Fornicotomy for the Treatment of Epilepsy: An Examination of Historical Literature in the Setting of Modern Operative Techniques

Abstract

Fornicotomy has been used to treat intractable temporal lobe epilepsy with mixed success historically; however, modern advances in stereotactic, neurosurgical, and imaging techniques offer new opportunities to target the fornix with greater precision and safety. In this review, we discuss the historical uses and quantify the outcomes of fornicotomy for the treatment of temporal lobe epilepsy, highlight the potential mechanisms of benefit, and address what is known about the side effects of the procedure. We find that fornicotomy, with or without anterior commissurotomy, resulted in 61% (83/136) of patients having some seizure control benefit. We discuss the potential operative approaches for targeting the fornix, including laser ablation and the use of focused ultrasound ablation. More work is needed to address the true efficacy of fornicotomy in the modern surgical setting. This review is intended to serve as a framework for developing this approach.

Levetiracetam Suppresses the Infiltration of Neutrophils and Monocytes and Downregulates Many Inflammatory Cytokines during Epileptogenesis in Pilocarpine-Induced Status Epilepticus Mice

“…A prospective observational study showed that LEV is more effective in controlling postoperative seizures than other AEDs [ 43 ]. Kundu et al reported the efficacy of surgical approaches for the treatment of temporal lobe epilepsy [ 44 ]. The historical literature has shown that approximately 60% of patients who undergo fornicotomy, with or without anterior commissurotomy, have some seizure control benefit.…”

Development of an MR-guided focused ultrasound (MRgFUS) lesioning approach for small and deep structures in the rat brain

“…Additionally, magnetic resonance-guided FUS (MRgFUS) combines the superior soft tissue contrast of magnetic resonance imaging (MRI) with magnetic resonance thermometry imaging (MRTI) for real-time temperature monitoring (2,3). MRgFUS is approved by the United States Food and Drug Administration (FDA) to treat neurological disorders, such as essential tremor and Parkinson’s disease (2,3). FUS is advantageous over other modern noninvasive surgical techniques, such as stereotactic radiosurgery, as it does not use ionizing radiation and produces immediate results, enabling real-time feedback from awake patients (1,4).…”

“…Recently, MRgFUS has been used in a Phase 1, open-label clinical trial for drug-resistant epilepsy targeting the anterior nucleus of the thalamus and a reduction in seizures was observed in the two patients in the study (6). While these results are promising, other targets in the circuit of Papez, such as the fornix, may offer alternative approaches with less risk of ablating adjacent tissue (2). Before attempting MRgFUS for alternative targets in human epilepsy, however, the investigation of MRgFUS for use in a preclinical animal model is needed.…”

“…Transcranial high-intensity focused ultrasound (FUS) is a modern noninvasive therapy that uses thermal energy to lesion brain tissue (1). Additionally, magnetic resonance-guided FUS (MRgFUS) combines the superior soft tissue contrast of magnetic resonance imaging (MRI) with magnetic resonance thermometry imaging (MRTI) for real-time temperature monitoring (2,3). MRgFUS is approved by the United States Food and Drug Administration (FDA) to treat neurological disorders, such as essential tremor and Parkinson's disease (2,3).…”

Ultrasonic therapies for seizures and drug-resistant epilepsy

“…The main benefit of MRgFUS for people with DRE, especially TLE, is that now smaller and deeper brain areas, such as the fornix, can be targets, especially when comparing against the current standard of resective surgical treatment, which is a temporal lobectomy (26). MRgFUS has recently been used for DRE to ablate the anterior nucleus of the thalamus in a Phase-1 open-label study in two people with DRE (27).…”