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Rajeev SP, Darshan HR, Vilanilam GC, Abraham M, Keshavapisharady K, Venkat EH, Stanley A, Menon RN, Radhakrishnan A, Cherian A, Narasimaiah D, Thomas B, Kesavadas C, Vimala S. Is intraoperative electrocorticography (ECoG) for long-term epilepsy-associated tumors (LEATs) more useful in children?-A Randomized Controlled Trial. Childs Nerv Syst 2024; 40:839-854. [PMID: 38010434 DOI: 10.1007/s00381-023-06216-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/03/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVES The utility of intraoperative electrocorticography (ECoG)-guided resective surgery for pediatric long-term epilepsy-associated tumors (LEATs) with antiseizure medication (ASM) resistant epilepsy is not supported by robust evidence. As epilepsy networks and their ramifications are different in children from those in adults, the impact of intraoperative ECoG-based tailored resections in predicting prognosis and influencing outcomes may also differ. We evaluated this hypothesis by comparing the outcomes of resections with and without the use of ECoG in children and adults by a randomized study. METHODS From June 2020 to January 2022, 42 patients (17 children and 25 adults) with LEATs and antiseizure medication (ASM)-resistant epilepsy were randomly assigned to one of the 2 groups (ECoG or no ECoG), prior to surgical resection. The 'no ECoG' arm underwent gross total lesion resection (GTR) without ECoG guidance and the ECoG arm underwent GTR with ECoG guidance and further additional tailored resections, as necessary. Factors evaluated were tumor location, size, lateralization, seizure duration, preoperative antiepileptic drug therapy, pre- and postresection ECoG patterns and tumor histology. Postoperative Engel score and adverse event rates were compared in the pediatric and adult groups of both arms. Eloquent cortex lesions and re-explorations were excluded to avoid confounders. RESULTS Forty-two patients were included in the study of which 17 patients were in the pediatric cohort (age < 18 years) and 25 in the adult cohort. The mean age in the pediatric group was 11.11 years (SD 4.72) and in the adult group was 29.56 years (SD 9.29). The mean duration of epilepsy was 9.7 years (SD 4.8) in the pediatric group and 10.96 (SD 8.8) in the adult group. The ECoG arm of LEAT resections had 23 patients (9 children and 14 adults) and the non-ECoG arm had 19 patients (8 children and 11 adults). Three children and 3 adults from the ECoG group further underwent ECoG-guided tailored resections (average 1.33 additional tailored resections/per patient.).The histology of the tailored resection specimen was unremarkable in 3/6 (50%).Overall, the commonest histology in both groups was ganglioglioma and the temporal lobe, the commonest site of the lesion. 88.23% of pediatric cases (n = 15/17) had an excellent outcome (Engel Ia) following resection, compared to 84% of adult cases (n = 21/25) at a mean duration of follow-up of 25.76 months in children and 26.72 months in adults (p = 0.405).There was no significant difference in seizure outcomes between the ECoG and no ECoG groups both in children and adults, respectively (p > 0.05). Additional tailored resection did not offer any seizure outcome benefit when compared to the non-tailored resections. CONCLUSIONS The use of intraoperative electrocorticography in LEATs did not contribute to postoperative seizure outcome benefit in children and adults. No additional advantage or utility was offered by ECoG in children when compared to its use in adults. ECoG-guided additional tailored resections did not offer any additional seizure outcome benefit both in children and adults.
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Affiliation(s)
- Sreenath Prabha Rajeev
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - H R Darshan
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - George Chandy Vilanilam
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India.
