Surgical treatment of hypothalamic hamartomas View Full Text


Ontology type: schema:ScholarlyArticle      Open Access: True


Article Info

DATE

2020-04-21

AUTHORS

Pierre Bourdillon, S. Ferrand-Sorbet, C. Apra, M. Chipaux, E. Raffo, S. Rosenberg, C. Bulteau, N. Dorison, O. Bekaert, V. Dinkelacker, C. Le Guérinel, M. Fohlen, G. Dorfmüller

ABSTRACT

Hypothalamic hamartomas are aberrant masses, composed of abnormally distributed neurons and glia. Along endocrine and cognitive symptoms, they may cause epileptic seizures, including the specific gelastic and dacrystic seizures. Surgery is the treatment of drug-resistant hamartoma epilepsy, with associated positive results on endocrine, psychiatric, and cognitive symptoms. Recently, alternatives to open microsurgical treatment have been proposed. We review these techniques and compare their efficacy and safety. Open resection or disconnection of the hamartoma, either through pterional, transcallosal, or transventricular approach, leads to good epileptological control, but its high complication rate, up to 30%, limits its indications. The purely cisternal peduncular forms remain the only indication of open, pterional approach, while other strategies have been developed to overcome the neurological, endocrine, behavioral, or cognitive complications. Laser and radiofrequency thermocoagulation-based disconnection through robot-guided stereo-endoscopy has been proposed as an alternative to open microsurgical resection and stereotactic destruction. The goal is to allow safe and complete disconnection of a possibly complex attachment zone, through a single intraparenchymal trajectory which allows multiple laser or radiofrequency probe trajectory inside the ventricle. The efficacy was high, with 78% of favorable outcome, and the overall complication rate was 8%. It was especially effective in patients with isolated gelastic seizures and pure intraventricular hamartomas. Stereotactic radiosurgery has proved as efficacious and safer than open microsurgery, with around 60% of seizure control and a very low complication rate. Multiple stereotactic thermocoagulation showed very interesting results with 71% of seizure freedom and 2% of permanent complications. Stereotactic laser interstitial thermotherapy (LiTT) seems as effective as open microsurgery (from 76 to 81% of seizure freedom) but causes up to 20% of permanent complications. This technique has however been highly improved by targeting only the epileptogenic onset zone in the hamartoma, as shown on preoperative functional MRI, leading to an improvement of epilepsy control by 45% (92% of seizure freedom) with no postoperative morbidity. All these results suggest that the impact of the surgical procedure does not depend on purely technical matters (laser vs radiofrequency thermocoagulation or stereotactic vs robot-guided stereo-endoscopy) but relies on the understanding of the epileptic network, including inside the hamartoma, the aim being to plan an effective disconnection or lesion of the epileptogenic part while sparing the adjacent functional structures. More... »

PAGES

753-762

Identifiers

URI

http://scigraph.springernature.com/pub.10.1007/s10143-020-01298-z

DOI

http://dx.doi.org/10.1007/s10143-020-01298-z

DIMENSIONS

https://app.dimensions.ai/details/publication/pub.1126862940

PUBMED

https://www.ncbi.nlm.nih.gov/pubmed/32318922


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26 schema:description Hypothalamic hamartomas are aberrant masses, composed of abnormally distributed neurons and glia. Along endocrine and cognitive symptoms, they may cause epileptic seizures, including the specific gelastic and dacrystic seizures. Surgery is the treatment of drug-resistant hamartoma epilepsy, with associated positive results on endocrine, psychiatric, and cognitive symptoms. Recently, alternatives to open microsurgical treatment have been proposed. We review these techniques and compare their efficacy and safety. Open resection or disconnection of the hamartoma, either through pterional, transcallosal, or transventricular approach, leads to good epileptological control, but its high complication rate, up to 30%, limits its indications. The purely cisternal peduncular forms remain the only indication of open, pterional approach, while other strategies have been developed to overcome the neurological, endocrine, behavioral, or cognitive complications. Laser and radiofrequency thermocoagulation-based disconnection through robot-guided stereo-endoscopy has been proposed as an alternative to open microsurgical resection and stereotactic destruction. The goal is to allow safe and complete disconnection of a possibly complex attachment zone, through a single intraparenchymal trajectory which allows multiple laser or radiofrequency probe trajectory inside the ventricle. The efficacy was high, with 78% of favorable outcome, and the overall complication rate was 8%. It was especially effective in patients with isolated gelastic seizures and pure intraventricular hamartomas. Stereotactic radiosurgery has proved as efficacious and safer than open microsurgery, with around 60% of seizure control and a very low complication rate. Multiple stereotactic thermocoagulation showed very interesting results with 71% of seizure freedom and 2% of permanent complications. Stereotactic laser interstitial thermotherapy (LiTT) seems as effective as open microsurgery (from 76 to 81% of seizure freedom) but causes up to 20% of permanent complications. This technique has however been highly improved by targeting only the epileptogenic onset zone in the hamartoma, as shown on preoperative functional MRI, leading to an improvement of epilepsy control by 45% (92% of seizure freedom) with no postoperative morbidity. All these results suggest that the impact of the surgical procedure does not depend on purely technical matters (laser vs radiofrequency thermocoagulation or stereotactic vs robot-guided stereo-endoscopy) but relies on the understanding of the epileptic network, including inside the hamartoma, the aim being to plan an effective disconnection or lesion of the epileptogenic part while sparing the adjacent functional structures.
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33 aim
34 alternative
35 approach
36 attachment zone
37 cognitive complications
38 cognitive symptoms
39 complete disconnection
40 complication rate
41 complications
42 control
43 dacrystic seizures
44 destruction
45 disconnection
46 effective disconnection
47 efficacy
48 epilepsy
49 epilepsy control
50 epileptic network
51 epileptic seizures
52 favorable outcome
53 form
54 freedom
55 functional MRI
56 functional structure
57 gelastic seizures
58 glia
59 goal
60 hamartoma
61 high complication rate
62 hypothalamic hamartoma
63 impact
64 improvement
65 indications
66 interesting results
67 interstitial thermotherapy
68 laser
69 laser interstitial thermotherapy
70 lesions
71 low complication rate
72 mass
73 matter
74 microsurgery
75 microsurgical resection
76 microsurgical treatment
77 morbidity
78 multiple lasers
79 network
80 neurons
81 only indication
82 onset zone
83 open microsurgery
84 open resection
85 outcomes
86 overall complication rate
87 part
88 patients
89 permanent complications
90 positive results
91 postoperative morbidity
92 preoperative functional MRI
93 probe
94 procedure
95 pterional approach
96 radiofrequency probe
97 radiosurgery
98 rate
99 resection
100 results
101 safety
102 seizure control
103 seizure freedom
104 seizures
105 stereotactic destruction
106 stereotactic radiosurgery
107 stereotactic thermocoagulation
108 strategies
109 structure
110 surgery
111 surgical procedures
112 surgical treatment
113 symptoms
114 technical matters
115 technique
116 thermocoagulation
117 thermotherapy
118 trajectories
119 transcallosal
120 transventricular approach
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123 ventricle
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