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Daly SR, Soto JM, Gonzalez SM, Ankrah N, Gogineni E, Andraos TY, Skalina KA, Fekrmandi F, Quinn AE, Romanelli P, Thomas E, Danish S. Stereotactic radiosurgery for medically refractory non-lesional epilepsy: A case-based Radiosurgery Society (RSS) practice review. Clin Neurol Neurosurg 2024; 246:108550. [PMID: 39278006 DOI: 10.1016/j.clineuro.2024.108550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2024] [Accepted: 09/10/2024] [Indexed: 09/17/2024]
Abstract
INTRODUCTION Medically refractory epilepsy (MRE) occurs in about 30 % of patients with epilepsy, and the treatment options available to them have evolved over time. The classic treatment for medial temporal lobe epilepsy (mTLE) is anterior temporal lobectomy (ATL), but an initiative to find less invasive options has resulted in treatments such as neuromodulation, ablative procedures, and stereotactic radiosurgery (SRS). SRS has been an appealing non-invasive option and has developed an increasing presence in the literature over the last few decades. This article provides an overview of SRS for MRE with two example cases, and we discuss the optimal technique as well as the advantages, alternatives, and risks of this therapeutic option. CASES We present two example cases of patients with MRE, who were poor candidates for invasive surgical treatment options and underwent SRS. The first case is a 65-year-old female with multiple medical comorbidities, whose seizure focus was localized to the left temporal lobe, and the second case is a 19-year-old male with Protein C deficiency and medial temporal lobe sclerosis. Both patients underwent SRS to targets within the medial temporal lobe, and both achieve significant improvements in seizure frequency and severity. DISCUSSION SRS has generally been shown to be inferior to ATL for seizure reduction in medically refractory mTLE. However, there are patients with epilepsy for which SRS can be considered, such as patients with medical comorbidities that make surgery high risk, patients with epileptogenic foci in eloquent cortex, patients who have failed to respond to surgical management, patients who choose not to undergo surgery, and patients with geographic constraints to epilepsy centers. Patients and their physicians should be aware that SRS is not risk-free. Patients should be counseled on the latency period and monitored for risks such as delayed cerebral edema, visual field deficits, and radiation necrosis.
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Affiliation(s)
- Samuel R Daly
- Department of Neurological Surgery, Baylor Scott and White Health/Baylor College of Medicine, Temple, TX, United States.
| | - Jose M Soto
- Department of Neurological Surgery, Baylor Scott and White Health/Baylor College of Medicine, Temple, TX, United States
| | - Sarah Mc Gonzalez
- Department of Neurological Surgery, Baylor Scott and White Health/Baylor College of Medicine, Temple, TX, United States
| | - Nii Ankrah
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Emile Gogineni
- Department of Radiation Oncology, The Ohio State University, Columbus, OH, United States
| | - Therese Y Andraos
- Department of Radiation Oncology, The Ohio State University, Columbus, OH, United States
| | - Karin A Skalina
- Department of Radiation Oncology, Montefiore Medical Center, New York, NY, United States
| | - Fatemeh Fekrmandi
- Department of Radiation Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Annette E Quinn
- Department of Radiation Oncology, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, PA, United States
| | | | - Evan Thomas
- Department of Radiation Oncology, The Ohio State University, Columbus, OH, United States
| | - Shabbar Danish
- Department of Neurosurgery, Jersey Shore University Medical Center, Neptune, NJ, United States
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Kim J, Byun J, Lee DH, Hong SH. A Potential Risk of Radiation-Induced Cavernous Malformations Following Adjuvant Gamma Knife Radiosurgery for Mesial Temporal Lobe Epilepsy. J Korean Neurosurg Soc 2024; 67:458-466. [PMID: 37933111 PMCID: PMC11220412 DOI: 10.3340/jkns.2023.0203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/23/2023] [Accepted: 11/03/2023] [Indexed: 11/08/2023] Open
Abstract
OBJECTIVE Several clinical studies have explored the feasibility and efficacy of radiosurgical treatment for mesial temporal lobe epilepsy, but the long-term safety of this treatment has not been fully characterized. This study aims to report and describe radiation-induced cavernous malformation as a delayed complication of radiosurgery in epilepsy patients. METHODS The series includes 20 patients with mesial temporal lobe epilepsy who underwent Gamma Knife radiosurgery (GKRS). The majority received a prescribed isodose of 24 Gy as an adjuvant treatment after anterior temporal lobectomy. RESULTS In this series, we identified radiation-induced cavernous malformation in three patients, resulting in a cumulative incidence of 18.4% (95% confidence interval, 6.3% to 47.0%) at an 8-year follow-up. These late sequelae of vascular malformation occurred between 6.9 and 7.6 years after GKRS, manifesting later than other delayed radiation-induced changes, such as radiation necrosis. Neurological symptoms attributed to intracranial hypertension were present in those three cases involving cavernous malformation. Of these, two cases, which initially exhibited an insufficient response to radiosurgery, ultimately demonstrated seizure remission following the successful microsurgical resection of the cavernous malformation. CONCLUSION All things considered, the development of radiation-induced cavernous malformation is not uncommon in this population and should be acknowledged as a potential long-term complication. Microsurgical resection of cavernous malformation can be preferentially considered in cases where the initial seizure outcome after GKRS is unsatisfactory.
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Affiliation(s)
- Junhyung Kim
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joonho Byun
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Heui Lee
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seok Ho Hong
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Youngerman BE, Banu MA, Khan F, McKhann GM, Schevon CA, Jagid JR, Cajigas I, Theodotou CB, Ko A, Buckley R, Ojemann JG, Miller JW, Laxton AW, Couture DE, Popli GS, Buch VP, Halpern CH, Le S, Sharan AD, Sperling MR, Mehta AD, Englot DJ, Neimat JS, Konrad PE, Sheth SA, Neal EG, Vale FL, Holloway KL, Air EL, Schwalb JM, D'Haese PF, Wu C. Long-term outcomes of mesial temporal laser interstitial thermal therapy for drug-resistant epilepsy and subsequent surgery for seizure recurrence: a multi-centre cohort study. J Neurol Neurosurg Psychiatry 2023; 94:879-886. [PMID: 37336643 PMCID: PMC10776034 DOI: 10.1136/jnnp-2022-330979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/30/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a minimally invasive alternative to surgical resection for drug-resistant mesial temporal lobe epilepsy (mTLE). Reported rates of seizure freedom are variable and long-term durability is largely unproven. Anterior temporal lobectomy (ATL) remains an option for patients with MRgLITT treatment failure. However, the safety and efficacy of this staged strategy is unknown. METHODS This multicentre, retrospective cohort study included 268 patients consecutively treated with mesial temporal MRgLITT at 11 centres between 2012 and 2018. Seizure outcomes and complications of MRgLITT and any subsequent surgery are reported. Predictive value of preoperative variables for seizure outcome was assessed. RESULTS Engel I seizure freedom was achieved in 55.8% (149/267) at 1 year, 52.5% (126/240) at 2 years and 49.3% (132/268) at the last follow-up ≥1 year (median 47 months). Engel I or II outcomes were achieved in 74.2% (198/267) at 1 year, 75.0% (180/240) at 2 years and 66.0% (177/268) at the last follow-up. Preoperative focal to bilateral tonic-clonic seizures were independently associated with seizure recurrence. Among patients with seizure recurrence, 14/21 (66.7%) became seizure-free after subsequent ATL and 5/10 (50%) after repeat MRgLITT at last follow-up≥1 year. CONCLUSIONS MRgLITT is a viable treatment with durable outcomes for patients with drug-resistant mTLE evaluated at a comprehensive epilepsy centre. Although seizure freedom rates were lower than reported with ATL, this series represents the early experience of each centre and a heterogeneous cohort. ATL remains a safe and effective treatment for well-selected patients who fail MRgLITT.
