Candela-Cantó Santiago, Muchart Jordi, Ramírez-Camacho Alia, Becerra Victoria, Alamar Mariana, Pascual Anna, Forero Carolina, Rebollo Polo Mónica, Munuera Josep, Aparicio Javier, Rumià Jordi, Hinojosa José
1Neurosurgery Department.
4Epilepsy Surgery Unit, Sant Joan de Déu Barcelona Children's Hospital, Universitat de Barcelona, Spain.
J Neurosurg Pediatr. 2022 Mar 25;29(6):681-692. doi: 10.3171/2022.2.PEDS21516. Print 2022 Jun 1.
Real-time, MRI-guided laser interstitial thermal therapy (MRgLITT) has been reported as a safe and effective technique for the treatment of epileptogenic foci in children and adults. After the recent approval of MRgLITT by the European Medicines Agency in April 2018, the authors began to use it for the treatment of hypothalamic hamartomas (HHs) in pediatric patients with the assistance of a robotic arm. In this study, the authors report their initial experience describing the surgical technique, accuracy of the robotic arm, safety, and efficacy.
The laser fiber was placed with the assistance of the stereotactic robotic arm. The accuracy of the robotic arm for this procedure was calculated by comparing the intraoperative MRI to the preoperative plan. Common demographic and seizure characteristics of the patients, laser ablation details, complications, and short-term seizure outcomes were prospectively collected.
Sixteen procedures (11 first ablations and 5 reablations) were performed in 11 patients between 15 months and 17 years of age (mean age 6.4 years) with drug-resistant epilepsy related to HHs. The mean target point localization error was 1.69 mm. No laser fiber needed to be repositioned. The mean laser power used per procedure was 4.29 W. The trajectory of the laser fiber was accidentally ablated in 2 patients, provoking transient hemiparesis in one of these patients. One patient experienced postoperative somnolence and syndrome of inappropriate antidiuretic hormone secretion, and 2 patients had transient oculomotor (cranial nerve III) palsy. Fifty-four percent of the patients were seizure free after the first ablation (mean follow-up 22 months, range 15-33 months). All 5 patients who experienced an epilepsy relapse underwent a second treatment, and 4 remain seizure free at least 5 months after reablation.
In the authors' experience, the robotic arm was sufficiently accurate for laser fiber insertion, even in very young patients. MRgLITT appears to be an effective treatment for selected cases of HH. MRgLITT for HH is a minimally invasive procedure with appealing safety features, as it allows delivery of energy precisely under real-time MRI control. Nonetheless, complications may occur, especially in voluminous HHs. The amount of delivered energy and the catheter cooling system must be closely monitored during the procedure. A larger sample size and longer follow-up duration are needed to judge the efficacy and safety of MRgLITT for HH more rigorously. This initial experience was very promising.
实时磁共振成像引导下的激光间质热疗（MRgLITT）已被报道为一种治疗儿童和成人致痫灶的安全有效的技术。2018年4月欧洲药品管理局最近批准MRgLITT后，作者开始在机器人手臂的辅助下将其用于治疗小儿下丘脑错构瘤（HHs）。在本研究中，作者报告了他们关于手术技术、机器人手臂的准确性、安全性和有效性的初步经验。
在立体定向机器人手臂的辅助下放置激光光纤。通过将术中磁共振成像与术前计划进行比较，计算该手术中机器人手臂的准确性。前瞻性收集患者的一般人口统计学和癫痫发作特征、激光消融细节、并发症和短期癫痫发作结果。
对11例年龄在15个月至17岁（平均年龄6.4岁）、患有与HHs相关的药物难治性癫痫的患者进行了16次手术（11次首次消融和5次再次消融）。平均靶点定位误差为1.69毫米。无需重新定位激光光纤。每次手术使用的平均激光功率为4.29瓦。2例患者的激光光纤轨迹意外被消融，其中1例引发短暂性偏瘫。1例患者术后出现嗜睡和抗利尿激素分泌不当综合征，2例患者出现短暂性动眼神经（Ⅲ 脑神经）麻痹。54%的患者在首次消融后无癫痫发作（平均随访22个月，范围15 - 33个月）。所有5例癫痫复发的患者均接受了第二次治疗，4例在再次消融后至少5个月无癫痫发作。
根据作者的经验，即使对于非常年幼的患者，机器人手臂在插入激光光纤时也足够精确。MRgLITT似乎是治疗某些HHs病例的有效方法。MRgLITT治疗HHs是一种具有吸引人的安全特性的微创手术，因为它允许在实时磁共振成像控制下精确地传递能量。尽管如此，仍可能发生并发症，尤其是在体积较大的HHs中。在手术过程中必须密切监测传递的能量量和导管冷却系统。需要更大的样本量和更长的随访时间来更严格地判断MRgLITT治疗HHs的疗效和安全性。这一初步经验非常有前景。
