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Mayur Sharma, Tyler Ball, Ahmad Alhourani, Beatrice Ugiliweneza, Dengzhi Wang, Maxwell Boakye, and Joseph S. Neimat

OBJECTIVE

Surgery for medically refractory epilepsy (RE) is an underutilized treatment modality, despite its efficacy. Laser interstitial thermal therapy (LITT), which is minimally invasive, is increasingly being utilized for a variety of brain lesions and offers comparable seizure outcomes. The aim of this study was to report the national trends of open surgical procedures for RE with the advent of LITT.

METHODS

Data were extracted using the ICD-9/10 codes from the Nationwide Inpatient Sample (NIS, 2012–2016) in this retrospective study. Patients with a primary diagnosis of RE who underwent either open surgeries (lobectomy, partial lobectomy, and amygdalohippocampectomy) or LITT were included. Patient demographics, complications, hospital length of stay (LOS), discharge disposition, and index hospitalization costs were analyzed. Propensity score matching (PSM) was used to analyze outcomes.

RESULTS

A cohort of 128,525 in-hospital patients with RE was included and 5.5% (n = 7045) of these patients underwent either open surgical procedures (94.3%) or LITT (5.7%). LITT is increasingly being performed at a rate of 1.09 per 1000 epilepsy admissions/year, while open surgical procedures are decreasing at a rate of 10.4/1000 cases/year. The majority of procedures were elective (92%) and were performed at large-bed-size hospitals (86%). All LITT procedures were performed at teaching facilities and the majority were performed in the South (37%) and West (30%) regions. The median LOS was 1 day for the LITT cohort and 4 days for the open cohort. Index hospitalization charges were significantly lower following LITT compared to open procedures ($108,332 for LITT vs $124,012 for open surgery, p < 0.0001). LITT was associated with shorter median LOS, high likelihood of discharge home, and lower median index hospitalization charges compared to open procedures for RE on PSM analysis.

CONCLUSIONS

LITT is increasingly being performed in favor of open surgical procedures. LITT is associated with a shorter LOS, a higher likelihood of being discharged home, and lower index hospitalization charges compared to open procedures. LITT is a safe treatment modality in carefully selected patients with RE and offers an opportunity to increase the utilization of surgical treatment in patients who may be opposed to open surgery or have contraindications that preclude open surgery.

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Guozhen Luo, Brent D. Cameron, Li Wang, Hong Yu, Joseph S. Neimat, Peter Hedera, Fenna Phibbs, Elise B. Bradley, Anthony J. Cmelak, and Austin N. Kirschner

OBJECTIVE

Stereotactic radiosurgery (SRS) treats severe, medically refractory essential tremor and tremor-dominant Parkinson disease. However, the optimal target for SRS treatment within the thalamic ventral intermediate nucleus (VIM) is not clearly defined. This work evaluates the precision of the physician-selected VIM target, and determines the optimal SRS target within the VIM by correlation between early responders and nonresponders.

METHODS

Early responders and nonresponders were assessed retrospectively by Elements Basal Ganglia Atlas autocontouring of the VIM on the pre–SRS-treatment 1-mm slice thickness T1-weighted MRI and correlating the center of the post–SRS-treatment lesion. Using pre- and posttreatment diffusion tensor imaging, the fiber tracking package in the Elements software generated tremor-related tracts from autosegmented motor cortex, thalamus, red nucleus, and dentate nucleus. Autocontouring of the VIM was successful for all patients.

RESULTS

Among 23 patients, physician-directed SRS targets had a medial–lateral target range from +2.5 mm to −2.0 mm from the VIM center. Relative to the VIM center, the SRS isocenter target was 0.7–0.9 mm lateral for 6 early responders and 0.9–1.1 mm medial for 4 nonresponders (p = 0.019), and without differences in the other dimensions: 0.2 mm posterior and 0.6 mm superior. Dose–volume histogram analyses for the VIM had no significant differences between responders and nonresponders between 20 Gy and 140 Gy, mean or maximum dose, and dose to small volumes. Tractography data was obtained for 4 patients.

CONCLUSIONS

For tremor control in early responders, the Elements Basal Ganglia Atlas autocontour for the VIM provides the optimal SRS target location that is 0.7–0.9 mm lateral to the VIM center.

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Michael C. Dewan, Robert Shults, Andrew T. Hale, Vishad Sukul, Dario J. Englot, Peter Konrad, Hong Yu, Joseph S. Neimat, William Rodriguez, Benoit M. Dawant, Srivatsan Pallavaram, and Robert P. Naftel

OBJECTIVE

Stereotactic electroencephalography (SEEG) is being used with increasing frequency to interrogate subcortical, cortical, and multifocal epileptic foci. The authors describe a novel technique for SEEG in patients with suspected epileptic foci refractory to medical management.

METHODS

In the authors’ technique, standard epilepsy evaluation and neuroimaging are used to create a hypothesis-driven SEEG plan, which informs the 3D printing of a novel single-path, multiple-trajectory, omnidirectional platform. Following skull-anchor platform fixation, electrodes are sequentially inserted according to the preoperative plan. The authors describe their surgical experience and technique based on a review of all cases, adult and pediatric, in which patients underwent invasive epilepsy monitoring via SEEG during an 18-month period at Vanderbilt University Medical Center. Platform and anatomical variables influencing localization error were evaluated using multivariate linear regression.

RESULTS

Using this novel technology, 137 electrodes were inserted in 15 patients with focal epilepsy with favorable recording results and no clinical complications. The mean entry point localization error was 1.42 mm (SD 0.98 mm), and the mean target point localization error was 3.36 mm (SD 2.68 mm). Platform distance, electrode trajectory angle, and intracranial distance, but not skull thickness, were independently associated with localization error.

CONCLUSIONS

The multiple-trajectory, single-path, omnidirectional platform offers satisfactory accuracy and favorable clinical results, while avoiding cumbersome frames and prohibitive up-front costs associated with other SEEG technologies.