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Stereotactic radiosurgery for medically refractory non-lesional epilepsy: A case-based Radiosurgery Society (RSS)
Samuel R Daly1, Jose M Soto1, Sarah Mc Gonzalez1
1Department of Neurological Surgery, Baylor Scott and White Health/Baylor College of Medicine, Temple, TX, United States.
Introduction:
Medically refractory epilepsy (MRE) occurs in about 30 % of patients with epilepsy, and the treatment options available to them have evolved over time. The classic treatment for medial temporal lobe epilepsy (mTLE) is anterior temporal lobectomy (ATL), but an initiative to find less invasive options has resulted in treatments such as neuromodulation, ablative procedures, and stereotactic radiosurgery (SRS). SRS has been an appealing non-invasive option and has developed an increasing presence in the literature over the last few decades. This article provides an overview of SRS for MRE with two example cases, and we discuss the optimal technique as well as the advantages, alternatives, and risks of this therapeutic option.
Cases:
We present two example cases of patients with MRE, who were poor candidates for invasive surgical treatment options and underwent SRS. The first case is a 65-year-old female with multiple medical comorbidities, whose seizure focus was localized to the left temporal lobe, and the second case is a 19-year-old male with Protein C deficiency and medial temporal lobe sclerosis. Both patients underwent SRS to targets within the medial temporal lobe, and both achieve significant improvements in seizure frequency and severity.
Discussion:
SRS has generally been shown to be inferior to ATL for seizure reduction in medically refractory mTLE. However, there are patients with epilepsy for which SRS can be considered, such as patients with medical comorbidities that make surgery high risk, patients with epileptogenic foci in eloquent cortex, patients who have failed to respond to surgical management, patients who choose not to undergo surgery, and patients with geographic constraints to epilepsy centers. Patients and their physicians should be aware that SRS is not risk-free. Patients should be counseled on the latency period and monitored for risks such as delayed cerebral edema, visual field deficits, and radiation necrosis.
Insights
Stereotactic radiosurgery (SRS) offers a less invasive option for medically refractory epilepsy (MRE) when traditional surgery is not feasible. While generally less effective than anterior temporal lobectomy (ATL), SRS can be a viable alternative for select patients, with potential risks to consider.
Area of Science:
- Neurosurgery
- Radiation Oncology
- Epileptology
Background:
- Medically refractory epilepsy (MRE) affects approximately 30% of epilepsy patients, necessitating advanced treatment strategies.
- Anterior temporal lobectomy (ATL) is a classic treatment for medial temporal lobe epilepsy (mTLE), but less invasive options like stereotactic radiosurgery (SRS) are gaining prominence.
- SRS presents a non-invasive therapeutic option for MRE, with its application expanding in recent literature.
Purpose of the Study:
- To provide an overview of stereotactic radiosurgery (SRS) for medically refractory epilepsy (MRE).
- To discuss the optimal techniques, advantages, alternatives, and risks associated with SRS in MRE management.
- To illustrate the application of SRS through two distinct patient case studies.
Main Methods:
- Presentation of two case studies involving patients with MRE unsuitable for invasive surgical options.
- Both patients underwent SRS targeting medial temporal lobe structures.
- Case 1: A 65-year-old female with comorbidities and left temporal lobe epilepsy.
- Case 2: A 19-year-old male with Protein C deficiency and medial temporal lobe sclerosis.
Main Results:
- Both patients treated with SRS demonstrated significant reductions in seizure frequency and severity.
- SRS provided a viable treatment alternative for patients with MRE who were poor candidates for traditional surgery.
Conclusions:
- Stereotactic radiosurgery (SRS) is generally less effective than anterior temporal lobectomy (ATL) for seizure reduction in medically refractory mTLE.
- SRS is a suitable consideration for specific patient groups, including those with high surgical risks due to comorbidities, epileptogenic foci in eloquent areas, or those who prefer non-surgical options.
- Patients and clinicians must be aware of SRS risks, including delayed cerebral edema, visual field deficits, and radiation necrosis, necessitating careful patient counseling and monitoring.
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