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Nico E, Adereti CO, Hackett AM, Bianconi A, Naik A, Eberle AT, Cifre Serra PJ, Koester SW, Malnik SL, Fox BM, Hartke JN, Winkler EA, Catapano JS, Lawton MT. Assessing the Relationship between Surgical Timing and Postoperative Seizure Outcomes in Cavernoma-Related Epilepsy: A Single-Institution Retrospective Analysis of 63 Patients with a Review of the Literature. Brain Sci 2024; 14:494. [PMID: 38790473 PMCID: PMC11120247 DOI: 10.3390/brainsci14050494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 04/19/2024] [Accepted: 04/20/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Patients with supratentorial cavernous malformations (SCMs) commonly present with seizures. First-line treatments for cavernoma-related epilepsy (CRE) include conservative management (antiepileptic drugs (AEDs)) and surgery. We compared seizure outcomes of CRE patients after early (≤6 months) vs. delayed (>6 months) surgery. Methods: We compared outcomes of CRE patients with SCMs surgically treated at our large-volume cerebrovascular center (1 January 2010-31 July 2020). Patients with 1 sporadic SCM and ≥1-year follow-up were included. Primary outcomes were International League Against Epilepsy (ILAE) class 1 seizure freedom and AED independence. Results: Of 63 CRE patients (26 women, 37 men; mean ± SD age, 36.1 ± 14.6 years), 48 (76%) vs. 15 (24%) underwent early (mean ± SD, 2.1 ± 1.7 months) vs. delayed (mean ± SD, 6.2 ± 7.1 years) surgery. Most (32 (67%)) with early surgery presented after 1 seizure; all with delayed surgery had ≥2 seizures. Seven (47%) with delayed surgery had drug-resistant epilepsy. At follow-up (mean ± SD, 5.4 ± 3.3 years), CRE patients with early surgery were more likely to have ILAE class 1 seizure freedom and AED independence than those with delayed surgery (92% (44/48) vs. 53% (8/15), p = 0.002; and 65% (31/48) vs. 33% (5/15), p = 0.03, respectively). Conclusions: Early CRE surgery demonstrated better seizure outcomes than delayed surgery. Multicenter prospective studies are needed to validate these findings.
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Affiliation(s)
- Elsa Nico
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Christopher O. Adereti
- Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, MA 01805, USA
| | - Ashia M. Hackett
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Andrea Bianconi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Anant Naik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Adam T. Eberle
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Pere J. Cifre Serra
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Stefan W. Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Samuel L. Malnik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Brandon M. Fox
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Joelle N. Hartke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Ethan A. Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Joshua S. Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
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Patel A, Valle D, Nguyen A, Molina E, Lucke-Wold B. Role of Genetics and Surgical Interventions for the Management of Cerebral Cavernous Malformations (CMM). CURRENT CHINESE SCIENCE 2023; 3:386-395. [PMID: 37981909 PMCID: PMC10657140 DOI: 10.2174/2210298103666230823094431] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 05/21/2023] [Accepted: 07/14/2023] [Indexed: 11/21/2023]
Abstract
Cerebral cavernous malformations (CCMs) are comprised of tissue matter within the brain possessing anomalous vascular architecture. In totality, the dilated appearance of the cavernomatakes on a mulberry-like shape contributed by the shape and relation to vascular and capillary elements. Analyzing its pathophysiology along with its molecular and genetic pathways plays a vital role in whether or not a patient receives GKRS, medical management, or Surgery, the most invasive of procedures. To avoid neurological trauma, microsurgical resection of cavernomas canbe guided by the novel clinical application of a 3D Slicer with Sina/MosoCam. When cavernomas present in deep lesions with poor accessibility, gamma knife stereotactic radiosurgery (GKSR) is recommended. For asymptomatic and non-multilobal lesions, medical and symptom management is deemed standard, such as antiepileptic therapy. The two-hit hypothesis serves to explain the mutations in three key genes that are most pertinent to the progression of cavernomas: CCM1/KRIT1, CCM2/Malcavernin, and CCM3/PDCD10. Various exon deletions and frameshift mutations can cause dysfunction in vascular structure through loss and gain of function mutations. MEKK3 and KLF2/4 are involved in a protein kinase signaling cycle that promotes abnormal angiogenesis and cavernoma formation. In terms of potential treatments, RhoKinase inhibitors have shown to decrease endothelial to mesenchymal transition and CCM lesion development in mice models. All in all, understanding the research behind the molecular genetics in CCMs can foster personalized medicine and potentially create new neurosurgical and medicative treatments.
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Affiliation(s)
- Anjali Patel
- Department of Neurosurgery, College of Medicine, University of Florida, Florida 32013, United States
| | - Daisy Valle
- Department of Neurosurgery, College of Medicine, University of Florida, Florida 32013, United States
| | - Andrew Nguyen
- Department of Neurosurgery, College of Medicine, University of Florida, Florida 32013, United States
| | - Eduardo Molina
- Department of Neurosurgery, College of Medicine, University of Florida, Florida 32013, United States
| | - Brandon Lucke-Wold
- Department of Neurosurgery, College of Medicine, University of Florida, Florida 32013, United States
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Tuleasca C, Peciu-Florianu I, Strachowski O, Derre B, Vannod-Michel Q, Reyns N. How to combine the use of intraoperative magnetic resonance imaging (MRI) and awake craniotomy for microsurgical resection of hemorrhagic cavernous malformation in eloquent area: a case report. J Med Case Rep 2023; 17:160. [PMID: 37041613 PMCID: PMC10091828 DOI: 10.1186/s13256-023-03816-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/08/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND Cavernous malformations are clusters of abnormal and hyalinized capillaries without interfering brain tissue. Here, we present a cavernous malformation operated under awake conditions, due to location, in an eloquent area and using intraoperative magnetic resonance imaging due to patient's movement upon the awake phase. CASE PRESENTATION We present the pre-, per-, and postoperative course of an inferior parietal cavernous malformation, located in eloquent area, in a 27-year-old right-handed Caucasian male, presenting with intralesional hemorrhage and epilepsy. Preoperative diffusion tensor imaging has shown the cavernous malformation at the interface between the arcuate fasciculus and the inferior fronto-occipital fasciculus. We describe the microsurgical approach, combining preoperative diffusion tensor imaging, neuronavigation, awake microsurgical resection, and intraoperative magnetic resonance imaging. CONCLUSION Complete microsurgical en bloc resection has been performed and is feasible even in eloquent locations. Intraoperative magnetic resonance imaging was considered an important adjunct, particularly used in this case as the patient moved during the "awake" phase of the surgery and thus neuronavigation was not accurate anymore. Postoperative course was marked by a unique, generalized seizure without any adverse event. Immediate and 3 months postoperative magnetic resonance imaging confirmed the absence of any residue. Pre- and postoperative neuropsychological exams were unremarkable.
