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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*,‡,‖,#

doi: 10.1227/NEU.0000000000000343
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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

Departments of *Neurosurgery,

Neurology,

§Pathology, and

Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia;

Interventional MRI Program, Emory University Hospital, Atlanta, Georgia;

#Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia;

**Department of Neurology, University of Washington School of Medicine, Seattle, Washington;

††Visualase, Inc., Houston, Texas

Correspondence: Robert E. Gross, MD, PhD, Department of Neurosurgery, Emory University School of Medicine, 1365 Clifton Road, NE, Suite 6200, Atlanta, GA 30322. E-mail: rgross@emory.edu

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.neurosurgery-online.com).

Received August 31, 2013

Accepted February 18, 2014

Copyright © by the Congress of Neurological Surgeons