1
|
Zarrin D, Goel K, Kim WJ, Holly LT, Batzdorf U. Chiari Type I Revision Decompressive Surgery Indications and Operative Technique: Experience in a Large Adult Cohort. World Neurosurg 2024; 185:e1074-e1085. [PMID: 38490446 DOI: 10.1016/j.wneu.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Chiari malformation is characterized by inferior displacement of the cerebellar tonsils through the foramen magnum, frequently resulting in strain related headaches, and motor/sensory dysfunction. Chiari decompression technique varies significantly, possibly contributing to frequent revisions. We reviewed revision Chiari decompressions at our institution to determine the primary indications for revision and outcomes after revision. METHODS We retrospectively reviewed patients who underwent revision of Chiari decompression at our institution from 2005 to 2020. Demographics, indications for revision surgery, operative techniques, imaging findings, and preoperative/postoperative symptoms were collected. χ2 test was performed to determine statistical significance using a P < 0.05. Independent predictors of operative outcomes were identified. RESULTS A total of 46 patients (91% females, mean age 38.8 years) were included for analysis. The median time to revision surgery was 69.1 months (range 0-364 months) with headache (n = 37, 80%) being the most commonly recurring symptom. Large craniectomy (n = 28, 61%) was the most frequent indication for revision surgery. Thirty-two (70%) patients underwent cranioplasty, 20 (43%) required duraplasty, 15 (33%) required arachnoid dissection, and 15 (33%) required tonsillar reduction during revision surgery. Postrevision follow-up (at 8.9 ± 5.2 months average, range 1-18 months), revealed an average reduction in all Chiari-related symptoms relative to symptoms before the revision. CONCLUSIONS The most common indication for revision Chiari decompression was a large craniectomy resulting in cerebellar ptosis. We found that tonsillar reduction paired with modest craniectomy achieved near-complete resolution of symptoms with minimal complications. For patients with recurrent or persistent sequelae of Chiari malformation after decompression, revision may reduce symptom severity.
Collapse
Affiliation(s)
- David Zarrin
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Keshav Goel
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Wi Jin Kim
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Langston T Holly
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Ulrich Batzdorf
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA.
| |
Collapse
|
2
|
Cuesta P, Bruña R, Shah E, Laohathai C, Garcia-Tarodo S, Funke M, Von Allmen G, Maestú F. An individual data-driven virtual resection model based on epileptic network dynamics in children with intractable epilepsy: a magnetoencephalography interictal activity application. Brain Commun 2023; 5:fcad168. [PMID: 37274829 PMCID: PMC10236945 DOI: 10.1093/braincomms/fcad168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 01/24/2023] [Accepted: 05/23/2023] [Indexed: 06/07/2023] Open
Abstract
Epilepsy surgery continues to be a recommended treatment for intractable (medication-resistant) epilepsy; however, 30-70% of epilepsy surgery patients can continue to have seizures. Surgical failures are often associated with incomplete resection or inaccurate localization of the epileptogenic zone. This retrospective study aims to improve surgical outcome through in silico testing of surgical hypotheses through a personalized computational neurosurgery model created from individualized patient's magnetoencephalography recording and MRI. The framework assesses the extent of the epileptic network and evaluates underlying spike dynamics, resulting in identification of one single brain volume as a candidate for resection. Dynamic-locked networks were utilized for virtual cortical resection. This in silico protocol was tested in a cohort of 24 paediatric patients with focal drug-resistant epilepsy who underwent epilepsy surgery. Of 24 patients who were included in the analysis, 79% (19 of 24) of the models agreed with the patient's clinical surgery outcome and 21% (5 of 24) were considered as model failures (accuracy 0.79, sensitivity 0.77, specificity 0.82). Patients with unsuccessful surgery outcome typically showed a model cluster outside of the resected cavity, while those with successful surgery showed the cluster model within the cavity. Two of the model failures showed the cluster in the vicinity of the resected tissue and either a functional disconnection or lack of precision of the magnetoencephalography-MRI overlapping could explain the results. Two other cases were seizure free for 1 year but developed late recurrence. This is the first study that provides in silico personalized protocol for epilepsy surgery planning using magnetoencephalography spike network analysis. This model could provide complementary information to the traditional pre-surgical assessment methods and increase the proportion of patients achieving seizure-free outcome from surgery.