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Affiliation(s)
- Constantin Tuleasca
- Neurosurgery and Neurooncology Service Lille, Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Lille, France.
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland.
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland.
- Signal Processing Laboratory (LTS 5), Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland.
| | - Iulia Peciu-Florianu
- Neurosurgery and Neurooncology Service Lille, Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Lille, France
| | - Ondine Strachowski
- Neurosurgery and Neurooncology Service Lille, Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Lille, France
| | - Benoit Derre
- Neurosurgery and Neurooncology Service Lille, Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Lille, France
| | - Quentin Vannod-Michel
- Neuroradiology Service, Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Lille, France
| | - Nicolas Reyns
- Neurosurgery and Neurooncology Service Lille, Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Lille, France
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Shoubash L, Nowak S, Greisert S, Al Menabbawy A, Rathmann E, von Podewils F, Fleck S, Schroeder HHW. Cavernoma-Related Epilepsy: Postoperative Epilepsy Outcome and Analysis of the Predictive Factors, Case Series. World Neurosurg 2023; 172:e499-e507. [PMID: 36693619 DOI: 10.1016/j.wneu.2023.01.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Epilepsy is common in patients harboring cavernous malformation, and surgery is reported to be an effective treatment. However, few patients still experience seizures after surgery. We analyzed the outcome and predictive factors after cavernoma-related epilepsy (CRE) surgery. METHODS A database was created for all patients with CRE treated surgically from 2003 to 2020 at a university hospital. A chart review, perioperative epilepsy workup, surgical strategies, and postoperative and follow-up notes were analyzed. Postoperative seizure outcome was evaluated according to the Engel classification. RESULTS Thirty-seven patients (40.5% women; mean age 39.1 ± 14.5 years) were studied. The mean follow-up time was 5.6 ± 3.9 years. Among 37 patients, 32 (86.5%) achieved Engel class I at the last follow-up. Engel class II was found in 1 (2.7%), Engel class III in 1 (2.7%), and Engel class IV in 3 (8.1%) cases. Engel class Ia was observed in 23 patients (62.2%). None of the patients had a worse seizure outcome after the operation (Engel class IVc). Univariate and multivariate analysis showed that short-standing, sporadic, or low-frequent (≤3) seizures were the only variables significantly associated with seizure freedom, whereas longstanding, drug-resistant, or high-frequent seizure history were associated with worse seizure outcomes. CONCLUSIONS Surgical treatment results in favorable seizure control in most patients after CRE surgery. Long duration of epilepsy before surgery, high seizure frequency, and drug-resistant epilepsy could have a negative effect on seizure outcome (Engel class II-IV). Therefore, early surgical resection of the cavernoma after careful presurgical planning is recommended to achieve an optimal result.
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Affiliation(s)
- Loay Shoubash
- Department of Neurosurgery, University Medicine of Greifswald, Greifswald, Germany.
| | - Stephan Nowak
- Department of Neurosurgery, University Medicine of Greifswald, Greifswald, Germany
| | - Stephan Greisert
- Department of Neurosurgery, University Medicine of Greifswald, Greifswald, Germany
| | - Ahmed Al Menabbawy
- Department of Neurosurgery, University Medicine of Greifswald, Greifswald, Germany
| | - Eico Rathmann
- Department of Neuroradiology, University Medicine of Greifswald, Greifswald, Germany
| | - Felix von Podewils
- Department of Neurology, Epilepsy Center, University Medicine of Greifswald, Greifswald, Germany
| | - Steffen Fleck
- Department of Neurosurgery, University Medicine of Greifswald, Greifswald, Germany
| | - Henry H W Schroeder
- Department of Neurosurgery, University Medicine of Greifswald, Greifswald, Germany
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Dziedzic TA, Koczyk K, Nowak A, Maj E, Marchel A. Long-Term Management of Seizures after Surgical Treatment of Supratentorial Cavernous Malformations : A Retrospective Single Centre Study. J Korean Neurosurg Soc 2022; 65:415-421. [PMID: 35508959 PMCID: PMC9082132 DOI: 10.3340/jkns.2020.0224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 07/21/2021] [Indexed: 11/27/2022] Open
Abstract
Objective Seizure recurrence after the first-ever seizure in patients with a supratentorial cerebral cavernous malformation (CCM) is almost certain, so the diagnosis and treatment of epilepsy is justified. The optimal method of management of these patients is still a matter of debate. The aim of our study was to identify factors associated with postoperative seizure control and assess the surgical morbidity rate.
Methods We retrospectively analysed 45 consecutive patients with a supratentorial CCM and symptomatic epilepsy in a single centre. Pre- and postoperative epidemiological data, seizure-related patient histories, neuroimaging results, surgery details and outcomes were obtained from hospital medical records. Seizure outcomes were assessed at least 12 months after surgery.
Results Thirty-five patients (77.8%) were seizure free at the long-term follow-up (Engel class I); six (13,3%) had rare, nocturnal seizures (Engel class II); and four (8.9%) showed meaningful improvement (Engel class III). In 15 patients (33%) in the Engel I group; it was possible to discontinue antiepileptic medication. Although there was not statistical significance, our results suggest that patients can benefit from early surgery. No deaths occurred in our study, and mild postoperative neurologic deficits were observed in two patients (4%) at the long-term follow-up.
Conclusion Surgical resection of CCMs should be considered in all patients with a supratentorial malformation and epilepsy due to the favourable surgical results in terms of the epileptic seizure control rate and low postoperative morbidity risk, despite the use of different predictors for the seizure outcome.
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He K, Alriashy MHS, Fan Z, Qiao N, Liao Y, An Q, Xu B, Song J, Zhang X, Zhu W, Chen L, Mao Y. Cavernoma -Associated Epilepsy Within the Mesial Temporal Lobe: Surgical Management and Seizure Outcome. World Neurosurg 2022; 160:e464-e470. [PMID: 35051640 DOI: 10.1016/j.wneu.2022.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Kangmin He
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - M H S Alriashy
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - Zhen Fan
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - Nidan Qiao
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - Yujun Liao
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - Qinzhu An
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - Bin Xu
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - Jianping Song
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - Xin Zhang
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - Wei Zhu
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
| | - Liang Chen
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China.
