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doi: 10.1227/NEU.0000000000000343
Concepts, Innovations and Techniques: Editor's Choice

Real-Time Magnetic Resonance-Guided Stereotactic Laser Amygdalohippocampotomy for Mesial Temporal Lobe Epilepsy

Willie, Jon T. MD*,‡,‖; Laxpati, Nealen G. BS*,#; Drane, Daniel L. PhD‡,**; Gowda, Ashok PhD††; Appin, Christina MD§; Hao, Chunhai MD§; Brat, Daniel J. MD, PhD§; Helmers, Sandra L. MD; Saindane, Amit MD¶,‖; Nour, Sherif G. MD¶,‖; Gross, Robert E. MD*,‡,‖,#

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Editor's Choice
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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.

ABBREVIATIONS: AHC, amygdalohippocampal complex

ATLAH, anterior temporal lobectomy with amygdalohippocampectomy

DWI, diffusion-weighted imaging

EEG, electroencephalography

FDA, Food and Drug Administration

18FDG, 18-fluorodeoxyglucose

FLAIR, fluid-attenuated inversion recovery

MRTI, magnetic resonance thermal imaging

MTLE, mesial temporal lobe epilepsy

MTS, mesial temporal sclerosis

RF, radiofrequency

SAH, selective amygdalohippocampectomy

SLAH, stereotactic laser amygdalohippocampotomy

SRS, stereotactic radiosurgery

Copyright © by the Congress of Neurological Surgeons


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