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Das N, Sharma A, Mann M, Gordillo A, Desai A, Serletis D, Moosa AN, Rammo R, Bingaman W. Postoperative shunt failure following hemispherectomy in pediatric patients with pre-existing hydrocephalus. Childs Nerv Syst 2024; 40:1507-1514. [PMID: 38273143 PMCID: PMC11026181 DOI: 10.1007/s00381-024-06295-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/17/2024] [Indexed: 01/27/2024]
Abstract
OBJECTIVE The risk of hydrocephalus following hemispherectomy for drug resistant epilepsy (DRE) remains high. Patients with pre-existing hydrocephalus pose a postoperative challenge, as maintaining existing shunt patency is necessary but lacks a clearly defined strategy. This study examines the incidence and predictors of shunt failure in pediatric hemispherectomy patients with pre-existing ventricular shunts. METHODS We performed a retrospective chart review at our center to identify pediatric patients diagnosed with DRE who were treated with ventricular shunt prior to their first hemispherectomy surgery. Demographic and perioperative data were obtained including shunt history, hydrocephalus etiology, epilepsy duration, surgical technique, and postoperative outcomes. Univariate analysis was performed using Fisher's exact test and Pearson correlation, with Bonferroni correction to a = 0.00625 and a = 0.01, respectively. RESULTS Five of nineteen (26.3%) patients identified with ventriculoperitoneal shunting prior to hemispherectomy experienced postoperative shunt malfunction. All 5 of these patients underwent at least 1 shunt revision prior to hemispherectomy, with a significant association between pre- and post-hemispherectomy shunt revisions. There was no significant association between post-hemispherectomy shunt failure and valve type, intraoperative shunt alteration, postoperative external ventricular drain placement, hemispherectomy revision, lateralization of shunt relative to resection, postoperative complications, or postoperative aseptic meningitis. There was no significant correlation between number of post-hemispherectomy shunt revisions and age at shunt placement, age at hemispherectomy, epilepsy duration, or shunt duration prior to hemispherectomy. CONCLUSIONS Earlier shunt revision surgery may portend a subsequent need for shunt revision following hemispherectomy. These findings may guide neurosurgeons in counseling patients with pre-existing ventricular shunts prior to hemispherectomy surgery.
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Affiliation(s)
- Nikita Das
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Akshay Sharma
- Epilepsy Center, Cleveland Clinic Neurological Institute, Cleveland, OH, USA.
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA.
| | - Michael Mann
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Alan Gordillo
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Ansh Desai
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Demitre Serletis
- Epilepsy Center, Cleveland Clinic Neurological Institute, Cleveland, OH, USA
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Ahsan N Moosa
- Epilepsy Center, Cleveland Clinic Neurological Institute, Cleveland, OH, USA
| | - Richard Rammo
- Epilepsy Center, Cleveland Clinic Neurological Institute, Cleveland, OH, USA
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - William Bingaman
- Epilepsy Center, Cleveland Clinic Neurological Institute, Cleveland, OH, USA
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
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Goel K, Ghadiyaram A, Krishnakumar A, Morden FTC, Higashihara TJ, Harris WB, Shlobin NA, Wang A, Karunungan K, Dubey A, Phillips HW, Weil AG, Fallah A. Hemimegalencephaly: A Systematic Comparison of Functional and Anatomic Hemispherectomy for Drug-Resistant Epilepsy. Neurosurgery 2024; 94:666-678. [PMID: 37975663 DOI: 10.1227/neu.0000000000002759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 09/19/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Hemimegalencephaly (HME) is a rare diffuse malformation of cortical development characterized by unihemispheric hypertrophy, drug-resistant epilepsy (DRE), hemiparesis, and developmental delay. Definitive treatment for HME-related DRE is hemispheric surgery through either anatomic (AH) or functional hemispherectomy (FH). This individual patient data meta-analysis assessed seizure outcomes of AH and FH for HME with pharmacoresistant epilepsy, predictors of Engel I, and efficacy of different FH approaches. METHODS PubMed, Web of Science, and Cumulative Index to Nursing and Allied Health Literature were searched from inception to Jan 13th, 2023, for primary literature reporting seizure outcomes in >3 patients with HME receiving AH or FH. Demographics, neurophysiology findings, and Engel outcome at the last follow-up were extracted. Postsurgical seizure outcomes were compared through 2-tailed t -test and Fisher exact test. Univariate and multivariate Cox regression analyses were performed to identify independent predictors of Engel I outcome. RESULTS Data from 145 patients were extracted from 26 studies, of which 89 underwent FH (22 vertical, 33 lateral), 47 underwent AH, and 9 received an unspecified hemispherectomy with a median last follow-up of 44.0 months (FH cohort) and 45.0 months (AH cohort). Cohorts were similar in preoperative characteristics and at the last follow-up; 77% (n = 66) of the FH cohort and 81% (n = 38) and of the AH cohort were Engel I. On multivariate analysis, only the presence of bilateral ictal electroencephalography abnormalities (hazard ratio = 11.5; P = .002) was significantly associated with faster time-to-seizure recurrence. A number-needed-to-treat analysis to prevent 1 additional case of posthemispherectomy hydrocephalus reveals that FH, compared with AH, was 3. There was no statistical significance for any differences in time-to-seizure recurrence between lateral and vertical FH approaches (hazard ratio = 2.59; P = .101). CONCLUSION We show that hemispheric surgery is a highly effective treatment for HME-related DRE. Unilateral ictal electroencephalography changes and using the FH approach as initial surgical management may result in better outcomes due to significantly lower posthemispherectomy hydrocephalus probability. However, larger HME registries are needed to further delineate the predictors of seizure outcomes.
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Affiliation(s)
- Keshav Goel
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles , California , USA
| | - Ashwin Ghadiyaram
- Virginia Commonwealth University School of Medicine, Richmond , Virginia , USA
| | - Asha Krishnakumar
- Virginia Commonwealth University School of Medicine, Richmond , Virginia , USA
| | - Frances T C Morden
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu , Hawaii , USA
| | - Tate J Higashihara
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu , Hawaii , USA
| | - William B Harris
- Department of Neurosurgery, University of Colorado, Boulder , Colorado , USA
| | - Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago , Illinois , USA
| | - Andrew Wang
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles , California , USA
| | - Krystal Karunungan
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles , California , USA
| | - Anwesha Dubey
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles , California , USA
| | - H Westley Phillips
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Alexander G Weil
- Division of Neurosurgery, Department of Surgery, Sainte-Justine University Hospital Centre, Montréal , Québec , Canada
- Division of Neurosurgery, Department of Surgery, University of Montreal Hospital Centre (CHUM), Montréal , Québec , Canada
- Brain and Development Research Axis, Sainte-Justine Research Center, Montréal , Québec , Canada
- Department of Neuroscience, University of Montreal, Montréal , Québec , Canada
| | - 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
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De Knegt VE, Børresen ML, Knudsen M, Thomsen KM, Uldall PV, Jakobsen AV, Hoei-Hansen CE. Current state of hemispherectomy and callosotomy for pediatric refractory epilepsy in Denmark. Brain Dev 2024; 46:142-148. [PMID: 38044196 DOI: 10.1016/j.braindev.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 11/25/2023] [Accepted: 11/27/2023] [Indexed: 12/05/2023]
Abstract
OBJECTIVE To evaluate outcomes from hemispherectomy and callosotomy related to the need for anti-seizure medication (ASM), seizure frequency, and cognition. METHODS A review of the medical charts of all Danish pediatric patients who underwent hemispherectomy or callosotomy from January 1996 to December 2019 for preoperative and postoperative ASM use, seizure frequency, and cognitive data. RESULTS The median age of epilepsy onset was two years (interquartile range (IQR): 0.0-5.3) for the hemispherectomy patients (n = 16) and one year (IQR: 0.6-1.7) for callosotomy patients (n = 5). Median time from onset to final surgery was 3.4 years for hemispherectomy and 10.2 years for callosotomy, while the median follow-up time was 6.9 years and 9.0 years, respectively. Preoperatively, all patients had daily seizures and were treated with ≥ 2 ASM. Hemispherectomy resulted in a reduction in seizure frequency in 87.5 % of patients, with 78.6 % achieving seizure freedom. Furthermore, 81.3 % experienced a reduction in ASM use and 56.3 % stopped all ASM. Median IQ/developmental quotient (IQ/DQ) was low preoperatively (44.0 [IQR: 40.0-55.0]) and remained unchanged postoperatively (IQ change: 0.0 [IQR: -10.0-+4.0]). Callosotomy resulted in a seizure reduction of 86-99 % in four patients, and ASM could be reduced in three patients. Median IQ/DQ was 20.0 preoperatively (IQR: 20.0-30.0) and remained unchanged postoperatively (IQ change: 0.0 [IQR: 0.0]). CONCLUSION Hemispherectomy and callosotomy result in a substantial reduction in seizure frequency and ASM use without deterioration of IQ. Extensive epilepsy surgery should be considered early in children with drug-resistant epilepsy.