- R Madhavan Nair Centre For Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India.
| | - Mathew Abraham
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Krishnakumar Keshavapisharady
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Easwer Hariharan Venkat
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Antony Stanley
- Regional Technical Resource Centre for Health Technology Assessment, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ramshekhar N Menon
- R Madhavan Nair Centre For Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ashalatha Radhakrishnan
- R Madhavan Nair Centre For Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ajith Cherian
- R Madhavan Nair Centre For Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Deepti Narasimaiah
- Department of Neuropathology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Bejoy Thomas
- Department of Neuroimaging and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Chandrasekhar Kesavadas
- Department of Neuroimaging and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Smita Vimala
- Department of Neuroanaesthesiology and Critical Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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Sevoflurane-induced high-frequency oscillations, effective connectivity and intraoperative classification of epileptic brain areas. Clin Neurophysiol 2023; 150:17-30. [PMID: 36989866 DOI: 10.1016/j.clinph.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 02/27/2023] [Accepted: 03/02/2023] [Indexed: 03/18/2023]
Abstract
OBJECTIVE To determine how sevoflurane anesthesia modulates intraoperative epilepsy biomarkers on electrocorticography, including high-frequency oscillation (HFO) effective connectivity (EC), and to investigate their relation to epileptogenicity and anatomical white matter. METHODS We studied eight pediatric drug-resistant focal epilepsy patients who achieved seizure control after invasive monitoring and resective surgery. We visualized spatial distributions of the electrocorticography biomarkers at an oxygen baseline, three time-points while sevoflurane was increasing, and at a plateau of 2 minimum alveolar concentration (MAC) sevoflurane. HFO EC was combined with diffusion-weighted imaging, in dynamic tractography. RESULTS Intraoperative HFO EC diffusely increased as a function of sevoflurane concentration, although most in epileptogenic sites (defined as those included in the resection); their ability to classify epileptogenicity was optimized at sevoflurane 2 MAC. HFO EC could be visualized on major white matter tracts, as a function of sevoflurane level. CONCLUSIONS The results strengthened the hypothesis that sevoflurane-activated HFO biomarkers may help intraoperatively localize the epileptogenic zone. SIGNIFICANCE Our results help characterize how HFOs at non-epileptogenic and epileptogenic networks respond to sevoflurane. It may be warranted to establish a normative HFO atlas incorporating the modifying effects of sevoflurane and major white matter pathways, as critical reference in epilepsy presurgical evaluation.
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Beatty CW, Lockrow JP, Gedela S, Gehred A, Ostendorf AP. The Missed Value of Underutilizing Pediatric Epilepsy Surgery: A Systematic Review. Semin Pediatr Neurol 2021; 39:100917. [PMID: 34620465 DOI: 10.1016/j.spen.2021.100917] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 10/20/2022]
Abstract
Pediatric epilepsy surgery is underutilized. Only 1%-11% of children with drug resistant epilepsy (DRE) undergo surgical treatment, or less than half of those estimated to benefit. We conducted a systematic review of articles published in PubMed, EMBASE, and Web of Science in order to study the factors related to surgery underutilization as well as the impact on both the individual and the healthcare system. Our review demonstrates multiple factors leading to underutilization, including family misconceptions about epilepsy surgery, lack of provider knowledge, as well as systemic health disparities. While the upfront cost of epilepsy surgery is significant, the long-term financial benefits and reduced health resource utilization tilt the economic advantage in favor of surgery in children with DRE. Additionally, timely interventions improve seizure and cognitive outcomes with low risk of complications. Further interventions are needed at the levels of family, provider, and the healthcare system to increase access to pediatric epilepsy surgery.
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Affiliation(s)
- Christopher W Beatty
- The Ohio State University and Nationwide Children's Hospital, Division of Neurology, Department of Pediatrics, Columbus, OH
| | - Jason P Lockrow
- Department of Neurology, Section of Pediatric Neurology, University of Washington, Seattle, WA
| | - Satyanarayana Gedela
- Emory University and Children's Healthcare of Atlanta, Division of Neurology, Department of Pediatrics, Atlanta, GA
| | - Alison Gehred
- Medical Library Division, Nationwide Children's Hospital, Columbus, OH
| | - Adam P Ostendorf
- The Ohio State University and Nationwide Children's Hospital, Division of Neurology, Department of Pediatrics, Columbus, OH.