| | - Ying Mao
- Department of Neurosurgery, Fudan University Huashan Hospital, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 200040, China
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Seizure outcome in patients with cavernous malformation after early surgery. Epilepsy Behav 2021; 115:107662. [PMID: 33339740 DOI: 10.1016/j.yebeh.2020.107662] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/22/2020] [Accepted: 11/23/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To describe seizure outcome and complications in patients with cavernous malformations (CM) undergoing early versus late surgery. METHODS A database was created for all CM patients who presented with seizure referred to the neurosurgical clinic at an academic center. A telephone survey and chart review were conducted to evaluate for preoperative and postoperative seizure frequency. Postoperative seizure-free outcome of patients who had ≤2 preoperative seizures versus those that had >2 preoperative seizures was compared. RESULTS A total of 35 CM patients were included for analysis. Nineteen patients had ≤2 preoperative seizures and 16 patients had >2 preoperative seizures, six of them drug resistant for over two years. Among the ≤2 seizure group, 15 had only a single seizure before surgical resection. 94.7% of patients with ≤2 preoperative seizures and 62.5% of patients with >2 preoperative seizures were seizure free one year following surgical resection (p = 0.019). 78.9% of patients with ≤2 preoperative seizures and 25% of patients with >2 preoperative seizures were able to wean off AEDs (p < 0.001). Among those patients who had a single preoperative seizure, 100% of patients were seizure free at one year. CONCLUSIONS Early surgical resection for CM patients who present after a CM-related seizure is an effective, well tolerated treatment and has good chance to offer seizure freedom without the need for long-term antiepileptic medications. Outcome for patients operated with only one or two preoperative seizures may lead to better results than patients who delay the procedure.
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Gao X, Yue K, Sun J, Cao Y, Zhao B, Zhang H, Dai S, Zhang L, Luo P, Jiang X. Treatment of Cerebral Cavernous Malformations Presenting With Seizures: A Systematic Review and Meta-Analysis. Front Neurol 2020; 11:590589. [PMID: 33193057 PMCID: PMC7649328 DOI: 10.3389/fneur.2020.590589] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 09/25/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Cerebral cavernous malformations (CCMs) presenting with seizures can be treated with neurosurgery or radiosurgery, but the ideal treatment remains unclear. Currently, there is no adequate randomized controlled trial comparing surgical treatment and radiotherapy for epileptogenic CCMs. Therefore, we conducted a systematic review and meta-analysis of available data from published literature to compare the efficacy and safety of neurosurgery and radiosurgery for epileptogenic CCMs. Methods: We performed a comprehensive search of the Ovid MEDLINE, Web of Science, PubMed, China Biological Medicine and China National Knowledge Infrastructure databases for studies published between January 1994 and October 2019. The search terms were as follows: "epilepsy," "seizures," "brain cavernous hemangioma," "cerebral cavernous malformation," "cerebral cavernous hemangioma," "hemangioma, cavernous, central nervous system." Two researchers independently extracted the data and reviewed all the articles. We compared the advantages and disadvantages of the two treatments. Results: A total of 45 studies were included in our analysis. Overall, the seizure control rate was 79% (95% CI: 75-83%) for neurosurgery and 49% (95% CI: 38-59%) for radiosurgery. In the neurosurgery studies, 4.4% of patients experienced permanent morbidity, while no patients in the radiotherapy studies had permanent morbidity. In addition, the results of subgroup analysis showed that ethnicity, CCMs location and average lesion number are likely significant factors influencing the seizure outcome following treatment. Conclusions: The epilepsy control rate after neurosurgery was higher than that after radiosurgery, but neurosurgery also had a relatively higher rate of permanent morbidity.
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Affiliation(s)
- Xiangyu Gao
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Kangyi Yue
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jidong Sun
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yuan Cao
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Boyan Zhao
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Haofuzi Zhang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Shuhui Dai
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Lei Zhang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Peng Luo
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xiaofan Jiang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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Grigoryan YA, Sitnikov AR, Grigoryan GY, Timoshenkov AV, Mishnyakova LP. [Surgical treatment of epilepsy in patients with mediobasal temporal cavernous malformations]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2018; 82:45-56. [PMID: 30137038 DOI: 10.17116/neiro201882445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Epilepsy is a frequent clinical manifestation of cavernous malformations (CMs) of the mediobasal temporal region (MBTR). Surgical removal of CMs is an excellent technique for treating associated epilepsy and may range from pure lesionectomy to tailored resection of the temporal lobe. PURPOSE The study purpose was to determine the optimal surgical management for epilepsy in patients with CMs of the MBTR. MATERIAL AND METHODS We retrospectively analyzed the clinical data, neuroimaging findings, surgical techniques, and surgical outcomes in 11 patients with epilepsy and CMs of the MBTR. All patients underwent video-electroencephalography, magnetic resonance imaging, and computed tomography in the pre- and postoperative periods. Nine patients underwent preoperative implantation of foramen ovale electrodes. In all cases, surgery was accompanied by electrocorticography (ECoG). RESULTS CMs were located in the anterior MBTR in 7 cases, anterior and middle thirds of the MBTR in 1 case, middle third in 2 cases, and middle and posterior thirds in 1 case. In 8 patients, preoperative monitoring revealed a seizure onset area in the MBTR. These patients underwent cavernomectomy with ECoG-guided resection of the hemosiderin ring and adjacent tissue using the pterional (4 cases) or supracerebellar transtentorial approach (4). In 3 cases, anterior temporal lobectomy with cavernomectomy was additionally used due to spreading of pathological activity to the lateral temporal neocortex. Seizure control after surgery was excellent in 7 patients (class 1 ILAE) and good in 4 (class 2 ILAE). CONCLUSION Surgery in patients with epilepsy caused by CMs of the MBTR should be performed based on non-invasive and invasive presurgical evaluation. If the seizure onset area is located in the MBTR, lesionectomy with ECoG-guided resection of the adjacent temporal cortical areas can be performed using the pterional or supracerebellar transtentorial approach. Lateral spread of epileptic activity requires cavernomectomy and anterior temporal lobectomy.