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Affiliation(s)
| | - Malene Landbo Børresen
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Marianne Knudsen
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Katrine Moe Thomsen
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Peter Vilhelm Uldall
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Neuropaediatrics, The Danish Epilepsy Center Filadelfia, Dianalund, Denmark
| | - Anne Vagner Jakobsen
- Department of Neuropaediatrics, The Danish Epilepsy Center Filadelfia, Dianalund, Denmark
| | - Christina Engel Hoei-Hansen
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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Sharma A, Mann M, Gordillo A, Desai A, Winkleman R, Serletis D, Moosa AN, Rammo R, Bingaman W. Predictive factors of hydrocephalus development in pediatric patients undergoing hemispherectomy for intractable epilepsy. J Neurosurg Pediatr 2024; 33:199-206. [PMID: 38100754 DOI: 10.3171/2023.11.peds23341] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/21/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE Hemispherectomy surgery is an effective procedure for pediatric patients with intractable hemispheric epilepsy. Hydrocephalus is a well-documented complication of hemispherectomy contributing substantially to patient morbidity. Despite some clinical and operative factors demonstrating an association with hydrocephalus development, the true mechanism of disease is incompletely understood. The aim of this study was to investigate a range of clinical and surgical factors that may contribute to hydrocephalus to enhance understanding of the development of this complication and to aid the clinician in optimizing peri- and postoperative surgical management. METHODS A retrospective chart review was conducted on all pediatric patients younger than 21 years who underwent hemispherectomy surgery at the Cleveland Clinic between 2002 and 2016. Data collected for each patient included general demographic information, neurological and surgical history, surgical technique, pathological analysis, presence and duration of perioperative CSF diversion, CSF laboratory values obtained while an external ventricular drain (EVD) was in place, length of hospital stay, postoperative aseptic meningitis, and in-hospital surgical complications (including perioperative stroke, hematoma formation, wound breakdown, and/or infection). Outcomes data included hemispherectomy revision and Engel grade at last follow-up (based on the Engel Epilepsy Surgery Outcome Scale). RESULTS Data were collected for 204 pediatric patients who underwent hemispherectomy at the authors' institution. Twenty-eight patients (14%) developed hydrocephalus requiring CSF diversion. Of these 28 patients, 13 patients (46%) presented with hydrocephalus during the postoperative period (within 90 days), while the remaining 15 patients (54%) presented later (beyond 90 days after surgery). Multivariate analysis revealed postoperative aseptic meningitis (OR 7.0, p = 0.001), anatomical hemispherectomy surgical technique (OR 16.3 for functional/disconnective hemispherectomy and OR 7.6 for modified anatomical, p = 0.004), male sex (OR 4.2, p = 0.012), and surgical complications (OR 3.8, p = 0.031) were associated with an increased risk of hydrocephalus development, while seizure freedom (OR 0.3, p = 0.038) was associated with a decreased risk of hydrocephalus. CONCLUSIONS Hydrocephalus remains a prominent complication following hemispherectomy, presenting both in the postoperative period and months to years after surgery. Aseptic meningitis, anatomical hemispherectomy surgical technique, male sex, and surgical complications show an association with an increased rate of hydrocephalus development while seizure freedom postsurgery is associated with a decreased risk of subsequent hydrocephalus. These findings speak to the multifactorial nature of hydrocephalus development and should be considered in the management of pediatric patients undergoing hemispherectomy for medically intractable epilepsy.
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Affiliation(s)
- Akshay Sharma
- 1Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland
| | - Michael Mann
- 2Case Western Reserve University School of Medicine, Cleveland
| | - Alan Gordillo
- 3Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland; and
| | - Ansh Desai
- 2Case Western Reserve University School of Medicine, Cleveland
| | - Robert Winkleman
- 1Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland
| | - Demitre Serletis
- 1Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland
| | - Ahsan N Moosa
- 4Department of Neurology, Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Richard Rammo
- 1Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland
| | - William Bingaman
- 1Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland
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Thomé U, Batista LA, Rocha RP, Terra VC, Hamad APA, Sakamoto AC, Santos AC, Santos MV, Machado HR. The Important Role of Hemispherotomy for Rasmussen Encephalitis: Clinical and Functional Outcomes. Pediatr Neurol 2024; 150:82-90. [PMID: 37992429 DOI: 10.1016/j.pediatrneurol.2023.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/05/2023] [Accepted: 10/20/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Rasmussen encephalitis (RE) is characterized by pharmacoresistant epilepsy and progressive neurological deficits concurrent with unilateral hemispheric atrophy. Evidence of an inflammatory autoimmune process has been extensively described in the literature; however, the precise etiology of RE is still unknown. Despite data supporting a beneficial effect of early immunosuppressive and immunomodulatory interventions, surgical disconnection of the affected hemisphere is considered the treatment of choice for these patients. The aim of this study was to report a series of children and adolescents who underwent hemispheric surgery (HS) for the treatment of RE, analyzing their clinical, electrographic, and neuroimaging features pre-operatively, as well as their postoperative status, including seizure and functional outcomes. METHODS All patients with RE who underwent HS in the Epilepsy Surgery Center (CIREP) of the University Hospital of Ribeirão Preto Medical School, between 1995 and 2020 were retrospectively reviewed. Preoperative and postoperative analyses included gender; age at epilepsy onset; seizure semiology; seizure frequency; interictal and ictal electroencephalographic (EEG) findings; age at surgery; duration of epilepsy; surgical complications; duration of follow-up; histopathological findings; and postoperative seizure, cognitive, and functional outcomes. RESULTS Forty-four patients were evaluated. Mean age at seizure onset and epilepsy duration was 6 years and 2.5 years, respectively. Mean age at surgery was 9 years, with an average follow-up ranging from 3 months to 23 years. All patients presented with severe epilepsy and distinct neurological abnormalities on MRI. Before HS, different degrees of abnormal intellectual performance as well as hemiparesis were seen in 86% and 90%, respectively. Histopathology examination confirmed this diagnosis in 95% patients. At the last follow-up, 68% of patients were seizure free, and 70% were classified as Engel Class I or II. Postoperatively, the cognitive status remained unchanged in 64% of patients. Likewise, the gross motor function remained unchanged in 54% of patients and 74% had functional hand ability after HS. CONCLUSIONS Considering the progressive damage course of RE, hemispheric surgery should be offered to pediatric patients. It has manageable risks and results in good seizure outcome, and the preoperative functional status of these children is often preserved (even when the left hemisphere is involved), thus improving their quality of life.
