Ali A. Baaj, Selim R. Benbadis, William O. Tatum and Fernando L. Vale
Vagus nerve stimulation (VNS) plays a significant role in the treatment of intractable epilepsy. The goal of this study was to analyze trends in the use of VNS for epilepsy in the US by using a nationwide database.
Data for patients undergoing VNS were obtained from the nationwide inpatient sample for the years 1998–2005. Trends regarding number of procedures, length of stay (LOS), hospital charges, patient sex, and payer information were retrieved and analyzed.
The number of VNS procedures for epilepsy increased between 1998 and 2003 but decreased in the subsequent 2 years. The LOS and hospital charges showed yearly increases. Female patients underwent VNS implantation more than males did, and most procedures were performed in the 18- to 64-year-old age group. The combination of Medicare and Medicaid provided most of the funding for VNS from 2002 through 2005. The VNS procedures were performed mostly in teaching hospitals.
Trends from a national database reveal consistent use of VNS for intractable epilepsy. Greater use of the procedure appears to be reflected in the female population, and the procedure has been performed most often at tertiary care teaching hospitals, where a comprehensive evaluation for all forms of therapy is arguably best able to target appropriate patients for appropriate therapies. With the recent application of VNS to target populations without epilepsy, such as patients with refractory depression, the trend of continued use of this treatment for epilepsy appears likely.
Karim ReFaey, Kaisorn L. Chaichana, Anteneh M. Feyissa, Tito Vivas-Buitrago, Benjamin H. Brinkmann, Erik H. Middlebrooks, Jake H. McKay, David J. Lankford, Shashwat Tripathi, Elird Bojaxhi, Grayson E. Roth, William O. Tatum and Alfredo Quiñones-Hinojosa
Epilepsy is common among patients with supratentorial brain tumors; approximately 40%–70% of patients with glioma develop brain tumor–related epilepsy (BTRE). Intraoperative localization of the epileptogenic zone during surgical tumor resection (real-time data) may improve intervention techniques in patients with lesional epilepsy, including BTRE. Accurate localization of the epileptogenic signals requires electrodes with high-density spatial organization that must be placed on the cortical surface during surgery. The authors investigated a 360° high-density ring-shaped cortical electrode assembly device, called the “circular grid,” that allows for simultaneous tumor resection and real-time electrophysiology data recording from the brain surface.
The authors collected data from 99 patients who underwent awake craniotomy from January 2008 to December 2018 (29 patients with the circular grid and 70 patients with strip electrodes), of whom 50 patients were matched-pair analyzed (25 patients with the circular grid and 25 patients with strip electrodes). Multiple variables were then retrospectively assessed to determine if utilization of this device provides more accurate real-time data and improves patient outcomes.
Matched-pair analysis showed higher extent of resection (p = 0.03) and a shorter transient motor recovery period during the hospitalization course (by approximately 6.6 days, p ≤ 0.05) in the circular grid patients. Postoperative versus preoperative Karnofsky Performance Scale (KPS) score difference/drop was greater for the strip electrode patients (p = 0.007). No significant difference in postoperative seizures between the 2 groups was present (p = 0.80).
The circular grid is a safe, feasible tool that grants direct access to the cortical surgical surface for tissue resection while simultaneously monitoring electrical activity. Application of the circular grid to different brain pathologies may improve intraoperative epileptogenic detection accuracy and functional outcomes, while decreasing postoperative complications.
Sanjeet S. Grewal, Richard S. Zimmerman, Gregory Worrell, Benjamin H. Brinkmann, William O. Tatum, Amy Z. Crepeau, David A. Woodrum, Krzysztof R. Gorny, Joel P. Felmlee, Robert E. Watson, Joseph M. Hoxworth, Vivek Gupta, Prasanna Vibhute, Max R. Trenerry, Timothy J. Kaufmann, W. Richard Marsh, Robert E. Wharen Jr. and Jamie J. Van Gompel
Although it is still early in its application, laser interstitial thermal therapy (LiTT) has increasingly been employed as a surgical option for patients with mesial temporal lobe epilepsy. This study aimed to describe mesial temporal lobe ablation volumes and seizure outcomes following LiTT across the Mayo Clinic’s 3 epilepsy surgery centers.
This was a multi-site, single-institution, retrospective review of seizure outcomes and ablation volumes following LiTT for medically intractable mesial temporal lobe epilepsy between October 2011 and October 2015. Pre-ablation and post-ablation follow-up volumes of the hippocampus were measured using FreeSurfer, and the volume of ablated tissue was also measured on intraoperative MRI using a supervised spline-based edge detection algorithm. To determine seizure outcomes, results were compared between those patients who were seizure free and those who continued to experience seizures.
There were 23 patients who underwent mesial temporal LiTT within the study period. Fifteen patients (65%) had left-sided procedures. The median follow-up was 34 months (range 12–70 months). The mean ablation volume was 6888 mm3. Median hippocampal ablation was 65%, with a median amygdala ablation of 43%. At last follow-up, 11 (48%) of these patients were seizure free. There was no correlation between ablation volume and seizure freedom (p = 0.69). There was also no correlation between percent ablation of the amygdala (p = 0.28) or hippocampus (p = 0.82) and seizure outcomes. Twelve patients underwent formal testing with computational visual fields. Visual field changes were seen in 67% of patients who underwent testing. Comparing the 5 patients with clinically noticeable visual field deficits to the rest of the cohort showed no significant difference in ablation volume between those patients with visual field deficits and those without (p = 0.94). There were 11 patients with follow-up neuropsychological testing. Within this group, verbal learning retention was 76% in the patients with left-sided procedures and 89% in those with right-sided procedures.
In this study, there was no significant correlation between the ablation volume after LiTT and seizure outcomes. Visual field deficits were common in formally tested patients, much as in patients treated with open temporal lobectomy. Further studies are required to determine the role of amygdalohippocampal ablation.