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Singh R, Zamanian C, Bcharah G, Stonnington H, George DD, Bhandarkar AR, Shahrestani S, Brown N, Abraham ME, Mammis A, Bydon M, Gonda D. High-Value Epilepsy Care in the United States: Predictors of Increased Costs and Complications from the National Inpatient Sample Database 2016-2019. World Neurosurg 2024; 185:e1230-e1243. [PMID: 38514037 DOI: 10.1016/j.wneu.2024.03.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 03/13/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND For patients with medically refractory epilepsy, newer minimally invasive techniques such as laser interstitial thermal therapy (LITT) have been developed in recent years. This study aims to characterize trends in the utilization of surgical resection versus LITT to treat medically refractory epilepsy, characterize complications, and understand the cost of this innovative technique to the public. METHODS The National Inpatient Sample database was queried from 2016 to 2019 for all patients admitted with a diagnosis of medically refractory epilepsy. Patient demographics, hospital length of stay, complications, and costs were tabulated for all patients who underwent LITT or surgical resection within these cohorts. RESULTS A total of 6019 patients were included, 223 underwent LITT procedures, while 5796 underwent resection. Significant predictors of increased patient charges for both cohorts included diabetes (odds ratio: 1.7, confidence interval [CI]: 1.44-2.19), infection (odds ratio: 5.12, CI 2.73-9.58), and hemorrhage (odds ratio: 2.95, CI 2.04-4.12). Procedures performed at nonteaching hospitals had 1.54 greater odds (CI 1.02-2.33) of resulting in a complication compared to teaching hospitals. Insurance status did significantly differ (P = 0.001) between those receiving LITT (23.3% Medicare; 25.6% Medicaid; 44.4% private insurance; 6.7 Other) and those undergoing resection (35.3% Medicare; 22.5% Medicaid; 34.7% private Insurance; 7.5% other). When adjusting for patient demographics, LITT patients had shorter length of stay (2.3 vs. 8.9 days, P < 0.001), lower complication rate (1.9% vs. 3.1%, P = 0.385), and lower mean hospital ($139,412.79 vs. $233,120.99, P < 0.001) and patient ($55,394.34 vs. $37,756.66, P < 0.001) costs. CONCLUSIONS The present study highlights LITT's advantages through its association with lower costs and shorter length of stay. The present study also highlights the associated predictors of LITT versus resection, such as that most LITT cases happen at academic centers for patients with private insurance. As the adoption of LITT continues, more data will become available to further understand these issues.
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Affiliation(s)
- Rohin Singh
- Department of Neurosurgery, University of Rochester, Rochester, New York, USA.
| | - Cameron Zamanian
- Department of Neurosurgery, University of Rochester, Rochester, New York, USA
| | - George Bcharah
- Department of Neurosurgery, Mayo Clinic, Scottsdale, Arizona, USA
| | | | - Derek D George
- Department of Neurosurgery, University of Rochester, Rochester, New York, USA
| | | | - Shane Shahrestani
- Department of Neurosurgery, Cedars-Sinai Hospital, Los Angeles, California, USA
| | - Nolan Brown
- Department of Neurosurgery, University of Rochester, Rochester, New York, USA
| | - Mickey E Abraham
- Department of Neurosurgery, University of California, San Diego, California, USA
| | - Antonios Mammis
- Departmernt of Neurosurgery, New York University, New York, New York, USA
| | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - David Gonda
- Department of Neurosurgery, University of California, San Diego, California, USA
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Al-Ramadhani R, Hect JL, Abel TJ. The changing landscape of palliative epilepsy surgery for Lennox Gastaut Syndrome. Front Neurol 2024; 15:1380423. [PMID: 38515452 PMCID: PMC10954786 DOI: 10.3389/fneur.2024.1380423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/21/2024] [Indexed: 03/23/2024] Open
Abstract
Lennox Gastaut Syndrome (LGS) is characterized by drug-resistant epilepsy that typically leads to decreased quality of life and deleterious neurodevelopmental comorbidities from medically refractory seizures. In recent years there has been a dramatic increase in the development and availability of novel treatment strategies for Lennox Gastaut Syndrome patient to improve seizure. Recent advances in neuromodulation and minimally invasive magnetic resonance guided laser interstitial thermal therapy (MRgLITT) have paved the way for new treatments strategies including deep brain stimulation (DBS), responsive neurostimulation (RNS), and MRgLITT corpus callosum ablation. These new strategies offer hope for children with drug-resistant generalized epilepsies, but important questions remain about the safety and effectiveness of these new approaches. In this review, we describe the opportunities presented by these new strategies and how each treatment strategy is currently being employed. Next, we will critically assess available evidence for these new approaches compared to traditional palliative epilepsy surgery approaches, such as vagus nerve stimulation (VNS) and open microsurgical corpus callosotomy (CC). Finally, we will describe future directions that would help define which of the available strategies should be employed and when.
