Cerebellar epilepsy

Experience in treating children with ocular dyskinesia and hemifacial spasm secondary to pontine tumours adjacent to the fourth ventricle and systematic review

OBJECTIVE

To investigate the treatment plan and prognosis of children with ocular dyskinesia and hemifacial spasm secondary to pontine tumours adjacent to the fourth ventricle.

METHODS

In this retrospective study, the clinical information of 10 consecutively collected children with ocular dyskinesia and hemifacial spasm secondary to pontine tumours adjacent to the fourth ventricle was analyzed. All 10 children underwent pontine tumour resection through a trans-cerebellomedullary fissure approach; 4 children underwent preoperative diffusion tensor imaging scans to determine the relationship between the tumour and facial nerve nucleus, and the other 6 children underwent intraoperative deep electroencephalography (EEG) tumour monitoring, in which the tumour electrical discharge activity of the tumour was recorded. A voxel distribution map was established to describe the distribution of the tumour location, and patient prognosis was evaluated through clinical and imaging follow-up.

RESULTS

All 10 children achieved total tumour resection; 9 tumours were pathologically suggested to be ganglioglioma (WHO grade I), and 1 was a hamartoma. The symptoms of the original ocular dyskinesia and hemifacial spasm disappeared immediately after the operation. The children were followed up for 4-75 months, and none of the symptoms recurred; four cases with preoperative diffusion tensor imaging showed that the tumour was close to the facial nerve. Four in six intraoperative electrophysiological monitoring showed that the tumour had electrical discharge behaviour, and the tumour distribution map indicates a high density of tumour presence in the facial nerve nucleus and the nucleus of the abducens nerve.

CONCLUSIONS

In paediatric patients, the facial symptoms are related to the location and abnormal electrical discharge of the tumour. There is no significant correlation between ocular dyskinesia and the location of the tumour. Conventional antiepileptic therapy for this disease is ineffective, and early surgical intervention for total tumour resection can achieve a clinical curative effect.

Ocular Dyskinesia and Hemifacial Spasm Secondary to Fourth Ventricular Tumor: Report of 4 Cases and Review of the Literature

In clinical pediatric neurosurgery practice, fourth ventricle and cerebellar tumors are not rare. However, reports of secondary refractory hemifacial spasm are very rare. No report is currently available on the treatment of hemifacial spasm secondary to fourth ventricle and cerebellar tumors in China. Zamponi et al. [Childs Nerv Syst 2011 Jun;27(6):1001-5] reported that these lesions can occur in neonates and infants, and surgical resection is effective.

Dysplastic Cerebellar Epilepsy: Complete Seizure Control Following Resection of a Ganglioglioma

Subcortical epilepsy has been a controversial issue, partially settled by evidence showing seizure generation in hypothalamic hamartomas and also by reports of seizures caused by cerebellar lesions. We report 4-year-old girl with right hemifacial seizures and autonomic phenomena, in whom MRI showed an irregular mass in the right cerebellar peduncle. Despite several unremarkable video-EEG recordings, seizure origin in the lesion was hypothesized. Complete resection was feasible, histopathology showed a ganglioglioma, and she has been seizure free for 3 years. A fine line separates these developmental tumors from focal cortical dysplasia, and the homogeneous presentation of this entity led us to propose the terminology dysplastic cerebellar epilepsy.

Facial spasms, but not hemifacial spasm: a case report and review of literature

INTRODUCTION

Facial spasms represent a complicated array of neurological motor disorders with unique diagnostic and treatment algorithms. Due to the rarity of many of these disorders in the pediatric population, special care must be taken in identifying subtle differences in presentation of these disorders.

METHODS

We present a case of a 3-year-old boy diagnosed with a brainstem ganglioglioma, Chiari 1 malformation, and a 2-year history of left-sided facial spasms. Stereotyped facial contractions and subtle eye deviation occurred every 10 s, with downward movement rather than upward elevation of the eyebrow.

