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Neurology Today Conference Reporter: AES Annual Meeting

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Thursday, December 6, 2018

Laser Ablation Outcomes Are Positive for Children with Hypothalamic Hamartoma

BY THOMAS R. COLLINS

NEW ORLEANS—Two-thirds of children who underwent laser ablation surgery for hypothalamic hamartoma (HH) emerged from one or more surgeries seizure-free, according to a presentation here at the American Epilepsy Society annual meeting.

The findings add to solid results that have been reported for an approach already regarded as a top choice for children with HH, a disorder characterized by non-neoplastic developmental malformations and associated with gelastic seizures, secondary epileptogenesis, and refractory epilepsy.

"This [option] should be considered; however, it will never be the only choice," said presenter Irfan Ali, MD, professor of neurophysiology at Baylor University.

Researchers did a retrospective review of the medical records of 44 patients with HH and refractory epilepsy who were referred to Texas Children's Hospital from 2012 to 2016. All of the patients underwent magnetic resonance imaging-guided stereotactic laser ablation.

All of the children — ages 10 months to 19 years old — had gelastic seizures, and some also had other seizure types: focal seizures (17) with impaired awareness; tonic seizures (five); myoclonic seizures (two); myoclonic-tonic seizures or spasms (two); and generalized tonic-clonic seizures (two).

Researchers found that seizures stopped in 61 percent of the patients and were significantly reduced in another 7 percent. Seizure frequency decreased in all of the patients. Post-surgery morbidity was minimal, with hospital stays averaging 1.6 days.

Researchers said there was no link between outcome and the number of surgeries performed. So additional laser surgeries were effective.

"Some of the children had better control of seizures but were not completely seizure-free," Dr. Ali said. "But once you re-do surgery with another ablation, they [can] become seizure-free."

He said the findings show that laser ablation should be the first option in many cases, since it avoids problems seen with other surgical approaches.

"We definitely have some co-morbidity associated with the open surgery," he said. "Children might lose a year or two before they see cognitive benefits with radiosurgery, for example, costing them important cognitive development time. With laser ablation, we have seen the cognitive effects immediately, and then they build on it."

Other surgery types will also sometimes have to be considered, he cautioned.

Dr. Ali explained that a large tumor may need debulking, and sometimes more than one session with laser ablation may be needed. But, he added, laser ablation can be repeated with less morbidity. "You can get the same results without the risks of open surgery," he said.

Sarah Bandt, MD, assistant professor of neurological surgery at Northwestern University, said laser ablation "has rapidly become the first line treatment option of choice for these lesions" and that these findings can give clinicians and surgeons even more confidence.

"Epilepsy specialists are hopeful that findings like this can bring more attention to surgical treatment options for the management of epilepsy," she said. "Approximately 30 percent of patients living with epilepsy don't achieve seizure freedom with medication alone. Surgery offers potential benefit to many of these patients."

Dr. Bandt offered this caveat, however. "While these preliminary findings are exciting and encouraging, we need to understand more about laser-targeting in patients with large lesions as well as ways to optimize seizure outcome for all patients undergoing this procedure."

Dr. Ali had no disclosures. Dr. Bandt received a stipend from the NFL for consulting work on neurotrauma and from Monteris for travel-related expenses.

LINK UP FOR RELATED INFORMATION

AES Abstract 3.331: Verma S, Ali I, Clarke DF, et al. Hypothalamic hamartoma and MRI-guided stereotactic laser ablation.