Long-term outcomes of mesial temporal laser interstitial thermal therapy for drug-resistant epilepsy and subsequent surgery for seizure recurrence: a multi-centre cohort study.

BACKGROUND: Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a minimally invasive alternative to surgical resection for drug-resistant mesial temporal lobe epilepsy (mTLE). Reported rates of seizure freedom are variable and long-term durability is largely unproven. Anterior temporal lobectomy (ATL) remains an option for patients with MRgLITT treatment failure. However, the safety and efficacy of this staged strategy is unknown. METHODS: This multicentre, retrospective cohort study included 268 patients consecutively treated with mesial temporal MRgLITT at 11 centres between 2012 and 2018. Seizure outcomes and complications of MRgLITT and any subsequent surgery are reported. Predictive value of preoperative variables for seizure outcome was assessed. RESULTS: Engel I seizure freedom was achieved in 55.8% (149/267) at 1 year, 52.5% (126/240) at 2 years and 49.3% (132/268) at the last follow-up ≥1 year (median 47 months). Engel I or II outcomes were achieved in 74.2% (198/267) at 1 year, 75.0% (180/240) at 2 years and 66.0% (177/268) at the last follow-up. Preoperative focal to bilateral tonic-clonic seizures were independently associated with seizure recurrence. Among patients with seizure recurrence, 14/21 (66.7%) became seizure-free after subsequent ATL and 5/10 (50%) after repeat MRgLITT at last follow-up≥1 year. CONCLUSIONS: MRgLITT is a viable treatment with durable outcomes for patients with drug-resistant mTLE evaluated at a comprehensive epilepsy centre. Although seizure freedom rates were lower than reported with ATL, this series represents the early experience of each centre and a heterogeneous cohort. ATL remains a safe and effective treatment for well-selected patients who fail MRgLITT.

Robotic-assisted stereotactic percutaneous balloon compression for trigeminal neuralgia treatment.

Trigeminal neuralgia (TN) is a facial pain disorder that can be a source of significant disability. Percutaneous balloon compression (PBC) has low cost, high efficacy, and minimal invasiveness. Complications can occur due to the balloon inflation or the needle placement itself. In this paper, we describe for the first time the clinical use of robotic-assistance to perform a PBC for TN, presenting our experience in two patients. The stereotactic planning targeted the foramen ovale (FO) establishing a safe and seamless needle trajectory. This yielded a streamlined, single pass needle placement and eliminated the need to "search" for the FO. There were no immediate complications and post-operatively both patients improved their symptoms. Robotic assistance is potentially a useful tool to reduce needle placement related complications, radiation exposure and PBC learning curve.

Long-term seizure and psychiatric outcomes following laser ablation of mesial temporal structures.

OBJECTIVE: Postsurgical seizure outcome following laser interstitial thermal therapy (LiTT) for the management of drug-resistant mesial temporal lobe epilepsy (MTLE) has been limited to 2 years. Furthermore, its impact on presurgical mood and anxiety disorders has not been investigated. The objectives of this study were (1) to identify seizure outcome changes over a period ranging from 18 to 81 months; (2) to investigate the seizure-free rate in the last follow-up year; (3) to identify the variables associated with seizure freedom; and (4) to identify the impact of LiTT on presurgical mood and anxiety disorders. METHODS: Medical records of all patients who underwent LiTT for MTLE from 2013 to 2019 at the University of Miami Comprehensive Epilepsy Center were retrospectively reviewed. Demographic, epilepsy-related, cognitive, psychiatric, and LiTT-related data were compared between seizure-free (Engel Class I) and non-seizure-free (Engel Class II + III + IV) patients. Statistical analyses included univariate and multivariate stepwise logistic regression analyses. RESULTS: Forty-eight patients (mean age = 43 ± 14.2 years, range = 21-78) were followed for a mean period of 50 ± 20.7 months (range = 18-81); 29 (60.4%) achieved an Engel Class I outcome, whereas 11 (22.9%) had one to three seizures/year. Seizure-freedom rate decreased from 77.8% to 50% among patients with 24- and >61-month follow-up periods, respectively. In the last follow-up year, 83% of all patients were seizure-free. Seizure freedom was associated with having mesial temporal sclerosis (MTS), no presurgical focal to bilateral tonic-clonic seizures, and no psychopathology in the last follow-up year. Presurgical mood and/or anxiety disorder were identified in 30 patients (62.5%) and remitted after LiTT in 19 (62%). SIGNIFICANCE: LiTT appears to be a safe and effective surgical option for treatment-resistant MTLE, particularly among patients with MTS. Remission of presurgical mood and anxiety disorders can also result from LiTT.

