Laser ablation for mesial temporal lobe epilepsy: Surgical and cognitive outcomes with and without mesial temporal sclerosis

Donos, Cristian; Breier, Joshua I.; Friedman, Elliott; Rollo, Patrick S.; Johnson, Jessica; Moss, Lauren; Thompson, Stephen A.; Thomas, Melissa S.; Hope, Omotola A; Slater, J. D. H.; Tandon, Nitin

doi:10.1111/epi.14443

Cited by 112 publications

(93 citation statements)

References 51 publications

(106 reference statements)

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“…[3][4][5][6][8][9][10][11][12] Unfortunately, without consideration of specific therapy location, which is subject to variability in patient anatomy and the surgery itself, these studies are limited in their ability to reliably report clinical outcomes. [3][4][5][6][8][9][10][11][12] Unfortunately, without consideration of specific therapy location, which is subject to variability in patient anatomy and the surgery itself, these studies are limited in their ability to reliably report clinical outcomes.…”

Section: Discussionmentioning

confidence: 99%

Effects of surgical targeting in laser interstitial thermal therapy for mesial temporal lobe epilepsy: A multicenter study of 234 patients

et al. 2019

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Objective Laser interstitial thermal therapy (LITT) for mesial temporal lobe epilepsy (mTLE) has reported seizure freedom rates between 36% and 78% with at least 1 year of follow‐up. Unfortunately, the lack of robust methods capable of incorporating the inherent variability of patient anatomy, the variability of the ablated volumes, and clinical outcomes have limited three‐dimensional quantitative analysis of surgical targeting and its impact on seizure outcomes. We therefore aimed to leverage a novel image‐based methodology for normalizing surgical therapies across a large multicenter cohort to quantify the effects of surgical targeting on seizure outcomes in LITT for mTLE. Methods This multicenter, retrospective cohort study included 234 patients from 11 centers who underwent LITT for mTLE. To investigate therapy location, all ablation cavities were manually traced on postoperative magnetic resonance imaging (MRI), which were subsequently nonlinearly normalized to a common atlas space. The association of clinical variables and ablation location to seizure outcome was calculated using multivariate regression and Bayesian models, respectively. Results Ablations including more anterior, medial, and inferior temporal lobe structures, which involved greater amygdalar volume, were more likely to be associated with Engel class I outcomes. At both 1 and 2 years after LITT, 58.0% achieved Engel I outcomes. A history of bilateral tonic‐clonic seizures decreased chances of Engel I outcome. Radiographic hippocampal sclerosis was not associated with seizure outcome. Significance LITT is a viable treatment for mTLE in patients who have been properly evaluated at a comprehensive epilepsy center. Consideration of surgical factors is imperative to the complete assessment of LITT. Based on our model, ablations must prioritize the amygdala and also include the hippocampal head, parahippocampal gyrus, and rhinal cortices to maximize chances of seizure freedom. Extending the ablation posteriorly has diminishing returns. Further work is necessary to refine this analysis and define the minimal zone of ablation necessary for seizure control.

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Section: Discussionmentioning

confidence: 99%

Effects of surgical targeting in laser interstitial thermal therapy for mesial temporal lobe epilepsy: A multicenter study of 234 patients

et al. 2019

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“…Whereas Kang et al found no statistically significant difference in total ablated volume between seizure‐free and non–seizure‐free patients among their 14 MTS patients, nor of specific structures including hippocampus, amygdala, entorhinal cortex, parahippocampal gyrus, and fusiform gyrus, Jermakowicz et al found that there was a significant correlation between volume of ablation of the mesial hippocampus (but not total ablation volume) and seizure outcome . The best results were recently reported by Donos et al; 79.5% of 39 patients were free of disabling seizures at 6‐month follow‐up, with continued 67.4% at 20.3 ± 13.8 (SD) months . Could this be related to volumes of structures ablated?…”

Section: What Is To Be Learned About “Optimal Extent” From Laser Ablamentioning

confidence: 94%

Tracking a changing paradigm and the modern face of epilepsy surgery: A comprehensive and critical review on the hunt for the optimal extent of resection in mesial temporal lobe epilepsy

