epilepsy (mTLE). The authors sought to determine whether intraoperative physiological variables are associated with ablation volume during MRgLiTT. METHODS Patients with mTLE who underwent MRgLiTT at our institution from 2014 to 2019 were retrospectively analyzed. Ablation volume was determined with volumetric analysis of intraoperative postablation MR images. Physiological parameters (systolic blood pressure [SBP], diastolic blood pressure [DBP], mean arterial pressure [MAP], end-tidal carbon dioxide [ETCO2]) measured 40 minutes prior to ablation were analyzed. Univariate and multivariate regression analyses were performed to determine independent predictors of ablation volume. RESULTS Forty-four patients met the inclusion criteria. The median (interquartile range) ablation volume was 4.27 (2.92-5.89) cm3, and median ablation energy was 7216 (6402-8784) J. The median MAP, SBP, DBP, and ETCO2 values measured during the 40-minute period leading up to ablation were 72.8 (66.2-81.5) mm Hg, 104.4 (96.4-114.4) mm Hg, 62.4 (54.1-69.8) mm Hg, and 34.1 (32.0-36.2) mm Hg, respectively. In univariate analysis, only total laser energy (r = 0.464, p = 0.003) and 40-minute average ETCO2 (r = -0.388, p = 0.012) were significantly associated with ablation volume. In multivariate analysis, only ETCO2 ≤ 33 mm Hg (p = 0.001) was significantly associated with ablation volume. CONCLUSIONS Total ablation energy and ETCO2, but not blood pressure, may significantly affect ablation volume in mTLE patients undergoing MRgLiTT. Mild hypocapnia was associated with increased extent of ablation. Intraoperative monitoring and modulation of ETCO2 may help improve extent of ablation, prediction of ablation volume, and potentially seizure outcome.
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Affiliation(s)
- Brian Y Hwang
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Alexander Eremiev
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Adhith Palla
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - David Mampre
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Serban Negoita
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Yohannes K Tsehay
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Min Jae Kim
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
- 2Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher Coogan
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Joon Y Kang
- 2Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - William S Anderson
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
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Hwang BY, Mampre D, Tsehay YK, Negoita S, Kim MJ, Coogan C, Eremiev A, Palla A, Weber-Levine C, Kang JY, Anderson WS. Piriform Cortex Ablation Volume Is Associated With Seizure Outcome in Mesial Temporal Lobe Epilepsy. Neurosurgery 2022; 91:414-421. [PMID: 35593730 DOI: 10.1227/neu.0000000000002041] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 04/03/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Growing evidence suggests that piriform cortex resection during anterior temporal lobectomy is important for achieving good seizure outcome in mesial temporal lobe epilepsy (mTLE). However, the relationship between seizure outcome and piriform cortex ablation during MR-guided laser interstitial thermal therapy (MRgLITT) remains unclear. OBJECTIVE To determine whether ablation of piriform cortex was associated with seizure outcome in patients with mTLE undergoing MRgLITT. METHODS We performed preablation and postablation volumetric analyses of hippocampus, amygdala, piriform cortex, and ablation volumes in patients with mTLE who underwent MRgLITT at our institution from 2014 to 2019. RESULTS Thirty nine patients with mTLE were analyzed. In univariate logistic regression, percent piriform cortex ablation was associated with International League Against Epilepsy (ILAE) class 1 at 6 months (odds ratio [OR] 1.051, 95% CI [1.001-1.117], P = .045), whereas ablation volume, percent amygdala ablation, and percent hippocampus ablation were not (P > .05). At 1 year, ablation volume was associated with ILAE class 1 (OR 1.608, 95% CI [1.071-2.571], P = .021) while percent piriform cortex ablation became a trend (OR 1.050, 95% CI [0.994-1.109], P = .054), and both percent hippocampus ablation and percent amygdala ablation were not significantly associated with ILAE class 1 (P > .05). In multivariable logistic regression, only percent piriform cortex ablation was a significant predictor of seizure freedom at 6 months (OR 1.085, 95% CI [1.012-1.193], P = .019) and at 1 year (OR 1.074, 95% CI [1.003-1.178], P = .041). CONCLUSION Piriform cortex ablation volume is associated with seizure outcome in patients with mTLE undergoing MRgLITT. The piriform cortex should be considered a high yield ablation target to achieve good seizure outcome.
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Affiliation(s)
- Brian Y Hwang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David Mampre
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yohannes K Tsehay
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Serban Negoita
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Min Jae Kim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher Coogan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alexander Eremiev
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Adhith Palla
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carly Weber-Levine
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joon Y Kang
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - William S Anderson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Hwang BY, Salimpour Y, Tsehay YK, Anderson WS, Mills KA. Perspective: Phase Amplitude Coupling-Based Phase-Dependent Neuromodulation in Parkinson's Disease. Front Neurosci 2020; 14:558967. [PMID: 33132822 PMCID: PMC7550534 DOI: 10.3389/fnins.2020.558967] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 05/04/2020] [Accepted: 08/13/2020] [Indexed: 11/13/2022] Open
Abstract
Deep brain stimulation (DBS) is an effective surgical therapy for Parkinson's disease (PD). However, limitations of the DBS systems have led to great interest in adaptive neuromodulation systems that can dynamically adjust stimulation parameters to meet concurrent therapeutic demand. Constant high-frequency motor cortex stimulation has not been remarkably efficacious, which has led to greater focus on modulation of subcortical targets. Understanding of the importance of timing in both cortical and subcortical stimulation has generated an interest in developing more refined, parsimonious stimulation techniques based on critical oscillatory activities of the brain. Concurrently, much effort has been put into identifying biomarkers of both parkinsonian and physiological patterns of neuronal activities to drive next generation of adaptive brain stimulation systems. One such biomarker is beta-gamma phase amplitude coupling (PAC) that is detected in the motor cortex. PAC is strongly correlated with parkinsonian specific motor signs and symptoms and respond to therapies in a dose-dependent manner. PAC may represent the overall state of the parkinsonian motor network and have less instantaneously dynamic fluctuation during movement. These findings raise the possibility of novel neuromodulation paradigms that are potentially less invasiveness than DBS. Successful application of PAC in neuromodulation may necessitate phase-dependent stimulation technique, which aims to deliver precisely timed stimulation pulses to a specific phase to predictably modulate to selectively modulate pathological network activities and behavior in real time. Overcoming current technical challenges can lead to deeper understanding of the parkinsonian pathophysiology and development of novel neuromodulatory therapies with potentially less side-effects and higher therapeutic efficacy.
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Affiliation(s)
- Brian Y Hwang
- Functional Neurosurgery Laboratory, Division of Functional Neurosurgery, Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Yousef Salimpour
- Functional Neurosurgery Laboratory, Division of Functional Neurosurgery, Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Yohannes K Tsehay
- Functional Neurosurgery Laboratory, Division of Functional Neurosurgery, Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - William S Anderson
- Functional Neurosurgery Laboratory, Division of Functional Neurosurgery, Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Kelly A Mills
- Neuromodulation and Advanced Therapies Clinic, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, United States
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