Subcentimeter epilepsy surgery targets by resting state functional magnetic resonance imaging can improve outcomes in hypothalamic hamartoma
Subcentimeter epilepsy surgery targets by resting state functional magnetic resonance imaging can improve outcomes in hypothalamic hamartoma
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DOI：
10.1111/epi.14583
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发表时间：
2018-12-01
期刊：
影响因子：
5.6
通讯作者：
Curry, Daniel J.
中科院分区：
文献类型：
--
作者：
Boerwinkle, Varina L.;Foldes, Stephen T.;Curry, Daniel J.
目的探讨下丘脑错构瘤（HH）亚厘米级静息状态功能磁共振成像（rs-fMRI）致痫起始区（EZ）为靶点的癫痫手术治疗效果。方法对51例HH相关难治性癫痫患儿行MRI引导下立体定向激光消融术（SLA）。其中15名儿童为对照组（CS），未接受rs-fMRI指导。36例患者术前接受rs-fMRI（RS）指导，以确定EZ，随后进行SLA靶向治疗。本研究的主要结局指标是术后1年癫痫发作频率降低30%和I级Engel结局改善的预定目标。还评估了总HH和消融组织的定量和定性体积分析。在RS组中，HH内的EZ靶消融具有高准确性（83%的受试者中>87.5%的靶消融）。两组消融的错构瘤体积百分比无差异（P = 0.137）。在rs-fMRI组中，总体癫痫发作减少率较高：RS组为85%，CS组为49%（P = 0.0006，校正后）。Engel癫痫手术结局量表显示无致残性癫痫发作（I级）的患者存在显著差异，92% RS vs 47% CS，改善45%（P = 0.001）。与之前的研究相比，I类结局有所改善（92% vs 76%-81%）。未发生术后并发症或死亡。意义首次，手术SLA靶向亚厘米大小的EZ，通过rs-fMRI定位，指导手术治疗难治性癫痫。我们的结果表明，无癫痫发作率最高，无手术并发症，与既往报告相比有显著改善。无论错构瘤大小或解剖学分类如何，与传统消融术相比，该方法使癫痫发作的发生率提高了45%。与最近的非rs-fMRI引导的SLA研究相比，该技术显示出相同或更低的发病率（0%），高达20%的永久性显著发病率。
Objective The purpose of this study is to investigate the outcomes of epilepsy surgery targeting the subcentimeter-sized resting state functional magnetic resonance imaging (rs-fMRI) epileptogenic onset zone (EZ) in hypothalamic hamartoma (HH). Methods Results Fifty-one children with HH-related intractable epilepsy received anatomical MRI-guided stereotactic laser ablation (SLA) procedures. Fifteen of these children were control subjects (CS) not guided by rs-fMRI. Thirty-six had been preoperatively guided by rs-fMRI (RS) to determine EZs, which were subsequently targeted by SLA. The primary outcome measure for the study was a predetermined goal of 30% reduction in seizure frequency and improvement in class I Engel outcomes 1 year postoperatively. Quantitative and qualitative volumetric analyses of total HH and ablated tissue were also assessed. In the RS group, the EZ target within the HH was ablated with high accuracy (>87.5% of target ablated in 83% of subjects). There was no difference between the groups in percentage of ablated hamartoma volume (P = 0.137). Overall seizure reduction was higher in the rs-fMRI group: 85% RS versus 49% CS (P = 0.0006, adjusted). The Engel Epilepsy Surgery Outcome Scale demonstrated significant differences in those with freedom from disabling seizures (class I), 92% RS versus 47% CS, a 45% improvement (P = 0.001). Compared to prior studies, there was improvement in class I outcomes (92% vs 76%-81%). No postoperative morbidity or mortality occurred. Significance For the first time, surgical SLA targeting of subcentimeter-sized EZs, located by rs-fMRI, guided surgery for intractable epilepsy. Our outcomes demonstrated the highest seizure freedom rate without surgical complications and are a significant improvement over prior reports. The approach improved freedom from seizures by 45% compared to conventional ablation, regardless of hamartoma size or anatomical classification. This technique showed the same or reduced morbidity (0%) compared to recent non-rs-fMRI-guided SLA studies with as high as 20% permanent significant morbidity.