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Affiliation(s)
- Ruba Al-Ramadhani
- Department of Pediatrics, Division of Child Neurology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jasmine L. Hect
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Taylor J. Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
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3
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Roth J, Bergman L, Weil AG, Brunette-Clement T, Weiner HL, Treiber JM, Shofty B, Cukiert A, Cukiert CM, Tripathi M, Sarat Chandra P, Bollo RJ, Machado HR, Santos MV, Gaillard WD, Oluigbo CO, Ibrahim GM, Jallo GI, Shimony N, O'Neill BR, Budke M, Pérez-Jiménez MÁ, Mangano FT, Iwasaki M, Iijima K, Gonzalez-Martinez J, Kawai K, Ishishita Y, Elbabaa SK, Bello-Espinosa L, Fallah A, Maniquis CAB, Ben-Zvi I, Tisdall M, Panigrahi M, Jayalakshmi S, Blount JP, Dorfmüller G, Bulteau C, Stone SS, Bolton J, Singhal A, Connolly M, Alsowat D, Alotaibi F, Ragheb J, Uliel-Sibony S. Added value of corpus callosotomy following vagus nerve stimulation in children with Lennox-Gastaut syndrome: A multicenter, multinational study. Epilepsia 2023; 64:3205-3212. [PMID: 37823366 DOI: 10.1111/epi.17796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/01/2023] [Accepted: 10/09/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE Lennox-Gastaut syndrome (LGS) is a severe form of epileptic encephalopathy, presenting during the first years of life, and is very resistant to treatment. Once medical therapy has failed, palliative surgeries such as vagus nerve stimulation (VNS) or corpus callosotomy (CC) are considered. Although CC is more effective than VNS as the primary neurosurgical treatment for LGS-associated drop attacks, there are limited data regarding the added value of CC following VNS. This study aimed to assess the effectiveness of CC preceded by VNS. METHODS This multinational, multicenter retrospective study focuses on LGS children who underwent CC before the age of 18 years, following prior VNS, which failed to achieve satisfactory seizure control. Collected data included epilepsy characteristics, surgical details, epilepsy outcomes, and complications. The primary outcome of this study was a 50% reduction in drop attacks. RESULTS A total of 127 cases were reviewed (80 males). The median age at epilepsy onset was 6 months (interquartile range [IQR] = 3.12-22.75). The median age at VNS surgery was 7 years (IQR = 4-10), and CC was performed at a median age of 11 years (IQR = 8.76-15). The dominant seizure type was drop attacks (tonic or atonic) in 102 patients. Eighty-six patients underwent a single-stage complete CC, and 41 an anterior callosotomy. Ten patients who did not initially have a complete CC underwent a second surgery for completion of CC due to seizure persistence. Overall, there was at least a 50% reduction in drop attacks and other seizures in 83% and 60%, respectively. Permanent morbidity occurred in 1.5%, with no mortality. SIGNIFICANCE CC is vital in seizure control in children with LGS in whom VNS has failed. Surgical risks are low. A complete CC has a tendency toward better effectiveness than anterior CC for some seizure types.