RESULTS

MRI revealed absence of a clear compressive vessel of the centrally-myelinized portion of the facial nerve, and EMG of the left facial nerve demonstrated no abnormal motor response or evidence of "lateral spread." Given these findings, a diagnosis of hemifacial seizures was made. Microvascular decompression was not recommended, and botulinum toxin injection was not pursued; however, the patient has remained refractory to antiepileptic drugs, possibly due to biochemical alteration by his ganglioglioma. He may eventually require surgical debulking should his symptoms progress.

CONCLUSION

Hemifacial spasm is a well-recognized disorder, but similar conditions can, at times, imitate its appearance. While our patient presented with facial spasms, his clinical history, examination, and radiographic and electrophysiological findings were more consistent with hemifacial seizures secondary to a brainstem lesion, rather than hemifacial spasms. It is important to distinguish the two entities, as misdiagnosis and inappropriate diagnostic or therapeutic measures may be taken inadvertently.

Lesional cerebellar epilepsy: a review of the evidence

Classical teaching in epileptology localizes the origins of focal seizures solely in the cerebral cortex, with only inhibitory effects attributed to subcortical structures. However, electrophysiological and neuroimaging studies over the last decades now provide evidence for an initiation of epileptic seizures within subcortical structures. Intrinsic epileptogenicity of hypothalamic hamartoma has already been established in recognition of subcortical epilepsy, whereas a seizure-generating impact of dysplastic cerebellar lesions remains to be clarified. Herein, we examine the supportive evidence and clinical presentation of cerebellar seizures and review therapy options.

Management of intracranial pathology during pregnancy: Case example and review of management strategies

BACKGROUND

Intracranial tumors during pregnancy are uncommon, and they present an interesting challenge to both the neurosurgeon and the obstetrician. Special considerations must be made in every aspect of care. The authors use the rare case of a 27-year-old pregnant female with suspected pineal region tumor eventually diagnosed as a thalamic region ganglioglioma to review the current literature on management of pathology in this unique patient population.

CASE DESCRIPTION

A 27-year-old female who was 26 weeks pregnant presented to her obstetrician with complaints of headaches, blurriness of vision, and left-sided numbness and tingling. She was diagnosed with 1-cm mass in the pineal region and obstructive hydrocephalus. She initially underwent an endoscopic third ventriculostomy with biopsy of what appeared grossly to be a thalamic mass. The child was delivered via cesarean section at 39 weeks. Serial postpartum imaging demonstrated increasing tumor size and enhancement, which led the authors to proceed with subtotal resection via a supracerebellar infratentorial approach with stereotactic neuronavigation. Tissue specimens obtained for pathological analysis resulted in a revised diagnosis of World Health Organization (WHO) grade II ganglioglioma.

CONCLUSIONS

Pregnancy presents a challenge for any patient requiring neurosurgical intervention. We present an interesting case example with a rare central nervous system neoplasm and discuss the management of intracranial pathology in pregnant patients.

Hemorrhagic ganglioglioma of the posterior fossa: case report

Gangliogliomas are rare tumors of the central nervous system that are usually found in the supratentorial compartment, although cases throughout the nervous system have been described. They are generally low-grade malignancies that are amenable to cure by surgical resection. Most manifest as seizures, though, based on location, they can present with focal neurological deficits. We present here a rare case of an infratentorial ganglioglioma presenting with hemorrhage. To our knowledge this is the only reported case of a hemorrhagic ganglioglioma and, as such, we examine its possible prognosis.

