Thursday, December 22, 2016

Hypothalamic hamartoma treated with stereotactic laser ablation

Brandmeir N, Acharya V, Sather M. Robot Assisted Stereotactic Laser Ablation for a Radiosurgery Resistant Hypothalamic Hamartoma. Cureus 2016 Apr; 8(4): e581. doi:10.7759/cureus.581

Hypothalamic hamartomas (HH) are benign tumors that can cause significant morbidity in adults as a cause of epilepsy, particularly gelastic seizures [GS]. Open and endoscopic resections of HH offer good seizure control but have high rates of morbidity and are technically challenging. Stereotactic radiosurgery has been an alternative treatment; however, it results in comparably poor seizure control. Recently, in children, stereotactic laser ablation has shown promise as a surgical technique that can combine the best features of both of these approaches for the treatment of HH. Here we present the first reported use of a frameless robot-assisted stereotactic system to treat an HH. The patient had failed two previous Gamma Knife radiosurgery treatments. Post-procedure he had a stable, but unintentional weight loss of 20 kg and a transient episode of hemiparesis the night of the operation. At six months postoperatively the patient remained seizure free. Stereotactic laser ablation[SLA] may represent a new standard in the treatment of HH in adults, especially in those who have failed radiosurgery. Further study is warranted in this population to determine efficacy and safety profiles.

From the article:

The patient is a 63-year-old man with a history of GS since the age of three. Imaging had consistently demonstrated a 1 cm non-enhancing mass on the wall of the left hypothalamus.. All treating physicians involved in the case felt that this mass represented an HH. As a child he also experienced generalized tonic-clonic seizures, but, as an adult, only auras of “riding an elevator.” Seven years and again one year prior to presenting again for surgical management, the patient had undergone Gamma Knife Radiosurgery (GKS) for his HH. The first GKS treatment consisted of one 8 mm collimated shot treated to 17 Gy to 50% isodose line. The second GKS treatment consisted of another 8 mm collimated shot delivering 17 Gy to the 50% isodose line. He did experience some temporary decrease in GS frequency after each procedure, but his GS returned to their usual rate within two months each time. After being made aware of the option of SLA and the associated risks and benefits, the patient wished to proceed with surgery. At that time informed consent for the procedure and the potential preparation of academic materials related to the procedure were obtained…

At his six-month follow-up visit, the patient was neurologically intact, seizure free, down to two anti-epileptic drugs from three, and had an improved mentation, alertness, and speech fluency compared to his preoperative function…

In conclusion, frameless robot-assisted SLA may be an effective and safe method for the treatment of HH in adults with GS who have failed stereotactic radiosurgery. Considering the potential decrease in morbidity when compared to endoscopic resection and the relatively high efficacy as demonstrated in children, SLA may be the treatment of choice in adults with HH. This application will require further research. This paper also demonstrates the potential role of SLA for patients with HH who have failed GKS and who do not wish to undergo resection. Finally, this report highlights some complications that may be unique to adults or to adults who have had previous radiosurgery, specifically a transient acute, postoperative hemiparesis and unintentional weight loss. Fortunately, in the case of our patient, side effects were either temporary or clinically silent, but further study of this technique in this patient population will be necessary to determine its full side effect profile.

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