Hemispherectomy: a further modification using omentum vascularized free flaps

Hemispherotomy for Epilepsy: The Procedure Evolution and Outcome

Hemispherectomy is a unique epilepsy surgery procedure that has undergone significant modification and evolution since Dandy's early description. This procedure is mainly indicated to treat early childhood and infancy medically intractable epilepsy. Various epileptic syndromes have been treated with this procedure, including hemimegalencephaly (HME), Rasmussen's encephalitis, Sturge-Weber syndrome (SWS), perinatal stroke, and hemispheric cortical dysplasia. In terms of seizure reduction, hemispherectomy remains one of the most successful epilepsy surgery procedures. The modification of this procedure over many years has resulted in lower mortality and morbidity rates. HME might increase morbidity and lower the success rate. Future studies should identify the predictors of outcomes based on the pathology and the type of hemispherectomy. Here, based on a literature review, we discuss the evolution of hemispherectomy techniques and their outcomes and complications.

Immediate Cranioplasty for Postcranioplasty Infection in Patients with Ventriculoperitoneal Shunt

BACKGROUND

Patients with a ventriculoperitoneal (VP) shunt tend to develop epidural fluid accumulation after cranioplasty and also have a higher frequency of syndrome of the trephined after bone flap removal. Thus treatment of patients with postcranioplasty infection and a VP shunt is often challenging.

CASE DESCRIPTION

We treated 2 patients with postcranioplasty infection and a VP shunt. One patient had undergone decompressive craniectomy for cerebral hemorrhage, and the other patient had a large frontal dead space following resection of a brain tumor. Both patients were treated by immediate cranioplasty with obliteration of the epidural dead space by using a vascularized free latissimus dorsi muscle flap. In both of them, the postoperative course was uneventful without any complications.

CONCLUSIONS

Immediate cranioplasty and obliteration of the epidural dead space with a vascularized free latissimus dorsi muscle flap is an alternative for patients with postcranioplasty infection who are unfavorable candidates for temporary bone flap removal because of the risk of neurologic deterioration.

Case Report: Free Latissimus Dorsi Flap in Combination With Subdural Space Reduction for the Prevention of Recurrent Hemorrhage Following Hemispherectomy

BACKGROUND AND IMPORTANCE

Extensive cerebral resections for the treatment of epilepsy may result in a large intracranial dead space that is prone to recurrent hemorrhage, either due to mechanical dislodgement or the development of extensive subdural membranes. Several techniques have been proposed to decrease the risk of hemorrhage by either reducing or filling the remaining intracranial dead space.

CLINICAL PRESENTATION

We present a case of persistent hemorrhage following functional hemispherectomy in a patient with a large porencephalic cyst. A treatment strategy involving both subdural space reduction and cranial vault filling with a vascularized free latissimus dorsi flap is discussed.

CONCLUSION

Subdural space reduction and cranial vault filling with a vascularized free latissimus dorsi flap is a viable treatment alternative in patients with large areas of intracranial dead space.

Endoscopy-Assisted Interhemispheric Transcallosal Hemispherotomy

BACKGROUND:

Various hemispherotomy techniques have been developed to reduce complication rates and achieve the best possible seizure control.

OBJECTIVE:

To present a novel and minimally invasive endoscopy-assisted approach to perform this procedure.

METHODS:

Endoscopy-assisted interhemispheric transcallosal hemispherotomy was performed in 5 children (April 2013-June 2014). The procedure consisted of performing a small craniotomy (4 × 3 cm) just lateral to midline using a transverse skin incision. After dural opening, the surgery was performed with the assistance of a rigid high-definition endoscope, and bayoneted self-irrigating bipolar forceps and other standard endoscopic instruments. Steps included a complete corpus callosotomy followed by the disconnection of the hemisphere at the level of the basal nuclei and thalamus. The surgeries were performed in a dedicated operating room with intraoperative magnetic resonance imaging and neuronavigation. Intraoperative magnetic resonance imaging confirmed a total disconnection.

RESULTS:

The pathologies for which surgeries were performed included sequelae of middle a cerebral artery infarct (n = 2), Rasmussen syndrome (n = 1), and hemimegalencephaly (2). Four patients had an Engel class I and 1 patient had a class II outcome at a mean follow-up of 10.2 months (range, 3-14 months). The mean blood loss was 80 mL, and mean operating time was 220 minutes. There were no complications in this study.

CONCLUSION:

This study describes a pilot novel technique and the feasibility of performing a minimally invasive, endoscopy-assisted hemispherotomy.

Intact intracranial breast prosthesis: a 28-year CT follow-up after treatment of late hemispherectomy complications

Anatomical hemispherectomy has had excellent results in treating drug-resistant seizures of infantile hemiplegia. This technique of hemispherectomy consists in the removal of a whole hemisphere, with or without the basal ganglia, the end result being a large cavity left at the end of the operation. The technique, however, is considered to be weighted by important complications, in particular intracranial hemorrhages due to vessels tearing secondary to dislodgement of the remaining hemisphere. Several techniques have been consequently proposed to reduce the volume of the residual hemicranial cavity. An alternative measure is the filling of the cavity itself. We have demonstrated that this type of procedure can be carried out using a silicone breast prosthesis. In this report, we demonstrate also that such an implant can have a surprisingly long duration in its unusual location.

Cranial-bone defects with depression deformity treated with ceramic implants and free-flap transfers

Hydroxyapatite ceramic has many advantages in the treatment of cranial-bone defects. However, for large skull defects with severe depression deformities, it may be risky to use ceramic implants because an extradural dead space will be left and the overlying scalp will have to be closed under tension. In these cases microvascular free-flap transfers are a good solution. We have treated three patients for large skull defects with severe depression deformities after repeated local infections and several operations or irradiation. A latissimus dorsi myocutaneous flap was combined with a serratus anterior muscle flap to fill the extradural space under the ceramic implant in the first patient. A latissimus dorsi muscle flap was inserted under the ceramic implant in an irradiated site and a combined small serratus anterior muscle flap was used as a monitor in the second patient. A latissimus dorsi myocutaneous flap was used to cover the ceramic implant and fill the scalp defect in the third patient. The follow-up periods varied from 12 to 35 months (mean: 20.7 months). The clinical courses of all three patients were uneventful and no flap was lost. The extradural space can be reduced to some extent by making the ceramic implant slightly flatter or thicker, but in patients with severe depression deformities, whose brain expansion cannot be expected, a muscle flap should be transferred into the space.

Hemispherectomy: a hemidecortication approach and review of 52 cases

Between 1975 and 1994, 52 hemispherectomies, of which two were anatomical and 50 hemidecortications, were performed at Johns Hopkins Medical Institutions. Eighteen patients were 2 years old or less. There were three perioperative mortalities and one patient died 9 months later from causes not related to surgery. One patient developed hydrocephalus 6 years postsurgery and has been treated effectively. Seizure control and the functional status of each patient were measured as outcome variables. Forty-six (96%) of the surviving patients were seizure free or had reduced seizures as of their last follow-up examination. Twenty-one individuals (44%) were participating in age-appropriate classes or working independently, 18 were classified as semiindependent, and nine children will likely depend on a lifetime of assisted living. The relationships between the outcome variables and the patient's age at surgery, the interval to surgery, and the etiology of the disease were compared. The authors' clinical experiences strongly suggest the importance of a multidisciplinary approach to patient selection and follow-up care. Moreover, anesthetic management of infant surgery is a major component of success.