Neonatal hemifacial spasm and fourth ventricle mass

Congential hemifacial spasm is a rare condition that is characterized by the occurrence of paroxysmal hemifacial contractions in neonates. We review the clinical, neurophysiological, neuroimaging, and histopathological findings, as well as the differential diagnosis, therapeutic approach, and outcome of all the described cases. Moreover, we report two new cases including the ictal video-electroencephalography recordings. Hemifacial spasm starts early in life, and is characterized by unilateral, involuntary, irregular tonic or clonic contractions of muscles innervated by the seventh cranial nerve. Hemifacial spasm is associated with eyelid blinking, and sometimes with breathing irregularities, hyperventilation, and/or other neurological manifestations (dystonic movements, nystagmus). Interictal and ictal video-electroencephalography did not reveal epileptiform abnormalities. In all cases, brain magnetic resonance imaging showed a mass involving the cerebellar peduncle, the cerebellar hemisphere, or the floor of the fourth ventricle. The semiology of the paroxysmal attacks is probably due to the activation of cranial nerve nuclei through intralesional hypersynchronous discharges, as shown by the intraoperative recordings and functional brain imaging described in the literature. We point out the importance of identifying such seizures in order to make an early diagnosis of the underlying cerebral lesion.

Posterior cranial fossa gangliogliomas

Ganglioglioma (GG) is an uncommon primary lesion of the central nervous system that is typically located supratentorially. There are only a few reports of GG arising from the cerebellum. To the best of our knowledge this is the first case of a cerebellar GG with supratentorial extension and a longstanding history before its recognition. In fact, this 29-year-old male presented with an 11-year history of intermittent headaches. A cranial computerized tomography (CT) performed at the onset of his complaints failed to reveal the tumor. After a particularly longstanding cephalalgic episode, the patient underwent a new CT scan that was also negative. However, magnetic resonance (MR) imaging of the brain revealed a space-occupying lesion in the right cerebellar hemisphere with extension to the level of the superior colliculi and pineal recess. The tumor was partially removed through a midline suboccipital craniotomy and supracerebellar approach. Pathological examination of the tumor showed composition of atypical ganglion cells and astrocytes, indicating the diagnosis of cerebellar GG. At last follow-up, 24 months after surgery, the patient reported a marked improvement of his clinical condition with significant reduction of intensity and frequency of the headache. The present report illustrates how cerebellar GG may remain undetectable by CT and may therefore present with a longstanding history and nonspecific signs and symptoms. MR investigation can lead to the proper diagnosis. Even after partial removal the prognosis remains good and remission of the symptoms may be achieved. In this article, we review the literature and summarize the current understanding of infratentorial GGs.

Fourth ventricular hamartoma presenting with status epilepticus treated with emergency surgery in an infant

A 4-week-old infant presented with hemifacial spasms noticed from the 4th day after delivery. These progressed in severity, with generalization every 3-4 h. On admission, the infant went into refractory status epilepticus and had to be electively ventilated and taken for surgery on a semi-emergency basis. MRI showed a fourth ventricular hamartoma and video EEG showed spikes that were synchronous with the facial 'twitches' with generalization. Following the first surgery, the infant had an initial complete recovery, but developed recurrence of facial twitches after 2 weeks. Repeat MRI showed a small residual tumor which was re-operated and completely excised (at 8 weeks). Following this, the patient had complete recovery from seizures (5-year follow-up). This is the youngest patient reported presenting with status epilepticus with a fourth ventricular hamartoma operated successfully.

Hemifacial seizures due to ganglioglioma of cerebellum

We present a male infant with hemifacial seizures refractory to antiepileptic medication. Hemifacial spasms around the left eye were frequent during wakefulness and sleep since birth. He also had mild psychomotor retardation. Magnetic resonance imaging (MRI) revealed a large tumor in the left middle cerebellar peduncle. Ictal single photon emission computed tomography (SPECT) and ictal (18)F-fluorodeoxyglucose [(18)F-FDG] positron emission tomography (PET) revealed hyperperfusion and hyper glucose metabolism at the tumor. Total removal of the tumor resulted in complete disappearance of hemifacial seizures and improved psychomotor development, indicating that the cerebellar tumor caused hemifacial seizures. A histopathological study confirmed that the tumor was a ganglioglioma. This case and the literature on similar cases indicated that this was a new epileptic syndrome originating in the cerebellum. Early diagnosis and early complete removal of the epileptogenic lesion should be recommended for this syndrome.