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Affiliation(s)
- Ursula Thomé
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil.
| | - Larissa A Batista
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Renata P Rocha
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Vera C Terra
- Epilepsy Center, Nsa Sra das Graças Hospital, Curitiba, Brazil
| | - Ana Paula A Hamad
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Americo C Sakamoto
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Antônio C Santos
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Marcelo V Santos
- Pediatric Neurosurgery Division, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Hélio R Machado
- Pediatric Neurosurgery Division, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
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Pearl MS, Tsuchida TN, Oluigbo C, Kratimenos P, Anwar T, Kousa Y, Gaillard WD, Chang T. Definitive treatment of seizures due to hemimegalencephaly in neonates and young infants by transarterial embolization: technical considerations for 'endovascular embolic hemispherectomy'. J Neurointerv Surg 2023; 16:81-87. [PMID: 36302639 DOI: 10.1136/jnis-2022-019049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 10/11/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND This case series describes the technical considerations and effectiveness of 'endovascular embolic hemispherectomy' for the treatment of medically intractable seizures in neonates and young infants with hemimegalencephaly (HME) and in whom surgical hemispherectomy is not a viable option. METHODS This is a descriptive review of the endovascular technique used to treat consecutive pediatric patients with serial transarterial embolization for intractable seizures due to HME between 2018 and 2022. Clinical presentation, endovascular procedural details and complications, and efficacy were examined. RESULTS Three infants (13-day-old, 13-week-old and 15-day-old) with HME and intractable seizures underwent a total of 10 transarterial embolizations. Anticipated intraprocedural events included vasospasm and focal subarachnoid hemorrhage in all three infants, effectively controlled endovascularly, and non-target embolization in one infant. No infants had symptomatic intracranial hemorrhage or femoral artery occlusion. EEG background quiescence and seizure cessation was achieved after the final stage of embolization in all patients. All infants were discharged home from the neonatal ICU (median length of stay 36 days, range 27-74 days) and remain seizure-free to date (4 years, 9 months, and 8 months). None have developed hydrocephalus, required surgical hemispherectomy or other neurosurgical interventions. CONCLUSION Endovascular hemispherectomy can be safely used to provide definitive treatment of HME-related epilepsy in neonates and young infants when intraprocedural events are managed effectively. This less invasive novel approach should be considered a feasible early alternative to surgical hemispherectomy. Further studies are needed to enhance the safety profile and to assess long-term neurodevelopmental outcome and durability of freedom from seizures.
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Affiliation(s)
- Monica S Pearl
- Radiology, Children's National Hospital, Washington, District of Columbia, USA
- Radiology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Tammy N Tsuchida
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Chima Oluigbo
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
- Department of Neurosurgery, Children's National Health System, Washington, District of Columbia, USA
| | - Panagiotis Kratimenos
- Neonatology, Children's National Hospital, Washington, District of Columbia, USA
- Neonatology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Tayyba Anwar
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Youssef Kousa
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - William D Gaillard
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Taeun Chang
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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Alexander N, Cip J, Müller E, Lengnick-Lampadius K, Broser PJ. Gait is not Affected by Hemispherotomy-Case Report from Two Children. Neuropediatrics 2023; 54:397-401. [PMID: 36706787 DOI: 10.1055/a-2021-0202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
In children with therapy refractory epilepsy, the functional disconnection of one hemisphere (hemispherotomy) may be considered as a treatment option. The visual field defects and hand function effects associated with the procedure have been extensively studied. However, the effect of the hemispherotomy on gait pattern has thus far only been analyzed qualitatively, and there is limited quantitative data. At the Children's Hospital, we regularly perform standardized quantitative gait analysis studies and care for children with complex epilepsies. During the standard routine of care for two children with structural therapy refractory epilepsy, gait analysis was performed prior to and after hemispherotomy. Both patients had prenatal ischemic brain lesions, had developed severe epilepsy during the first 3 years of life, and were treated with the hemispherotomy at about 7 years of age. Interestingly, one patient did not show any changes in gait pattern, while for the other patient, differences could be observed by means of three-dimensional gait analysis. However, greater deviations to controls postoperatively may also be related to day-to-day variability.
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Affiliation(s)
- Nathalie Alexander
- Laboratory for Motion Analysis, Department of Paediatric Orthopaedics, Children's Hospital of Eastern Switzerland, Street Gallen, Switzerland
- Department of Orthopaedics and Traumatology, Cantonal Hospital, St. Gallen, Switzerland
| | - Johannes Cip
- Department of Paediatric Orthopaedics, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Elisabeth Müller
- Department of Paediatric Neurology, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Katrin Lengnick-Lampadius
- Department of Paediatric Neurology, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
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Nava BC, Costa UT, Hamad APA, Garcia CAB, Sakamoto AC, Aragon DC, Machado HR, Santos MV. Long-term seizure outcome and mobility after surgical treatment for Rasmussen encephalitis in children: A single-center experience. Epileptic Disord 2023; 25:749-757. [PMID: 37589547 DOI: 10.1002/epd2.20147] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVE Rasmussen Encephalitis (RE) is a rare inflammatory neurodegenerative disease associated with refractory seizures, hemiparesis, and cognitive deterioration, due to lateralized cortical atrophy. Hemispheric surgery (hemispherotomy) is the mainstay of treatment, but its unavoidable motor deficits and lack of long-term data regarding seizure outcomes can make patients and families apprehensive to undergo this procedure. The present study aimed at analyzing the results of surgical treatment for RE from a motor and epilepsy standpoint, and mitigate such concerns. METHODS Clinical and operative data were retrospectively collected from medical records of pharmacoresistant patients treated with functional hemispherectomy at a tertiary reference center for epilepsy surgery, during a 24-year period (1996-2020). Variables such as age of epilepsy onset, seizure semiology, seizure frequency, immunomodulatory therapy, age at surgery, duration of epilepsy, surgical procedures and complications, number of medications used preoperatively and postoperatively were described and statistically analyzed. RESULTS Forty-three (43) patients were included in this study. Mean age of epilepsy onset was 6.14 years, the average interval between epilepsy onset and hemispherotomy was 2.21 years. and the mean age at surgery was 8.28 years. Thirty patients (69.7%) were Engel I at their last follow-up, of whom 23 (56.4%) were Engel Ia, within a mean follow-up of 11.3 years. Duration of epilepsy, seizure frequency, and age at surgery, among others, did not correlate with seizure outcome, except the use of immunotherapy which led to worse outcomes (p < .05). Also, after surgery, motor functionality was significantly recovered (i.e., most patients returned to their previous status) with time. SIGNIFICANCE This study tackled some issues regarding the surgical treatment of this disease, particularly showing that hemispherotomy is safe and leads to potentially recoverable disability of motor functions while providing high rates of effective and long-lasting seizure control; therefore, early surgical indication should be warranted once medical refractoriness has been established.
