Authors :
Presenting Author: Daniel Drane, PhD – Emory University School of Medicine
Robert Gross, MD, PhD – Rutgers University
Guy McKhann, MD – Columbia University
Vincenta Salanova, MD – Indiana University School of Medicine
Jamie J Van Gompel, MD – Mayo Clinic, Rochester MN, USA.
Jonathan Jagid, MD – University of Miami
Brian Cabaniss, MD – Emory University
Nitin Tandon, MD – McGovern Medical School, University of Texas Health Science Center at Houston
Jon Willie, MD, PhD – Washington University Schoold of Medicine in St. Louis
Robert Knowlton, MD, MSPH – University of California, San Francisco
Kristie Wallace, PhD – Medtronic
Alejandra Gracia, PhD – Medtronic
Ash Sharan, MD – Medtronic
Jonathon Giftakis, PhD – Medtronic
Michael R. Sperling, MD – Jefferson Comprehensive Epilepsy Center, Thomas Jefferson University
Rationale:
We report psychiatric outcomes for a recently completed prospective, single‐arm, multicenter study of the VisualaseTM MRI‐Guided Laser Ablation System for the treatment of drug-resistant medial temporal lobe epilepsy (mTLE). Stereotactic laser amygdalohippocampotomy (SLAH), which targets a unilateral amygdalo-hippocampal complex, has proven efficacious for management of seizures with outcomes approximating traditional open resection (OR) mTLE surgery options with evidence of improved cognitive outcomes. Single-center studies of SLAH have suggested comparable or superior changes in mood and anxiety levels as compared to OR procedures for mTLE, with mostly stable or improved scores.
Methods:
We explored mood and anxiety in 106 adult mTLE patients undergoing SLAH using the Beck psychiatric symptoms scales (i.e., Beck Depression Inventory-II [BDI-II] and Beck Anxiety Inventory [BAI]) pre- and post-operatively (1 year follow-up) (complete sets of data were available for at least 86 patients for most analyses). We examined outcome on these measures using a paired t-test comparison, a categorical shift from a depressed state to normal, and using a minimally meaningful change proportion, while considering the effect of seizure outcome and baseline status on these metrics.
Results:
Significant declines in mean BDI-II (11.9 to 7.3) and BAI (10.6 to 6.5) scores following SLAH were observed at the group level (p < .001). Resolution of depression and anxiety occurred in a significant proportion of the post-ablation sample who exhibited baseline symptoms (i.e., depression rates declined from 50.5% to 27.5%; anxiety rates declined from 51.1% to 27.2%, p< .0001, McNemar’s). Using metrics of clinically meaningful change rather than complete symptom resolution, 59 of 86 (68.6%) patients experienced improvement in depression and 16 of 86 (18.6%) experienced worsening. For anxiety, 61 of 86 (70.9%) experienced meaningful improvement and 12 of 86 (14.0%) experienced worsening. SLAH patients were much more likely to improve on psychiatric parameters than decline (p< .0001, binomial test). Complete seizure freedom (Engel I) specifically contributed to decreased anxiety (p=.05, Fisher). De novo occurrence of anxiety or mood disturbance occurred in only one patient without any history of psychiatric illness for those with available data (1 of 77, 1.3%), and an additional 3 cases experienced a new type of psychiatric illness (i.e., someone with depression developed anxiety or vice versa; 3 of 77, 3.9%)
Conclusions:
There was a significant improvement in both clinical depression and anxiety following SLAH, with anxiety status more likely to improve if seizure freedom was achieved. New onset psychiatric status was rare, and much lower than reported in most OR studies. Declines in psychiatric status were much less likely to occur as compared to improvement and mood declines appeared less tied to seizure outcome, perhaps due to the reduced risk of cognitive decline with SLAH (i.e., fewer “double losers” than with OR procedures).
Funding: Medtronic FDA trial of stereotactic laser amygdalohippocampotomy