Early surgery of hamartoma of the floor of the fourth ventricle: a case report

Epilepsy from hamartoma of the floor of fourth ventricle (HFFV) is very rare, starting in neonate or infantile period, good response to surgery. We report a 3-month-old boy with episodes of medically intractable abnormal eyelid blinking and hemifacial seizure. The episodes began from the first day of life and were unresponsive to medication. A magnetic resonance imaging scan revealed mass lesion on the floor of fourth ventricle, with extended cerebellar peduncle and cerebellar hemisphere. Surgery had been performed two times previously for treatment; only a subtotal resection was performed due to severe bradycardia during the first operation. The patient underwent second operation for gross total removal of tumor. Complete resection of the mass after second surgery resulted in remission of seizures and histopathology revealed hamartoma with hemangiomatous vessel proliferation. Identification of characteristic semiology and associated HFFV can help prediction of intractability even in infant and favoring surgical treatment in early age. To our knowledge, this is the youngest patient who underwent early surgery just after progressing into status for HFFV, showing complete lesion resection resulting in successful seizure outcome.

Cerebellar gangliocytoma presenting with hemifacial spasms: clinical report, literature review and possible mechanisms

Cerebellar lesions have classically been considered not to cause epilepsy. However, previous reports have attributed seizures, beginning as hemifacial spasms to lesions of the cerebellar peduncles. We report an example of paroxysmal facial contractions associated with a cerebellar gangliocytoma. The seizures began on the first day of life and consisted of paroxysmal contractions involving the left orbicularis oculi, often the left forehead and lower facial muscles, sometimes accompanied by nystagmoid eye movements to the right and by head deviation to the left. Video-EEG monitoring showed only artifacts from muscle contractions. Magnetic resonance imaging showed a mass arising from the left superior cerebellar peduncle and partially occupying the fourth ventricle. The lesion was removed subtotally and partial seizure control was achieved. The neuropathological findings were consistent with a gangliocytoma. The literature in the association of cerebellar lesions with hemifacial spasms is reviewed and its possible mechanisms discussed.

Epilepsy associated with a cerebellar arachnoid cyst: seizure control following fenestration of the cyst

OBJECTIVE

The role of the cerebellum in the pathogenesis of seizures remains controversial. Cerebellar origin of seizures, albeit rare, has been described in the literature in association with intrinsic lesions of the cerebellum. We present a unique case of a patient with medically intractable, secondary generalized epilepsy, associated with a superior cerebellar quadrigeminal arachnoid cyst.

CLINICAL PRESENTATION

A 9-year-old child presented with medically refractory secondary generalized epilepsy associated with recurrent headaches since 6 months of age. The child also had moderate intellectual impairment and autism. On the magnetic resonance imaging (MRI) of the head, he was noticed to have a small superior cerebellar arachnoid cyst in the quadrigeminal area that had increased in size slightly. Interictal electroencephalograph (EEG) was unable to localize the site of the epilepsy. Neurological examination was unremarkable.

INTERVENTION

A suboccipital craniotomy and supracerebellar infratentorial approach to the cyst was performed at 9 years of age. Intraoperative electrocorticography (ECOG) demonstrated epileptic activity from the cerebellar tissue adjacent to the cyst. The cyst was fenestrated, and the cyst wall was sent for histology. Seizure control improved dramatically after fenestration of the cyst.

CONCLUSION

This case provides strong evidence that, albeit rare, the cerebellum may be a source of epileptic activity due to compression by a lesion in the posterior fossa. Hence, in cases with intractable epilepsy of unknown supratentorial source, the differential diagnosis should include a posterior fossa lesion. The finding of a posterior fossa lesion in such cases, even if it is small and appears benign, should precipitate a discussion about the possible relationship between the posterior fossa lesion and the epilepsy.

