Tag: Ablation

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Focused Ultrasound Central Lateral Thalamotomy for the Treatment of Refractory Neuropathic Pain

Neurosurgery 94:690–699, 2024

Magnetic resonance–guided focused ultrasound (MRgFUS) central lateral thalamotomy (CLT) has not yet been validated for treating refractory neuropathic pain (NP). Our aim was to assess the safety and potential efficacy of MRgFUS CLT for refractory NP.

METHODS: In this prospective, nonrandomized, single-arm, investigator-initiated phase I trial, patients with NP for more than 6 months related to phantom limb pain, spinal cord injury, or radiculopathy/radicular injury and who had undergone at least one previous failed intervention were eligible. The main outcomes were safety profile and pain as assessed using the brief pain inventory, the pain disability index, and the numeric rating scale. Medication use and the functional connectivity of the default mode network (DMN) were also assessed.

RESULTS: Ten patients were enrolled, with nine achieving successful ablation. There were no serious adverse events and 12 mild/moderate severity events. The mean age was 50.9 years (SD: 12.7), and the mean symptom duration was 12.3 years (SD: 9.7). Among eight patients with a 1-year follow-up, the brief pain inventory decreased from 7.6 (SD: 1.1) to 3.8 (SD: 2.8), with a mean percent decrease of 46.3 (SD: 40.6) (paired t-test, P = .017). The mean pain disability index decreased from 43.0 (SD: 7.5) to 25.8 (SD: 16.8), with a mean percent decrease of 39.3 (SD: 41.6) (P = .034). Numeric rating scale scores decreased from a mean of 7.2 (SD: 1.8) to 4.0 (SD: 2.8), with a mean percent decrease of 42.8 (SD: 37.8) (P = .024). Patients with predominantly intermittent pain or with allodynia responded better than patients with continuous pain or without allodynia, respectively. Some patients decreased medication use. Resting-state functional connectivity changes were noted, from disruption of the DMN at baseline to reactivation of connectivity between DMN nodes at 3 months.

CONCLUSION: MRgFUS CLT is feasible and safe for refractory NP and has potential utility in reducing symptoms as measured by validated pain scales.

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Initial experience with magnetic resonance–guided focused ultrasound stereotactic surgery for central brain lesions in young adults

J Neurosurg 137:760–767, 2022

Magnetic resonance–guided focused ultrasound (MRgFUS) is an incisionless procedure capable of thermoablation through the focus of multiple acoustic beams. Although MRgFUS is currently approved for the treatment of tremor in adults, its safety and feasibility profile for intracranial lesions in the pediatric and young adult population remains unknown.

METHODS The long-term outcomes of a prospective single-center, single-arm trial of MRgFUS at Nicklaus Children’s Hospital in Miami, Florida, are presented. Patients 15–22 years of age with centrally located lesions were recruited, clinically consistent with WHO grade I tumors that require surgical intervention. This cohort consisted of 4 patients with hypothalamic hamartoma (HH), and 1 patient with tuberous sclerosis complex harboring a subependymal giant cell astrocytoma (SEGA).

RESULTS In each case, high-intensity FUS was used to target the intracranial lesion. Real-time MRI was used to monitor the thermoablations. Primary outcomes of interest were tolerability, feasibility, and safety of FUS. The radiographic ablation volume on intra- and postoperative MRI was also assessed. All 5 patients tolerated the procedure without any complications. Successful thermoablation was achieved in 4 of the 5 cases; the calcified SEGA was undertreated due to intratumor calcification, which prevented attainment of the target ablation temperature. The HHs underwent target tissue thermoablations that led to MR signal changes at the treatment site. For the patients harboring HHs, FUS thermoablations occurred without procedure-related complications and led to improvement in seizure control or hypothalamic hyperphagia. All 5 patients were discharged home on postoperative day 1 or 2, without any readmissions. There were no cases of hemorrhage, electrolyte derangement, endocrinopathy, or new neurological deficit in this cohort.

CONCLUSIONS This experience demonstrates that FUS thermoablation of centrally located brain lesions in adolescents and young adults can be performed safely and that it provides therapeutic benefit for associated symptoms. Clinical trial registration no.: NCT03028246

 

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A stereotactic frame‐based drill guide‐aided setting for laser interstitial thermal therapy

Acta Neurochirurgica (2021) 163:3447–3453

Magnetic resonance imaging (MRI)-guided laser interstitial thermal therapy (MRIgLITT) was demonstrated to be a viable neurosurgical tool. Apart from its variety of indications, different operative and technical nuances exist. In the present report, for the first time, the use and ability of a traditional Riechert-Mundinger (RM) stereotactic system combined with a novel drill guide kit for MRIgLITT are described.