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Lesko R, Benova B, Jezdik P, Liby P, Jahodova A, Kudr M, Tichy M, Zamecnik J, Krsek P. The clinical utility of intraoperative electrocorticography in pediatric epilepsy surgical strategy and planning. J Neurosurg Pediatr 2020; 26:533-542. [PMID: 32736347 DOI: 10.3171/2020.4.peds20198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 04/29/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In this study, the authors aimed to determine 1) whether the use of intraoperative electrocorticography (ECoG) affects outcomes and complication rates of children undergoing resective epilepsy surgery; 2) which patient- and epilepsy-related variables might influence ECoG-based surgical strategy; and 3) what the predictors of epilepsy surgery outcomes are. METHODS Over a period of 12 years, data were collected on pediatric patients who underwent tailored brain resections in the Motol Epilepsy Center. In patients in whom an abnormal ECoG pattern (e.g., spiking, suppression burst, or recruiting rhythm) was not observed beyond presurgically planned resection margins, the authors did not modify the surgical plan (group A). In those with significant abnormal ECoG findings beyond resection margins, the authors either did (group B) or did not (group C) modify the surgical plan, depending on the proximity of the eloquent cortex or potential extent of resection. Using Fisher's exact test and the chi-square test, the 3 groups were compared in relation to epilepsy surgery outcomes and complication rate. Next, multivariate models were constructed to identify variables associated with each of the groups and with epilepsy surgery outcomes. RESULTS Patients in group C achieved significantly lower rates of seizure freedom compared to groups A (OR 30.3, p < 0.001) and B (OR 35.2, p < 0.001); groups A and B did not significantly differ (p = 0.78). Patients in whom the surgical plan was modified suffered from more frequent complications (B vs A+C, OR 3.8, p = 0.01), but these were mostly minor (duration < 3 months; B vs A+C, p = 0.008). In all cases, tissue samples from extended resections were positive for the presence of the original pathology. Patients with intended modification of the surgical plan (groups B+C) suffered more often from daily seizures, had a higher age at first seizure, had intellectual disability, and were regarded as MR-negative (p < 0.001). Unfavorable surgical outcome (Engel class II-IV) was associated with focal cortical dysplasia, incomplete resection based on MRI and/or ECoG findings, negative MRI finding, and inability to modify the surgical plan when indicated. CONCLUSIONS Intraoperative ECoG serves as a reliable tool to guide resection and may inform the prognosis for seizure freedom in pediatric patients undergoing epilepsy surgery. ECoG-based modification of the surgical plan is associated with a higher rate of minor complications. Children in whom ECoG-based modification of the surgical plan is indicated but not feasible achieve significantly worse surgical outcomes.
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Affiliation(s)
| | | | - Petr Jezdik
- 3Department of Circuit Theory, Faculty of Electrical Engineering, Czech Technical University of Prague, Czech Republic
| | | | | | | | | | - Josef Zamecnik
- 4Pathology and Molecular Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital; and
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Mohan A, Weiner H, Mohila C, Adesina A, Chintagumpala M, Curry D, Jea A, Lee J, Lam S, Whitehead W, Dauser R, Yoshor D, Aldave G. Epilepsy outcome following resection of low-grade brain tumors in children. J Neurosurg Pediatr 2019; 23:726–731. [PMID: 34806856 DOI: 10.3171/2019.1.peds18367] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe indication for and timing of surgery for epilepsy associated with low-grade mixed neuronal-glial tumors may be controversial. The purpose of this study was to evaluate the effect of resection and associated variables on epilepsy and on progression-free survival (PFS).METHODSA retrospective chart review of patients treated between 1992 and 2016 was conducted to identify individuals with epilepsy and low-grade gliomas or neuronal-glial tumors who underwent resective surgery. Data analyzed included age at epilepsy onset, age at surgery, extent of resection, use of electrocorticography, the number of antiepileptic drugs (AEDs) before and after surgery, the presence of dysplasia, Engel class, histological findings, and PFS. The institutional review board protocol was specifically approved to conduct this study.RESULTSA total of 107 patients were identified. The median follow-up was 4.9 years. The most common pathology was dysembryoplastic neuroepithelial tumor (36.4%), followed by ganglioglioma (31.8%). Eighty-four percent of patients had Engel class I outcomes following surgery. Gross-total resection was associated with a higher