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Affiliation(s)
- Brenda Cristina Nava
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Ursula Thome Costa
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Ana Paula Andrade Hamad
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Camila Araujo Bernardino Garcia
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Americo Ceiki Sakamoto
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Davi Casale Aragon
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Helio Rubens Machado
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Marcelo Volpon Santos
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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Chen JS, Harris WB, Wu KJ, Phillips HW, Tseng CH, Weil AG, Fallah A. Comparison of Hemispheric Surgery Techniques for Pediatric Drug-Resistant Epilepsy: An Individual Patient Data Meta-analysis. Neurology 2023; 101:e410-e424. [PMID: 37202158 PMCID: PMC10435062 DOI: 10.1212/wnl.0000000000207425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 04/03/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Hemispheric surgery effectively treats unihemispheric pediatric drug-resistant epilepsy (DRE) by resecting and/or disconnecting the epileptic hemisphere. Modifications to the original anatomic hemispherectomy have generated multiple functionally equivalent, disconnective techniques for performing hemispheric surgery, termed functional hemispherotomy. While a myriad of hemispherotomy variants exist, all of them can be categorized according to the anatomic plane they are performed in, which includes vertical approaches at or near the interhemispheric fissure and lateral approaches at or near the Sylvian fissure. This meta-analysis of individual patient data (IPD) aimed to compare seizure outcomes and complications between the hemispherotomy approaches to better characterize their relative efficacy and safety in the modern neurosurgical treatment of pediatric DRE, given emerging evidence that outcomes may differ between them. METHODS CINAHL, Embase, PubMed, and Web of Science were searched from inception to September 9, 2020, for studies reporting IPD from pediatric patients with DRE who underwent hemispheric surgery. Outcomes of interest were seizure freedom at last follow-up, time-to-seizure recurrence, and complications including hydrocephalus, infection, and mortality. The χ2 test compared the frequency of seizure freedom and complications. Multivariable mixed-effects Cox regression controlling for predictors of seizure outcome was performed on propensity score-matched patients to compare time-to-seizure recurrence between approaches. Kaplan-Meier curves were made to visualize differences in time-to-seizure recurrence. RESULTS Fifty-five studies reporting on 686 unique pediatric patients treated with hemispheric surgery were included for meta-analysis. Among the hemispherotomy subgroup, vertical approaches resulted in a greater proportion of seizure free patients (81.2% vs 70.7%, p = 0.014) than lateral approaches. While there were no differences in complications, lateral hemispherotomy had higher rates of revision hemispheric surgery due to incomplete disconnection and/or recurrent seizures than vertical hemispherotomy (16.3% vs 1.2%, p < 0.001). After propensity score matching, vertical hemispherotomy approaches independently conferred longer time-to-seizure recurrence than lateral hemispherotomy approaches (hazard ratio 0.44, 95% CI 0.19-0.98). DISCUSSION Among functional hemispherotomy techniques, vertical hemispherotomy approaches confer more durable seizure freedom than lateral approaches without compromising safety. Future prospective studies are required to definitively determine whether vertical approaches are indeed superior and how it should influence clinical guidelines for performing hemispheric surgery.
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Affiliation(s)
- Jia-Shu Chen
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles
| | - William B Harris
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles
| | - Katherine J Wu
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles
| | - H Westley Phillips
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles
| | - Chi-Hong Tseng
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles
| | - Alexander G Weil
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles
| | - Aria Fallah
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles.
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Phillips HW, Chen JS, Tucker AM, Ding K, Kashanian A, Nagahama Y, Mathern GW, Weil AG, Fallah A. Preliminary Experience Suggests the Addition of Choroid Plexus Cauterization to Functional Hemispherectomy May Reduce Posthemispherectomy Hydrocephalus. Neurosurgery 2023; 92:300-307. [PMID: 36637266 PMCID: PMC10553136 DOI: 10.1227/neu.0000000000002193] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/20/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Cerebral hemispherectomy can effectively treat unihemispheric epilepsy. However, posthemispherectomy hydrocephalus (PHH), a serious life-long complication, remains prevalent, requiring careful considerations in technique selection and postoperative management. In 2016, we began incorporating open choroid plexus cauterization (CPC) into our institution's hemispherectomy procedure in an attempt to prevent PHH. OBJECTIVE To determine whether routine CPC prevented PHH without exacerbating hemispherectomy efficacy or safety. METHODS A retrospective review of consecutive patients who underwent hemispherectomy for intractable epilepsy between 2011 and 2021 was performed. Multivariate logistic regression was used to identify factors independently associated with PHH requiring cerebrospinal fluid (CSF) shunting. RESULTS Sixty-eight patients were included in this study, of whom 26 (38.2%) underwent CPC. Fewer patients required CSF shunting in the CPC group (7.7% vs 28.7%, P = .033) and no patients who underwent de novo hemispherectomy with CPC developed PHH. Both cohorts experienced seizure freedom (65.4% vs 59.5%, P = .634) and postoperative complications, including infection (3.8% vs 2.4%, P = .728), hemorrhage (0.0% vs 2.4%, P = .428), and revision hemispherectomy (19.2% vs 14.3%, P = .591) at similar rates. Patients without CPC had greater odds of developing PHH requiring CSF shunting (odds ratio = 8.36, P = .026). The number needed to treat with CPC to prevent an additional case of PHH was 4.8, suggesting high effectiveness. CONCLUSION Preventing PHH is critical. Our early experience demonstrated that routinely incorporating CPC into hemispherectomy effectively prevents PHH without causing additional complications, especially in first-time hemispherectomies. A multicenter randomized controlled trial with long-term follow-up is required to corroborate the findings of our single-institutional case series and determine whether greater adoption of this technique is justified.
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Affiliation(s)
- H. Westley Phillips
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA;
| | - Jia-Shu Chen
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA;
| | - Alexander M. Tucker
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA;
| | - Kevin Ding
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA;
| | - Alon Kashanian
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA;
| | - Yasunori Nagahama
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA;
| | - Gary W. Mathern
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA;
- The Intellectual Disabilities and Developmental Research Center, Department of Psychiatry and Biobehavioral Medicine, University of California, Los Angeles, Los Angeles, California, USA;
| | - Alexander G. Weil
- Department of Neurosurgery, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada;
| | - Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA;
- Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
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Sundar SJ, Lu E, Schmidt ES, Kondylis ED, Vegh D, Poturalski MJ, Bulacio JC, Jehi L, Gupta A, Wyllie E, Bingaman WE. Seizure Outcomes and Reoperation in Surgical Rasmussen Encephalitis Patients. Neurosurgery 2022; 91:93-102. [PMID: 35544031 PMCID: PMC9514735 DOI: 10.1227/neu.0000000000001958] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 01/08/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Rasmussen encephalitis (RE) is a rare inflammatory disease affecting one hemisphere, causing progressive neurological deficits and intractable seizures. OBJECTIVE To report long-term seizure outcomes, reoperations, and functional outcomes in patients with RE who underwent hemispherectomy at our institution. METHODS Retrospective review was performed for all patients with RE who had surgery between 1998 and 2020. We collected seizure history, postoperative outcomes, and functional data. Imaging was independently reviewed in a blinded fashion by 2 neurosurgeons and a neuroradiologist. RESULTS We analyzed 30 patients with RE who underwent 35 hemispherectomies (5 reoperations). Using Kaplan-Meier analysis, seizure-freedom rate was 81.5%, 63.6%, and 55.6% at 1, 5, and 10 years after surgery, respectively. Patients with shorter duration of hemiparesis preoperatively were less likely to be seizure-free at follow-up (P = .011) and more likely to undergo reoperation (P = .004). Shorter duration of epilepsy (P = .026) and preoperative bilateral MRI abnormalities (P = .011) were associated with increased risk of reoperation. Complete disconnection of diseased hemisphere on postoperative MRI after the first operation improved seizure-freedom (P = .021) and resulted in fewer reoperations (P = .034), and reoperation resulted in seizure freedom in every case. CONCLUSION Obtaining complete disconnection is critical for favorable seizure outcomes from hemispherectomy, and neurosurgeons should have a low threshold to reoperate in patients with RE with recurrent seizures. Rapid progression of motor deficits and bilateral MRI abnormalities may indicate a subpopulation of patients with RE with increased risk of needing reoperation. Overall, we believe that hemispherectomy is a curative surgery for the majority of patients with RE, with excellent long-term seizure outcome.
