Hypothalamic hamartomas: Optimal approach to clinical evaluation and diagnosis

Abstract

Summary Hypothalamic hamartomas (HHs) present a difficult medical problem, manifested by gelastic seizures, which are often medically intractable. Although existing techniques offer modest surgical outcomes with the potential for significant morbidity, the relatively novel technique of magnetic resonance imaging (MRI)–guided stereotactic laser ablation (SLA) offers a potentially safer, minimally invasive method with high efficacy for the HH treatment. We report here on 14 patients with medically refractory gelastic epilepsy who underwent stereotactic frame–based placement of an MR‐compatible laser catheter (1.6 mm diameter) through a 3.2‐mm twist drill hole. A U.S. Food and Drug Administration (FDA)–cleared laser surgery system (Visualase, Inc.) was utilized to ablate the HH, using real‐time MRI thermometry. Seizure freedom was obtained in 12 (86%) of 14 cases, with mean follow‐up of 9 months. There were no permanent surgical complications, neurologic deficits, or neuroendocrine disturbances. One patient had a minor subarachnoid hemorrhage that was asymptomatic. Most patients were discharged home within 1 day. SLA was demonstrated to be a safe and effective minimally invasive tool in the ablation of epileptogenic HH. Because use of SLA for HH is being adopted by other medical centers, further data will be acquired to help treat this difficult disorder.

Magnetic Resonance Imaging-Guided Laser Interstitial Thermal Therapy for Treatment of Drug-Resistant Epilepsy

“…The group at Texas Children's Hospital reported the outcome of the largest cases in literature to date, with 14 patients [33]. MR-guided stereotatic laser ablation resulted in 12 of 14 (86%) patients with HH becoming seizure-free at a mean follow-up of 9 months.…”

Magnetic resonance imaging–guided laser interstitial thermal therapy for previously treated hypothalamic hamartomas

“…Early reports of MRg-LITT have indicated preliminary safety and efficacy in the treatment of recurrent primary and metastatic tumors, 2,8,9,19,23 mesial temporal lobe epilepsy, 27 and other epileptic foci 3,8 including HHs and periventricular nodular heterotopias. 5,26 Furthermore, MRg-LITT may offer the possibility of another less invasive option for epilepsy surgery and in this case will significantly limit approachrelated morbidity. 18,25 Careful approach planning is also critical to minimize morbidity, especially with hypothalamic and other deep lesions.…”

“…26 Their patients' ages ranged from 22 months to 20 years with a 90% seizure-free rate at 6 months (among 10 patients with adequate follow-up and with 1 retreatment) and no permanent surgical morbidity. Five of these pediatric patients had undergone previous methods of treatment, including SRS and microsurgical resection.…”

Surgical advancements in pediatric epilepsy surgery: from the mysterious to the minimally invasive

“…The stereotactic placement of cooled lasers of different sizes, followed by ablation of the epileptogenic zone monitored in real-time using MR thermography, has demonstrated promising efficacy in the management of deep epileptic foci in children such as hypothalamic hamartomas (12). LITT is now being used to treat a variety of epileptic lesions in children (13). Previously, minimally invasive diagnostics like SEEG were uncoupled with minimally invasive treatment approaches such as LITT.…”