Anterior Reduction and Fusion of Cervical Facet Dislocations.

BACKGROUND: Cervical facet dislocations are among the most common traumatic spinal injuries. Posterior, anterior, and combined surgical approaches have been described and are widely debated. OBJECTIVE: To demonstrate efficacy in anterior-only surgical management for subaxial cervical facet dislocations. METHODS: A consistent surgical algorithm for cervical facet dislocation was applied over a 19-yr period and analyzed retrospectively in adults with acute unilateral or bilateral facet dislocation of the subaxial cervical spine. The primary endpoint was maintenance of early cervical alignment. The need for additional posterior instrumented fusion was determined. RESULTS: A database search identified 96 patients (mean age = 37.9, range = 14-74 yr, 68 (70%) male. The most common affected levels were C4-C5 (30), C5-C6 (29), and C6-C7 (30). Bilateral dislocation occurred in 51 patients (53%). Seventy-eight (81%) patients had neurological deficits, 31 (32%) being complete (Abbreviated Injury Score A) spinal cord injuries. Preoperative closed reduction was attempted in 60 (63%) patients, with 33 (55%) achieving satisfactory alignment. After anterior cervical discectomy, reduction, allograft placement, and instrumentation, a total of 92 (96%) patients had achieved satisfactory realignment. Median time to surgery was 13.27 h. Eight (8%) patients required posterior fixation due to intraoperative determination of incomplete realignment (4; 4%) and development of early progressive deformity (4; 4%). Mean follow-up was 4.5 mo (range 0.5-24 mo) with 33 (34%) patients lost to follow-up. CONCLUSION: Anterior approaches are viable for reduction and stabilization of cervical facet dislocations. Further prospective studies are required to evaluate clinical and long-term success.

Genetic associations of intracranial aneurysm formation and sub-arachnoid hemorrhage.

Risk factors for cerebral aneurysms typically include age, hypertension, smoking, and alcohol usage. However, the possible connection of aneurysms with genetic conditions such as Marfan's syndrome, polycystic kidney disease, and neurofibromatosis raises the question of possible genetic risk factors for aneurysm, and additionally, genetic risk factors for rupture. We conducted a literature review using the PubMed database for studies regarding genetic correlation with cerebral aneurysm formation as well as rupture from December 2008 to Jun 2015. Twenty-one studies related to IA formation and 10 concerning IA rupture that met our criteria were found and tabulated. The most studied gene and the strongest association was 9p21/CDKN2, which is involved in vessel wall remodelling. Other possible genes that may contribute to IA formation include EDNRA and SOX17; however, these factors were not studied as robustly as CDKN2. Multiple factors contribute to aneurysm formation and rupture and the contributions of blood flow dynamics and comorbidities as mentioned previously, cannot be ignored. While these elements are important to development and rupture of aneurysms, genetic influence may predispose certain patients to formation of aneurysms and eventual rupture.

Atlantoaxial Synovial Cyst: Case Report and Literature Review.

BACKGROUND: Degenerative cystic lesions of atlantoaxial joints are rare and generally believed to be due to mechanical instability. There is currently no consensus on the management of such lesions in symptomatic and asymptomatic patients. Both conservative and surgical strategies have been described. Surgery may involve anterior or posterior approaches with and without decompression and instrumentation. METHODS: We present a case report of a 45-year-old man who presented with new onset weakness and ataxia. Physical examination revealed decreased motor function in all extremities as well as positive Hoffman sign and ankle clonus bilaterally. An MRI of cervical spine showed a large atlantoaxial, T-2 hyperintense cystic lesion with cord compression and cord signal changes. RESULTS: A C1 partial laminectomy was performed with resection of the cyst and C1-2 instrument fusion. Intra-operatively, the cystic lesion was found to be anatomically connected to the right C1-2 atlantoaxial joint with pathology showing fibroconnective tissue and chronic inflammatory changes. Post-operatively there were no complications and the patient was discharged to a rehabilitation facility. The patient was regaining gait and hand function by 3 months after surgery. CONCLUSIONS: Atlantoaxial synovial cysts are rare and the optimal surgical approach has not been determined. We further conducted a literature review and found a total of 70 other cases of atlantoaxial synovial cysts reported to date in the literature. We attempt to analyze available data and evaluate anterior versus posterior approaches and the need for decompression, amount of cyst resection, and instrumentation.