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Affiliation(s)
- Jonathan Roth
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Lottem Bergman
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Alexander G Weil
- Division of Neurosurgery, Department of Surgery, Sainte-Justine University Hospital Centre and University of Montreal Hospital Centre, Montreal, Quebec, Canada
| | - Tristan Brunette-Clement
- Division of Neurosurgery, Department of Surgery, Sainte-Justine University Hospital Centre and University of Montreal Hospital Centre, Montreal, Quebec, Canada
| | - Howard L Weiner
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Jeffrey M Treiber
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Ben Shofty
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Arthur Cukiert
- Department of Neurosurgery, Epilepsy Surgery Program, Clinica Cukiert, Sao Paulo, Brazil
| | - Cristine Mella Cukiert
- Department of Neurology and Neurophysiology, Epilepsy Surgery Program, Clinica Cukiert, Sao Paulo, Brazil
| | - Manjari Tripathi
- Center of Excellence for Epilepsy and MEG, AIIMS, New Delhi, India
| | | | - Robert J Bollo
- Division of Pediatric Neurosurgery, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Hélio Rubens Machado
- Division of Pediatric Neurosurgery, Center for Epilepsy Surgery in Children, Ribeirão Preto Medical School, University of São Paulo, Sao Paulo, Brazil
| | - Marcelo Volpon Santos
- Division of Pediatric Neurosurgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Sao Paulo, Brazil
| | - William D Gaillard
- Department of Neurology, Children's National Medical Center, Washington, District of Columbia, USA
| | - Chima O Oluigbo
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA
| | - George M Ibrahim
- Department of Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - George I Jallo
- Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Nir Shimony
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brent R O'Neill
- Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Marcelo Budke
- Department of Neurosurgery, Niño Jesus University Children's Hospital, Madrid, Spain
| | | | - Francesco T Mangano
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Masaki Iwasaki
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Keiya Iijima
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Jorge Gonzalez-Martinez
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kensuke Kawai
- Department of Neurosurgery, Jichi Medical University, Tochigi, Japan
| | - Yohei Ishishita
- Department of Neurosurgery, Jichi Medical University, Tochigi, Japan
| | - Samer K Elbabaa
- Pediatric Neurosurgery, Leon Pediatric Neuroscience Center of Excellence, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Luis Bello-Espinosa
- Pediatric Neurology and Epilepsy, Leon Pediatric Neuroscience Center of Excellence, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Cassia A B Maniquis
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Ido Ben-Zvi
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Martin Tisdall
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Manas Panigrahi
- Department of Neurosurgery, Krishna Institute of Medical Sciences, Hyderabad, India
| | - Sita Jayalakshmi
- Department of Neurology, Krishna Institute of Medical Sciences, Hyderabad, India
| | - Jeffrey P Blount
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Children's Hospital of Alabama, Birmingham, Alabama, USA
| | - Georg Dorfmüller
- Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France
| | | | - Scellig S Stone
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey Bolton
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ashutosh Singhal
- Division of Pediatric Neurosurgery, Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mary Connolly
- Comprehensive Epilepsy Program, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Daad Alsowat
- Neuroscience Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Faisal Alotaibi
- Neuroscience Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - John Ragheb
- Department of Surgery, Nicklaus Children's Hospital, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Shimrit Uliel-Sibony
- Pediatric Neurology Unit, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
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4
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Aum DJ, Reynolds RA, McEvoy S, Tomko S, Zempel J, Roland JL, Smyth MD. Surgical outcomes of open and laser interstitial thermal therapy approaches for corpus callosotomy in pediatric epilepsy. Epilepsia 2023; 64:2274-2285. [PMID: 37303192 DOI: 10.1111/epi.17679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Corpus callosotomy (CC) is a palliative surgical intervention for patients with medically refractory epilepsy that has evolved in recent years to include a less-invasive alternative with the use of laser interstitial thermal therapy (LITT). LITT works by heating a stereotactically placed laser fiber to ablative temperatures under real-time magnetic resonance imaging (MRI) thermometry. This study aims to (1) describe the surgical outcomes of CC in a large cohort of children with medically refractory epilepsy, (2) compare anterior and complete CC, and (3) review LITT as a surgical alternative to open craniotomy for CC. METHODS This retrospective cohort study included 103 patients <21 years of age with at least 1 year follow-up at a single institution between 2003 and 2021. Surgical outcomes and the comparative effectiveness of anterior vs complete and open versus LITT surgical approaches were assessed. RESULTS CC was the most common surgical disconnection (65%, n = 67) followed by anterior two-thirds (35%, n = 36), with a portion proceeding to posterior completion (28%, n = 10). The overall surgical complication rate was 6% (n = 6/103). Open craniotomy was the most common approach (87%, n = 90), with LITT used increasingly in recent years (13%, n = 13). Compared to open, LITT had shorter hospital stay (3 days [interquartile range (IQR) 2-5] vs 5 days [IQR 3-7]; p < .05). Modified Engel class I, II, III, and IV outcomes at last follow-up were 19.8% (n = 17/86), 19.8% (n = 17/86), 40.2% (n = 35/86), and 19.8% (n = 17/86). Of the 70 patients with preoperative drop seizures, 75% resolved postoperatively (n = 52/69). SIGNIFICANCE No significant differences in seizure outcome between patients who underwent only anterior CC and complete CC were observed. LITT is a less-invasive surgical alternative to open craniotomy for CC, associated with similar seizure outcomes, lower blood loss, shorter hospital stays, and lower complication rates, but with longer operative times, when compared with the open craniotomy approach.