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Affiliation(s)
| | - A R Sitnikov
- Treatment and rehabilitation center, Moscow, Russia
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Ishida W, Morino M, Matsumoto T, Casaos J, Ramhmdani S, Lo SFL. Hippocampal Transection Plus Tumor Resection as a Novel Surgical Treatment for Temporal Lobe Epilepsy Associated with Cerebral Cavernous Malformations. World Neurosurg 2018; 119:e209-e215. [PMID: 30064030 DOI: 10.1016/j.wneu.2018.07.108] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 07/11/2018] [Accepted: 07/12/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The optimal surgical treatment for cavernous malformation-related temporal lobe epilepsy (CRTLE) is still controversial because it frequently involves the hippocampus as an epileptogenic zone. Here we describe our unique surgical strategy of performing hippocampal transection (HT) plus tumor resection for CRTLE to solve the question of how to balance postoperative seizure outcomes and neuropsychologic outcomes. METHODS From 2005 to 2016, 7 cases of HT (3 on dominant side) plus tumor resection were performed for patients with CRTLE. We routinely perform intraoperative electrocorticography just before and after the resection of the tumor with hemosiderin rim. In cases with residual spikes from the hippocampus after the resection, we add HT, considering laterality of the lesion, preoperative memory functions, and magnetic resonance imaging abnormalities in hippocampi. Patient information, including seizure outcomes and preoperative and postoperative (24 months) Wechsler Memory Scale-Revised (WMS-R), were collected. RESULTS In the mean follow-up of 62.7 months (range 20-119), the postoperative seizure outcome was as follows: Engel class I in 6 cases (85.7%) and II in 1 case (14.3%). Perioperative changes in WMS-R score were as follows: 93.5 preoperatively versus 99.5 postoperatively (P = 0.408) in verbal memory and 90.7 versus 98.0 (P = 0.351) in delayed recall. Overall, no patient presented with more than 25% decline in any of the WMS-R indices postoperatively. CONCLUSIONS Despite the small sample size and noncontrolled study design, postoperative seizure outcomes were deemed acceptable with favorable memory outcomes, which rather improved postoperatively with marginal statistical significance. In patients with CRTLE, additional HT is a reasonable treatment option.
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Affiliation(s)
- Wataru Ishida
- Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA.
| | - Michiharu Morino
- Department of Neurosurgery, Kumagaya General Hospital, Kumagaya, Japan
| | | | - Joshua Casaos
- Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Seba Ramhmdani
- Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
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Yang PF, Pei JS, Jia YZ, Lin Q, Xiao H, Zhang TT, Zhong ZH. Surgical Management and Long-Term Seizure Outcome After Surgery for Temporal Lobe Epilepsy Associated with Cerebral Cavernous Malformations. World Neurosurg 2017; 110:e659-e670. [PMID: 29175574 DOI: 10.1016/j.wneu.2017.11.067] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 11/11/2017] [Accepted: 11/14/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Operative strategies for cerebral cavernous malformation (CCM)-associated temporal lobe epilepsy and timing of surgical intervention continue to be debated. This study aimed to establish an algorithm to evaluate the efficacy of surgical intervention strategies, to maximize positive surgical outcomes and minimize postsurgical neurologic deficits. METHODS 47 patients having undergone operation for CCM-associated temporal lobe epilepsy were retrospectively reviewed. They had received a diagnostic series for seizure localization, including long-term video electroencephalography (vEEG), high-resolution magnetic resonance imaging (MRI), and positron emission tomography-computed tomography (PET-CT). In patients with mesial temporal lobe CCMs, the involved structures (amygdala, hippocampus, or parahippocampal gyrus) were resected in addition to the lesions. Patients with neocortical epileptogenic CCM underwent extended lesionectomy guided by intraoperative electrocorticography; further performance of amygdalohippocampectomy depended on the extent of hippocampal epileptogenicity. RESULTS The study cohort contained 28 patients with drug-resistant epilepsy (DRE), 12 with chronic epilepsy (CE), and 7 with sporadic seizure (SS). Normal temporal lobe metabolism was seen in 7/7 patients of the SS group. Hypometabolism was found in all patients with chronic disease except for those with posterior inferior and middle temporal gyrus cavernous malformations (CMs). Of the 31 patients with superficial neocortical CCM, 7 had normal PET without hippocampal sclerosis, 14 had ipsilateral temporal lobe hypometabolism without hippocampal sclerosis, and 10 had obvious hippocampal sclerosis and hypometabolism. Seizure freedom in DRE, CE, and SS was 82.1%, 75%, and 100%, respectively. A significant difference was found between lesion laterality and postoperative seizure control; the rate was lower in left-sided cases because of less aggressive resection. CONCLUSIONS Our study demonstrates that the data from the presurgical evaluation, particularly regarding CM location, responsiveness to antiepileptic drugs, and temporal lobe metabolism, are crucial parameters for choosing surgical approaches to CCM-associated temporal lobe epilepsy. By this operative strategy, patients may receive maximized seizure control and minimized postsurgical neurologic sequelae.
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Affiliation(s)
- Peng-Fan Yang
- Department of Neurosurgery, Fuzhou General Hospital, Fujian Medical University, Fuzhou, China.
| | - Jia-Sheng Pei
- Department of Neurosurgery, Fuzhou General Hospital, Fujian Medical University, Fuzhou, China
| | - Yan-Zeng Jia
- Department of Epileptology, Fuzhou General Hospital, Fujian Medical University, Fuzhou, China
| | - Qiao Lin
- Department of Epileptology, Fuzhou General Hospital, Fujian Medical University, Fuzhou, China
| | - Hui Xiao
- Department of Medical Imaging, Fuzhou General Hospital, Fujian Medical University, Fuzhou, China
| | - Ting-Ting Zhang
- Department of Pathology, Fuzhou General Hospital, Fujian Medical University, Fuzhou, China
| | - Zhong-Hui Zhong
- Department of Epileptology, Fuzhou General Hospital, Fujian Medical University, Fuzhou, China
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Campero A, Ajler P, Rica C, Rhoton A. Cavernomas and Arteriovenous Malformations in the Mesial Temporal Region: Microsurgical Anatomy and Approaches. Oper Neurosurg (Hagerstown) 2017; 13:113-123. [PMID: 28931254 DOI: 10.1227/neu.0000000000001239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 12/26/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The mesial temporal region (MTR) is located deep in the temporal lobe and it is surrounded by important vascular and nervous structures that should be preserved during surgery. OBJECTIVE To describe microsurgical anatomy and approaches to the MTR in relation to cavernomas and arteriovenous malformations (AVMs). METHODS Five formalin-fixed and red silicone-embedded heads of adult cadavers were used for this study. Between January 2003 and June 2014, 7 patients with cavernomas and 6 patients with AVMs in the MTR underwent surgery. RESULTS The MTR of the cadavers was divided into 3 areas: anterior, middle, and posterior. Of the 7 patients with MTR cavernomas, 4 were located anteriorly, 2 were located medially, and 1 was located posteriorly. Of the 6 patients with MTR AVMs, 3 were located in the anterior sector, 2 in the middle sector, and 1 in the posterior sector. For the anterior portion of the MTR, a transsylvian-transinsular approach was used; for the middle portion of the MTR, a transtemporal approach was used (anterior temporal lobectomy); and for the posterior portion of the MTR, a supracerebellar-transtentorial approach was used. CONCLUSION Dividing the MTR into 3 regions allows us to adapt the approach to lesion location. Thus, the anterior sector can be approached via the sylvian fissure, the middle sector can be approached transtemporally, and the posterior sector can be approached via the supracerebellar approach.
