MRI-guided laser interstitial thermal therapy in an infant with tuberous sclerosis: technical case report

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Cortical tubers associated with tuberous sclerosis complex (TSC) are potential epileptic foci that are often amenable to resective or ablative surgeries, and controlling seizures at a younger age may lead to improved functional outcomes. MRI-guided laser interstitial thermal therapy (MRgLITT) has become a popular minimally invasive alternative to traditional craniotomy. Benefits of MRgLITT include the ability to monitor the ablation in real time, a smaller incision, shorter hospital stay, reduced blood loss, and reduced postoperative pain. To place the laser probe for LITT, however, stereotaxy is required—which classically involves head fixation with cranial pins. This creates a relative minimum age limit of 2 years old because it demands a mature skull and fused cranial sutures. A novel technique is presented for the application of MRgLITT in a 6-month-old infant for the treatment of epilepsy associated with TSC. To the authors’ knowledge this is the youngest patient treated with laser ablation. The authors used a frameless navigation technique with a miniframe tripod system and intraoperative reference points. This technique expands the application of MRgLITT to younger patients, which may lead to safer surgical interventions and improved outcomes for these children.

ABBREVIATIONS AEDs = antiepileptic drugs; DRE = drug-resistant epilepsy; EEG = electroencephalography; MRgLITT = MRI-guided laser interstitial thermal therapy; TSC = tuberous sclerosis complex.

Article Information

Correspondence Kristopher G. Hooten: Duke University, Durham, NC. kristopher.hooten@neurosurgery.ufl.edu.

INCLUDE WHEN CITING Published online September 28, 2018; DOI: 10.3171/2018.6.PEDS1828.

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.

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Figures

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    Pretreatment axial FLAIR MR image demonstrating a right frontal cortical tuber.

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    Intraoperative setup. Initial surface matching registration was performed and additional intraoperative reference landmarks were placed on the scalp to confirm accuracy of registration during the application of the NeuroBlate AXiiiS miniframe tripod to the infant’s head. Once the laser probe was inserted, the Brainlab frame was removed and the infant was transferred into the intraoperative MRI scanner to confirm accuracy of placement prior to ablation. Careful attention must be paid to avoid disrupting the probe when transferring the patient. Figure is available in color online only.

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    Intraoperative view demonstrating laser located within the lesion. The area of expected ablation at the tuber is outlined in blue. Figure is available in color online only.

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    Left: Immediate posttreatment axial FLAIR MR image demonstrating surrounding edema. Right: Six-month posttreatment axial FLAIR MR image demonstrating lesion ablation.

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