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Nicholas J. Brandmeir, James McInerney and Brad E. Zacharia

Over the last several years, laser interstitial thermotherapy (LITT) has gained wide acceptance for the treatment of a myriad of cranial lesions. A wide variety of techniques for placement of the laser fiber have been reported with a spectrum of perceived benefits and drawbacks. The authors present the first report of a customized 3D printed stereotactic frame for LITT.

Approximately 1 week prior to surgery, 3–4 skull fiducials were placed after each of 5 patients received a local anesthetic as an outpatient. Radiographs with these fiducials were then used to create a trajectory to the lesion that would be treated with LITT. After the plan was completed, software was used to render a customized frame. On the day of surgery, the frame was attached to the implanted skull fiducials and the LITT catheter was placed. This procedure was carried out in 5 consecutive patients. In 2 patients, a needle biopsy was also performed.

Intraoperative and postoperative imaging studies confirmed the accurate placement of the LITT catheter and the lesion created. Mean operating room time for all patients was 45 minutes but only 26 minutes when excluding the cases in which a biopsy was performed.

To the best of the authors' knowledge, this is the first report of the use of a specific system, the STarFix microTargeting system, for use with LITT and brain biopsy. This system offers several advantages including fast operating times, extensive preoperative planning, no need for cranial fixation, and no need for frame or fiducial placement on the day of surgery. The accuracy of the system combined with these advantages may make this a preferred stereotactic method for LITT, especially in centers where LITT is performed in a diagnostic MRI suite.

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Michael Glantz and Nicholas Brandmeir

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Richard L. Nolan, Nicholas Brandmeir, Eric S. Tucker, John L. Magruder, Mark R. Lee, Gang Chen and James W. Lewis

The object of this study was to extensively characterize a region of periventricular nodular heterotopia (PVNH) in an epilepsy patient to reveal its possible neurocognitive functional role(s). The authors used 3-T MRI approaches to exhaustively characterize a single, right hemisphere heterotopion in a high-functioning adult male with medically responsive epilepsy, which had manifested during late adolescence. The heterotopion proved to be spectroscopically consistent with a cortical-like composition and was interconnected with nearby ipsilateral cortical fundi, as revealed by fiber tractography (diffusion-weighted imaging) and resting-state functional connectivity MRI (rsfMRI). Moreover, the region of PVNH demonstrated two novel characterizations for a heterotopion. First, functional MRI (fMRI), as distinct from rsfMRI, showed that the heterotopion was significantly modulated while the patient watched animated video scenes of biological motion (i.e., cartoons). Second, rsfMRI, which demonstrated correlated brain activity during a task-negative state, uniquely showed directionality within an interconnected network, receiving positive path effects from patent cortical and cerebellar foci while outputting only negative path effects to specific brain foci.

These findings are addressed in the context of the impact on noninvasive presurgical brain mapping strategies for adult and pediatric patient workups, as well as the impact of this study on an understanding of the functional cortical architecture underlying cognition from a neurodiversity and evolutionary perspective.

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Elsa V. Arocho-Quinones, Sean M. Lew, Michael H. Handler, Zulma Tovar-Spinoza, Matthew Smyth, Robert Bollo, David Donahue, M. Scott Perry, Michael L. Levy, David Gonda, Francesco T. Mangano, Phillip B. Storm, Angela V. Price, Daniel E. Couture, Chima Oluigbo, Ann-Christine Duhaime, Gene H. Barnett, Carrie R. Muh, Michael D. Sather, Aria Fallah, Anthony C. Wang, Sanjiv Bhatia, Kadam Patel, Sergey Tarima, Sarah Graber, Sean Huckins, Daniel M. Hafez, Kavelin Rumalla, Laurie Bailey, Sabrina Shandley, Ashton Roach, Erin Alexander, Wendy Jenkins, Deki Tsering, George Price, Antonio Meola, Wendi Evanoff, Eric M. Thompson, Nicholas Brandmeir and the Pediatric Stereotactic Laser Ablation Workgroup

OBJECTIVE

This study aimed to assess the safety and efficacy of MR-guided stereotactic laser ablation (SLA) therapy in the treatment of pediatric brain tumors.

METHODS

Data from 17 North American centers were retrospectively reviewed. Clinical, technical, and radiographic data for pediatric patients treated with SLA for a diagnosis of brain tumor from 2008 to 2016 were collected and analyzed.

RESULTS

A total of 86 patients (mean age 12.2 ± 4.5 years) with 76 low-grade (I or II) and 10 high-grade (III or IV) tumors were included. Tumor location included lobar (38.4%), deep (45.3%), and cerebellar (16.3%) compartments. The mean follow-up time was 24 months (median 18 months, range 3–72 months). At the last follow-up, the volume of SLA-treated tumors had decreased in 80.6% of patients with follow-up data. Patients with high-grade tumors were more likely to have an unchanged or larger tumor size after SLA treatment than those with low-grade tumors (OR 7.49, p = 0.0364). Subsequent surgery and adjuvant treatment were not required after SLA treatment in 90.4% and 86.7% of patients, respectively. Patients with high-grade tumors were more likely to receive subsequent surgery (OR 2.25, p = 0.4957) and adjuvant treatment (OR 3.77, p = 0.1711) after SLA therapy, without reaching significance. A total of 29 acute complications in 23 patients were reported and included malpositioned catheters (n = 3), intracranial hemorrhages (n = 2), transient neurological deficits (n = 11), permanent neurological deficits (n = 5), symptomatic perilesional edema (n = 2), hydrocephalus (n = 4), and death (n = 2). On long-term follow-up, 3 patients were reported to have worsened neuropsychological test results. Pre-SLA tumor volume, tumor location, number of laser trajectories, and number of lesions created did not result in a significantly increased risk of complications; however, the odds of complications increased by 14% (OR 1.14, p = 0.0159) with every 1-cm3 increase in the volume of the lesion created.

CONCLUSIONS

SLA is an effective, minimally invasive treatment option for pediatric brain tumors, although it is not without risks. Limiting the volume of the generated thermal lesion may help decrease the incidence of complications.