likelihood of an Engel class I outcome (90%) as compared to subtotal resection (58%) (p = 0.0005). Surgery reduced the AED burden, with 40% of patients requiring no AEDs after surgery (p < 0.0001). Children with neurodevelopmental comorbidities (n = 5) uniformly did not experience seizure improvement following resection (0% vs 83% overall; p < 0.0001). Electrocorticography was used in 33% of cases and did not significantly increase class I outcomes. PFS was 90% at 5 years. Eleven percent of tumors recurred, with subtotal resection more likely to result in recurrence (hazard ratio 5.3, p = 0.02). Histological subtype showed no significant impact on recurrence.CONCLUSIONSGross-total resection was strongly associated with Engel class I outcome and longer PFS. Further studies are needed to elucidate the suitable time for surgery and to identify factors associated with oncological transformation.
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Affiliation(s)
- Arvind Mohan
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children’s Hospital, and Department of Neurosurgery, Baylor College of Medicine
| | - Howard Weiner
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children’s Hospital, and Department of Neurosurgery, Baylor College of Medicine
| | - Carrie Mohila
- Department of Pathology, Texas Children’s Hospital, Baylor College of Medicine
| | - Adekunle Adesina
- Department of Pathology, Texas Children’s Hospital, Baylor College of Medicine
| | - Murali Chintagumpala
- Cancer and Hematology Center, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Daniel Curry
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children’s Hospital, and Department of Neurosurgery, Baylor College of Medicine
| | - Andrew Jea
- Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine and Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Jonathan Lee
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
| | - Sandi Lam
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children’s Hospital, and Department of Neurosurgery, Baylor College of Medicine
| | - William Whitehead
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children’s Hospital, and Department of Neurosurgery, Baylor College of Medicine
| | - Robert Dauser
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children’s Hospital, and Department of Neurosurgery, Baylor College of Medicine
| | - Daniel Yoshor
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children’s Hospital, and Department of Neurosurgery, Baylor College of Medicine
| | - Guillermo Aldave
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children’s Hospital, and Department of Neurosurgery, Baylor College of Medicine
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Roessler K, Heynold E, Buchfelder M, Stefan H, Hamer HM. Current value of intraoperative electrocorticography (iopECoG). Epilepsy Behav 2019; 91:20-24. [PMID: 30420228 DOI: 10.1016/j.yebeh.2018.06.053] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 06/28/2018] [Accepted: 06/29/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Intraoperative electrocorticography (iopECoG) can contribute to delineate the resection borders of the anticipated epileptogenic zone in epilepsy surgery. However, it has several caveats that should be considered to avoid incorrect interpretation during intraoperative monitoring. METHODS The literature on iopECoG application was reviewed, and pros and cons as well as obstacles to this technique were analyzed. RESULTS The literature of the first half of the nineties was very enthusiastic in using iopECoG for tailoring the resection in temporal as well as extratemporal epilepsy surgery. Mostly, this resulted in a good correlation of postresection ECoG and excellent seizure outcome. In the second half of the nineties, many authors demonstrated lack of correlation between iopECoG and postoperative seizure outcome, especially in surgery for temporal lobe epilepsy with hippocampal sclerosis. In the noughties, investigators found that ECoG was significantly useful in neocortical lesional temporal lobe epilepsy as well as in extratemporal lesional epilepsies. Extratemporal epilepsy without lesions proved to be more a domain of chronic extraoperative ECoG, especially using depth electrode recordings. In recent years, iopECoG detecting high-frequency oscillations (ripples, 80-250 Hz, fast ripples, 250-500 Hz) for tailored resection was found to allow intraoperative prediction of postoperative seizure outcome. CONCLUSION After a period of scepticism, iopECoG seems back in the focus of interest for intraoperative guidance of resecting epileptogenic tissue to raise postoperative favorable seizure outcome. In temporal and extratemporal lesional epilepsies, especially in cases of focal cortical dysplasia, tuberous sclerosis, or cavernous malformations, an excellent correlation between iopECoG-guided resection and postoperative seizure relief was found.