Methods A stereotactic frame-based setting was developed by combining an RM system with a drill guide kit and centering bone anchor screwing aid for application together with an MRIgLITT neuro-accessory kit and cooled laser applicator system. The apparatus was used for stereotactic biopsy and consecutive MRIgLITT with an intraoperative high-field MRI scanner in a brain tumor case.

Results The feasibility of an RM stereotactic apparatus and a drill guide kit for MRIgLITT was successfully assessed. Both stereotactic biopsy and subsequent MRIgLITT in a neurooncological patient could easily and safely be performed. No technical problems or complications were observed.

Conclusion The combination of a traditional RM stereotactic system, a new drill guide tool, and intraoperative high-field MRI provides neurosurgeons with the opportunity to reliably confirm the diagnosis by frame-based biopsy and allows for stable and accurate real-time MRIgLITT.

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Magnetic Resonance Imaging-Guided Laser Thermal Ventral Capsulotomy for Intractable Obsessive-Compulsive Disorder

Neurosurgery 88:1128–1135, 2021

Obsessive-compulsive disorder (OCD) is a disabling condition characterized by intrusive thoughts and repetitive behaviors. A subset of individuals have severe, treatment-resistant illness and are nonresponsive to medication or behavioral therapies. Without response to conventional therapeutic options, surgical intervention becomes an appropriate consideration.

OBJECTIVE: To report clinical outcomes and the safety profile of bilateral ventral anterior capsulotomy for OCD using magnetic resonance (MR)-guided laser interstitial thermal therapy (LITT) in 10 patients followed for 6 to 24 mo.

METHODS: A total of 10 patients underwent LITT for severe OCD; 1 patient withdrew prior to follow-up. LITT is a minimally invasive ablative technique performed with precise targeting and use of thermography under MR guidance. Lesions of the ventral anterior limb of the internal capsule by other techniques have been shown to be efficacious in prior studies.

RESULTS: A total of 7 of the 9 patients were considered full responders (77.8%; Yale- Brown Obsessive-Compulsive Scale change ≥35%). Adverse effects included transient apathy/amotivation postsurgery (2 patients). One patient had a small tract hemorrhage where the laser fiber traversed the cerebral cortex as well as persistent insomnia postsurgery. One individual died after a drug overdose 7 mo postsurgery, which was judged unrelated to the surgery.

CONCLUSION: LITT ventral capsulotomy was generally well tolerated, with promising evidence of effectiveness in the largest such series to date. Results were comparable to those after gamma knife ventral capsulotomy, as well as ventral anterior limb deep brain stimulation.

 

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Ultrasound Ablation in Neurosurgery: Current Clinical Applications and Future Perspectives

Neurosurgery 87:1–10, 2020

The concept of focusing high-intensity ultrasound beams for the purpose of cerebral ablation has interested neurosurgeons for more than 70 yr. However, the need for a craniectomy or a cranial acoustic window hindered the clinical diffusion of this technique.

Recent technological advances, including the development of phased-array transducers and magnetic resonance imaging technology, have rekindled the interest in ultrasound for ablative brain surgery and have led to the development of the transcranial magnetic resonance-guided focused ultrasound (MRgFUS) thermal ablation procedure. In the last decade, this method has become increasingly popular, and its clinical applications are broadening.

Despite the demonstrated efficacy of MRgFUS, transcranial thermal ablation using ultrasound is limited in that it can target exclusively the central region of the brain where the multiple acoustic beams are most optimally focused. On the contrary, lesioning of the cortex, the superficial subcortical areas, and regions close to the skull base is not possible with the limited treatment envelope of current phased-array transducers.

Therefore, new ultrasound ablative techniques, which are not based on thermal mechanisms, have been developed and tested in experimental settings. This review describes the mechanisms by which these novel, nonthermal ablative techniques are based and also presents the current clinical applications of MRgFUS thermal ablation.

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Minimally Invasive Trigeminal Ablation: Novel Transoral Technique for Targeted Treatment of V3

World Neurosurg. (2018) 118:193-196

Trigeminal neuralgia (TN) is a chronic orofacial pain syndrome that presents with debilitating shooting pains in the V3 nerve distribution. The condition is traditionally responsive to anticonvulsant therapy; however, cases that become refractory to medications often require surgical intervention.

CASE DESCRIPTION: We present a case of TN that was treated with minimally invasive trigeminal ablation. The patient presented with a 6-year history of TN that had been resistant to medical management. The patient opted for minimally invasive management, refused stereotactic radiosurgery, and was treated using the minimally invasive trigeminal ablation approach. At 16 weeks postoperatively, the patient reported complete alleviation of pain with minimal sensorineural numbness.

CONCLUSIONS: The endoscopic approach allows for precise targeting through visual guidance, which is ideal in patients undergoing neuroablation for pain within specific nerve distributions. This is the first documented case of an endoscopic minimally invasive transoral approach toward ablative TN management.

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