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Affiliation(s)
- Brett E Youngerman
- Department of Neurological Surgery, Columbia University, New York, New York, USA
| | - Matei A Banu
- Department of Neurological Surgery, Columbia University, New York, New York, USA
| | - Farhan Khan
- Department of Neurological Surgery, Columbia University, New York, New York, USA
| | - Guy M McKhann
- Department of Neurological Surgery, Columbia University, New York, New York, USA
| | | | - Jonathan R Jagid
- Department of Neurological Surgery, Jackson Memorial Hospital, University of Miami, Miami, Florida, USA
| | - Iahn Cajigas
- Department of Neurological Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christian B Theodotou
- Department of Neurological Surgery, Jackson Memorial Hospital, University of Miami, Miami, Florida, USA
| | - Andrew Ko
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Robert Buckley
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Jeffrey G Ojemann
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - John W Miller
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Adrian W Laxton
- Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Daniel E Couture
- Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Gautam S Popli
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Vivek P Buch
- Department of Neurological Surgery, Stanford Neuroscience Health Center, Stanford, California, USA
| | - Casey H Halpern
- Department of Neurological Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scheherazade Le
- Department of Neurology, Stanford Comprehensive Epilepsy Center, Stanford, California, USA
| | - Ashwini D Sharan
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael R Sperling
- Department of Neurology, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ashesh D Mehta
- Department of Neurological Surgery, Zucker School of Medicine at Hofstra Northwell, Hempstead, New York, USA
| | - Dario J Englot
- Department of Neurological Surgery, Vanderbilt University, Nashville, Nashville, Tennessee, USA
| | - Joseph S Neimat
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Peter E Konrad
- Department of Neurological Surgery, Vanderbilt University, Nashville, Nashville, Tennessee, USA
| | - Sameer A Sheth
- Department of Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Elliot G Neal
- Department of Neurological Surgery, University of South Florida Health South Tampa Center, Tampa, Florida, USA
| | - Fernando L Vale
- Department of Neurological Surgery, Medical College of Georgia-Augusta University, Augusta, Georgia, USA
| | - Kathryn L Holloway
- Department of Neurological Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Ellen L Air
- Department of Neurological Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Jason M Schwalb
- Department of Neurological Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Pierre-François D'Haese
- Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Chengyuan Wu
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Nardone V, D’Ippolito E, Grassi R, Sangiovanni A, Gagliardi F, De Marco G, Menditti VS, D’Ambrosio L, Cioce F, Boldrini L, Salvestrini V, Greco C, Desideri I, De Felice F, D’Onofrio I, Grassi R, Reginelli A, Cappabianca S. Non-Oncological Radiotherapy: A Review of Modern Approaches. J Pers Med 2022; 12:1677. [PMID: 36294816 PMCID: PMC9605240 DOI: 10.3390/jpm12101677] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/05/2022] Open
Abstract
Despite being usually delivered in oncological patients, radiotherapy can be used as a successful treatment for several non-malignant disorders. Even though this use of radiotherapy has been scarcely investigated since the 1950s, more recent interest has actually shed the light on this approach. Thus, the aim of this narrative review is to analyze the applications of non-oncological radiotherapy in different disorders. Key references were derived from a PubMed query. Hand searching and clinicaltrials.gov were also used. This review contains a narrative report and a critical discussion of non-oncological radiotherapy approaches. In conclusion, non-oncological radiotherapy is a safe and efficacious approach to treat several disorders that needs to be further investigated and used in clinical practice.
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Affiliation(s)
- Valerio Nardone
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy
| | - Emma D’Ippolito
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy
| | - Roberta Grassi
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy
| | - Angelo Sangiovanni
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy
| | - Federico Gagliardi
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy
| | - Giuseppina De Marco
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy
| | | | - Luca D’Ambrosio
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy
| | - Fabrizio Cioce
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy
| | - Luca Boldrini
- Radiation Oncology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli, 00168 Rome, Italy
| | - Viola Salvestrini
- Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Department of Experimental and Clinical Biomedical Sciences, University of Florence, 50134 Florence, Italy
| | - Carlo Greco
- Department of Radiation Oncology, Università Campus Bio-Medico di Roma, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 00128 Rome, Italy
| | - Isacco Desideri
- Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Department of Experimental and Clinical Biomedical Sciences, University of Florence, 50134 Florence, Italy
| | - Francesca De Felice
- Radiation Oncology, Policlinico Umberto I “Sapienza” University of Rome, Viale Regina Elena 326, 00161 Rome, Italy
| | - Ida D’Onofrio
- Radiation Oncology, Ospedale del Mare, ASL Napoli 1 Centro, 80147 Naples, Italy
| | - Roberto Grassi
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy
| | - Alfonso Reginelli
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy
| | - Salvatore Cappabianca
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy
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5
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Ganz JC. Epilepsy. PROGRESS IN BRAIN RESEARCH 2022; 268:329-345. [PMID: 35074089 DOI: 10.1016/bs.pbr.2021.10.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
GKNS has been introduced as an alternative to microsurgery for the treatment of certain types of focal epilepsy. It was first noted that epilepsy associated with AVMs often improved before the obliteration of the vascular lesion. It was subsequently shown that the treatment could be effective in mesial temporal lobe epilepsy (MTLE) producing remission in around 60% of patients, provided the treatment was carried out as originally designed. GKNS has also been useful in the treatment of gelastic epilepsy associated with hypothalamic hamartomas.
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Affiliation(s)
- Jeremy C Ganz
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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Marathe K, Alim-Marvasti A, Dahele K, Xiao F, Buck S, O'Keeffe AG, Duncan JS, Vakharia VN. Resective, Ablative and Radiosurgical Interventions for Drug Resistant Mesial Temporal Lobe Epilepsy: A Systematic Review and Meta-Analysis of Outcomes. Front Neurol 2021; 12:777845. [PMID: 34956057 PMCID: PMC8695716 DOI: 10.3389/fneur.2021.777845] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/01/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: One-third of individuals with focal epilepsy do not achieve seizure freedom despite best medical therapy. Mesial temporal lobe epilepsy (MTLE) is the most common form of drug resistant focal epilepsy. Surgery may lead to long-term seizure remission if the epileptogenic zone can be defined and safely removed or disconnected. We compare published outcomes following open surgical techniques, radiosurgery (SRS), laser interstitial thermal therapy (LITT) and radiofrequency ablation (RF-TC). Methods: PRISMA systematic review was performed through structured searches of PubMed, Embase and Cochrane databases. Inclusion criteria encompassed studies of MTLE reporting seizure-free outcomes in ≥10 patients with ≥12 months follow-up. Due to variability in open surgical approaches, only comparative studies were included to minimize the risk of bias. Random effects meta-analysis was performed to calculate effects sizes and a pooled estimate of the probability of seizure freedom per person-year. A mixed effects linear regression model was performed to compare effect sizes between interventions. Results: From 1,801 screened articles, 41 articles were included in the quantitative analysis. Open surgery included anterior temporal lobe resection as well as transcortical and trans-sylvian selective amygdalohippocampectomy. The pooled seizure-free rate per person-year was 0.72 (95% CI 0.66-0.79) with trans-sylvian selective amygdalohippocampectomy, 0.59 (95% CI 0.53-0.65) with LITT, 0.70 (95% CI 0.64-0.77) with anterior temporal lobe resection, 0.60 (95% CI 0.49-0.73) with transcortical selective amygdalohippocampectomy, 0.38 (95% CI 0.14-1.00) with RF-TC and 0.50 (95% CI 0.34-0.73) with SRS. Follow up duration and study sizes were limited with LITT and RF-TC. A mixed-effects linear regression model suggests significant differences between interventions, with LITT, ATLR and SAH demonstrating the largest effects estimates and RF-TC the lowest. Conclusions: Overall, novel "minimally invasive" approaches are still comparatively less efficacious than open surgery. LITT shows promising seizure effectiveness, however follow-up durations are shorter for minimally invasive approaches so the durability of the outcomes cannot yet be assessed. Secondary outcome measures such as Neurological complications, neuropsychological outcome and interventional morbidity are poorly reported but are important considerations when deciding on first-line treatments.
