Stereotactic laser ablation for completion corpus callosotomy

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OBJECTIVE

Completion corpus callosotomy can offer further remission from disabling seizures when a prior partial corpus callosotomy has failed and residual callosal tissue is identified on imaging. Traditional microsurgical approaches to section residual fibers carry risks associated with multiple craniotomies and the proximity to the medially oriented motor cortices. Laser interstitial thermal therapy (LITT) represents a minimally invasive approach for the ablation of residual fibers following a prior partial corpus callosotomy. Here, the authors report clinical outcomes of 6 patients undergoing LITT for completion corpus callosotomy and characterize the radiological effects of ablation.

METHODS

A retrospective clinical review was performed on a series of 6 patients who underwent LITT completion corpus callosotomy for medically intractable epilepsy at Stanford University Medical Center and Lucile Packard Children’s Hospital at Stanford between January 2015 and January 2018. Detailed structural and diffusion-weighted MR images were obtained prior to and at multiple time points after LITT. In 4 patients who underwent diffusion tensor imaging (DTI), streamline tractography was used to reconstruct and evaluate tract projections crossing the anterior (genu and rostrum) and posterior (splenium) parts of the corpus callosum. Multiple diffusion parameters were evaluated at baseline and at each follow-up.

RESULTS

Three pediatric (age 8–18 years) and 3 adult patients (age 30–40 years) who underwent completion corpus callosotomy by LITT were identified. Mean length of follow-up postoperatively was 21.2 (range 12–34) months. Two patients had residual splenium, rostrum, and genu of the corpus callosum, while 4 patients had residual splenium only. Postoperative complications included asymptomatic extension of ablation into the left thalamus and transient disconnection syndrome. Ablation of the targeted area was confirmed on immediate postoperative diffusion-weighted MRI in all patients. Engel class I–II outcomes were achieved in 3 adult patients, whereas all 3 pediatric patients had Engel class III–IV outcomes. Tractography in 2 adult and 2 pediatric patients revealed time-dependent reduction of fractional anisotropy after LITT.

CONCLUSIONS

LITT is a safe, minimally invasive approach for completion corpus callosotomy. Engel outcomes for completion corpus callosotomy by LITT were similar to reported outcomes of open completion callosotomy, with seizure reduction primarily observed in adult patients. Serial DTI can be used to assess the presence of tract projections over time but does not classify treatment responders or nonresponders.

ABBREVIATIONS AD = axial diffusivity; ADC = apparent diffusion coefficient; AED = antiepileptic drug; AFQ = Automated Fiber Quantitation; dMRI = diffusion MRI; DTI = diffusion tensor imaging; FA = fractional anisotropy; LGS = Lennox-Gastaut syndrome; LITT = laser interstitial thermal therapy; MD = mean diffusivity; RD = radial diffusivity; ROI = region of interest; VNS = vagal nerve stimulator.

Article Information

Correspondence Gerald A. Grant: Stanford University School of Medicine, Stanford, CA. ggrant2@stanford.edu.

INCLUDE WHEN CITING Published online August 2, 2019; DOI: 10.3171/2019.5.PEDS19117.

Y.H. and D.Y. contributed equally to this work. C.H.H. and G.A.G. share senior authorship of this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Representative trajectories for rostral/genu and splenial targets (A and B). A: T1-weighted imaging showing probe trajectory reaching the splenium of the corpus callosum. B: T1-weighted imaging showing probe trajectory reaching the rostrum/genu of the corpus callosum. Extension of laser ablation into the left postero-medial thalamus (C and D). C: T2-weighted FLAIR imaging showing evidence of ablation and small extension into the left thalamus. D: T2-weighted FLAIR imaging 3.5 months postoperatively showing resolution of the prior FLAIR signal in the thalamus. Real-time ablation dynamics (E and F). E: Temperature dynamic during the first burn indicating extension into the posterior-thalamic region. The ablation was immediately stopped and the laser catheter was pulled back. F: Temperature dynamic during the second burn indicating the posterior-thalamic region was no longer at risk. Figure is available in color online only.

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    Time-dependent effect of laser ablation. One day postsurgery, laser ablation changes are present on diffusion-weighted imaging in the expected splenial and/or rostral/genu corpus callosum. One month or longer postsurgery, previously seen abnormal signal associated with laser ablation is attenuated.

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    Effect of laser ablation on DTI fiber tracking. Tractography shows robust crossing fiber projections in the splenium and/or the rostrum of the corpus callosum prior to surgery. One day postsurgery, residual crossing fiber projections were seen, although more attenuated in appearance compared to MRI prior to surgery. In patient 1 fiber projections could not be performed on postoperative day 1. After 1 month or more, more attenuated appearance of the fiber projections was observed for patients 5 and 6. Patient 1 demonstrated some residual fiber projections. Patient 4 did not have additional DTI data after the first scan on postoperative day 1. Figure is available in color online only.

  • View in gallery

    Diffusion parameters in the transected corpus callosum. Left: FA shows marked decrease 1 day postsurgery and further decrease 1 month or more after surgery. Patient 4 (pat04) did not have additional DTI data after the first scan on postoperative day 1. Right: ADC remains nearly normal 1 day postsurgery and appears to diverge 1 month or more after surgery. Two patients showed increases in ADC while one patient showed a small decrease in ADC. pre = preoperative.

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