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Affiliation(s)
- Alvaro Campero
- Department of Neurological Surgery, Hospital Padilla, Tucumán, Argentina.,Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Pablo Ajler
- Department of Neurological Surgery, Hospital Italiano, Buenos Aires, Argentina
| | - Carlos Rica
- Department of Neurological Surgery, Sanatorio Güemes, Buenos Aires, Argentina
| | - Albert Rhoton
- Department of Neurological Surgery, University of Florida, Gainesville, Florida
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Brain tumors incidences and a retrospective clinical analysis from a tertiary hospital in India. J Neurooncol 2016; 129:383-7. [PMID: 27311727 DOI: 10.1007/s11060-016-2183-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 06/09/2016] [Indexed: 12/22/2022]
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Meguins LC, Rocha da Cruz Adry RA, da Silva Júnior SC, Pereira CU, de Oliveira JG, de Morais DF, de Araújo Filho GM, Marques LHN. Microsurgical treatment of patients with refractory epilepsy and mesial temporal cavernous malformations: Clinical experience of a tertiary epilepsy center. Surg Neurol Int 2015; 6:169. [PMID: 26629395 PMCID: PMC4653350 DOI: 10.4103/2152-7806.169552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 09/03/2015] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Mesiotemporal cavernous malformation can occur in 10-20% of patients with cerebral cavernomas and are frequently associated with refractory. METHODS A retrospective investigation was performed in the epilepsy clinic of a Brazilian tertiary referral epilepsy center, from January 2000 to March 2012. RESULTS A total of 21 patients were included in the study. Thirteen patients (62%) evolved to Engel I; 5 (24%) to Engel II, 2 (10%) to Engel III, and 1 (5%) to Engel IV. We observed that 10 (48%) patients with 12 years or less of epilepsy duration evolved to Engel I and 1 (5%) to Engel II; whereas from a total of 10 patients with epilepsy duration of more than 12 years, 3 (30%) evolved to Engel I and 7 (70%) to Engel II, III, or IV (P < 0.001 [bilateral]; P1 ≠ P2). CONCLUSION Postsurgical seizure outcome for temporal lobe epilepsy associated with mesiotemporal cavernomas is very satisfactory.
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Affiliation(s)
- Lucas Crociati Meguins
- Department of Neurologic Sciences, Division of Neurosurgery, Hospital de Base, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Rodrigo Antônio Rocha da Cruz Adry
- Department of Neurologic Sciences, Division of Neurosurgery, Hospital de Base, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Sebastião Carlos da Silva Júnior
- Department of Neurologic Sciences, Division of Neurosurgery, Hospital de Base, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | | | - Jean Gonçalves de Oliveira
- Department of Medical Sciences, Division of Neurosurgery, School of Medicine, University Nove de Julho, São Paulo, Brazil ; Department of Cerebrovascular and Skull Base Surgery, Center of Neurology and Neurosurgery Associates, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Dionei Freitas de Morais
- Department of Neurologic Sciences, Division of Neurosurgery, Hospital de Base, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | | | - Lúcia Helena Neves Marques
- Department of Neurologic Sciences, Division of Neurology, Hospital de Base, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
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Campero A. [Microsurgical anatomy and approaches of mesial temporal cavernomas]. Surg Neurol Int 2015; 6:S530-7. [PMID: 26600986 PMCID: PMC4623614 DOI: 10.4103/2152-7806.167204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 08/16/2015] [Indexed: 11/08/2022] Open
Abstract
Objetivo: Describir la anatomía microquirúrgica y los abordajes a la región temporal mesial (RTM), en relación a cavernomas de dicho sector. Materiales y Método: Cinco cabezas de cadáveres adultos, fijadas en formol e inyectadas con silicona coloreada, fueron estudiadas. Además, desde enero de 2007 a junio de 2014, 7 pacientes con cavernomas localizados en la RTM fueron operados por el autor. Resultados: Anatomia: La RTM fue dividida en 3 sectores: Anterior, medio y posterior. Pacientes: 7 enfermos con cavernomas de la RTM fueron operados por el autor. De acuerdo a la ubicacion en la RTM, 4 cavernomas se ubicaron en el sector anterior, 2 cavernomas se localizaron en el sector medio y 1 cavernoma se ubico en el sector posterior. Para el sector anterior de la RTM se utilizo un abordaje transsilviano-transinsular; para el sector medio de la RTM se utilizo un abordaje transtemporal (lobectomia temporal anterior); y para el sector posterior de la RTM se utilizo un abordaje supracerebeloso-transtentorial. Conclusión: Dividir la RTM en 3 sectores nos permite adecuar el abordaje en función a la localización de la lesión. Así, el sector anterior es bien abordable a través de la fisura silviana; el sector medio a través de una vía transtemporal; y el sector posterior por un abordaje supracerebeloso.
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Affiliation(s)
- Alvaro Campero
- Servicio de Neurocirugía, Hospital Padilla, Tucumán, Argentina
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Vale FL, Vivas AC, Manwaring J, Schoenberg MR, Benbadis SR. Temporal lobe epilepsy and cavernous malformations: surgical strategies and long-term outcomes. Acta Neurochir (Wien) 2015; 157:1887-95; discussion 1895. [PMID: 26416611 DOI: 10.1007/s00701-015-2592-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 09/15/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Cerebral cavernous malformations (CCM) of the temporal lobe often present with seizures. Surgical resection of these lesions can offer durable seizure control. There is, however, no universally accepted methodology for assessing and surgically treating these patients. We propose an algorithm to maximize positive surgical outcomes (seizure control) while minimizing post-surgical neurological deficit. METHODS A retrospective review of 34 patients who underwent epilepsy surgery for radiographically proven temporal lobe CCM was conducted. Patients underwent a relatively standard work-up for seizure localization. In patients with mesial temporal lobe epilepsy (MTLE), a complete resection of the epileptogenic zone was performed including amygdalo-hippocampectomy in addition to a lesionectomy if not contraindicated by pre-operative work-up. Patients with neocortical epilepsy underwent intraoperative electrocorticography (ECoG)-guided lesionectomy. RESULTS Seizure-free rate for mesial and neocortical (anterior, lateral, and basal) location was 90 vs. 83 %, respectively. Complete resection of the lesion, irrespective of location, was statistically significant for seizure control (p = 0.018). There was no difference in seizure control based on disease duration or location (p > 0.05). Patients with mesial temporal CCM who presented with MTLE were presumed to also have mesial temporal sclerosis (MTS), or dual pathology. These patients underwent routine resection of the mesial structures. Interestingly, patients who had MTLE and basal (neocortical) lesions who underwent a mesial resection for suspected MTS were found not to have dual pathology. CONCLUSIONS Patients with temporal lobe CCM should be offered resection for durable seizure control, prevention of secondary epileptogenic foci, and elimination of hemorrhage risk. The preoperative work-up should follow a team approach. Surgical intervention should include complete lesionectomy in all cases. Intra or extra-operative ECoG for neocortical lesions may be beneficial. Management of mesial temporal CCMs (archicortex) should consider resection of a well-defined epileptogenic zone (including mesial structures) due to high probability of pathologically proven MTS. The use of this treatment algorithm is useful for the education and treatment of these patients.