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Affiliation(s)
- Diane J Aum
- Department of Neurosurgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Rebecca A Reynolds
- Division of Pediatric Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Sean McEvoy
- Department of Neurosurgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Stuart Tomko
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - John Zempel
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Jarod L Roland
- Department of Neurosurgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Matthew D Smyth
- Division of Pediatric Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
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Treiber JM, Bayley JC, Curry D. Minimally Invasive Destructive, Ablative, and Disconnective Epilepsy Surgery. JOURNAL OF PEDIATRIC EPILEPSY 2023. [DOI: 10.1055/s-0042-1760106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
AbstractConventional epilepsy surgery performed by microsurgical dissection typically requires large cranial working windows created with high-speed drills and lengthy incisions. In the past few decades, minimally invasive techniques have been developed with smaller incisions, comparable efficacy, shorter hospitalizations, and better safety profiles. These minimally invasive alternatives utilize stereotactic, ultrasonic, radiotherapeutic, and endoscopic techniques. Although not able to completely replace conventional surgery for all etiologies of epilepsy, these minimally invasive techniques have revolutionized modern epilepsy surgery and have been an invaluable asset to the neurosurgeon's repertoire. The endoscope has allowed for surgeons to have adequate visualization during resective and disconnective epilepsy surgeries using keyhole or miniature craniotomies. Modern stereotactic techniques such as laser interstitial thermal therapy and radiofrequency ablation can be used as viable alternatives for mesial temporal lobe epilepsy and can destroy lesional tissue deep areas without the approach-related morbidity of microsurgery such as with hypothalamic hamartomas. These stereotactic techniques do not preclude future surgery in the settings of treatment failure and have been used successfully after failed conventional surgery. Multiple ablation corridors can be performed in a single procedure that can be used for lesioning of large targets or to simplify treating multifocal epilepsies. These stereotactic techniques have even been used successfully to perform disconnective procedures such as hemispherotomies and corpus callosotomies. In patients unable to tolerate surgery, stereotactic radiosurgery is a minimally invasive option that can result in improved seizure control with minimal procedural risks. Advances in minimally invasive neurosurgery provide viable treatment options for drug-resistant epilepsy with quicker recovery, less injury to functional brain, and for patients that may otherwise not choose conventional surgery.