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Affiliation(s)
- Kajol Marathe
- Department of Clinical and Experimental Epilepsy, University College London, London, United Kingdom
| | - Ali Alim-Marvasti
- Department of Clinical and Experimental Epilepsy, University College London, London, United Kingdom.,National Hospital for Neurology and Neurosurgery, London, United Kingdom.,Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Karan Dahele
- Department of Clinical and Experimental Epilepsy, University College London, London, United Kingdom
| | - Fenglai Xiao
- Department of Clinical and Experimental Epilepsy, University College London, London, United Kingdom
| | - Sarah Buck
- Department of Clinical and Experimental Epilepsy, University College London, London, United Kingdom
| | - Aidan G O'Keeffe
- Department of Statistical Science, University College London, London, United Kingdom
| | - John S Duncan
- Department of Clinical and Experimental Epilepsy, University College London, London, United Kingdom.,National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Vejay N Vakharia
- Department of Clinical and Experimental Epilepsy, University College London, London, United Kingdom.,National Hospital for Neurology and Neurosurgery, London, United Kingdom
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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] [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.
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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
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8
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Youngerman BE, Save AV, McKhann GM. Magnetic Resonance Imaging-Guided Laser Interstitial Thermal Therapy for Epilepsy: Systematic Review of Technique, Indications, and Outcomes. Neurosurgery 2020; 86:E366-E382. [PMID: 31980831 DOI: 10.1093/neuros/nyz556] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 11/20/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND For patients with focal drug-resistant epilepsy (DRE), surgical resection of the epileptogenic zone (EZ) may offer seizure freedom and benefits for quality of life. Yet, concerns remain regarding invasiveness, morbidity, and neurocognitive side effects. Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) has emerged as a less invasive option for stereotactic ablation rather than resection of the EZ. OBJECTIVE To provide an introduction to MRgLITT for epilepsy, including historical development, surgical technique, and role in therapy. METHODS The development of MRgLITT is briefly recounted. A systematic review identified reported techniques and indication-specific outcomes of MRgLITT for DRE in human studies regardless of sample size or follow-up duration. Potential advantages and disadvantages compared to available alternatives for each indication are assessed in an unstructured review. RESULTS Techniques and outcomes are reported for mesial temporal lobe epilepsy, hypothalamic hamartoma, focal cortical dysplasia, nonlesional epilepsy, tuberous sclerosis, periventricular nodular heterotopia, cerebral cavernous malformations, poststroke epilepsy, temporal encephalocele, and corpus callosotomy. CONCLUSION MRgLITT offers access to foci virtually anywhere in the brain with minimal disruption of the overlying cortex and white matter, promising fewer neurological side effects and less surgical morbidity and pain. Compared to other ablative techniques, MRgLITT offers immediate, discrete lesions with real-time monitoring of temperature beyond the fiber tip for damage estimates and off-target injury prevention. Applications of MRgLITT for epilepsy are growing rapidly and, although more evidence of safety and efficacy is needed, there are potential advantages for some patients.
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Affiliation(s)
- Brett E Youngerman
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Akshay V Save
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Guy M McKhann
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
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9
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Foundations of the Diagnosis and Surgical Treatment of Epilepsy. World Neurosurg 2020; 139:750-761. [DOI: 10.1016/j.wneu.2020.03.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 03/02/2020] [Indexed: 12/29/2022]
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11
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Sheikh S, Thompson N, Bingaman W, Gonzalez‐Martinez J, Najm I, Jehi L. (Re)Defining success in epilepsy surgery: The importance of relative seizure reduction in patient‐reported quality of life. Epilepsia 2019; 60:2078-2085. [DOI: 10.1111/epi.16327] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/05/2019] [Accepted: 08/05/2019] [Indexed: 01/08/2023]
Affiliation(s)
- Shehryar Sheikh
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland Ohio
| | - Nic Thompson
- Quantitative Health Sciences Cleveland Clinic Cleveland Ohio
| | - William Bingaman
- Neurosurgery Cleveland Clinic Cleveland Ohio
- Epilepsy Center Cleveland Clinic Cleveland Ohio
| | | | - Imad Najm
- Epilepsy Center Cleveland Clinic Cleveland Ohio
| | - Lara Jehi
- Epilepsy Center Cleveland Clinic Cleveland Ohio
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12
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Lausanne checklist for safe stereotactic radiosurgery. Acta Neurochir (Wien) 2019; 161:721-727. [PMID: 30790090 DOI: 10.1007/s00701-019-03843-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 02/12/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Stereotactic radiosurgery (SRS) is increasingly used as a minimally invasive alternative in many neurosurgical conditions, including benign and malignant tumors, vascular malformations, and functional procedures. As for any surgical procedure, strict safety guidelines and checklists are necessary to avoid errors and the inherent unnecessary complications. With regard to the former, other groups have already reported human and/or technical errors. We describe our safety checklist for Gamma Knife radiosurgical procedures. METHODS We describe our checklist protocol after an experience gained over 1500 radiosurgical procedures, using Gamma Knife radiosurgery, performed over a period of 8 years, while employing the same list of items. Minor implementation has been performed over time to address some safety issues that could be improved. RESULTS Two types of checklist are displayed. One is related to the indications when a specific tissue volume is irradiated, including tumors or vascular disorders. The second corresponds to functional disorders, such as when the dose is prescribed to one specific point. Using these checklists, no human error had been reported during the past 8 years of practice in our institution. CONCLUSION The use of a safety checklist for SRS procedures promotes a zero-tolerance attitude for errors. This can lower the complications and is of major help in promoting multidisciplinary cooperation. We highly recommend the use of such tool, especially in the context of the increased use of SRS in the neurosurgical field.
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Eekers DB, Pijnappel EN, Schijns OE, Colon A, Hoeben A, Zindler JD, Postma AA, Hoffmann AL, Lambin P, Troost EG. Evidence on the efficacy of primary radiosurgery or stereotactic radiotherapy for drug-resistant non-neoplastic focal epilepsy in adults: A systematic review. Seizure 2018; 55:83-92. [DOI: 10.1016/j.seizure.2018.01.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 01/09/2018] [Accepted: 01/11/2018] [Indexed: 12/28/2022] Open
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Radiosurgery for epilepsy: Systematic review and International Stereotactic Radiosurgery Society (ISRS) practice guideline. Epilepsy Res 2017; 137:123-131. [DOI: 10.1016/j.eplepsyres.2017.08.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 08/27/2017] [Indexed: 10/18/2022]
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Abstract
While open surgical resection for medically refractory epilepsy remains the gold standard in current neurosurgical practice, modern techniques have targeted areas for improvement over open surgical resection. This review focuses on how a variety of these new techniques are attempting to address these various limitations. Stereotactic electroencephalography offers the possibility of localizing deep epileptic foci, improving upon subdural grid placement which limits localization to neocortical regions. Laser interstitial thermal therapy (LITT) and stereotactic radiosurgery can minimally or non-invasively ablate specific regions of interest, with near real-time feedback for laser interstitial thermal therapy. Finally, neurostimulation offers the possibility of seizure reduction without needing to ablate or resect any tissue. However, because these techniques are still being evaluated in current practice, there are no evidence-based guidelines for their use, and more research is required to fully evaluate their proper role in the current management of medically refractory epilepsy.
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Affiliation(s)
- Robert A McGovern
- Department of Neurological Surgery, The Neurological Institute, Columbia University Medical Center, 710 W. 168th St, New York, NY, 10032, USA.
| | - Garrett P Banks
- Department of Neurological Surgery, The Neurological Institute, Columbia University Medical Center, 710 W. 168th St, New York, NY, 10032, USA
| | - Guy M McKhann
- Department of Neurological Surgery, The Neurological Institute, Columbia University Medical Center, 710 W. 168th St, New York, NY, 10032, USA
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Kubota Y, Ochiai T, Hori T, Kawamata T. Usefulness of StereoEEG-based tailored surgery for medial temporal lobe epilepsy. Preliminary results in 11 patients. Clin Neurol Neurosurg 2017; 158:67-71. [PMID: 28482271 DOI: 10.1016/j.clineuro.2017.04.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 03/22/2017] [Accepted: 04/30/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Surgical options for medial temporal lobe epilepsy (MTLE) include anterior temporal lobectomy (ATL) and selective amygdalohippocampectomy (SAH). Optimal criteria for choosing the appropriate surgical approach remain uncertain. This article reports 11 consecutive cases in which electrophysiological findings of stereoelectroencephalography (SEEG) were used to determine the optimal surgical approach. PATIENTS AND METHODS Eleven consecutive patients with MTLE underwent SEEG evaluation and were placed in either the medial or the medial+lateral group based on the findings. Patients in the medial group underwent SAH using the subtemporal approach, and patients in the medial+lateral group underwent SEEG-guided anterior temporal lobectomy. SEEG findings were also compared with other examinations including flumazenil (FMZ)-positron emission tomography (PET), fluorine-18 labeled fluorodeoxyglucose (FDG)-PET, and magnetoencephalography (MEG). Results were evaluated to determine which examinations most consistently identified the epileptogenic zone. RESULTS Of the 11 cases, 4 patients were placed in the medial group, and 7 patients in the medial+lateral group. Of patients, 90.9% were classified in class I of the Engel Epilepsy Surgery Outcome Scale, while 72.7% were classified in class I by the International League Against Epilepsy (ILAE) system. Analyzed by group, 100% of the medial group experienced an Engel class I outcome in the medial group, compared to 85.7% in the medial+lateral group. SEEG findings were comparable with FDG-PET results (10 of 11, 91%). CONCLUSION Tailored surgery guided by SEEG is an electrophysiologically feasible treatment for MTLE that can result in favorable outcomes. Although seizures are thought to originate in the medial temporal lobe in MTLE, it is important for involvement of the lateral temporal cortex to be also considered in some cases.
