Dr. Ramesh Doddamani Podcast

This video presents robotic-guided radiofrequency ablation (RFA) for the treatment of hypothalamic hamartoma in a 15-year-old boy with drug-refractory gelastic epilepsy. The patient had a long-standing history of daily gelastic seizures beginning at age 5, later progressing to head drops and generalized seizures despite multiple antiseizure medications.

High-resolution 3T MRI revealed a non-enhancing lesion arising from the hypothalamus and projecting into the third ventricle and suprasellar cistern, consistent with a Delalande type III hypothalamic hamartoma with bilateral broad pedicles.

The surgical strategy focused on minimally invasive disconnection at the interface between the hamartoma and normal hypothalamus. Preoperative 3D MRI planning was performed to precisely map trajectories while avoiding critical neurovascular structures including the optic apparatus, anterior cerebral arteries, basilar artery, fornix, and hypothalamus.

Using the ROSA robotic platform with intraoperative O-arm verification, eight trajectories were executed with overlapping radiofrequency lesions (74°C for 60 seconds) to achieve complete disconnection. A meticulous outside-to-inside lesioning technique and dural sealing with fibrin glue minimized CSF leak and brain shift.

Postoperative imaging confirmed adequate bilateral interface ablation. The patient had an uneventful recovery, no new neurological or hormonal deficits, and achieved seizure freedom at 1-year follow-up (ILAE Class 1A outcome).

This case highlights the evolution of hypothalamic hamartoma treatment from open skull base surgery to precision robotic ablative disconnection, demonstrating the safety, accuracy, and effectiveness of robotic RFA in managing drug-resistant epilepsy.