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Affiliation(s)
- Swetha J. Sundar
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA;
| | - Elaine Lu
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA;
| | - Eric S. Schmidt
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA;
| | | | - Deborah Vegh
- The Charles Shor Epilepsy Center, Cleveland Clinic, Cleveland, Ohio, USA;
| | - Matthew J. Poturalski
- Department of Neuroradiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Juan C. Bulacio
- The Charles Shor Epilepsy Center, Cleveland Clinic, Cleveland, Ohio, USA;
| | - Lara Jehi
- The Charles Shor Epilepsy Center, Cleveland Clinic, Cleveland, Ohio, USA;
| | - Ajay Gupta
- The Charles Shor Epilepsy Center, Cleveland Clinic, Cleveland, Ohio, USA;
| | - Elaine Wyllie
- The Charles Shor Epilepsy Center, Cleveland Clinic, Cleveland, Ohio, USA;
| | - William E. Bingaman
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA;
- The Charles Shor Epilepsy Center, Cleveland Clinic, Cleveland, Ohio, USA;
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Sousa S, Sá Pinto V, Chaves J, Martins da Silva A, Ramalheira J, Lopes J, Temudo T, Lopes Lima JM, Calheiros A, Rangel R. Long term outcome of functional hemispherectomy for refractory epilepsy: Experience from a single center. Neurocirugia (Astur : Engl Ed) 2022; 33:82-89. [PMID: 35248302 DOI: 10.1016/j.neucie.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/25/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Hemispherectomy has an established role as a treatment of last resort in patients with unilateral hemispheric lesions suffering from refractory epilepsy. METHODS Seven patients were evaluated at our Epilepsy Unit. We compared the seizure outcome at 6 months, 1, 2, 5 years post-surgery, as well as at end follow-up (mean 7.1 years) using Engel classification. Reduction of antiepileptic drugs (AEDs) was also assessed utilizing equal time frames. RESULTS The mean age of seizure onset was 5.4 years. Engel I was achieved in 5 patients at 6 months (71.4%). Engel at 1 year was predicted by the Engel at 6 months (p=0.013) with a similar number of patients being classified as Engel I outcome. Engel at 2 years was also predicted by Engel at 6 months and at 1 year (p=0.030). At end follow-up only 3 patients (42.9%) remained categorized as Engel I outcome. There was a trend toward a stability in Engel classification. All patients with developmental causes for their epilepsy experienced some deterioration of the surgical outcomes. Conversely, all patients with acquired causes were stable throughout follow-up. Seizure outcome at 6 months was worse in the patients who had post-op complications (p=0.044). Adult and pediatric populations did not differ significantly in any tested variable. CONCLUSIONS Hemispherectomy is a valuable resource for seizure control in properly selected patients. Engel patient's evolution could be predicted at 6 months interval. Hemispherectomy could be considered a useful attitude in difficult cases.
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Affiliation(s)
- Sérgio Sousa
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurosurgery, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal.
| | - Vasco Sá Pinto
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurosurgery, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal
| | - João Chaves
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurology, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal; UMIB/ICBAS - University of Porto, Porto, Portugal
| | - António Martins da Silva
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurophysiology, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal; UMIB/ICBAS - University of Porto, Porto, Portugal
| | - João Ramalheira
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurophysiology, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal
| | - João Lopes
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurophysiology, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal
| | - Teresa Temudo
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neuropediatrics Department, Centro Hospitalar Universitário do Porto, Portugal
| | - José Manuel Lopes Lima
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal
| | - Alfredo Calheiros
- Neurosurgery, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal
| | - Rui Rangel
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurosurgery, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal
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13
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Keng A, Stewart DE, Sheehan KA. Neuropsychiatric Symptoms After Brain Tumor Resection in Children and Adolescents: A Scoping Review. J Acad Consult Liaison Psychiatry 2021; 63:110-118. [PMID: 34229094 DOI: 10.1016/j.jaclp.2021.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/23/2021] [Accepted: 06/26/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Brain tumors are one of the most common solid tumors in pediatric populations, with their treatments having significant neuropsychiatric impact. OBJECTIVE The objective of this study was to review the literature on neuropsychiatric sequelae after surgical resection of brain tumors in children and adolescents. METHODS Using a scoping method, we reviewed empirical articles describing pediatric patients with brain tumors who underwent partial or total resection and examined major neuropsychiatric domains postoperatively over time. RESULTS The initial search yielded 15,543 articles. After duplicate removal, abstract screening, and review, 44 articles were included. Cognitive deficits were the most widely studied outcomes and found to be associated with tumor location, operative variables, perioperative complications, treatment types, and psychosocial factors. Cerebellar mutism, or posterior fossa syndrome, commonly co-occurred with emotional and behavioral dysregulation after posterior fossa resections. Depression, anxiety, and somatization were frequently grouped together as "distress," with higher rates among pediatric patients with brain tumor than among healthy peers. Problematic school behaviors, antisocial, and attention-deficit traits were increased; however, several other behaviors (e.g., risky sexual behaviors, substance use) were equal or lower when compared to peers. Posttraumatic stress disorder was highly prevalent and often interfered with social functioning. Delirium, eating disorders, and longer-term outcomes received inadequate attention. CONCLUSION Identifying risk factors of neuropsychiatric sequelae and their impact after pediatric brain tumor resection is important for prognostication and the development of tailored management strategies for these children and adolescents.
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Affiliation(s)
- Alvin Keng
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
| | - Donna E Stewart
- Centre for Mental Health, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Kathleen Ann Sheehan
- Centre for Mental Health, University Health Network, University of Toronto, Toronto, ON, Canada
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Melikyan AG, Kushel YV, Sorokin VS, Vlasov PA, Demin MO, Shults EI, Shevchenko AM, Strunina YV. [Lessons learnt from 101 hemispheric pediatric epilepsy surgeries part ii: pitfalls and complications]. Zh Vopr Neirokhir Im N N Burdenko 2021; 85:44-52. [PMID: 34951759 DOI: 10.17116/neiro20218506144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To evaluate the spectrum of pitfalls and complications after hemisherotomy basing on a retrospective study of a large consecutive pediatric cohort of patients from a single institution. MATERIAL AND METHODS One hundred and one patients (med. age - 43 months) with refractory seizures underwent hemispherotomy. Developmental pathology was the anatomical substrate of disorder in 42 patients. The infantile post-stroke scarring and gliosis was the origin of epilepsy in the majority of 43 cases with acquired etiology. The progressive pathology (RE, S-W and TS) was the etiology in the rest of children (16 cases). The lateral periinsular technique was used to isolate the sick hemisphere in 55 patients; the vertical parasagittal approach was employed in 46 cases. Median perioperative blood loss constituted 10.5 ml/kg, but was markedly larger in kids with hemimegaly (52.8 ml/kg); 57 patients needed hemotransfusion during surgery. Median length of stay in ICU was 14.7 hours, and the length of stay in the hospital until discharge - 6.5 days. Eight patients underwent second-look surgery to complete sectioning of undercut commissural fibers. FU is known in 91 patients (med. length - 1.5 years). RESULTS Major surgical complications with serious hemorrhage and/or surgery induced life-threatening events developed in 7 patients (one of them has died on the 5th day post-surgery for the causes of brain edema and uncontrolled hyponatremia). Various early and late infectious complications were noted in 4 cases. Ten patients experienced new not anticipated but temporary neurological deficit. Nine patients needed shunting for the causes of hydrocephalus within several first months post-hemispherotomy. Early seizure onset was associated with probability of all complications in general (p=0.02), and developmental etiology - with intraoperative bleeding and hemorrhagic complications (p=0.03). CONCLUSION Children with developmental etiology, particularly those with hemimegalencephaly, are most challengeable in terms of perioperative hemorrhage and serious complications. Patients with relapse or persisting seizures should be evaluated for the possibility of incomplete hemispheric isolation and have good chances to become SF by re-doing hemispherotomy.
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Affiliation(s)
| | - Yu V Kushel
- Burdenko Neurosurgical Center, Moscow, Russia
| | - V S Sorokin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - P A Vlasov
- Burdenko Neurosurgical Center, Moscow, Russia
| | - M O Demin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - E I Shults
- Burdenko Neurosurgical Center, Moscow, Russia
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Jain P, Haller C, Pulcine E, Ochi A, Dipchand A, Weiss SK, Chin V, Ibrahim GM. A child with a stroke, drug-refractory epilepsy and congenital heart disease: can a hemispherectomy be safely performed between staged cardiac procedures? Childs Nerv Syst 2019; 35:1245-1249. [PMID: 31044297 DOI: 10.1007/s00381-019-04171-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 04/21/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The safety of hemispherectomy between staged cardiac procedures is unknown and not previously reported. METHOD Retrospective review of a case with drug-resistant epilepsy due to stroke following bidirectional cavopulmonary connection (BDCPC). RESULTS This report describes the first case of a successful pediatric peri-insular functional hemispherectomy in the setting of a BDCPC. A discussion of the complex preoperative planning from both a cardiac and neurological perspective is presented. Considerations regarding hemispherectomy and its effects on the cardiac physiology, and perioperative considerations are emphasized in clinical decision making. CONCLUSIONS A multidisciplinary approach was critical in this child which led to a successful outcome.