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Affiliation(s)
- Yuichi Kubota
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan.
| | - Taku Ochiai
- Ochiai Brain Clinic, Saitama, Saitama, Japan
| | | | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan
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Feng ES, Sui CB, Wang TX, Sun GL. Stereotactic radiosurgery for the treatment of mesial temporal lobe epilepsy. Acta Neurol Scand 2016; 134:442-451. [PMID: 26846702 DOI: 10.1111/ane.12562] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Stereotactic radiosurgery (RS) is a potential option for some patients with temporal lobe epilepsy (TLE). The aim of this meta-analysis was to determine the pooled seizure-free rate and the time interval to seizure cessation in patients with lesions in the mesial temporal lobe, and who were eligible for either stereotactic or gamma knife RS. MATERIALS & METHODS We searched the Medline, Cochrane, EMBASE, and Google Scholar databases using combinations of the following terms: RS, stereotactic radiosurgery, gamma knife, and TLE. RESULTS We screened 103 articles and selected 13 for inclusion in the meta-analysis. Significant study heterogeneity was detected; however, the included studies displayed an acceptable level of quality. We show that approximately half of the patients were seizure free over a follow-up period that ranged from 6 months to 9 years [pooled estimate: 50.9% (95% confidence interval: 0.381-0.636)], with an average of 14 months to seizure cessation [pooled estimate: 14.08 months (95% confidence interval: 11.95-12.22 months)]. Nine of 13 included studies reported data for adverse events (AEs), which included visual field deficits and headache (the two most common AEs), verbal memory impairment, psychosis, psychogenic non-epileptic seizures, and dysphasia. Patients in the individual studies experienced AEs at rates that ranged from 8%, for non-epileptic seizures, to 85%, for headache. CONCLUSION Our findings indicate that RS may have similar or slightly less efficacy in some patients compared with invasive surgery. Randomized controlled trials of both treatment regimens should be undertaken to generate an evidence base for patient decision-making.
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Affiliation(s)
- E.-S. Feng
- Department of Neurosurgery; Beijing Ditan Hospital; Capital Medical University; Beijing China
| | - C.-B. Sui
- Department of Neurology; Beihai Hospital; Yantai Shandong China
| | - T.-X. Wang
- Department of Neurosurgery; Yidu Central Hospital of Weifang; Weifang Shandong China
| | - G.-L. Sun
- Department of Neurosurgery; Yidu Central Hospital of Weifang; Weifang Shandong China
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Abstract
The use of epilepsy surgery in various medically resistant epilepsies is well established. For patients with intractable pediatric epilepsy, the role of intracranial electrodes, resective surgery, hemispherectomy, corpus callosotomy, neurostimulation, and multiple subpial transections continues to be very effective in select cases. Newer treatment and diagnostic methods include laser thermal ablation, minimally invasive surgeries, stereo electroencephalography, electrocorticography, and other emerging techniques. This article will review the established and emerging surgical therapies for severe pediatric epilepsies, their respective indications and overall efficacy.
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Park HR, Chung HT, Lee SK, Kim DG, Paek SH. Fractionated Stereotactic Gamma Knife Radiosurgery for Medial Temporal Lobe Epilepsy: A Case Report. Exp Neurobiol 2016; 25:93-101. [PMID: 27122996 PMCID: PMC4844568 DOI: 10.5607/en.2016.25.2.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 01/22/2016] [Accepted: 01/23/2016] [Indexed: 11/19/2022] Open
Abstract
An 18-year-old left-handed male harbored intractable medial temporal lobe epilepsy (MTLE) underwent fractionated gamma knife surgery (GKS) instead of open surgery, considering the mental retardation and diffuse cerebral dysfunction. GKS treatment parameters were: target volume, 8.8 cm3; total marginal dose, 24 Gy in 3 fractionations at the 50% isodose line. The patient has been free from seizures since 9 months after GKS, with notable improvement in cognitive outcome. Fractionated GKS could be considered as a safe tool for seizure control and neuropsychological improvement in patients with MTLE.
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Affiliation(s)
- Hye Ran Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea.; Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Seoul 04401, Korea
| | - Hyun-Tai Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea
| | - Sang Kun Lee
- Department of Neurology, Seoul National University Hospital, Seoul 03080, Korea
| | - Dong Gyu Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea
| | - Sun Ha Paek
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea
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Gianaris T, Witt T, Barbaro NM. Radiosurgery for Medial Temporal Lobe Epilepsy Resulting from Mesial Temporal Sclerosis. Neurosurg Clin N Am 2015; 27:79-82. [PMID: 26615110 DOI: 10.1016/j.nec.2015.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Medial temporal lobe epilepsy associated with mesial temporal sclerosis (MTS) is perhaps the most well-defined epilepsy syndrome that is responsive to structural interventions such as surgery. Several minimally invasive techniques have arisen that provide additional options for the treatment of MTS while potentially avoiding many of open surgery's associated risks. By evading these risks, they also open up treatment options to patients who otherwise are poor surgical candidates. Radiosurgery is one of the most intensively studied of these alternatives and has found a growing role in the treatment of medial temporal lobe epilepsy.
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Affiliation(s)
- Thomas Gianaris
- Department of Neurological Surgery, Indiana University School of Medicine, 355 W. 16th St., Suite 5100, Indianapolis, IN 46202, USA
| | - Thomas Witt
- Department of Neurological Surgery, Indiana University School of Medicine, 355 W. 16th St., Suite 5100, Indianapolis, IN 46202, USA
| | - Nicholas M Barbaro
- Department of Neurological Surgery, Indiana University School of Medicine, 355 W. 16th St., Suite 5100, Indianapolis, IN 46202, USA.
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Vojtěch Z, Malíková H, Syrůček M, Krámská L, Šroubek J, Vladyka V, Liščák R. Morphological changes after radiosurgery for mesial temporal lobe epilepsy. Acta Neurochir (Wien) 2015; 157:1783-91; discussion 1791-2. [PMID: 26277098 PMCID: PMC4569650 DOI: 10.1007/s00701-015-2525-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Accepted: 07/28/2015] [Indexed: 11/24/2022]
Abstract
Background To review our experience with morphological developments during the long-term follow-up of patients treated by Gamma Knife radiosurgery for mesial temporal lobe epilepsy. Method Between 1995 and 1999, we treated 14 patients with marginal doses of 24 Gy (n = 6) and 18–20 Gy (n = 8). Nine of these were operated on for insufficient seizure control. We reviewed seizure outcome and magnetic resonance images in both operated and unoperated patients and also re-examined histopathology specimens. Results Of the nine operated patients, two were Engel IIIA, one was IVA, five were IVB, and one was Engel IVC prior to surgery. At their final visit, five cases had become Engel class IA, one patient was ID, and two were IIC. In one patient the follow-up was not long enough for classification. Of the five unoperated patients, one was Engel class IB, one was IIIA, one IIB and one IVB at their final visit. Radionecrosis developed in 11 patients, occurring more often and earlier in those treated with higher doses. Collateral edema reached outside the temporal lobe in six patients, caused uncal herniation in two and intracranial hypertension in three. During longer follow-up, postnecrotic pseudocysts developed in 9 patients, and postcontrast enhancement persisted for 2.5–16 years after GKRS in all 14 patients. In five of them we detected its progression between 2 and 16 years after treatment. Signs of neoangiogenesis were found in two patients and microbleeds could be seen in five. Histopathology revealed blood vessel proliferation and macrophage infiltration. Conclusions Early delayed complications and morphological signs suggesting a risk of development of late delayed complications are frequent after radiosurgery for mesial temporal lobe epilepsy. Together with its unproven antiseizure efficacy, these issues should be taken into account when planning future studies of this method. Electronic supplementary material The online version of this article (doi:10.1007/s00701-015-2525-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zdeněk Vojtěch
- Department of Neurology, Na Homolce Hospital, Roentgenova 2, 15030, Prague 5-Motol, Czech Republic.