Ganglioglioma in the cerebellopontine angle in a child. Case report and review of the literature

The authors report a case of a posterior fossa ganglioglioma centered in the cerebellopontine angle occurring in a child. As with cortically based gangliogliomas, the primary therapy is resection. When the tumor presents in the posterior fossa, often only partial resection can be accomplished without significant neurological deficit. The role of adjuvant chemotherapy and radiation therapy remains controversial, although these are usually reserved for high-grade lesions or progressive growth. The literature regarding the natural history, surgical outcomes, and indications for adjuvant therapy is reviewed. Although it occurs rarely, ganglioglioma should be included in the differential diagnosis of a posterior fossa mass in a child or young adult.

Pediatric infratentorial gangliogliomas: a retrospective series

OBJECT

The aim of this study was to retrospectively review the clinical presentation, the roles of surgery and adjuvant therapy, and the treatment-related morbidity in children with a ganglioglioma in the posterior fossa and to try and determine the prognostic factors.

METHODS

Between 1991 and 2006, 10 children were treated for a posterior fossa ganglioglioma at the authors' institution. The mean age of the children, the duration of symptoms prior to diagnosis, and the follow-up were 8.2, 2.4, and 3.9 years, respectively. Nine of the children presented with symptoms of raised intracranial pressure. Preoperative imaging showed enhancement in all patients; in eight it was in a patchy distribution. The operations consisted of radical resection (> 75%) in seven children, biopsy in two, and a total macroscopic excision in one.

RESULTS

The surgical procedure did not cause deterioration in the neurological condition in any of the children. There was no recurrence in the child who underwent total macroscopic excision of the tumor, and there has been no tumor progression in three children, two of whom have had no evidence of enhancement of the postoperative residual tumor. The tumor has progressed in six children, requiring further surgery in three, chemotherapy in four, and radiotherapy and second-line chemotherapy in one child to control the tumor.

CONCLUSIONS

The imaging of gangliogliomas in the posterior fossa showed patchy enhancement. The patients in whom it was possible to achieve a radical resection, aimed at removing at least the enhancing portion of the tumor, have not required further treatment. A second excision, for progressive tumors, is an effective adjuvant therapy.

A fourth ventricular ganglioneurocytoma representing with cerebellar epilepsy: a case report and review of the literature

Fourth ventricular low-grade tumoral or dysplastic neuronal lesions have been reported as an epileptic focus for recently described cerebellar epilepsy in the form of repetitive and stereotyped attacks of hemifascial spasm, eye blinking, fascial movements, head deviation and dysautonomic manifestations. The case of a 3-month old infant having fourth ventricular mass with similar symptoms such as paroxysmal facial movements, eye blinking, eyelid contractions and abnormal head posture is reported in this article. After a few days of her admission, her attacks displayed a new form with altered consciousness and left limb jerks which were unresponsive to medical therapy. Following the surgical excision of the lesion 10 months ago, attacks disappeared and she is still seizure free. Histopathological diagnosis was ganglioneurocytoma. The seizures (which may be intractable in cerebellar epilepsy) are thought to have arisen from subcortical structures such as cerebellum, brain stem nuclei or the lesion itself. In the case of intractable episodes, surgical excision may prevent further seizures and help patients have a normal cognitive and motor development.

Epilepsy and neuropsychologic deficit in a child with cerebellar astrocytoma

We report the case of a 32-month-old female patient presenting with cerebellar pilocytic astrocytoma with epileptic seizures, psychomotor delay, and severe language delay. Usually, the typical onset of cerebellar tumor is characterized by raised intracranial pressure and cerebellar incoordination. A review of the few cases reported in the literature evidencing epileptic seizures symptomatic of a focal, nondegenerative mass limited to the cerebellum is included. Moreover, a discussion about the cerebellar contribution to nonmotor functions in children is presented, in particular following tumor resection.

Successful surgical relief of seizures associated with hamartoma of the floor of the fourth ventricle in children: report of two cases

OBJECTIVE AND IMPORTANCE

To discuss the physiopathology and surgical handling of seizures due to hamartoma of the floor of the fourth ventricle in two children.

