Surgical Modalities for Epilepsy Treatment. C.J. Bui, MD, FAANS Ochsner Neuroscience Symposium 2016

Transcription

1 Surgical Modalities for Epilepsy Treatment C.J. Bui, MD, FAANS Ochsner Neuroscience Symposium 2016

2 Conflict of Interest Nothing to disclose

3 Surgical Modalities Diagnostic Subdural Grids Depth Electrodes Resection Lesionectomies Lobectomies Disconnection Corpus Callosotomies Multiple Subpial Transections Functional Hemispherectomy Neuromodulation Vagal Nerve Stimulations (VNS) DBS NeuroPace RNS Ablative Stereotaxic Radiosurgery Imagine-guided Laser/Thermoablation

4 Localization Key to successful (seizure freedom) surgical result Concordance of tests Non-lesional epilepsy Limitations of noninvasive monitoring

5 Subdural Grids

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7 Depth Electrodes

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9 Stereoelectroencephalography (SEEG) For difficult localization cases Monitor bilateral hemisphere More précised 3D localization Improved analytical software

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11 Robotic-Assisted SEEG

12 Complications Subdural Electrodes Mortality: % Aseptic Meningitis: 10% Hemorrhage: 2 8% Depth Electrodes Hemorrhage: 2.9% per hemisphere (4 or more electrodes) Infection: 0.5%

13 Surgical Treatments Epilepsy: up to 50 million worldwide Medically Intractable Epilepsy: 20-30% Approximately 12-20% are candidates for surgical treatment

14 Cortical Resection Lesionectomy Tumors, vascular lesions (AVM, cavernoma), gliosis (trauma), congenital lesions (hamartomas, tubers) Anterior Temporal Lobectomy (ATL) with Amydalohippocampectomy & Selective Amydalohippocampectomy Mesial Temporal Sclerosis Cortical Resection of Frontal, Parietal, Occipital lobe(s) Hemispherectomy

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17 Anatomic Hemispherectomy Rasmussen s Encephalitis Sturge-Weber Hemimegaencephaly Large pediatric strokes

18 Disconnection Surgeries Hypothalamic Disconnection Hypothalamic Hamartomas (Gelastic seizures pressure to laugh Corpus Callosotomy Atonic Seizures ( drop attacks ), Lennox Gastaut Multiple Subpial Transections (MSTs) Epilepsy foci in eloquent cortex (motor,speech) Functional Hemispherectomy Same indications anatomic but lower complications

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21 Corpus Callosotomy

22 MST

23 Functional & Periinsular Hemispherectomy

24 Results Resection 60% - 95% long term seizure freedom (+) Lesion > (-) Lesion Disconnection Callosotomy: seizure reduction of >50% in 50% of patients, for atonic sz 35% seizure freedom MST + Resection: 95% sz reduction in 63 87% (depends on type of Sz), MST alone: 62 71% Hemispherectomy: 75-95% seizure control rate, functional = anatomic but much lower complication rate

25 Neuromodulation Vagal Nerve Stimulation (VNS) Deep Brain Stimulation (DBS) Responsive Neuro Stimulation (RNS) Closed Loop FDA approved in Nov 2013

26 VNS

27 DBS Target: Anterior Nucleus of Thalamus Others: Hippocampus, Amygdala, Centromedian, Subthalamic, Caudate & Cerebellum

28 NeuroPace RNS System

29 Results DBS SANTE trial: 41% seizure reduction at 1 year, 69% at 5 years but seizure freedom is only 16% NeuroPace RNS Seizure Reduction: 44% at 1 yr, 60% at 3 yrs, & 66% at 6 yrs Infection: 5%, Battery life: years

30 Result VNS First implanted in 1988, FDA approved in 1997 Longest experience with and currently the workhorse of neuromodulation for seizure (>75,000 implants) Results improved over time with long term use Battery Life: 5 12 years depending on model and amount of amount and frequency of stimulation Very low complication rate: <3% infection rate, OMC currently has 0 infections in 8 years

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32 Ablation Stereotactic Radiosurgery AVMs Works better with smaller lesions Hypothalamic Hamartomas. Not as good with MTS Non invasive Delay effect Side effects

33 Ablation MRI-guided Laser Ablation (Visualase, NeuroBlate systems) MRI-guided localization and temperature setting Target lesion or foci

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35 Epilepsy Team Neurologists: Gene Ramsay, Fawad Khan, Neil Billeaud, Thomas Gann, Allison Conravey, John Willis Neuropsychology: Brian Mizuki, Christina Brown PA: Brooke Richard Nurses: Bonnie Burratto, Susan Holden MA: Quina Fortuna, Carmonique Carter EEG Supervisor: Theresa Regas EEG: Paige Kimble, Kena Oatis, Darrell Schuler, Jack Lundin, Rachelle Jones, Rebecca Alexanian,Madeline Timmons, Dana Samul, Charlene Betts, Kerri Matherne, Maria Arcuri

36 Thank You