| | - Hana Malíková
- Department of Radiodiagnostics, Na Homolce Hospital, Prague, Czech Republic
| | - Martin Syrůček
- Department of Pathology, Na Homolce Hospital, Prague, Czech Republic
| | - Lenka Krámská
- Department of Psychology, Na Homolce Hospital, Prague, Czech Republic
| | - Jan Šroubek
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Vilibald Vladyka
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Roman Liščák
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
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Studer F, Serduc R, Pouyatos B, Chabrol T, Bräuer-Krisch E, Donzelli M, Nemoz C, Laissue J, Estève F, Depaulis A. Synchrotron X-ray microbeams: A promising tool for drug-resistant epilepsy treatment. Phys Med 2015; 31:607-14. [DOI: 10.1016/j.ejmp.2015.04.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 04/07/2015] [Accepted: 04/09/2015] [Indexed: 12/26/2022] Open
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Lee EM, Kang JK, Kim SJ, Hong SH, Ko TS, Lee SA, Lee DH, Lee JK. Gamma Knife radiosurgery for recurrent or residual seizures after anterior temporal lobectomy in mesial temporal lobe epilepsy patients with hippocampal sclerosis: long-term follow-up results of more than 4 years. J Neurosurg 2015; 123:1375-82. [PMID: 26162046 DOI: 10.3171/2014.12.jns141280] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Gamma Knife radiosurgery (GKRS) has proven efficacy in the treatment of drug-resistant mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) and is comparable to conventional resective surgery. It may be effective as an alternative treatment to reoperation after failed temporal lobe surgery in patients with MTLE-HS. The purpose of this study was to investigate the efficacy of GKRS in patients with unilateral MTLE-HS who did not achieve seizure control or had recurrent seizures after anterior temporal lobectomy (ATL). METHODS Twelve patients (8 males; mean age 35.50 ± 9.90 years) with MTLE-HS who underwent GKRS after failed ATL (Engel Classes III-IV) were included. GKRS targets included the remnant tissue or adjacent regions of the previously performed ATL with a marginal dose of 24-25 Gy at the 50% isodose line in all patients. Final seizure outcome was assessed using Engel's modified criteria during the final 2 years preceding data analysis. A comparison between signal changes on follow-up MRI and clinical outcome was performed. RESULTS All patients were followed up for at least 4 years with a mean duration of 6.18 ± 1.77 years (range 4-8.8 years) after GKRS. At the final assessment, 6 of 12 patients were classified as seizure free (Engel Class Ia, n = 3; Ic, n = 2; and Id, n = 1) and 6 patients were classified as not seizure free (Engel Class II, n = 1; III, n = 2; and IV, n = 3). Neither initial nor late MRI signal changes after GKRS statistically correlated with surgical outcome. Clinical seizure outcome did not differ significantly with initial or late MRI changes after GKRS. CONCLUSIONS GKRS can be considered an alternative option when the patients with MTLE-HS who had recurrent or residual seizures after ATL refuse a second operation.
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Affiliation(s)
- Eun Mi Lee
- Department of Neurology, Ulsan University Hospital, Ulsan; and
| | | | | | | | | | | | - Do Heui Lee
- Medical Physics Support Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Surgical treatment for mesial temporal lobe epilepsy associated with hippocampal sclerosis. Rev Neurol (Paris) 2015; 171:315-25. [DOI: 10.1016/j.neurol.2015.01.561] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 01/01/2015] [Accepted: 01/30/2015] [Indexed: 02/07/2023]
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Willie JT, Laxpati NG, Drane DL, Gowda A, Appin C, Hao C, Brat DJ, Helmers SL, Saindane A, Nour SG, Gross RE. Real-time magnetic resonance-guided stereotactic laser amygdalohippocampotomy for mesial temporal lobe epilepsy. Neurosurgery 2015; 74:569-84; discussion 584-5. [PMID: 24618797 DOI: 10.1227/neu.0000000000000343] [Citation(s) in RCA: 251] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Open surgery effectively treats mesial temporal lobe epilepsy, but carries the risk of neurocognitive deficits, which may be reduced with minimally invasive alternatives. OBJECTIVE To describe technical and clinical outcomes of stereotactic laser amygdalohippocampotomy with real-time magnetic resonance thermal imaging guidance. METHODS With patients under general anesthesia and using standard stereotactic methods, 13 adult patients with intractable mesial temporal lobe epilepsy (with and without mesial temporal sclerosis [MTS]) prospectively underwent insertion of a saline-cooled fiberoptic laser applicator in amygdalohippocampal structures from an occipital trajectory. Computer-controlled laser ablation was performed during continuous magnetic resonance thermal imaging followed by confirmatory contrast-enhanced anatomic imaging and volumetric reconstruction. Clinical outcomes were determined from seizure diaries. RESULTS A mean 60% volume of the amygdalohippocampal complex was ablated in 13 patients (9 with MTS) undergoing 15 procedures. Median hospitalization was 1 day. With follow-up ranging from 5 to 26 months (median, 14 months), 77% (10/13) of patients achieved meaningful seizure reduction, of whom 54% (7/13) were free of disabling seizures. Of patients with preoperative MTS, 67% (6/9) achieved seizure freedom. All recurrences were observed before 6 months. Variances in ablation volume and length did not account for individual clinical outcomes. Although no complications of laser therapy itself were observed, 1 significant complication, a visual field defect, resulted from deviated insertion of a stereotactic aligning rod, which was corrected before ablation. CONCLUSION Real-time magnetic resonance-guided stereotactic laser amygdalohippocampotomy is a technically novel, safe, and effective alternative to open surgery. Further evaluation with larger cohorts over time is warranted.
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Affiliation(s)
- Jon T Willie
- Departments of *Neurosurgery, ‡Neurology, §Pathology, and ¶Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia; ‖Interventional MRI Program, Emory University Hospital, Atlanta, Georgia; #Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia; **Department of Neurology, University of Washington School of Medicine, Seattle, Washington; ††Visualase, Inc., Houston, Texas
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Annan M, Bartolomei F, Biberon J, Cottier JP, De Toffol B. Appearance of post ictal psychosis after radiosurgical damage in the temporal lobe. Seizure 2015; 24:140-2. [DOI: 10.1016/j.seizure.2014.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 09/07/2014] [Accepted: 09/24/2014] [Indexed: 11/29/2022] Open
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Quigg M, Harden C. Minimally invasive techniques for epilepsy surgery: stereotactic radiosurgery and other technologies. J Neurosurg 2014; 121 Suppl:232-40. [DOI: 10.3171/2014.8.gks141608] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Minimally invasive surgical techniques for the treatment of medically intractable epilepsy, which have been developed by neurosurgeons and epileptologists almost simultaneously with standard open epilepsy surgery, provide benefits in the traditional realms of safety and efficacy and the more recently appreciated realms of patient acceptance and costs. In this review, the authors discuss the shortcomings of the gold standard of open epilepsy surgery and summarize the techniques developed to provide minimally invasive alternatives. These minimally invasive techniques include stereotactic radiosurgery using the Gamma Knife, stereotactic radiofrequency thermocoagulation, laser-induced thermal therapy, and MRI-guided focused ultrasound ablation.