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Affiliation(s)
- Fernando L Vale
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
| | - Andrew C Vivas
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Jotham Manwaring
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Mike R Schoenberg
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Selim R Benbadis
- Department of Neurology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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Shan YZ, Fan XT, Meng L, An Y, Xu JK, Zhao GG. Treatment and outcome of epileptogenic temporal cavernous malformations. Chin Med J (Engl) 2015; 128:909-13. [PMID: 25836611 PMCID: PMC4834007 DOI: 10.4103/0366-6999.154289] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: The aim of this study is to explore the treatment and outcome of epileptogenic temporal lobe cavernous malformations (CMs). Methods: We analyzed retrospectively the profiles of 52 patients diagnosed as temporal lobe CMs associated with epilepsy. Among the 52 cases, 11 underwent a direct resection of CM along with the adjacent zone of hemosiderin rim without electrocorticogram (ECoG) monitoring while the other 41 cases had operations under the guidance of ECoG. Forty-six patients were treated by lesionectomy + hemosiderin rim while the other six were treated by lesionectomy + hemosiderin rim along with extended epileptogenic zone resection. The locations of lesions, the duration of illness, the manifestation, the excision ranges and the outcomes of postoperative follow-up were analyzed, respectively. Results: All of the 52 patients were treated by microsurgery. There was no neurological deficit through the long-term follow-up. Outcomes of seizure control are as follows: 42 patients (80.8%) belong to Engel Class I, 5 patients (9.6%) belong to Engel Class II, 3 patients (5.8%) belong to Engel Class III and 2 patients (3.8%) belong to Engel Class IV. Conclusion: Patients with epilepsy caused by temporal CMs should be treated as early as possible. Resection of the lesion and the surrounding hemosiderin zone is necessary. Moreover, an extended excision of epileptogenic cortex or cerebral lobes is needed to achieve a better prognosis if the ECoG indicates the existence of an extra epilepsy onset origin outside the lesion itself.
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Affiliation(s)
| | | | | | | | - Jian-Kun Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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18
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Pterional transsylvian-transinsular approach in three cavernomas of the left anterior mesiotemporal region. Clin Neurol Neurosurg 2014; 130:14-9. [PMID: 25576880 DOI: 10.1016/j.clineuro.2014.12.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 12/15/2014] [Accepted: 12/20/2014] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To describe the pterional transsylvian-transinsular approach for cavernomas of the left anterior mesiotemporal region in three patients. METHODS A retrospective analysis of patients who underwent surgery for cavernous angiomas in the temporal lobe was performed via the left mesiotemporal lobe (MTL). The technique was as follows: using the pterional approach, the Sylvian fissure was widely opened, distally to proximally. The temporal branch of the middle cerebral artery was displaced medially, and once the limiting sulcus of the insula was located, an 8mm long corticotomy was performed, just behind the limen insulae. The dissection was extended through the white matter until the anterior portion of the temporal horn was reached. Finally, lesion resection was performed. RESULTS Three patients presented with cavernomas in the anterior sector of the MTL and underwent the transsylvian-transinsular approach. There were no deaths in this series. One patient sustained a permanent postoperative deficit, a right homonymous quadrantanopia. CONCLUSION The pterional transsylvian-transinsular approach allows for selective resection of lesions located in the anterior mesiotemporal region (MTR) of the dominant hemisphere, while avoiding damage to the lateral or basal cortex of the temporal lobe or to structures in the dominant hemisphere.
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Wang C, You C, Han GQ, Wang J, Xiong YB, Liu CX. Electrocorticography-guided surgical treatment of solitary supratentorial cavernous malformations with secondary epilepsy. ACTA ACUST UNITED AC 2014; 29:112-6. [PMID: 24998234 DOI: 10.1016/s1001-9294(14)60038-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the efficacy of electrocorticographic (ECoG) monitoring and the application of different surgical approaches in the surgical treatment of solitary supretentorial cavernous malformations with secondary epilepsy. METHODS This study enrolled a consecutive series of 36 patients with solitary supratentorial cavernous malformations and secondary epilepsy who underwent surgery with intraoperative ECoG monitoring in the Department of Neurosurgery between January 2004 and January 2008. The patients were composed of 15 males and 21 females, aged between 8 and 52 years (mean age 27.3±2.8 years) at the time of surgery. Epilepsy history, the type of epilepsy at the presentation, lesion location, the incidence of residual epileptiform discharges, and postoperative outcomes were evaluated. RESULTS Histopathological examination indicated cavernous malformations and hippocampal sclerosis in 36 and 5 cases, respectively. Neuronal degeneration, glial cell proliferation, and neurofibrillary tangles were found in all the resected cerebral tissues of extended lesionectomy of residual epileptic foci. Lesionectomy, anterior temporal lobectomy, anterior temporal lobectomy plus cortical thermocoagulation, extended lesionectomy, extended lesionectomy plus cortical thermocoagulation were performed in 4, 4, 1, 14, and 13 cases, respectively. Residual epileptiform discharges were captured in 9 out of the 14 patients who had additional cortical thermocoagulation. According to Engle class for postoperative outcomes, 27 cases were class I (75.00%), 5 were class II (13.89%), 2 were class III (5.56%), and 2 were class IV (5.56%), thus the total effective rate (class I+class II) was 88.89%. Neither of epilepsy history, the type of epilepsy, and the location of cavernous malformation was significantly related to outcomes (P>0.05). A significant relationship was found between the incidence of residual epileptiform discharges and outcomes (P=0.041). CONCLUSIONS Intraoperative ECoG monitoring, the application of different surgical approaches, and the resection of residual epileptic foci could produce good result in the surgical treatment of supratentorial cavernous malformation with secondary epilepsy. Postoperative residual epileptiform discharges could be a useful predictor for evaluating the outcomes.