Subdural hematoma in a patient taking imatinib for GIST: a case report and discussion of risk with other chemotherapeutics.

Although anticancer drugs have existed for over 50 years, targeted drugs have only recently been marketed, and their side effects may not be completely understood. The patient is a 56-year-old woman with a gastrointestinal stromal tumor who presented with headache, nausea, and vomiting lasting 2 weeks. An MRI to rule out brain metastasis found a large right-hemispheric subdural hematoma without metastases. She denied trauma, seizures, or alcohol abuse. Laboratory test results were normal. Eight months prior, she had begun a dose escalation of imatinib, which became the suspected cause of her hemorrhage. The literature was reviewed for reports of intracranial hemorrhage with targeted chemotherapeutics excluding metastases, anticoagulation, and trauma. Multiple events have been documented but only one for imatinib with gastrointestinal stromal tumor. Imatinib is believed to cause platelet dysfunction (missed by standard testing), leading to intracranial hemorrhage. Intracranial hemorrhage risk may be under-reported and neurosurgical consultation for immediate treatment and oncology for reinitiation of chemotherapy are recommended.

The role of intra-arterial chemotherapy as an adjuvant treatment for glioblastoma.

Glioblastoma multiforme (GBM) is an aggressive tumor with poor survival outcomes and limited treatment options. We conducted a literature review to compare the survival outcomes of intra-arterial (IA) and intravenous (IV) chemotherapy delivery for GBM. Nine studies of IA chemotherapy infusion with 301 total patients met our criteria for inclusion and three studies contained IV treatment groups for comparison (n = 230 for IA, n = 71 for IV). The studies were grouped by either using newly diagnosed or recurrent GBM patients. In the newly diagnosed group, IV chemotherapy produced a statistically higher median overall survival (MOS; 16.3 months) compared with IA treatment (14.02 months). However, the total number of adverse events in IA chemotherapy was 1.08 per patient whereas for IV it was higher at 1.54 events per patient. Our recurrent GBM group includes only patients treated with IA chemotherapy which resulted in an average MOS of 10.84 months. This group had 2.7 adverse events per patient but no IV group is available for comparison. Historically, the survival of patients with recurrent GBM ranges from 3 to 9 months (Gil-Gil et al. Bevacizumab for the treatment of glioblastoma. Clin Med Insights Oncol 2013;7:123-35). For this reason, we believe IA chemotherapy to be a viable methodology in recurrent GBM patients to prolong survival at the risk of procedure-related complications and in newly diagnosed patients with the benefit of decreased complications.

Cervical puncture and perimedullary cistern shunt placement for idiopathic intracranial hypertension: An alternative to lumbar cistern or cerebral ventricular catheter placement a report of two cases.

OBJECTIVE: Idiopathic intracranial hypertension (IIH) is a syndrome characterized by increased intracranial pressure (ICP) in the absence of an identifiable cause, and if untreated, can result in permanent vision loss. In symptomatic IIH patients, cerebrospinal fluid (CSF) diversion can lower ICP and protect vision; however, currently used CSF diversion systems are prone to malfunction in this population. MATERIALS AND METHODS: In two IIH patients with histories of numerous prior shunt revisions that presented with proximal ventriculoperitoneal shunt malfunction, ICP reduction was achieved by an alternative surgical cerebrospinal fluid (CSF) diversion technique: Fluoroscopically guided, percutaneous placement of a catheter in the premedullary cistern and subsequent connection to the valve and distal shunt system. RESULTS: Postoperatively, both patients' papilledema resolved, headaches improved, and the shunts were working well at 3-month follow-up. At 1-year follow-up, one patient was well without papilledema or symptom recurrence, and the second patient had the shunt system removed by an outside surgeon. CONCLUSION: This technique may hold promise as an alternative shunting strategy in IIH patients with numerous proximal shunt failures or who are poor candidates for ventricular and lumbar shunts.