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Affiliation(s)
- Mark Quigg
- 1Department of Neurology, University of Virginia Heath System, Charlottesville, Virginia; and
| | - Cynthia Harden
- 2Department of Neurology, Hofstra University, Hempsted, New York
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Chen N, Du SQ, Yan N, Liu C, Zhang JG, Ge Y, Meng FG. Delayed complications after Gamma Knife surgery for intractable epilepsy. J Clin Neurosci 2014; 21:1525-8. [DOI: 10.1016/j.jocn.2013.11.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 11/06/2013] [Accepted: 11/13/2013] [Indexed: 11/24/2022]
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Affiliation(s)
- Jean Régis
- Aix-Marseille University, INSERM, UMR 1106 and Timone University Hospital, Functional and Stereotactic Neurosurgery Service and Gamma Knife Unit, 264 rue Saint Pierre, 13385, Marseille, CEDEX 05, France,
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Kondziolka D, Flickinger JC, Lunsford LD. Stereotactic radiosurgery for epilepsy and functional disorders. Neurosurg Clin N Am 2014; 24:623-32. [PMID: 24093580 DOI: 10.1016/j.nec.2013.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Stereotactic radiosurgery is used for many indications. In functional neurosurgery, it is used to modulate the function of axons, neurons, and related brain circuits. In this article, indications, current techniques, and outcomes are discussed.
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Affiliation(s)
- Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, 530 First Avenue, Suite 8R, New York, NY 10016, USA.
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Wellmer J, Kopitzki K, Voges J. Lesion focused stereotactic thermo-coagulation of focal cortical dysplasia IIB: a new approach to epilepsy surgery? Seizure 2014; 23:475-8. [PMID: 24582999 DOI: 10.1016/j.seizure.2014.01.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 01/26/2014] [Accepted: 01/29/2014] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Over the last few decades, preferred epilepsy surgical approaches have developed from standard lobectomies to individually tailored resections. Yet, it remains uncertain how small surgical interventions can be without compromising the success of the surgery. Particularly in patients with epileptogenic lesions identified by magnetic resonance imaging (MRI), it is unresolved whether resection or destruction of the lesion suffices to eliminate the epileptogenic zone. We present a minimally invasive surgical approach that may provide insight into this issue. METHODS Two patients with pharmacoresistant epilepsy due to focal cortical dysplasia type IIB demonstrated by 3 Tesla MRI were treated with lesion-focused stereotactic radio-frequency thermo-coagulation. In both patients, pathognomonic epileptic discharges were recorded from the lesion via a stimulation device prior to coagulation. In one patient, the suspected proximity of the lesion to the pyramidal tract was verified by eliciting motor evoked potentials from the depths of the lesion. RESULTS Following complete and near complete lesion destruction, seizures (several per day or per week, respectively) ceased in patients A and B, with no seizures for 12 months and 5 months, respectively, at the time of this publication. Neither patient acquired persistent postoperative neurological deficits. CONCLUSION The fact that seizure activity stopped after destruction of small bottom-of-sulcus dysplasias implies that in these cases, the epileptogenic zone and the epileptogenic lesion may overlap. If future studies can replicate this finding, focused lesion destruction could be a further development of individually tailored epilepsy surgery. The technique described here is especially suited for high-precision surgery close to eloquent brain structures.
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Affiliation(s)
- Jörg Wellmer
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus, In der Schornau 23-25, 44892 Bochum, Germany.
| | - Klaus Kopitzki
- Department of Stereotactic Neurosurgery, Otto-von-Guericke University, and Leibniz Institute for Neurobiology, Leipziger Str. 44, 39120 Magdeburg, Germany
| | - Jürgen Voges
- Department of Stereotactic Neurosurgery, Otto-von-Guericke University, and Leibniz Institute for Neurobiology, Leipziger Str. 44, 39120 Magdeburg, Germany
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McGonigal A, Bartolomei F, Gavaret M, Chauvel P, Régis J. Gamma Knife Radiosurgery of Paracentral Epilepsy. Stereotact Funct Neurosurg 2014; 92:346-53. [DOI: 10.1159/000364915] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 05/30/2014] [Indexed: 11/19/2022]
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Finet P, Rooijakkers H, Godfraind C, Raftopoulos C. Delayed compressive angiomatous degeneration in a case of mesial temporal lobe epilepsy treated by γ knife radiosurgery: case report. Neurosurgery 2013; 67:218-20; discussion 220. [PMID: 20559073 DOI: 10.1227/01.neu.0000370011.36820.ed] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Mesial temporal lobe epilepsy (MTLE) is one of the most common causes of intractable partial epilepsy. The conventional treatment of patients with MTLE is surgical excision. Currently, gamma knife (GK) radiosurgery is being explored as an alternative treatment. We report the first delayed major complication related to this treatment. CLINICAL PRESENTATION A 54-year-old woman with a medical history of a post-viral encephalitis in childhood was treated in April 2001 by GK radiosurgery for a medically refractory MTLE. Her right temporomesial area received a dose of 20 Gy at the 50% marginal isodose line. Unfortunately, the patient continued to experience seizures, although they were of shorter duration and occurred less frequently. She was seen in our department on November 8, 2007, for an intracranial hypertensive syndrome. The imaging work-up showed an expansive hemorrhagic lesion in the right mesiotemporal area. Despite corticosteroid treatment, the patient still complained about headaches on November 13, and surgery was scheduled for November 22. However, the patient returned to the emergency department on November 16 with a temporal herniation syndrome requiring an urgent surgical procedure. INTERVENTION The expansive lesion was completely removed. Histologic examination revealed lesions of the gray and white matter consisting of severe gliosis, hemorrhagic foci, hyalinized vessels, and neovascularization, giving the brain parenchyma an angiomatous aspect. CONCLUSION Although reports on GK radiosurgical treatment of MTLE are encouraging, this case stresses the risk of developing 6 years later an angiomatous degeneration of the targeted brain with life-threatening intracranial hypertension.
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Affiliation(s)
- Patrice Finet
- Department of Neurosurgery, Saint-Luc Hospital, Brussels, Belgium
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Vale FL, Reintjes S, Garcia HG. Complications after mesial temporal lobe surgery via inferiortemporal gyrus approach. Neurosurg Focus 2013; 34:E2. [DOI: 10.3171/2013.3.focus1354] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The purpose of this study was to identify the complications associated with the inferior temporal gyrus approach to anterior mesial temporal lobe resection for temporal lobe epilepsy.
Methods
This retrospective study examined complications experienced by 483 patients during the 3 months after surgery. All surgeries were performed during 1998–2012 by the senior author (F.L.V.).
Results
A total of 13 complications (2.7%) were reported. Complications were 8 delayed subdural hematomas (1.6%), 2 superficial wound infections (0.4%), 1 delayed intracranial hemorrhage (0.2%), 1 small lacunar stroke (0.2%), and 1 transient frontalis nerve palsy (0.2%). Three patients with subdural hematoma (0.6%) required readmission and surgical intervention. One patient (0.2%) with delayed intracranial hemorrhage required readmission to the neuroscience intensive care unit for observation. No deaths or severe neurological impairments were reported. Among the 8 patients with subdural hematoma, 7 were older than 40 years (87.5%); however, this finding was not statistically significant (p = 0.198).
Conclusions
The inferior temporal gyrus approach to mesial temporal lobe resection is a safe and effective method for treating temporal lobe epilepsy. Morbidity and mortality rates associated with this procedure are lower than those associated with other neurosurgical procedures. The finding that surgical complications seem to be more common among older patients emphasizes the need for early surgical referral of patients with medically refractory epilepsy.
