Laser interstitial thermal therapy: A first line treatment for seizures due to hypothalamic hamartoma?

Abstract

Successful treatment of hypothalamic hamartoma (HH) can result in the resolution of its sequelae including epilepsy and rage attacks. Risks and morbidity of open surgical management of this lesion have motivated the development of laser interstitial thermal therapy (LITT) as a less invasive treatment approach to the disease. Although overall morbidity and risk would appear to be lower, complications related to LITT therapy have been reported, and the longer-term follow-up that is now possible after initial experience helps address the question of whether LITT provides equivalent efficacy compared to other treatment options. We conducted a retrospective analysis of clinical outcomes in eight patients undergoing LITT for HH at our center using the Visualase/Medtronic device. Five patients had refractory epilepsy, one had rage attacks, and two had both. We also compared the published seizure-free outcomes over time and the complication rates for different interventional approaches to the treatment of epilepsy due to HH including open craniotomy, neuroendoscopic, radiosurgical, and radiofrequency approaches. With a mean follow-up of 19.1 months in our series of eight patients, six of seven epilepsy patients achieved seizure freedom, whereas the one patient with rage attacks only did not have improvement of his symptoms. A length of hospital stay of 2.6 days reflects low morbidity and rapid postoperative recuperation with LITT. Considering other reported series and case reports, the overall published seizure freedom rate of 21 of 25 patients is superior to published outcomes of HH cases treated by stereotactic radiosurgery (SRS), craniotomy, or neuroendoscopy, and comparable to radiofrequency ablation. The cumulative experience of our center with other published series supports relatively lower operative morbidity than more invasive approaches and efficacy that is as good or better than open craniotomy procedures and SRS. Although morbidity appears to be lower than other open approaches, complications related to LITT and their avoidance should be considered carefully.

Subcentimeter epilepsy surgery targets by resting state functional magnetic resonance imaging can improve outcomes in hypothalamic hamartoma

“…There were no surgical side effects in either group, as assessed by a treating neurologist’s examination, endocrinological testing, and postoperative neuropsychiatric assessment. In comparison with the total participants in this study (both RS and CS groups), all prior surgical reports had equal or higher permanent surgical morbidity …”

“…To further verify that the current study’s method is an improvement over non–rs‐fMRI‐guided surgery, the outcomes were compared to all prior studies in the literature with at least four patients, 6 months of postoperative observation, and a minimum outcome of 75% seizure freedom rate (Table ) . The improvement in Engel class I outcomes present in the current study is 92% versus 76%‐81% in the prior studies.…”

“…In HH, modern and less‐invasive surgical methods, such as stereotactic laser ablation (SLA), have improved surgical morbidity, mortality, and seizure freedom ranging from 66% to 81% . Despite this improvement, there remains significant and permanent morbidity in postsurgical HH cases reportedly as high as 20% .…”

Hypothalamic hamartomas in adulthood: Clinical spectrum and treatment outcome—A unicenter experience

“…Good result (Engel class I or II) was achieved in 68.8% of the patients in terms of seizure control and none of the patients showed cognitive decline or disabling endocrinological deficits after treatment (Burrows et al, ). The latest surgical approach for HH associated with refractory epilepsy is the magnetic resonance imaging‐guided laser interstitial thermal therapy (MRg‐LITT), which offers the advantage of real‐time imaging of direct thermal ablation with minimal major surgical complications (Du, Gandhi, Rekate, & Mehta, ).…”

Achieving a cure for hypothalamic hamartomas: a Sisyphean quest?

“…29 More precise understanding of the anatomic location and extent of the HH is turning out to be increasingly crucial. First, the large spectrum of clinical and radiologic variability of patient presentation 20,39 needs to be addressed, with more attention 40 to better personalize the prediction of natural evolution and to better tailor the therapeutic strategy. Second, the precise location of the HH is suspected to influence the propagation and thus the topology of the epileptic network, particularly the relationship to the mammillary bodies 32,33 and posterior hypothalamus.…”