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Affiliation(s)
- Jeffrey M. Treiber
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - James C. Bayley
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Daniel Curry
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, United States
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Best BJ, Kim I, Lew SM. Magnetic resonance imaging-guided laser interstitial thermal therapy for complete corpus callosotomy: technique and 1-year outcomes. Patient series. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22364. [PMID: 36536524 PMCID: PMC9764374 DOI: 10.3171/case22364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/27/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI)-guided stereotactic laser interstitial thermal therapy (LITT) is a minimally invasive technique that has been described for the treatment of certain forms of epilepsy through partial or complete callosotomy, with few cases describing single-stage complete LITT callosotomy. The authors aimed to demonstrate this technique's feasibility and efficacy through description of the technique and 1-year outcomes in 3 cases of single-stage complete LITT callosotomy in patients with anatomically normal corpa callosa (CCs). OBSERVATIONS The patients were aged 14-27 years and experienced atonic seizures. Completeness of callosotomy was determined from MRI scans obtained >3 months after LITT procedures. The estimated ablations of the CC were 94%, 89%, and 100%, respectively. The second patient had a catheter breach the lateral ventricle, resulting in the lowest estimated percentage of ablation in this series (89%), with minimal atonic seizure reduction. The first patient had significant reduction in atonic seizure frequency, and the third patient had complete resolution of atonic seizures. None of the patients experienced any long-term complications. Intensive care length of stay was 1 night for each patient, and total length of stay was between 2 and 7 nights. Postoperative follow-up was between 14 and 18 months. LESSONS Complete laser callosotomy is achievable and is a safe alternative to microsurgical or endoscopic approaches.
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Affiliation(s)
- Benjamin J. Best
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin; and ,Division of Pediatric Neurosurgery, Children’s Wisconsin, Milwaukee, Wisconsin
| | - Irene Kim
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin; and ,Division of Pediatric Neurosurgery, Children’s Wisconsin, Milwaukee, Wisconsin
| | - Sean M. Lew
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin; and ,Division of Pediatric Neurosurgery, Children’s Wisconsin, Milwaukee, Wisconsin
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7
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Miller KJ, Fine AL. Decision-making in stereotactic epilepsy surgery. Epilepsia 2022; 63:2782-2801. [PMID: 35908245 PMCID: PMC9669234 DOI: 10.1111/epi.17381] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 11/27/2022]
Abstract
Surgery can cure or significantly improve both the frequency and the intensity of seizures in patients with medication-refractory epilepsy. The set of diagnostic and therapeutic interventions involved in the path from initial consultation to definitive surgery is complex and includes a multidisciplinary team of neurologists, neurosurgeons, neuroradiologists, and neuropsychologists, supported by a very large epilepsy-dedicated clinical architecture. In recent years, new practices and technologies have emerged that dramatically expand the scope of interventions performed. Stereoelectroencephalography has become widely adopted for seizure localization; stereotactic laser ablation has enabled more focal, less invasive, and less destructive interventions; and new brain stimulation devices have unlocked treatment of eloquent foci and multifocal onset etiologies. This article articulates and illustrates the full framework for how epilepsy patients are considered for surgical intervention, with particular attention given to stereotactic approaches.
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Affiliation(s)
- Kai J. Miller
- Neurosurgery, Mayo Clinic, 200 First St., Rochester, MN, 55902
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8
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Mallela AN, Hect JL, Abou-Al-Shaar H, Akwayena E, Abel TJ. Stereotactic laser interstitial thermal therapy corpus callosotomy for the treatment of pediatric drug-resistant epilepsy. Epilepsia Open 2021; 7:75-84. [PMID: 34758204 PMCID: PMC8886067 DOI: 10.1002/epi4.12559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/21/2021] [Accepted: 10/31/2021] [Indexed: 11/14/2022] Open
Abstract
Objective Corpus callosotomy is a safe and effective procedure for reducing the frequency of drop attacks. MR‐guided laser interstitial thermal therapy (MRgLITT) offers a minimally invasive alternative to conventional open craniotomy for callosotomy. We hypothesized that MRgLITT callosotomy could be safely performed in pediatric patients with similar seizure control. Methods We present an institutional case series of 11 procedures in 10 patients for the treatment of drop attacks in drug‐refractory primary generalized epilepsy. MRgLITT was used for complete callosotomy, anterior two‐thirds, posterior, or ablation of residual callosal fibers following prior callosotomy (open or MRgLITT). We retrospectively reviewed clinical course, operative details, radiographic imaging, clinical outcomes, and complications. Results Operative time ranged from 4‐8 hours, and median hospitalization was 2 days. No complications were encountered. Among the 7 patients with at least 3 months of follow‐up, 71% experienced freedom from drop attacks at longest follow‐up and 57% of cases showed improvement in their other seizure semiologies as well (Engel Class II: 28%, Class III: 28%, Class IV: 43%). Significance MR‐guided LITT callosotomy is safe and effective modality in the management of pediatric patients with medically intractable epilepsy characterized by drop attacks. While this is among the largest pediatric series to date, further studies are required to delineate its safety and efficacy among such patients.
