Journal
EPILEPSIA
Volume 62, Issue 10, Pages 2344-2356Publisher
WILEY
DOI: 10.1111/epi.17019
Keywords
computer simulation; entorhinal cortex; laser interstitial thermal therapy; medial temporal lobe epilepsy; piriform cortex
Categories
Funding
- NIH Training Grant (NINDS) [T32MH020068]
- Doris Duke Clinical Scientist Development Award [2014101]
- NIH COBRE Award: NIGMS [P20 GM103645]
- Neurosurgery Research and Education Foundation (NREF) grant
- Lifespan Norman Prince Neurosciences Institute
- Brown University Robert J. and Nancy D. Carney Institute for Brain Science
- NIH Office of the Director grant [S10OD025181]
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The study suggests that a two-trajectory approach can improve the ablation of relevant medial temporal lobe structures, potentially leading to excellent seizure outcomes. Initial clinical results show that LITT amygdalohippocampotomy performed via two-laser trajectories may be effective in achieving Engel class I outcomes. Further research is needed to confirm the long-term efficacy and safety of this approach.
Objective Laser interstitial thermal therapy (LITT) for mesial temporal lobe epilepsy (mTLE) is typically performed with one trajectory to target the medial temporal lobe (MTL). MTL structures such as piriform and entorhinal cortex are epileptogenic, but due to their relative geometry, they are difficult to target with one trajectory while simultaneously maintaining adequate ablation of the amygdala and hippocampus. We hypothesized that a two-trajectory approach could improve ablation of all relevant MTL structures. First, we created large-scale computer simulations to compare idealized one- vs two-trajectory approaches. A two-trajectory approach was then validated in an initial cohort of patients. Methods We used magnetic resonance imaging (MRI) from the Human Connectome Project (HCP) to create subject-specific target structures consisting of hippocampus, amygdala, and piriform/entorhinal/perirhinal cortex. An algorithm searched for safe potential trajectories along the hippocampal axis (catheter one) and along the amygdala-piriform axis (catheter two) and compared this to a single trajectory optimized over all structures. The proportion of each structure ablated at various burn radii was evaluated. A cohort of 11 consecutive patients with mTLE received two-trajectory LITT; demographic, operative, and outcome data were collected. Results The two-trajectory approach was superior to the one-trajectory approach at nearly all burn radii for all hippocampal subfields and amygdala nuclei (p < .05). Two-laser trajectories achieved full ablation of MTL cortical structures at physiologically realistic burn radii, whereas one-laser trajectories could not. Five patients with at least 1 year of follow-up (mean = 21.8 months) experienced Engel class I outcomes; 6 patients with less than 1 year of follow-up (mean = 6.6 months) are on track for Engel class I outcomes. Significance Our anatomic analyses and initial clinical results suggest that LITT amygdalohippocampotomy performed via two-laser trajectories may promote excellent seizure outcomes. Future studies are required to validate the long-term clinical efficacy and safety of this approach.
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