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Affiliation(s)
- Fernando L. Vale
- 1Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida; and
| | - Stephen Reintjes
- 1Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida; and
| | - Hermes G. Garcia
- 2Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
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Gamma knife irradiation of injured sciatic nerve induces histological and behavioral improvement in the rat neuropathic pain model. PLoS One 2013; 8:e61010. [PMID: 23593377 PMCID: PMC3625209 DOI: 10.1371/journal.pone.0061010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 03/05/2013] [Indexed: 11/21/2022] Open
Abstract
We examined the effects of gamma knife (GK) irradiation on injured nerves using a rat partial sciatic nerve ligation (PSL) model. GK irradiation was performed at one week after ligation and nerve preparations were made three weeks after ligation. GK irradiation is known to induce immune responses such as glial cell activation in the central nervous system. Thus, we determined the effects of GK irradiation on macrophages using immunoblot and histochemical analyses. Expression of Iba-1 protein, a macrophage marker, was further increased in GK-treated injured nerves as compared with non-irradiated injured nerves. Immunohistochemical study of Iba-1 in GK-irradiated injured sciatic nerves demonstrated Iba-1 positive macrophage accumulation to be enhanced in areas distal to the ligation point. In the same area, myelin debris was also more efficiently removed by GK-irradiation. Myelin debris clearance by macrophages is thought to contribute to a permissive environment for axon growth. In the immunoblot study, GK irradiation significantly increased expressions of βIII-tubulin protein and myelin protein zero, which are markers of axon regeneration and re-myelination, respectively. Toluidine blue staining revealed the re-myelinated fiber diameter to be larger at proximal sites and that the re-myelinated fiber number was increased at distal sites in GK-irradiated injured nerves as compared with non-irradiated injured nerves. These results suggest that GK irradiation of injured nerves facilitates regeneration and re-myelination. In a behavior study, early alleviation of allodynia was observed with GK irradiation in PSL rats. When GK-induced alleviation of allodynia was initially detected, the expression of glial cell line-derived neurotrophic factor (GDNF), a potent analgesic factor, was significantly increased by GK irradiation. These results suggested that GK irradiation alleviates allodynia via increased GDNF. This study provides novel evidence that GK irradiation of injured peripheral nerves may have beneficial effects.
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Irislimane M, Mathieu D, Bouthillier A, Deacon C, Nguyen DK. Gamma Knife Surgery for Refractory Insular Cortex Epilepsy. Stereotact Funct Neurosurg 2013; 91:170-6. [DOI: 10.1159/000343205] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 09/04/2012] [Indexed: 01/22/2023]
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Abstract
Radiosurgery is commonly considered to be effective through a destructive physical mechanism acting on neural tissue. However, the results of modern neurophysiological, radiological, and histological studies are providing a basis on which to question this assumption. There are now multiple pieces of evidence pointing to a nonlesional mechanism of the radiosurgical action. It appears that tissue destruction is absent or minimal and in almost all cases insufficient to explain the clinical effects produced. There is a real possibility that radiosurgery induces changes in the functioning of neural tissue by differential effects on various neuronal populations and remodeling the glial environment, leading to modulation of function while preserving basic processing. Hence, the majority of radiosurgical procedures induce the desired biological effect without histological destruction of tissue. These findings may result in a major paradigm shift in the treatment of functional brain disorders.
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Affiliation(s)
- Jean Régis
- Department of Stereotactic and Functional Neurosurgery, Aix Marseille University, Timone University Hospital, and INSERM U751, 264 rue Saint Pierre, Marseille, 13385, Cedex 05, France.
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Kerrigan JF, Parsons A, Rice SG, Simeone K, Shetter AG, Abla AA, Prenger E, Coons SW. Hypothalamic Hamartomas: Neuropathological Features with and without Prior Gamma Knife Radiosurgery. Stereotact Funct Neurosurg 2013. [DOI: 10.1159/000341076] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Wu C, Sperling MR, Falowski SM, Chitale AV, Werner-Wasik M, Evans JJ, Andrews DW, Sharan AD. Radiosurgery for the treatment of dominant hemisphere periventricular heterotopia and intractable epilepsy in a series of three patients. EPILEPSY & BEHAVIOR CASE REPORTS 2012; 1:1-6. [PMID: 25688044 PMCID: PMC4150677 DOI: 10.1016/j.ebcr.2012.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 10/06/2012] [Indexed: 11/26/2022]
Abstract
Periventricular heterotopia (PVH) is a neuronal migration disorder characterized by masses of gray matter located along the lateral ventricles that commonly cause epilepsy. The benefit of surgical resection of the PVH has been demonstrated in case reports to date; however, the location of the PVH in the paratrigonal region of the lateral ventricles can present significant surgical challenges. Noninvasive modalities of ablating this epileptogenic focus must therefore be considered. We present a small series of three patients who underwent stereotactic radiosurgery (SRS) for inoperable unilateral dominant hemisphere PVHs in order to illustrate the potential benefits and risks of this treatment modality. A total dose of 37.5–65 Gy resulted in seizure freedom for at least 14 months at the time of their last follow-up, even in patients harboring a second independent epileptic focus. Whether intracranial electrode recording truly offers added value is therefore uncertain. The two patients who received higher radiation doses suffered from symptomatic radiation necrosis and associated cerebral edema, requiring further medical intervention, and persistent monocular visual loss in one patient. While a longer interval prior to re-treatment may have been attempted, neither patient demonstrated radiographic findings typically associated with seizure remission. Refractory epilepsy due to PVH may be successfully treated with radiation therapy; but further work is needed to define the optimal dosing parameters in order to lower toxicity to normal tissue.
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Affiliation(s)
- Chengyuan Wu
- Thomas Jefferson University Hospitals, Department of Neurological Surgery, 909 Walnut Street, Third Floor, Philadelphia, PA, USA
| | - Michael R Sperling
- Thomas Jefferson University, Department of Neurology, Philadelphia, PA, USA
| | - Steven M Falowski
- Thomas Jefferson University, Department of Neurological Surgery, Philadelphia, PA, USA
| | - Ameet V Chitale
- Thomas Jefferson University, Department of Neurological Surgery, Philadelphia, PA, USA
| | - Maria Werner-Wasik
- Thomas Jefferson University, Department of Radiation Oncology, Philadelphia, PA, USA
| | - James J Evans
- Thomas Jefferson University, Department of Neurological Surgery, Philadelphia, PA, USA
| | - David W Andrews
- Thomas Jefferson University, Department of Neurological Surgery, Philadelphia, PA, USA
| | - Ashwini D Sharan
- Thomas Jefferson University, Department of Neurological Surgery, Philadelphia, PA, USA
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Vale FL, Bozorg AM, Schoenberg MR, Wong K, Witt TC. Long-term radiosurgery effects in the treatment of temporal lobe epilepsy. J Neurosurg 2012; 117:962-9. [DOI: 10.3171/2012.6.jns111905] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Epilepsy surgery is an effective treatment for medically resistant temporal lobe epilepsy (TLE). To minimize complication rates and potentially improve neuropsychology outcomes, stereotactic radiosurgery (SRS) has been explored as an alternative. Two pilot trials have demonstrated the effectiveness of SRS for the treatment of medically resistant TLE, with seizure-free outcomes for approximately 65% of patients at last follow-up. Despite encouraging results, no conclusive long-term outcomes are available for SRS. This article discusses a single patient who presented with recurrent seizures, worsening headaches, and persistent abnormal MRI findings 7 years and 8 months after SRS.
This 29-year-old woman with a history of medically refractory complex partial seizures since childhood was referred for evaluation. Medical management had failed in this patient. The workup was compatible with left mesial temporal lobe onset, with MRI findings suggestive of mesial temporal sclerosis. In 2003, at the age of 23 years, she underwent Gamma Knife surgery (GKS) targeting the left temporal mesial area with a dose of 24 Gy at the 50% marginal isodose line. After GKS, the patient's seizures decreased in frequency over several months, but auras were persistent. Nine months after treatment, she developed worsening headaches. A follow-up MRI study demonstrated a thick, irregular, enhancing lesion in the medial part of the temporal lobe. She was placed on corticosteroids, with resolution of her headaches.
Her seizures and headaches recurred in March 2010. An MRI study showed a 2.2-cm, ill-defined, enhancing cystic lesion in the left mesial temporal lobe with T2 and FLAIR hyperintensity, which was presumably radiation induced. At that time, the patient opted for left temporal lobe resection to control her seizures. Histological examination showed moderately severe, remote, longstanding sclerosis at the level of the hippocampus. A vascular lesion was identified, and it was most consistent with radiation-induced capillary hemangioma. The entorhinal region was severely damaged, with hemorrhage, necrosis, neuronal loss, astrogliosis, and hemosiderin deposition. There was evidence of radiation vasculopathy.
Radiation-induced lesions after SRS for the treatment of epilepsy are not well documented. Although GKS is a promising technique for the treatment of medically resistant TLE, the ideal candidate is not yet well defined. The selection of the appropriate technical parameters to obtain a desirable functional effect without histological damage to the surrounding neural tissue remains a challenge. This case illustrates the need for long-term follow-up when radiosurgery is used for epilepsy.