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Affiliation(s)
- Puneet Jain
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, M5G 1X8, Canada
- Division of Pediatric Neurology, Department of Pediatrics, BL Kapur (BLK) Super Speciality Hospital, Pusa Road, New Delhi, 110005, India
| | - Christoph Haller
- Division of Cardiac Surgery, The Hospital for Sick Children, Toronto, M5G 1X8, Canada
| | - Elizabeth Pulcine
- Stroke Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, M5G 1X8, Canada
| | - Ayako Ochi
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, M5G 1X8, Canada
| | - Anne Dipchand
- Labatt Family Heart Center, The Hospital for Sick Children, Toronto, M5G 1X8, Canada
| | - Shelly K Weiss
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, M5G 1X8, Canada
| | - Vannessa Chin
- Department of Anesthesia, The Hospital for Sick Children, Toronto, M5G 1X8, Canada
| | - George M Ibrahim
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada.
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Rodriguez-Osorio X, Lopez-Gonzalez FJ, Eiris-Punal J, Frieiro-Dantas C, Gomez-Lado C, Peleteiro-Fernandez M, Prieto-Gonzalez A. [Functional hemispherectomy: long-term follow-up in a series of five patients]. Rev Neurol 2018; 66:147-153. [PMID: 29480510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Functional hemispherectomy consists in palliative epilepsy surgical procedure usually performed in patients with pharmaco-resistant epilepsy and hemispheric syndromes. It is based on the neural disconnection of the affected hemisphere with preservation of the vascular supply. AIM To analyze long-term prognosis and safety of the hemispherectomies performed in our institution. PATIENTS AND METHODS Retrospective analysis collecting the following variables: age, gender, age of epilepsy onset, type of seizures, etiology, age of epilepsy surgery, prognosis and potential surgical complications. All patients had a minimum of five years of follow up. RESULTS Five patients (60% females) underwent hemispherotomy between 1999 and 2010. Age of epilepsy onset was 36 months and time of evolution until surgery was 7 years. The most frequent type of seizures were simple motor seizures with secondary generalization (n = 5). Three patients remained seizure free persistently after surgery and another patient had a more than 90% improvement. Time of follow up was 13 years. One patient suffered a bacterial meningitis without sequelae. Six years after surgery a patient suffered hydrocephalous requiring ventriculoperitoneal shunt. CONCLUSIONS Functional hemispherectomy constitutes an effective method to treat patients with pharmaco-resistant epilepsy, extensive unihemispheric pathology and seizures limited to that hemisphere. Late complications may occur thus long-term follow-up is needed.
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Affiliation(s)
- X Rodriguez-Osorio
- Complejo Hospitalario Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Espana
| | - F J Lopez-Gonzalez
- Complejo Hospitalario Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Espana
| | - J Eiris-Punal
- Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Espana
| | - C Frieiro-Dantas
- Complejo Hospitalario Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Espana
| | - C Gomez-Lado
- Complejo Hospitalario Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Espana
| | - M Peleteiro-Fernandez
- Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Espana
| | - A Prieto-Gonzalez
- Complejo Hospitalario Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Espana
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Cao K, Liu M, Wang C, Liu Q, Yang K, Tao L, Guo X. Five-Year Long-Term Prognosis of Epileptic Children After Hemispheric Surgery: A Systematic Review and Meta-analysis. Medicine (Baltimore) 2016; 95:e3743. [PMID: 27281073 PMCID: PMC4907651 DOI: 10.1097/md.0000000000003743] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 04/13/2016] [Accepted: 04/21/2016] [Indexed: 11/26/2022] Open
Abstract
To estimate children's long-term seizure outcomes after hemispheric surgery and the associated predictors.A systematic review of 4 databases and a meta-analysis were performed from January 1, 1995 to August 31, 2015. The databases included PubMed, Embase, Science Direct, and Web of Science; patients were classified into the Engel Class I group and the Engel Class II to IV group, according to their seizure outcomes. Nine potential predictors were then stratified across the groups and estimated using the Wilcoxon rank-sum test for continuous variables and the Chi-squared test for categorical variables.The search yielded 15 retrospective studies, with a total sample size of 380. Five years after surgery, 268 (0.71, 95% confidence interval [CI]: 0.64-0.78) children were seizure free; the seizure onset age in the Engel Class I group was significantly higher than that of the Engel Class II to IV group (standardized mean difference [SMD] = 0.26, 95% CI: 0.03-0.49, P = 0.028); specifically, when predicting the positive long-term outcomes, the odds ratio for late onset age (≥3.6 months, median value of the Engel Class II-IV group) versus early onset age was 2.65 (95% CI: 1.454-4.836, z = 3.18, P = 0.001). The abnormal magnetic resonance imaging (MRI) findings were more predictive for positive seizure outcomes than the normal findings (odds ratio [OR] = 4.60, 95% CI: 1.27-16.62, P = 0.02).Following hemispheric surgery, the long-term prognosis of children with epilepsy was good. Late seizure onset (age ≥ 3.6 months) and abnormal MRI findings were positive predictors for long-term seizure control in children.
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Affiliation(s)
- Kai Cao
- From the Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University (KC, CW, QL, KY, LT, XG); Beijing Municipal Key Laboratory of Clinical Epidemiology (KC, CW, QL, KY, LT, XG); Beijing Key Laboratory of Environment Toxicology (ML); School of Public Health, Capital Medical University (ML); and Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology & Visual Science Key Laboratory (KC), Beijing, China
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van Schooneveld MMJ, Braun KPJ, van Rijen PC, van Nieuwenhuizen O, Jennekens-Schinkel A. The spectrum of long-term cognitive and functional outcome after hemispherectomy in childhood. Eur J Paediatr Neurol 2016; 20:376-84. [PMID: 26897542 DOI: 10.1016/j.ejpn.2016.01.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/23/2015] [Accepted: 01/09/2016] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate cognition, behavior, daily functioning and health-related quality of life (HrQoL) five years to more than a decade after hemispherectomy (HE) in childhood. METHODS This countrywide Dutch cohort study of 31 patients, who underwent HE between 1994 and 2009, included a semi-structured interview with parents, an assessment of cognition, and screening of behavioral problems and HrQoL. RESULTS Twenty-two school-age children and young adults [median age 13.8 years (0.5 at epilepsy onset, 5.3 at HE)] were assessed with age-appropriate cognitive tests. IQ ranged from 45 to 82 (median 61). Despite performing below mean norm scores, these participants could learn and remember, sustain attention, inhibit irrelevant responses, read and write. Nine more children [median age 9.7 years (0.25 at epilepsy onset, 1.4 at HE)] were so mentally retarded that age-appropriate testing was impossible. This group was almost totally dependent on others in daily activities, had the highest proportion of pre-existing contralateral MRI-abnormalities and after HE the highest rates of seizure recurrence and behavioral problems. Parents in both groups rated HrQoL surprisingly positively (mean VAS-score 72.5), with a scarce low rating (40). All parents reported problems with respect to their children's self-care, daily activities and mobility. CONCLUSION At least five years after HE, cognitive, behavioral and daily functioning encompasses a broad spectrum that varies from profound retardation and almost total dependence to low normal cognition and a reasonably independent existence. Pre-existing contralateral MRI abnormalities reflect a more generally affected brain with a limited ability to mediate development after HE.
