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Robot-Assisted Stereotactic Laser Ablation in Medically Intractable Epilepsy: Operative Technique

Gonzalez-Martinez, Jorge MD, PhD*; Vadera, Sumeet MD*; Mullin, Jeffrey MD, MBA*; Enatsu, Rei MD*; Alexopoulos, Andreas V. MD, MPH*; Patwardhan, Ravish MD; Bingaman, William MD*; Najm, Imad MD*

Neurosurgery:
doi: 10.1227/NEU.0000000000000286
Operative Technique: Editor's Choice
Editor's Choice
Abstract

BACKGROUND: Stereotactic laser ablation offers an advantage over open surgical procedures for treatment of epileptic foci, tumors, and other brain pathology. Robot-assisted stereotactic laser ablation could offer an accurate, efficient, minimally invasive, and safe method for placement of an ablation catheter into the target.

OBJECTIVE: To determine the feasibility of placement of a stereotactic laser ablation catheter into a brain lesion with the use of robotic assistance, via a safe, accurate, efficient, and minimally invasive manner.

METHODS: A laser ablation catheter (Visualase, Inc) was placed by using robotic guidance (ROSA, Medtech Surgical, Inc) under general anesthesia into a localized epileptogenic periventricular heterotopic lesion in a 19-year-old woman with 10-year refractory focal seizure history. The laser applicator (1.65 mm diameter) position was confirmed by using magnetic resonance imaging (MRI). Ablation using the Visualase system was performed under multiplanar imaging with real-time thermal imaging and treatment estimates in each plane. A postablation MRI sequence (T1 postgadolinium contrast injection) was used to immediately confirm the ablation.

RESULTS: MRI showed accurate skin entry point and trajectory, with the applicator advanced to the lesion's distal boundary. Ablation was accomplished in less than 3 minutes of heating. The overall procedure, from time of skin incision to end of last ablation, was approximately 90 minutes. After confirmation of proper lesioning by using a T1 contrast-enhanced MRI, the applicator was removed, and the incision was closed using a single stitch. No hemorrhage or other untoward complication was visualized. The patient awoke without any complication, was observed overnight after admitting to a regular floor bed, and was discharged to home the following day.

CONCLUSION: This technique, using a combination of Visualase laser ablation, ROSA robot, and intraoperative MRI, facilitated a safe, efficacious, efficient, and minimally invasive approach that could be used for placement of 1 or multiple electrodes in the future.

ABBREVIATIONS: EEG, electroencephalography

SEEG, stereoelectroencephalography

Author Information

*Epilepsy Center, Neuroscience Institute Cleveland Clinic, Cleveland, Ohio;

Visualase Inc, Houston, Texas

Correspondence: Jorge Gonzalez-Martinez, MD, PhD, 9500 Euclid Ave, S6, Cleveland, OH 44195. E-mail: gonzalj1@ccf.org

Received August 13, 2013

Accepted January 02, 2014

Copyright © by the Congress of Neurological Surgeons