目的:本研究的作者评估了立体定向激光消融(SLA)治疗儿童耐药性癫痫(DRE)的安全性和有效性。
方法:研究纳入了17个北美中心。回顾性分析了2008年至2018年间接受SLA治疗的DRE儿科患者的数据。
结果:总共225名患者,平均年龄12.8±5.8岁,已确定。感兴趣的目标(TOI)位置包括颞外(44.4%),颞叶新皮质(8.4%),中颞叶(23.1%),下丘脑(14.2%),和call(9.8%)。199例和26例使用Visualase和NeuroBlateSLA系统,分别。手术目标包括消融(149例),断开(63),或两者(13)。平均随访27±20.4个月。179例(84.0%)患者的目标癫痫发作类型(TST)有所改善。恩格尔分类报告了167例(74.2%)患者;不包括姑息病例,74(49.7%),35(23.5%),10(6.7%),30名(20.1%)患者患有恩格尔一级,II,III,和IV结果,分别。对于随访时间≥12个月的患者,25(51.0%),18(36.7%),3(6.1%),3人(6.1%)有恩格尔一级,II,III,和IV结果,分别。有与TOI相关的SLA前手术史的患者,皮质发育畸形的病理学,和每个TOI的2+轨迹更有可能在癫痫发作频率和/或有不利的结果没有改善。更多的较小的热损伤与TST的更大改善相关。30例(13.3%)患者出现51例短期并发症,包括导管错位(3例),颅内出血(2),短暂性神经功能缺损(19),永久性神经功能缺损(3),症状性病灶周围水肿(6),脑积水(1),脑脊液泄漏(1),伤口感染(2),计划外ICU住院(5),和计划外的30天再入院(9)。下丘脑靶部位并发症的相对发生率较高。目标体积,激光轨迹的数量,热损伤的数量或大小,或使用围手术期类固醇对短期并发症没有显著影响.
结论:SLA似乎是DRE患儿的一种有效且耐受性良好的治疗选择。需要进行大量前瞻性研究,以更好地了解治疗适应症,并证明SLA在该人群中的长期疗效。
OBJECTIVE: The authors of this
study evaluated the safety and efficacy of stereotactic laser ablation (SLA) for the treatment of drug-resistant epilepsy (DRE) in children.
METHODS: Seventeen North American centers were enrolled in the
study. Data for pediatric patients with DRE who had been treated with SLA between 2008 and 2018 were retrospectively reviewed.
RESULTS: A total of 225 patients, mean age 12.8 ± 5.8 years, were identified. Target-of-interest (TOI) locations included extratemporal (44.4%), temporal neocortical (8.4%), mesiotemporal (23.1%), hypothalamic (14.2%), and callosal (9.8%). Visualase and NeuroBlate SLA systems were used in 199 and 26 cases, respectively. Procedure goals included ablation (149 cases), disconnection (63), or both (13). The mean follow-up was 27 ± 20.4 months. Improvement in targeted seizure type (TST) was seen in 179 (84.0%) patients. Engel classification was reported for 167 (74.2%) patients; excluding the palliative cases, 74 (49.7%), 35 (23.5%), 10 (6.7%), and 30 (20.1%) patients had Engel class I, II, III, and IV outcomes, respectively. For patients with a follow-up ≥ 12 months, 25 (51.0%), 18 (36.7%), 3 (6.1%), and 3 (6.1%) had Engel class I, II, III, and IV outcomes, respectively. Patients with a history of pre-SLA surgery related to the TOI, a pathology of malformation of cortical development, and 2+ trajectories per TOI were more likely to experience no improvement in seizure frequency and/or to have an unfavorable outcome. A greater number of smaller thermal lesions was associated with greater improvement in TST. Thirty (13.3%) patients experienced 51 short-term complications including malpositioned catheter (3 cases), intracranial hemorrhage (2), transient neurological deficit (19), permanent neurological deficit (3), symptomatic perilesional edema (6), hydrocephalus (1), CSF leakage (1), wound infection (2), unplanned ICU stay (5), and unplanned 30-day readmission (9). The relative incidence of complications was higher in the hypothalamic target location. Target volume, number of laser trajectories, number or size of thermal lesions, or use of perioperative steroids did not have a significant effect on short-term complications.
CONCLUSIONS: SLA appears to be an effective and well-tolerated treatment option for children with DRE. Large-volume prospective studies are needed to better understand the indications for treatment and demonstrate the long-term efficacy of SLA in this population.