CLINICAL PRESENTATION

Two girls aged 3 years at the time of their operations presented with seizures due to a lesion of the floor of the fourth ventricle. The seizures began within the first days of life and consisted of hemifacial contraction, then head deviation, blinking of the eyelids, and intermittent dysautonomic manifestations. The interictal neurological condition seemed normal in one patient and showed a slight development delay in the other. An ictal electroencephalogram showed slow waves in the posterior areas. A magnetic resonance imaging scan revealed a mass that remained unchanged on serial examinations bordering the fourth ventricle, with an isointense signal on T1-weighted sequences and high-intensity signals on T2-weighted sequences without gadolinium enhancement. An ictal single-photon emission computed tomographic scan showed hyperperfusion in the lesion in both girls.

INTERVENTION

The operation consisted of resection and disconnection of the lesion. An electrical recording was obtained in one patient during the operation while she was anesthetized; the recording, made by means of a depth electrode with five contacts inside the lesion, indicated that repetitive theta rhythmic discharges were present. Neuropathology was consistent with a hamartoma. In both girls, the seizures disappeared after their operations, and antiepileptic drugs were withdrawn (follow-up periods, 8 and 3 yr, respectively).

CONCLUSION

Considering the results of single-photon emission computed tomography, the intralesional electrical record, and the relief of seizures after the operation, we postulate that the seizures arose from inside the lesion. This particular kind of noncortical seizure is similar to gelastic seizure due to hypothalamic hamartoma.

Hemifacial seizure of cerebellar ganglioglioma origin: seizure control by tumor resection

The cerebellum is known to have an inhibitory effect on seizures. Nevertheless, cerebellar dysplastic lesions can be epileptogenic. A 4-month-old infant had paroxysmal facial contractions; tachypnea and nystagmoid eyeball and tremulous movements were occasionally combined. These evolved to stereotypic clinical patterns and frequencies, which increased despite administration of antiepileptic drugs (AEDs). Magnetic resonance imaging (MRI) demonstrated a mass arising from the superior cerebellar peduncle, although video-scalp EEG monitoring revealed no abnormal findings. Positron emission tomography with [(18)F]fluorodeoxyglucose revealed focal hypermetabolism in the same area identified by MRI. A depth electrode implanted in the mass revealed focal spike-and-wave discharges. The lesion was partly removed; pathologic diagnosis was ganglioglioma. Because of incomplete seizure control and residual tumor visible on MRI, a second operation was performed. After complete excision of the tumor, the patient became seizure free without AEDs. This case confirms the presence of seizure originating from the cerebellum and emphasizes the need for the complete removal of an epileptogenic lesion.

Low insulin-like growth factor (IGF-1) in the cerebrospinal fluid of children with progressive encephalopathy, hypsarrhythmia, and optic atrophy (PEHO) syndrome and cerebellar degeneration

PURPOSE

In patients with progressive encephalopathy, hypsarrhythmia, and optic atrophy (PEHO) syndrome, the pathophysiology underlying early progressive cerebellar and brainstem degeneration and severe epilepsy is unknown. Because insulin-like growth factor (IGF)-1 has been shown significantly to promote survival of cerebellar neurons, we wanted to see if the IGF system played a role in the pathogenesis of cerebellar atrophy.

METHODS

We used a sensitive enzyme immunoassay kit for measuring cerebrospinal fluid (CSF) IGF-1 and insulin-like growth-binding protein (IGFBP)-3 in four groups of patients: PEHO syndrome patients (eight), PEHO-like patients (seven), age-matched controls (31), and patients with other types of cerebellar atrophy (11).

RESULTS

Patients with PEHO syndrome and those with other progressive, degenerative cerebellar diseases had lower levels of CSF IGF-1 than the controls with other neurologic diseases. The CSF IGF-1 also allowed us to differentiate the "true" PEHO patients from the "PEHO-like" patients (those with similar clinical symptoms but without the typical neuroophthalmologic or neuroradiologic findings). The concentrations of IGFBP-3 did not significantly differ in any of the patient or control groups studied.

CONCLUSIONS

CSF IGF-1 levels might be used as a marker of the degeneration of neurons in specific areas.