Collapse
Affiliation(s)
- Pablo Cuesta
- Correspondence to: Pablo Cuesta Pza. Ramón y Cajal, s/n. Ciudad Universitaria 28040 Madrid, Spain E-mail:
| | - Ricardo Bruña
- Department of Radiology, Rehabilitation and Physiotherapy, Universidad Complutense de Madrid, Madrid, 28040, Spain
- Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, 28040, Spain
| | - Ekta Shah
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | | | - Stephanie Garcia-Tarodo
- Département de la femme, de l'enfant et de l'adolescent, Hôpital des Enfants - Hôpitaux Universitaires de Genève, Geneva, 1211 Genève 14, Switzerland
| | - Michael Funke
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Gretchen Von Allmen
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Fernando Maestú
- Center for Cognitive and Computational Neuroscience, Complutense University of Madrid, Madrid, 28040, Spain
- Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, 28040, Spain
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
- Department of Experimental Psychology, Cognitive Processes and Speech Therapy, Universidad Complutense de Madrid, Madrid, 28040, Spain
| |
Collapse
|
3
|
Goel K, Pek V, Shlobin NA, Chen JS, Wang A, Ibrahim GM, Hadjinicolaou A, Roessler K, Dudley RW, Nguyen DK, El-Tahry R, Fallah A, Weil AG. Clinical utility of intraoperative electrocorticography for epilepsy surgery: A systematic review and meta-analysis. Epilepsia 2023; 64:253-265. [PMID: 36404579 DOI: 10.1111/epi.17472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022]
Abstract
Despite the widespread use of intraoperative electrocorticography (iECoG) during resective epilepsy surgery, there are conflicting data on its overall efficacy and inability to predict benefit per pathology. Given the heterogeneity of iECoG use in resective epilepsy surgery, it is important to assess the utility of interictal-based iECoG. This individual patient data (IPD) meta-analysis seeks to identify the benefit of iECoG during resective epilepsy surgery in achieving seizure freedom for various pathologies. Embase, Scopus, and PubMed were searched from inception to January 31, 2021 using the following terms: "ecog", "electrocorticography", and "epilepsy". Articles were included if they reported seizure freedom at ≥12-month follow-up in cohorts with and without iECoG for epilepsy surgery. Non-English articles, noncomparative iECoG cohorts, and studies with <10% iECoG use were excluded. This meta-analysis followed the PRISMA 2020 guidelines. The primary outcome was seizure freedom at last follow-up and time to seizure recurrence, if applicable. Forest plots with random effects modeling assessed the relationship between iECoG use and seizure freedom. Cox regression of IPD was performed to identify predictors of longer duration of seizure freedom. Kaplan-Meier curves with log-rank test were created to visualize differences in time to seizure recurrence. Of 7504 articles identified, 18 were included for study-level analysis. iECoG was not associated with higher seizure freedom at the study level (relative risk = 1.09, 95% confidence interval [CI] = 0.96-1.23, p = .19, I2 = 64%), but on IPD (n = 7 studies, 231 patients) iECoG use was independently associated with more favorable seizure outcomes (hazard ratio = 0.47, 95% CI = .23-.95, p = .037). In Kaplan-Meier analysis of specific pathologies, iECoG use was significantly associated with longer seizure freedom only for focal cortical dysplasia (FCD; p < .001) etiology. Number needed to treat for iECoG was 8.8, and for iECoG in FCD it was 4.7. We show iECoG seizure freedom is not achieved uniformly across centers. iECoG is particularly beneficial for FCD etiology in improving seizure freedom.