et al. 2019

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Surgical management of medically intractable epilepsy was historically based on the premise of excising the presumed substrate of disease, that is, “the epileptogenic zone.” There was early interest in establishing the extent of resection of the temporal lobe that optimized postoperative reduction in seizure burden while preserving neurocognitive function. Studies approaching this question used varied methods of defining and measuring “extent,” complicating the task of distilling evidence‐based recommendations for surgical practice. A palpable shift in the paradigm of surgical epilepsy has gained traction and greatly altered not only the kind of studies being undertaken but the focus of inquiry itself. Key to this paradigm shift has been the increasingly well‐held notion that epilepsy, far from being a disease of a single problem focus, is rather a disease of a problem network. Where a former generation of investigators labored to find an optimal extent of resection, concentrating on magnetic resonance imaging–visible lesions and on standardization of the extent of resection (ie, “standard temporal lobectomy”), the modern strategy is more concerned with understanding network activation and its concordance with presurgical clinical and electrophysiological features and the organization of epileptic activity over time. The vital lessons of the early literature investigating optimal extent of resection, however, remain informative to the field, and it is worthwhile to contextualize them within the modern network‐focused paradigm. In this comprehensive review of the literature, we aim to recapitulate the major findings of the “optimal extent of resection” literature (focusing on both seizure control and neuropsychological outcomes) and distill wherever possible the consensus findings that may guide surgical approach to epileptic disease of the temporal lobe. We also review the particular implications of modern laser ablation techniques on the question of “optimal extent of resection” in temporal lobe epilepsy, and contextualize them as a marker of a shifting paradigm.

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“…This suggests a complex correlation that may be affected by other, as yet undefined, ablation parameters as well as patient selection. Furthermore, the total ablation volume of the hippocampal ablation does not correlate with seizure‐freedom rate, despite correction for preoperative anatomic volume . The extent of hippocampal resection in the open surgical literature has also failed to show a significant correlation with seizure‐freedom rates in MTLE .…”

Section: Discussionmentioning

confidence: 95%

“…Single‐center case series report that LITT for MTLE is a safe and effective first‐line alternative to open temporal lobe surgery in cases of mesial temporal sclerosis or where mesial temporal seizure onset has been proven by SEEG . A recent meta‐analysis of LITT for MTLE has suggested an overall seizure freedom rate of 50% at 12‐36 months, rising to 62% when considering “lesional” cases only .…”

Section: Discussionmentioning

confidence: 99%

“…Laser interstitial thermal therapy (LITT) is a novel minimally invasive technique for performing highly selective ablations within the brain and spine . Contemporary series of LITT for mesial temporal lobe epilepsy (MTLE) have reported seizure‐freedom rates comparable to those for open neurosurgical resection, with some centers now offering this as first‐line treatment . The highly selective nature of the thermal ablation has also been suggested to result in less neuropsychological deficit as a consequence of limiting damage to collateral brain structures .…”

Section: Introductionmentioning

confidence: 99%

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Multicenter validation of automated trajectories for selective laser amygdalohippocampectomy

Vakharia

Sparks

et al. 2019

Epilepsia

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Objective Laser interstitial thermal therapy (LITT) is a novel minimally invasive alternative to open mesial temporal resection in drug‐resistant mesial temporal lobe epilepsy (MTLE). The safety and efficacy of the procedure are dependent on the preplanned trajectory and the extent of the planned ablation achieved. Ablation of the mesial hippocampal head has been suggested to be an independent predictor of seizure freedom, whereas sparing of collateral structures is thought to result in improved neuropsychological outcomes. We aim to validate an automated trajectory planning platform against manually planned trajectories to objectively standardize the process. Methods Using the EpiNav platform, we compare automated trajectory planning parameters derived from expert opinion and machine learning to undertake a multicenter validation against manually planned and implemented trajectories in 95 patients with MTLE. We estimate ablation volumes of regions of interest and quantify the size of the avascular corridor through the use of a risk score as a marker of safety. We also undertake blinded external expert feasibility and preference ratings. Results Automated trajectory planning employs complex algorithms to maximize ablation of the mesial hippocampal head and amygdala, while sparing the parahippocampal gyrus. Automated trajectories resulted in significantly lower calculated risk scores and greater amygdala ablation percentage, whereas overall hippocampal ablation percentage did not differ significantly. In addition, estimated damage to collateral structures was reduced. Blinded external expert raters were significantly more likely to prefer automated to manually planned trajectories. Significance Retrospective studies of automated trajectory planning show much promise in improving safety parameters and ablation volumes during LITT for MTLE. Multicenter validation provides evidence that the algorithm is robust, and blinded external expert ratings indicate that the trajectories are clinically feasible. Prospective validation studies are now required to determine if automated trajectories translate into improved seizure freedom rates and reduced neuropsychological deficits.

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Laser ablation for mesial temporal lobe epilepsy: Surgical and cognitive outcomes with and without mesial temporal sclerosis

Cited by 112 publications

References 51 publications

Effects of surgical targeting in laser interstitial thermal therapy for mesial temporal lobe epilepsy: A multicenter study of 234 patients

Effects of surgical targeting in laser interstitial thermal therapy for mesial temporal lobe epilepsy: A multicenter study of 234 patients

Tracking a changing paradigm and the modern face of epilepsy surgery: A comprehensive and critical review on the hunt for the optimal extent of resection in mesial temporal lobe epilepsy

Multicenter validation of automated trajectories for selective laser amygdalohippocampectomy

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