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Affiliation(s)
| | | | - Mike R. Schoenberg
- 1Departments of Neurosurgery,
- 2Neurology, and
- 3Psychiatry and Behavioral Neurosciences, University of South Florida
| | - Kondi Wong
- 4Department of Pathology, Tampa General Hospital, University of South Florida, Tampa, Florida; and
| | - Thomas C. Witt
- 5Goodman Campbell Brain and Spine, Department of Neurosurgery, Indiana University, Indianapolis, Indiana
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Devergnas A, Piallat B, Prabhu S, Torres N, Louis Benabid A, David O, Chabardès S. The subcortical hidden side of focal motor seizures: evidence from micro-recordings and local field potentials. ACTA ACUST UNITED AC 2012; 135:2263-76. [PMID: 22710196 DOI: 10.1093/brain/aws134] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Focal motor seizures are characterized by transient motor behaviour that occurs simultaneously with paroxystic activity in the controlateral motor cortex. The implication of the basal ganglia has already been shown for generalized seizure but the propagation pathways from the motor cortex towards the basal ganglia during focal motor seizures are largely unknown. With a better knowledge of those pathways, a therapeutic modulation for reducing drug resistant motor epilepsy could be considered. Here, we recorded single-unit activities and local field potentials in the basal ganglia of two Macaca fascicularis in which acute focal motor seizures were induced by the injection of penicillin over the arm motor cortex territory. Each neuron was characterized using its mean firing rate and its type of firing pattern during interictal periods and seizures. Time-frequency analyses of local field potentials and electroencephalographic signals were used to assess dynamic changes occurring during seizure at a larger spatial level. The firing rate of neurons of input stages of basal ganglia (subthalamic nucleus and putamen) and those from the external part of the globus pallidus were significantly higher during seizures as compared to interictal periods. During seizures, the proportion of oscillatory neurons in subthalamic nucleus (71%), external globus pallidus (45%) and putamen (53%) significantly increased in comparison to interictal periods. Rhythmic activity was synchronized with ictal cortical spikes in external globus pallidus and subthalamic nucleus, but not in the putamen which oscillated faster than motor cortex. In contrast, no significant modification of the firing rate of the output stages of basal ganglia (internal part of the globus pallidus, substantia nigra pars reticulata) could be found during seizures. The local field potentials of subthalamic nucleus and external globus pallidus changed abruptly at the onset of the seizure, showing synchronization with the cortical activity throughout the seizure. In putamen, the synchronization appeared only by the end of seizures and for the two output structures, despite some increase of the oscillatory activity, the synchronization with the cortex was not significant. Our results suggest that the subthalamo-(external)-pallidal pathway is the main subcortical route involved during ictal motor seizures. Surprisingly, ictal activity did not propagate to the output structure of basal ganglia in that model. This finding may be important for clinical decisions of targeting when considering anti-epileptic neuromodulation in human beings suffering from disabling, drug resistant motor epilepsy.
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Usami K, Kawai K, Koga T, Shin M, Kurita H, Suzuki I, Saito N. Delayed complication after Gamma Knife surgery for mesial temporal lobe epilepsy. J Neurosurg 2012; 116:1221-5. [DOI: 10.3171/2012.2.jns111296] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Despite the controversy over the clinical significance of Gamma Knife surgery (GKS) for refractory mesial temporal lobe epilepsy (MTLE), the modality has attracted attention because it is less invasive than resection. The authors report long-term outcomes for 7 patients, focusing in particular on the long-term complications.
Methods
Between 1996 and 1999, 7 patients with MTLE underwent GKS. The 50% marginal dose covering the medial temporal structures was 18 Gy in 2 patients and 25 Gy in the remaining 5 patients.
Results
High-dose treatment abolished the seizures in 2 patients and significantly reduced them in 2 others. One patient in this group was lost to follow-up. However, 2 patients presented with symptomatic radiation necrosis (SRN) necessitating resection after 5 and 10 years. One patient who did not need necrotomy continued to show radiation necrosis on MRI after 10 years. One patient died of drowning while swimming in the sea 1 year after GKS, before seizures had disappeared completely.
Conclusions
High-dose treatment resulted in sufficient seizure control but carried a significant risk of SRN after several years. Excessive target volume was considered as a reason for delayed necrosis. Drawbacks such as a delay in seizure control and the risk of SRN should be considered when the clinical significance of this treatment is evaluated.
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Affiliation(s)
- Kenichi Usami
- 1Department of Neurosurgery, The University of Tokyo Hospital, Tokyo
| | - Kensuke Kawai
- 1Department of Neurosurgery, The University of Tokyo Hospital, Tokyo
| | - Tomoyuki Koga
- 1Department of Neurosurgery, The University of Tokyo Hospital, Tokyo
| | - Masahiro Shin
- 1Department of Neurosurgery, The University of Tokyo Hospital, Tokyo
| | - Hiroki Kurita
- 2Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Saitama; and
| | - Ichiro Suzuki
- 3Department of Neurosurgery, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Nobuhito Saito
- 1Department of Neurosurgery, The University of Tokyo Hospital, Tokyo
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Rauch C, Semrau S, Fietkau R, Rampp S, Kasper B, Stefan H. Long-term experience with fractionated stereotactic radiotherapy in pharmacoresistant epilepsy: Neurological and MRI changes. Epilepsy Res 2012; 99:14-20. [DOI: 10.1016/j.eplepsyres.2011.10.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 10/30/2011] [Indexed: 10/14/2022]
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Kondziolka D, Flickinger JC, Niranjan A, Lunsford LD. Trends and importance of radiosurgery for the development of functional neurosurgery. Surg Neurol Int 2012; 3:S3-9. [PMID: 22826808 PMCID: PMC3400481 DOI: 10.4103/2152-7806.91604] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 12/20/2011] [Indexed: 11/29/2022] Open
Abstract
Functional neurosurgery includes surgery conducted to ablate, augment, or modulate targets that lead to improvement in neurological function or behavior. Surgical approaches for this purpose include destructive lesioning with different mechanical or biologic agents or energy sources, non-destructive electrical modulation, and cellular or chemical augmentation. Our purpose was to review the role of stereotactic radiosurgery used for functional indications and to discuss future applications and potential techniques. Imaging and neurophysiological research will enable surgeons to consider new targets and circuits that may be clinically important. Radiosurgery is one minimal access approach to those targets.
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Affiliation(s)
- Douglas Kondziolka
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John C. Flickinger
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - L. Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Abstract
Stereotactic radiosurgery, well established in the noninvasive treatment of focal lesions that are otherwise difficult to access through open surgery, is an emerging technology in the treatment of focal epileptic lesions. Recent studies suggest that seizures from hypothalamic hamartomas and mesial temporal lobe epilepsy remit at clinically significant rates with radiosurgery, but large variations among different studies have raised questions about appropriate treatment protocols and mechanisms. Proposed anticonvulsant mechanisms include neuromodulatory effects or ischemic necrosis of epileptic tissue. An ongoing trial that directly compares efficacy, morbidities, and cost of radiosurgery versus open surgery for mesial temporal lobe epilepsy is underway.
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Affiliation(s)
- Mark Quigg
- Department of Neurology, University of Virginia, Charlottesville, Virginia 22908, USA.
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Helmstaedter C, Witt JA. Clinical neuropsychology in epilepsy: theoretical and practical issues. HANDBOOK OF CLINICAL NEUROLOGY 2012; 107:437-459. [PMID: 22938988 DOI: 10.1016/b978-0-444-52898-8.00036-7] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Hauptman JS, Mathern GW. Epilepsy neurosurgery in children. HANDBOOK OF CLINICAL NEUROLOGY 2012; 108:881-95. [PMID: 22939072 DOI: 10.1016/b978-0-444-52899-5.00034-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Affiliation(s)
- Jason S Hauptman
- Department of Neurosurgery, University of California, Los Angeles, CA, USA
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KAWAMURA T, ONISHI H, KOHDA Y, HIROSE G. Serious Adverse Effects of Gamma Knife Radiosurgery for Mesial Temporal Lobe Epilepsy. Neurol Med Chir (Tokyo) 2012; 52:892-8. [DOI: 10.2176/nmc.52.892] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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