Safety and effectiveness of stereotactic laser ablation for epileptogenic cerebral cavernous malformations

Abstract

Summary Objective Magnetic resonance (MR) thermography–guided laser interstitial thermal therapy, or stereotactic laser ablation (SLA), is a minimally invasive alternative to open surgery for focal epilepsy caused by cerebral cavernous malformations (CCMs). We examined the safety and effectiveness of SLA of epileptogenic CCMs. Methods We retrospectively analyzed 19 consecutive patients who presented with focal seizures associated with a CCM. Each patient underwent SLA of the CCM and adjacent cortex followed by standard clinical and imaging follow‐up. Results All but one patient had chronic medically refractory epilepsy (median duration 8 years, range 0.5‐52 years). Lesions were located in the temporal (13), frontal (five), and parietal (one) lobes. CCMs induced magnetic susceptibility artifacts during thermometry, but perilesional cortex was easily visualized. Fourteen of 17 patients (82%) with >12 months of follow‐up achieved Engel class I outcomes, of which 10 (59%) were Engel class IA. Two patients who were not seizure‐free from SLA alone became so following intracranial electrode‐guided open resection. Delayed postsurgical imaging validated CCM involution (median 83% volume reduction) and ablation of surrounding cortex. Histopathologic examination of one previously ablated CCM following open surgery confirmed obliteration. SLA caused no detectable hemorrhages. Two symptomatic neurologic deficits (visual and motor) were predictable, and neither was permanently disabling. Significance In a consecutive retrospective series, MR thermography–guided SLA was an effective alternative to open surgery for epileptogenic CCM. The approach was free of hemorrhagic complications, and clinically significant neurologic deficits were predictable. SLA presents no barrier to subsequent open surgery when needed.

Stereotactic laser interstitial thermal therapy for epilepsy associated with solitary and multiple cerebral cavernous malformations

“…25 In a recent follow-up study of 19 patients with solitary, nonfamilial CCMs from the same center by Willie et al, 14 of 17 (82%) patients with > 12 months of follow-up achieved Engel class I outcomes, of whom 10 of 17 (59%) were Engel IA. 35 The findings in this study are in line with those of McCracken et al and Willie et al 25,35 Overall, 5 of the 6 (83%) patients achieved seizure freedom (Engel I), of whom 4 (67%) were seizure free without auras (Engel IA). One patient was seizure free for > 24 months after a single seizure on postoperative day 4 (Engel IC), and the remaining patient continued to have rare seizures (Engel II).…”

“…No genetic characterization of these patients was reported. 35 Here, we provide complementary evidence for the safety and effectiveness of LITT in a series of 6 patients with distinct clinical and genetic features and over 12 months of postoperative follow-up in an independent epilepsy center. This series is to our knowledge the first investigation of LITT to include patients with multifocal CCM lesions.…”

Surgery for temporal lobe epilepsy

“…Die bisherigen Erfahrungen mit LITT zeigen, dass nach einer zumindest kurzen Beobachtungszeit von 1 bis 2 Jahren bei etwa 60 % der Patienten eine Anfallsfreiheit erreicht werden kann [15,27,28]. Im Hinblick auf das erhoffte bessere kognitive Outcome zeigen Arbeiten, dass LITT Sprachfunktionen und Objekt/Gesichtserkennung besser erhält als resektive Verfahren und dass Patienten v. a. im Hinblick auf das episodische Gedächtnis zu profitieren scheinen [7].…”

Cavernous angiomas: deconstructing a neurosurgical disease

“…7,11,80,101 Recent reports suggest a role for laser fiber ablation of CAs as a potentially promising treatment of associated epilepsy. 104 There are conflicting data on resection of a DVA associated with CA, with most authors advocating DVA preservation to prevent serious complications such as edema, hemorrhage, and/or venous infarctions. 111 In general, a DVA can only be resected if it is very small, or if the brain it drains is also being resected (as in rare cases of modified lobectomies for regional venous dysmorphism and seizures).…”