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Affiliation(s)
- Karl Roessler
- Neurosurgical Clinic, University Hospital Erlangen, Germany.
| | | | | | - Hermann Stefan
- Epilepsy Center, Neurological Clinic, University Hospital Erlangen, Germany
| | - Hajo M Hamer
- Epilepsy Center, Neurological Clinic, University Hospital Erlangen, Germany
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Gröppel G, Dorfer C, Samueli S, Dressler A, Mühlebner A, Prayer D, Czech T, Feucht M. Single stage epilepsy surgery in children and adolescents with focal cortical dysplasia type II – Prognostic value of the intraoperative electrocorticogram. Clin Neurophysiol 2019; 130:20-24. [DOI: 10.1016/j.clinph.2018.09.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 09/12/2018] [Accepted: 09/27/2018] [Indexed: 11/29/2022]
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Robertson FC, Ullrich NJ, Manley PE, Al-Sayegh H, Ma C, Goumnerova LC. The Impact of Intraoperative Electrocorticography on Seizure Outcome After Resection of Pediatric Brain Tumors: A Cohort Study. Neurosurgery 2018; 85:375-383. [DOI: 10.1093/neuros/nyy342] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 06/29/2018] [Indexed: 11/13/2022] Open
Abstract
AbstractBACKGROUNDIntraoperative electrocorticography (ECoG) has been utilized in patients with tumor-associated seizures; however, its effectiveness for seizure control remains controversial.OBJECTIVETo evaluate clinical outcomes in pediatric patients undergoing lesionectomy with or without ECoG.METHODSPatients undergoing brain tumor resection at Boston Children's Hospital were examined retrospectively (2005-2014). Inclusion criteria involved diagnosis of a supratentorial tumor, ≥2 unequivocal seizures, and ≥6 mo follow-up. Patients with isolated cortical dysplasia or posterior fossa tumors were excluded. Logistic regression models evaluated predictors of ECoG use, and the impact of ECoG, gross total resection, and focal cortical dysplasia with tumors on seizure freedom by Engel Class and anti-epileptic drug use (AED).RESULTSA total of 119 pediatric patients were included (n = 69 males, 58%; median age, 11.3 yr). Forty-one patients (34.5%) had ECoG-guided surgery. Preoperative seizure duration and number and duration of AED use were significant predictors for undergoing ECoG. There were no differences in seizure freedom (Engel Class I) or improved Engel Score (Class I-II vs III-IV) in patients who did or did not have ECoG at 30 d, 6 mo, and 1, 2, or 5 yr. Patients undergoing ECoG required a greater number of AEDs at 6 mo (P = .01), although this difference disappeared at subsequent time intervals. Gross total resection predicted seizure freedom at 30 d and 6 mo postsurgery (P = .045).CONCLUSIONThis retrospective study, one of the largest evaluating the use of ECoG during tumor resection, suggests that ECoG does not provide improved seizure freedom compared to lesionectomy alone for children.
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Affiliation(s)
| | - Nicole J Ullrich
- Harvard Medical School, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Peter E Manley
- Harvard Medical School, Boston, Massachusetts
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Hasan Al-Sayegh
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Clement Ma
- Harvard Medical School, Boston, Massachusetts
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Liliana C Goumnerova
- Harvard Medical School, Boston, Massachusetts
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
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