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Affiliation(s)
| | - Kees P J Braun
- Department of Child Neurology, Brain Center Rudolf Magnus, UMC Utrecht, Utrecht, The Netherlands.
| | - Peter C van Rijen
- Department of Neurosurgery, Brain Center Rudolf Magnus, UMC Utrecht, Utrecht, The Netherlands.
| | - Onno van Nieuwenhuizen
- Department of Child Neurology, Brain Center Rudolf Magnus, UMC Utrecht, Utrecht, The Netherlands.
| | - Aag Jennekens-Schinkel
- Department of Pediatric Psychology, Sector of Neuropsychology, UMC Utrecht, Utrecht, The Netherlands; Department of Child Neurology, Brain Center Rudolf Magnus, UMC Utrecht, Utrecht, The Netherlands.
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Dorfer C, Ochi A, Snead OC, Donner E, Holowka S, Widjaja E, Rutka JT. Functional hemispherectomy for catastrophic epilepsy in very young infants: technical considerations and complication avoidance. Childs Nerv Syst 2015; 31:2103-9. [PMID: 26099232 DOI: 10.1007/s00381-015-2794-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 06/10/2015] [Indexed: 11/27/2022]
Abstract
PURPOSE We report on our experience in performing peri-insular functional hemispherectomy (PIH) in very young infants with catastrophic epilepsy. METHODS We retrospectively reviewed the medical charts of all infants with catastrophic epilepsy that underwent PIH under the age of 4 months at our institution. RESULTS Four infants (three female, one male) were included (median age at time of surgery 2.9 months, range from 2.4 to 4.2 months; median patient's weight at time of surgery 5650 g, range from 4300 to 7500 g). None of the patients experienced hemodynamic instability during surgery. All four patients were given red blood cell replacement (median 435 ml, range from 230 to 800 ml), three of the four patients experienced coagulopathy during surgery and were given platelet cells transfusion in one (50 ml) and fresh frozen plasma in two patients (191 and 320 ml). Two patients experienced severe complications that, however, did not cause a permanent morbidity due to prompt diagnosis and correct management. After a median follow-up time of 4.3 years (range from 1.3 to 7.9 years), three of four patients are completely seizure free. The remaining patient is experiencing brief daily staring episodes. All of them have a hemiparesis but are fully ambulatory and have a useful upper limb function. CONCLUSION In catastrophic epilepsy, PIH within the first months of life is feasible provided that an experienced multidisciplinary team is involved. Awareness of surgical challenges and potential complications is indispensible when the life-threatening nature of the epilepsy compels neurosurgeons to operate at this very young age.
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Affiliation(s)
- Christian Dorfer
- Division of Pediatric Neurosurgery, The Hospital for Sick Children, Suite 1503, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ayako Ochi
- Division of Pediatric Neurology, The Hospital for Sick Children, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - O Carter Snead
- Division of Neuroradiology, The Hospital for Sick Children, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Elizabeth Donner
- Division of Pediatric Neurology, The Hospital for Sick Children, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Stephanie Holowka
- Division of Neuroradiology, The Hospital for Sick Children, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Elysa Widjaja
- Division of Neuroradiology, The Hospital for Sick Children, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - James T Rutka
- Division of Pediatric Neurosurgery, The Hospital for Sick Children, Suite 1503, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada.
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
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Abstract
AIM The aim of this study was to evaluate the long-term results of resective surgery on children with difficult-to-treat epilepsy in Norway. METHODS In the period 1995-2004, 64 surgical procedures (54 resections and 10 functional hemispherotomies) were performed in 54 children. The children's medical records were retrospectively reviewed at a minimum of 2 years after surgery. We sent a questionnaire regarding their epilepsy (seizures, usage of antiepileptic drugs) and general functioning (social situation, motor, language, cognition, behavioural or emotional problems, any remedial action) to the children/parents after a mean follow-up period of 7 years. RESULTS 55.5% of the children were seizure-free. The success rate varied according to the type of surgery. Best results were found after functional hemispherotomies and temporal lobe resections, as nine of 10 (90%) and 10 of 19 (53%) of these patients, respectively, became seizure-free. In addition to a better seizure control, 71% of the children/parents reported of a better cognitive and psychosocial functioning. CONCLUSION The results of epilepsy surgery in this paediatric cohort are very edifying, and it is our impression that this treatment option is underused in Norway.
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Affiliation(s)
- K M Aaberg
- National Center for Epilepsy, Division of Surgery and Neuroscience, Oslo University Hospital, Oslo, Norway.
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21
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Paes-Branco D, Abreu-Villaça Y, Manhães AC, Filgueiras CC. Unilateral hemispherectomy at adulthood asymmetrically affects motor performance of male Swiss mice. Exp Brain Res 2012; 218:465-76. [PMID: 22367398 DOI: 10.1007/s00221-012-3034-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 02/06/2012] [Indexed: 01/23/2023]
Abstract
Evidence exists indicating that cerebral lateralization is a fundamental feature of all vertebrates. In humans, a series of studies demonstrated that the left hemisphere plays a major role in controlling movement. No such asymmetries have been identified in rodents, in spite of the fact that these animals have been frequently used in studies assessing motor behavior. In this regard, here, we used unilateral hemispherectomy to study the relative importance of each hemisphere in controlling movement. Adult Swiss mice were submitted to right unilateral hemispherectomy (RH), left unilateral hemispherectomy (LH) or sham surgery. Fifteen days after surgery, motor performance was assessed in the accelerating rotarod test and in the foot-fault test (in which performance depends on skilled limb use) and in the elevated body swing test (in which performance depends on trunk movements). The surgical removal of the right hemisphere caused a more pronounced impairment in performance than the removal of the left hemisphere both in the rotarod and in the foot-fault tests. In the rotarod, the RH group presented smaller latencies to fall than both LH and sham groups. In the foot-fault test, while both the sham and the LH groups showed no differences between left and right hind limbs, the RH group showed significantly worse performance with the left hind limb than with the right one. The elevated body swing test revealed a similar impairment in the two hemispherectomized groups. Our data suggest a major role of the right hemisphere in controlling skilled limb movements in mice.
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Affiliation(s)
- Danielle Paes-Branco
- Laboratório de Neurofisiologia, Departamento de Ciências Fisiológicas, Instituto Roberto Alcantara Gomes, Centro Biomédico, Universidade do Estado do Rio de Janeiro, Avenida Professor Manoel de Abreu 444, 5 andar, Vila Isabel, Rio de Janeiro, RJ, 20550-170, Brazil
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22
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Liégeois F, Connelly A, Baldeweg T, Vargha-Khadem F. Speaking with a single cerebral hemisphere: fMRI language organization after hemispherectomy in childhood. Brain Lang 2008; 106:195-203. [PMID: 18329093 DOI: 10.1016/j.bandl.2008.01.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2007] [Revised: 01/15/2008] [Accepted: 01/18/2008] [Indexed: 05/26/2023]
Abstract
Speech-related fMRI activation was examined in six hemispherectomy patients (three left LX, three right RX, four with congenital and two with late-acquired hemiplegia) operated in childhood for the relief of drug-resistant epilepsy. Although the temporal and sensorimotor pattern of activation was similar to that found in neurologically intact control participants, activation in Broca's area and its right homolog varied greatly. Involvement of pars triangularis and orbitalis was found in the three cases with best outcome (two RX, one LX), whereas pars opercularis alone was activated in the two remaining LX patients. The results suggest that distinct subregions of Broca's area and their right homologs can subserve speech and language, and that this variability may determine functional outcome.