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Affiliation(s)
- Chao Wang
- Department of Neurosurgery, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Guo-Qiang Han
- Department of Neurosurgery, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Jun Wang
- Department of Neurosurgery, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Yun-Biao Xiong
- Department of Neurosurgery, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Chuang-Xi Liu
- Department of Neurosurgery, Guizhou Provincial People's Hospital, Guiyang 550002, China
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Kim J, Kim CH, Chung CK. Longitudinal changes in seizure outcomes after resection of cerebral cavernous malformations in patients presenting with seizures: a long-term follow-up of 46 patients. Acta Neurochir (Wien) 2014; 156:1539-47; discussion 1546-7. [PMID: 24829156 DOI: 10.1007/s00701-014-2121-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 04/30/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Seizure is the most common presentation in patients with cerebral cavernous malformations (CCMs). Although many articles have documented seizure outcomes after resection of CCM, few have conducted long-term follow-ups; thus, the fluctuating seizure outcomes have been neglected. The purpose of this study is to describe long-term postoperative seizure outcomes in patients with CCM and to compare seizure outcomes between patients with sporadic seizures and those with chronic seizures. METHODS Forty-six patients with CCM presenting with seizures underwent surgery. The male-to-female ratio was 1:1, and the average age at initial seizure onset was 27.6 years. The mean preoperative seizure duration was 42.7 months. Patients were divided into two groups: a chronic group (N = 20) and a sporadic group (N = 26) according to seizure frequency and duration. The mean postoperative follow-up duration was 96.3 months, and the postoperative seizure outcomes were checked annually based upon Engel's classification. RESULTS After the first year of follow-up, 80.8 % of the sporadic group and 75.0 % of the chronic group were evaluated as Engel class I. These rates increased to 100.0 % and 90.0 %, respectively, at the eighth year of follow-up. Overall, 29 (63.0 %) of the 46 patients experienced changes in seizure outcomes over the follow-up period. Despite their delayed improvements, the chronic group showed less favorable outcomes throughout follow-up (p = 0.025). CONCLUSIONS Long-term follow-up is indispensable for accurately assessing postoperative seizure outcomes because these outcomes change continuously. We recommend earlier surgery to achieve seizure-free status in patients with CCM. However, even in the chronic group, surgery is recommended, considering the overall delayed improvement.
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Rosenow F, Alonso-Vanegas MA, Baumgartner C, Blümcke I, Carreño M, Gizewski ER, Hamer HM, Knake S, Kahane P, Lüders HO, Mathern GW, Menzler K, Miller J, Otsuki T, Özkara C, Pitkänen A, Roper SN, Sakamoto AC, Sure U, Walker MC, Steinhoff BJ. Cavernoma-related epilepsy: Review and recommendations for management-Report of the Surgical Task Force of the ILAE Commission on Therapeutic Strategies. Epilepsia 2013; 54:2025-35. [DOI: 10.1111/epi.12402] [Citation(s) in RCA: 143] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Felix Rosenow
- Department of Neurology; Epilepsy Center Hessen; University Hospital and Philipps-University Marburg; Marburg Germany
| | - Mario A. Alonso-Vanegas
- ABC Neurological Center & National Institute of Neurology and Neurosurgery; México City Mexico
| | - Christoph Baumgartner
- Second Neurological Department; Karl Landsteiner Institute for Clinical Epilepsy Research and Cognitive Neurology; General Hospital Hietzing with Neurological Center Rosenhügel; Vienna Austria
| | - Ingmar Blümcke
- Department of Neuropathology; University Hospitals Erlangen; Friedrich-Alexander University Erlangen-Nuremberg; Erlangen Germany
| | - Maria Carreño
- Neurology Service; Epilepsy Unit; Hospital Clinic of Barcelona; Barcelona Spain
| | - Elke R. Gizewski
- Department of Radiology; University Clinic for Neuroradiology; Medical University Innsbruck; Innsbruck Austria
| | - Hajo M. Hamer
- Department of Neurology; Epilepsy Center Erlangen; University Hospitals Erlangen; Friedrich-Alexander University Erlangen-Nuremberg; Erlangen Germany
| | - Susanne Knake
- Department of Neurology; Epilepsy Center Hessen; University Hospital and Philipps-University Marburg; Marburg Germany
| | - Philippe Kahane
- Department of Neurology and GIN INSERM U836-UJF-CEA; University Hospital of Grenoble; Grenoble France
| | - Hans O. Lüders
- Department of Neurosurgery; Epilepsy Center; University Hospitals Case Medical Center/Case Western Reserve University; Cleveland Ohio U.S.A
| | - Gary W. Mathern
- Departments of Neurosurgery and Psychiatry & BioBehavioral Medicine; David Geffen School of Medicine; Mattel Children's Hospital; University of California; Los Angeles California U.S.A
| | - Katja Menzler
- Department of Neurology; Epilepsy Center Hessen; University Hospital and Philipps-University Marburg; Marburg Germany
| | - Jonathan Miller
- Department of Neurosurgery; University Hospitals Case Medical Center/Case Western Reserve University; Cleveland Ohio U.S.A
| | - Taisuke Otsuki
- Epilepsy Center; National Center of Neurology and Psychiatry; Tokyo Japan
| | - Cigdem Özkara
- Cerrahpasa Medical Faculty; Istanbul University; Istanbul Turkey
| | - Asla Pitkänen
- A. I. Virtanen Institute for Molecular Sciences; University of Eastern Finland (UEF); Kuopio Finland
- Department of Neurology; Kuopio University Hospital; Kuopio Finland
| | - Steven N. Roper
- Department of Neurosurgery; University of Florida; Gainesville Florida U.S.A
| | - Americo C. Sakamoto
- Department of Neurosciences and Behavioral Science; Ribeirão Preto School of Medicine; University of São Paulo; São Paulo Brazil
| | - Ulrich Sure
- Department of Neurosurgery; University Hospital Essen; University of Duisburg-Essen; Essen Germany
| | - Matthew C. Walker
- Department of Clinical and Experimental Epilepsy; UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery; London United Kingdom
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von der Brelie C, Malter MP, Niehusmann P, Elger CE, von Lehe M, Schramm J. Surgical management and long-term seizure outcome after epilepsy surgery for different types of epilepsy associated with cerebral cavernous malformations. Epilepsia 2013; 54:1699-706. [DOI: 10.1111/epi.12327] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2013] [Indexed: 11/28/2022]
Affiliation(s)
| | - Michael P. Malter
- Department of Epileptology; University of Bonn Medical Centre; Bonn Germany
| | - Pitt Niehusmann
- Department of Neuropathology; University of Bonn Medical Centre; Bonn Germany
| | - Christian E. Elger
- Department of Epileptology; University of Bonn Medical Centre; Bonn Germany
| | - Marec von Lehe
- Department of Neurosurgery; University of Bonn Medical Centre; Bonn Germany
| | - Johannes Schramm
- Department of Neurosurgery; University of Bonn Medical Centre; Bonn Germany
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Technical, Anatomical, and Functional Study after Removal of a Symptomatic Cavernous Angioma Located in Deep Wernicke's Territories with Cortico-Subcortical Awake Mapping. Case Rep Neurol Med 2013; 2013:835029. [PMID: 23864972 PMCID: PMC3707287 DOI: 10.1155/2013/835029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 06/06/2013] [Indexed: 11/20/2022] Open
Abstract
Introduction. The subcortical region underneath Wernicke's area (WA) is a critical crossing of the eloquent language pathways involved in all semantic, phonological, syntactic, and working memory elaboration. We report the resection of a CA located underneath the dominant WA discussing the functional and anatomical evidence provided by fMRI, dissections with Klingler's technique, and intraoperative mapping during awake surgery. Case Report. A 64-year-old right-handed female affected by daily complex focal seizures underwent f-MRI, showing language activations in the middle and inferior temporal gyri and an unusual free entry zone in the “classical” WA. The cortical intraoperative mapping partially confirmed the f-MRI results, and we approached the lesion directly through WA. Subcortical DES allowed the identification of the eloquent language pathways and the radical resection of the perilesional gliotic rim. The patient did not report deficits and she is seizures and drug free after 1-year surgery. Discussion. Cortical DES demonstrated the variability of the eloquent areas within the cortex of the dominant temporal lobe. The subcortical DES confirmed the crucial role in language elaboration and the anatomical course of the bundles underneath WA. Conclusions. Awake surgery with DES represents a reliable and dynamic technique also for safer and functional-customized resection of CAs.