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Affiliation(s)
- Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jasmine L Hect
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Emefa Akwayena
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
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9
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Ung TH, Kahn L, Hirt L, Chatain G, Humes E, David-Gerecht P, Drees C, Thompson JA, Ojemann S, Abosch A. Using a Robotic-Assisted Approach for Stereotactic Laser Ablation Corpus Callosotomy: A Technical Report. Stereotact Funct Neurosurg 2021; 100:61-66. [PMID: 34515241 DOI: 10.1159/000518109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/26/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Corpus callosotomy for medically intractable epilepsy is an effective ablative procedure traditionally achieved using either standard open craniotomy or with less-invasive approaches. Advances in robotic-assisted stereotactic guidance for neurosurgery can be applied for LITT for corpus callosotomy. CLINICAL PRESENTATIONS Two patients were included in this study. One was a 25-year-old female patient with extensive bi-hemispheric malformations of cortical development and medically refractory epilepsy, and the other was an 18-year-old male with medically refractory epilepsy and atonic seizures, who underwent a complete corpus callosotomy using robotic-assisted stereotactic guidance for LITT. RESULTS Both patients underwent successful intended corpus callosotomy with volumetric analysis demonstrating a length disconnection of 74% and a volume disconnection of 55% for patient 1 and a length disconnection of 83% and a volume disconnection of 33% for patient 2. Postoperatively, both patients had clinical reductions in seizure. CONCLUSION Our experience demonstrates that robotic guidance systems can safely and effectively be adapted for minimally invasive LITT corpus callosotomy.
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Affiliation(s)
- Timothy H Ung
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado, USA.,School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Lora Kahn
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado, USA.,School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Lisa Hirt
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado, USA
| | - Gregoire Chatain
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado, USA.,School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Elizabeth Humes
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado, USA.,School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Pamela David-Gerecht
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado, USA.,School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Cornelia Drees
- School of Medicine, University of Colorado, Aurora, Colorado, USA.,Department of Neurology, University of Colorado Hospital, Aurora, Colorado, USA
| | - John A Thompson
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado, USA.,School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Steven Ojemann
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado, USA.,School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Aviva Abosch
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado, USA.,School of Medicine, University of Colorado, Aurora, Colorado, USA
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Postoperative Pneumocephalus on Computed Tomography Might Predict Post-Corpus Callosotomy Chemical Meningitis. Brain Sci 2021; 11:brainsci11050638. [PMID: 34063350 PMCID: PMC8156846 DOI: 10.3390/brainsci11050638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/10/2021] [Accepted: 05/13/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND A corpus callosotomy (CC) is a procedure in which the corpus callosum, the largest collection of commissural fibers in the brain, is disconnected to treat epileptic seizures. The occurrence of chemical meningitis has been reported in association with this procedure. We hypothesized that intraventricular pneumocephalus after CC surgery represents a risk factor for postoperative chemical meningitis. The purpose of this study was to analyze the potential risk factors for postoperative chemical meningitis in patients with medically intractable epilepsy who underwent a CC. METHODS Among the patients who underwent an anterior/total CC for medically intractable epilepsy between January 2009 and March 2021, participants were comprised of those who underwent a computed tomography scan on postoperative day 0. We statistically compared the groups with (c-Group) or without chemical meningitis (nc-Group) to determine the risk factors. RESULTS Of the 80 patients who underwent a CC, 65 patients (25 females and 40 males) met the inclusion criteria. Their age at the time of their CC procedure was 0-57 years. The c-Group (17%) was comprised of seven females and four males (age at the time of their CC procedure, 1-43 years), and the nc-Group (83%) was comprised of 18 females and 36 males (age at the time of their CC procedure, 0-57 years). Mann-Whitney U-tests (p = 0.002) and univariate logistic regression analysis (p = 0.001) showed a significant difference in pneumocephalus between the groups. CONCLUSION Postoperative pneumocephalus identified on a computed tomography scan is a risk factor for post-CC chemical meningitis.
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