Collapse
Affiliation(s)
- Keshav Goel
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Valérie Pek
- Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jia-Shu Chen
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Andrew Wang
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
- College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, Los Angeles, California, USA
| | - George M Ibrahim
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Aristides Hadjinicolaou
- Division of Neurology, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, Quebec, Canada
- Brain and Development Research Axis, Sainte-Justine Research Centre, Montreal, Quebec, Canada
| | - Karl Roessler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Roy W Dudley
- Division of Pediatric Neurosurgery, Department of Pediatric Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Dang K Nguyen
- Department of Neurology, University of Montreal Hospital Centre, Montreal, Quebec, Canada
| | - Riëm El-Tahry
- Saint Luc University Hospital, Brussels, Belgium
- Institute of Neuroscience, Neurology pole, Catholic University of Louvain, Brussels, Belgium
| | - Aria Fallah
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Alexander G Weil
- Brain and Development Research Axis, Sainte-Justine Research Centre, Montreal, Quebec, Canada
- Division of Neurosurgery, Department of Surgery, Sainte-Justine University Hospital Centre, Montreal, Quebec, Canada
- Division of Neurosurgery, Department of Surgery, University of Montreal Hospital Centre, Montreal, Quebec, Canada
- Department of Neuroscience, University of Montreal, Montreal, Quebec, Canada
| |
Collapse
|
4
|
Nakamura T, Sato Y, Kobayashi Y, Kawauchi Y, Shimizu K, Mizutani T. Visualization of ictal networks using gamma oscillation regularity correlation analysis in focal motor epilepsy: Illustrative cases. Surg Neurol Int 2022; 13:105. [PMID: 35399885 PMCID: PMC8986657 DOI: 10.25259/sni_193_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/16/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Focal motor epilepsy is difficult to localize within the epileptogenic zone because ictal activity quickly spreads to the motor cortex through ictal networks. We previously reported the usefulness of gamma oscillation (30–70 Hz) regularity (GOR) correlation analysis using interictal electrocorticographic (ECoG) data to depict epileptogenic networks. We conducted GOR correlation analysis using ictal ECoG data to visualize the ictal networks originating from the epileptogenic zone in two cases — a 26-year-old woman with negative motor seizures and a 53-year-old man with supplementary motor area (SMA) seizures.
Case Description:
In both cases, we captured several habitual seizures during monitoring after subdural electrode implantation and performed GOR correlation analysis using ictal ECoG data. A significantly high GOR suggestive of epileptogenicity was identified in the SMA ipsilateral to the lesions, which were connected to the motor cortex through supposed ictal networks. We resected the high GOR locations in the SMA and the patients’ previously identified tumors were removed. The patients were seizure-free without any neurological deficits after surgery.
Conclusion:
The GOR correlation analysis using ictal ECoG data could be a powerful tool for visualizing ictal networks in focal motor epilepsy.
Collapse
|
5
|
Earlier Age at Surgery for Brain Cavernous Angioma-Related Epilepsy May Achieve Complete Seizure Freedom without Aid of Anti-Seizure Medication. Brain Sci 2022; 12:brainsci12030403. [PMID: 35326359 PMCID: PMC8946282 DOI: 10.3390/brainsci12030403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 02/06/2023] Open
Abstract
Background: The present study hypothesized that some factors may distinguish between patients with a brain cavernous angioma (BCA), who were free from anti-seizure medication (ASM), and patients who still required ASMs postoperatively. The purpose of the study was thus to identify factors associated with ceasing ASMs for patients with drug-resistant epilepsy secondary to BCA, who underwent BCA removal surgery. Methods: We divided patients into those with drug-resistant epilepsy secondary to BCA who achieved complete seizure freedom without ASMs a year after surgery (No-ASM group) (International League Against Epilepsy (ILAE) classification class I with no epileptiform discharges), and others (ASM group) (ILAE classification ≤ II and/or epileptiform discharges). We statistically compared groups in terms of: (1) age at operation; (2) history of epilepsy; (3) size of BCA; and (4) location of BCA. Results: Overall, a year after the surgery, the No-ASM group comprised 12 patients (48%), and the ASM group comprised 13 patients (52%). In both multi- and univariate logistic regression analyses, age at BCA removal surgery correlated significantly with the No-ASM group (p = 0.043, p = 0.019), but history of epilepsy did not (p = 0.581, p = 0.585). Conclusions: Earlier age at surgery for patients with drug-resistant epilepsy is encouraged to achieve complete seizure freedom without the need for ASMs when the cause of epilepsy is BCA.
Collapse
|