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Arraez MA, Ros B. Subdural hematoma from a cavernous malformation: two old friends of neurosurgeons working together! World Neurosurg 2013; 82:e399-400. [PMID: 23524028 DOI: 10.1016/j.wneu.2013.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 03/12/2013] [Indexed: 10/27/2022]
Affiliation(s)
| | - Bienvenido Ros
- Department of Neurosurgery, Carlos Haya University Hospital, Malaga, Spain
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Kivelev J, Niemelä M, Hernesniemi J. Characteristics of cavernomas of the brain and spine. J Clin Neurosci 2012; 19:643-8. [DOI: 10.1016/j.jocn.2011.08.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Revised: 08/18/2011] [Accepted: 08/19/2011] [Indexed: 01/05/2023]
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Kivelev J, Niemelä M, Hernesniemi J. Treatment strategies in cavernomas of the brain and spine. J Clin Neurosci 2012; 19:491-7. [PMID: 22325075 DOI: 10.1016/j.jocn.2011.08.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Revised: 07/27/2011] [Accepted: 08/01/2011] [Indexed: 12/25/2022]
Abstract
The management of brain and spinal cavernomas includes two main options: (i) conservative treatment or (ii) surgical removal. Clinical experience related to cavernoma patients falls into four major categories: the surgical or conservative treatment of incidental or symptomatic cavernomas. In many patients, cavernomas exist as fairly benign lesions, frequently remaining clinically silent for life. This observation argues against the active treatment of all cavernoma patients; rather for the meticulous selection of only those more likely to benefit from surgery. Thus, the most crucial task in successful management of cavernomas is appropriate patient selection. In this review, we present our institutional experience on cavernoma management supplemented with data from the literature.
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Affiliation(s)
- Juri Kivelev
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, Helsinki 00260, Finland.
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Alonso-Vanegas MA, Cisneros-Franco JM, Otsuki T. Surgical management of cavernous malformations presenting with drug-resistant epilepsy. Front Neurol 2012; 2:86. [PMID: 22319505 PMCID: PMC3249612 DOI: 10.3389/fneur.2011.00086] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Accepted: 12/07/2011] [Indexed: 11/30/2022] Open
Abstract
Cerebral cavernous malformations (CMs) are dynamic lesions characterized by continuous size changes and repeated bleeding. When involving cortical tissue, CMs pose a significant risk for the development of drug-resistant epilepsy, which is thought to be result of an altered neuronal network caused by the lesion itself and its blood degradation products. Preoperative evaluation should comprise a complete seizure history, neurological examination, epilepsy-oriented MRI, EEG, video-EEG, completed with SPECT, PET, functional MRI, and/or invasive monitoring as needed. Radiosurgery shows variable rates of seizure freedom and a high incidence of complications, thus microsurgical resection remains the optimal treatment for CMs presenting with drug-resistant epilepsy. Two thirds of patients reach Engel I class at 3-year follow-up, regardless of lobar location. Those with secondarily generalized seizures, a higher seizure frequency, and generalized abnormalities on preoperative or postoperative EEG, show poorer outcomes, while factors such as gender, duration of epilepsy, lesion size, age, bleeding at the time of surgery, do not correlate consistently with seizure outcome. Electrocorticography and a meticulous removal of all cortical hemosiderin - beyond pure lesionectomy - reduce the risk of symptomatic recurrences.
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Englot DJ, Han SJ, Lawton MT, Chang EF. Predictors of seizure freedom in the surgical treatment of supratentorial cavernous malformations. J Neurosurg 2011; 115:1169-74. [PMID: 21819194 DOI: 10.3171/2011.7.jns11536] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Seizures are the most common presenting symptom of supratentorial cerebral cavernous malformations (CCMs) and progress to medically refractory epilepsy in 40% of patients. Predictors of seizure freedom in the resection of CCMs are incompletely understood. METHODS The authors systematically reviewed the published literature on seizure freedom following the resection of supratentorial CCMs in patients presenting with seizures. Seizure outcomes were stratified across 12 potential prognostic variables. A total of 1226 patients with supratentorial CCMs causing seizures were identified across 31 predominantly retrospective studies; 361 patients had medically refractory epilepsy. RESULTS Seventy-five percent of the patients were seizure free after microsurgical lesion removal, whereas 25% continued to have seizures. All patients had had preoperative seizures and > 6 months of postoperative follow-up. Modifiable predictors of postoperative seizure freedom included gross-total resection (OR 36.6, 95% CI 8.5-157.5) and surgery within 1 year of symptom onset (OR 1.83, 95% CI 1.30-2.58). Additional prognostic indicators of a favorable outcome were a CCM size < 1.5 cm (OR 15.4, 95% CI 5.2-45.4), the absence of multiple CCMs (OR 2.02, 95% CI 1.13-3.60), medically controlled seizures (OR 2.38, 95% CI 1.29-4.39), and the lack of secondarily generalized seizures (OR 3.33, 95% CI 2.09-5.30). Other factors, including extended resection of the hemosiderin ring, were not significantly predictive. CONCLUSIONS In the surgical treatment of supratentorial CCMs, gross-total resection and early operative intervention may improve seizure outcome. While surgery should not be considered the first-line treatment for CCM-related epilepsy, it is important to understand the variables associated with seizure freedom in CCM resection given the considerable morbidity and diminished quality of life associated with epilepsy.
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Affiliation(s)
- Dario J Englot
- Department of Neurological Surgery, University of California, San Francisco, California 94143-0112, USA
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