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Affiliation(s)
- Frédérique Liégeois
- Developmental Cognitive Neuroscience Unit, UCL Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
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Lettori D, Battaglia D, Sacco A, Veredice C, Chieffo D, Massimi L, Tartaglione T, Chiricozzi F, Staccioli S, Mittica A, Di Rocco C, Guzzetta F. Early hemispherectomy in catastrophic epilepsy. Seizure 2008; 17:49-63. [PMID: 17689988 DOI: 10.1016/j.seizure.2007.06.006] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2007] [Revised: 04/23/2007] [Accepted: 06/18/2007] [Indexed: 11/26/2022] Open
Abstract
The authors report their experience about a neuro-cognitive and epileptic long-term follow-up of children with catastrophic epilepsy treated with hemispherectomy in the first 5 years of life. Nineteen children with resistant epilepsy that significantly interfered with their neuro-cognitive development underwent hemispherectomy within 5 years of life (mean: 2 years, 3 months; range: 5 months to 5 years). All patients were assessed before surgery and after, at least at the end of the follow-up (mean: 6 years and 6 months; range: 2-11 years and 2 months) with a full clinical examination including motor ability and functional status evaluation as well as behaviour observation, neuroimaging and an ictal/interictal prolonged scalp video-EEG. A seizure-free outcome was obtained in 73.7% of patients. Gross motility generally improved and cognitive competence did not worsen, with an evident progress in two cases. Consistently with previous reports, evolution was worse in cortical dysplasia than in progressive or acquired vascular cerebropathies. The excellent epileptic outcome and the lack of developmental deterioration in comparison with other more aged series seem to suggest a possible better evolution in earlier surgery treatment. To confirm this suggestion, however, further experience with larger series is needed.
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Affiliation(s)
- D Lettori
- Child Neurology and Psychiatry, Catholic University, Rome, Italy
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24
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Abdallah C, McMillan B. Pheumocephalus in an infant with Ohtahara syndrome--a case report. Middle East J Anaesthesiol 2007; 19:679-682. [PMID: 18044295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- C Abdallah
- The Children's National Medical Center, Department of Anesthesiology, Washington DC 20010-2970, USA
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25
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Basheer SN, Connolly MB, Lautzenhiser A, Sherman EMS, Hendson G, Steinbok P. Hemispheric surgery in children with refractory epilepsy: seizure outcome, complications, and adaptive function. Epilepsia 2007; 48:133-40. [PMID: 17241220 DOI: 10.1111/j.1528-1167.2006.00909.x] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To describe seizure control, complications, adaptive function and language skills following hemispheric surgery for epilepsy. METHODS Retrospective chart review of patients who underwent hemispheric surgery from July 1993 to June 2004 with a minimum follow-up of 12 months. RESULTS The study population comprised 24 children, median age at seizure onset six months and median age at surgery 41 months. Etiology included malformations of cortical development (7), infarction (7), Sturge-Weber Syndrome (6), and Rasmussen's encephalitis (4). The most frequent complication was intraoperative bleeding (17 transfused). Age <2 yr, weight <11 kg, and hemidecortication were risk factors for transfusion. Postoperative complications included aseptic meningitis (6), and hydrocephalus (3). At median follow-up of 7 yr, 79% of patients are seizure free. Children with malformations of cortical development and Rasmussen's encephalitis were more likely to have ongoing seizures. Overall adaptive function scores were low, but relative strengths in verbal abilities were observed. Shorter duration of epilepsy prior to surgery was related significantly to better adaptive functioning. CONCLUSIONS Hemispheric surgery is an effective therapy for refractory epilepsy in children. The most common complication was bleeding. Duration of epilepsy prior to surgery is an important factor in determining adaptive outcome.
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Affiliation(s)
- Sheikh Nigel Basheer
- Division of Neurology, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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26
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Abstract
Destruction of the occipital cortex presumably leads to permanent blindness in the contralateral visual field. Residual abilities to respond to visual stimuli in the blind field without consciously experiencing them have, however, been described in cortically blind patients and are termed 'blindsight'. Although the neuronal basis of blindsight remains unknown, possible neuronal correlates have been proposed based on the nature of the residual vision observed. The most prominent but still controversial hypothesis postulates the involvement of the superior colliculi in blindsight. Here we demonstrate, using a computer-based reaction time test in a group of hemispherectomized subjects, that human 'attention-blindsight' can be measured for achromatic stimuli but disappears for stimuli that solely activate S-cones. Given that primate data have shown that the superior colliculi lacks input from S-cones, our results lend strong support to the hypothesis that 'attention-blindsight' is mediated through a collicular pathway. The contribution of a direct geniculo-extrastriate-koniocellular projection was ruled out by testing hemispherectomized subjects in whom a whole hemisphere has been removed or disconnected for the treatment of epilepsy. A direct retino-pulvinar-cortical connection is also unlikely as the pulvinar nucleus is known to receive input from S-cones as well as from L/M-cone-driven colour-opponent ganglion cells.
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Affiliation(s)
- Sandra E Leh
- Neuropsychology/Cognitive Neuroscience Unit, Montreal Neurological Institute, 3801 University Street, Montreal, Quebec, Canada H3A 2B4.
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Guzzetta F, Battaglia D, Di Rocco C, Caldarelli M. Symptomatic epilepsy in children with poroencephalic cysts secondary to perinatal middle cerebral artery occlusion. Childs Nerv Syst 2006; 22:922-30. [PMID: 16816980 DOI: 10.1007/s00381-006-0150-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2006] [Indexed: 01/18/2023]
Abstract
BACKGROUND Perinatal cerebral artery occlusion is responsible for ischemic cerebral infarction leading to brain cavitation and gliosis; the territory of the middle cerebral artery is most frequently involved. The resulting poroencephalic cysts are frequently associated with hemiplegia and epilepsy; that can be managed medically in most cases, only 6-7% of them being refractory to medical treatment. This particular subset of congenitally hemiplegic children will be possible candidates for electrophysiological investigation and eventually for resective surgery. Whatever the kind of surgical treatment, surgery should be performed as soon as possible to optimize functional brain reorganization. CLINICAL MATERIAL Twelve children with poroencephalic cysts and refractory epilepsy were studied and operated on at the Divisions of Child Neurology and Pediatric Neurosurgery, the Catholic University Medical School, Rome. The hemiparesis ranged from mild to moderate; the developmental delay was of mild degree in three cases, moderate in four cases and severe in the remaining five. Behavioral disorders were observed in patients with mental retardation; two of them also manifested autistic features. All the children presented with a severe epileptic syndrome (starting almost invariably during the first year of life); six patients presented with a West syndrome followed by symptomatic partial epilepsy; the other six presented with partial epilepsy, followed in two cases by continuous spike-waves during sleep. The electroencephalograph (EEG) recordings disclosed focal unilateral interictal epileptiform abnormalities that usually corresponded to the side of the cystic lesion; however, paroxysmal activity often spread synchronously over the contralateral hemisphere. The selection of candidates for surgical treatment was based on neuroimaging and video-EEG monitoring; in particular, we did not use invasive intraoperative neurophysiologic techniques. The convergence of neuroimaging and neurophysiologic findings guided us in performing a limited cortical excision corresponding to the malacic cortex (cyst "membrane"). RESULTS All the patients underwent excision of the cyst wall. Careful attention was paid not to enter the body of the lateral ventricle to avoid ventriculo-subarachnoid fistulas, eventually responsible for subdural hygroma or cerebrospinal fluid leak. There was one surgery-related death secondary to disseminated intravascular coagulation, following an otherwise uneventful surgical procedure. An elevated systemic blood pressure, secondary to repeated adrenocorticotropic hormone therapy, can represent a possible concurrent factor for this event. No major complications were recorded among the remaining 11 children. Seizure control was excellent in all the 11 survivors in the early postoperative period. Two children presented a relapse of seizures, after an initial improvement, respectively 3 and 4 years after the operation. These two children underwent subsequently a functional hemispherectomy. Overall, seizure outcome was excellent in all the cases. Seven patients (including the two who underwent functional hemispherectomy) are seizure-free (Engel's class Ia), and in one of them antiepileptic therapy has been weaned. In the remaining five children, seizures are sporadic and definitely improved (Engel's class II). An improvement of developmental delay, in particular of cognitive competence, was registered in 8 out of the 11 patients. Two of the four severely retarded children, who also presented behavioral abnormalities, did not show any cognitive improvement, whereas some mild improvement of their basal abilities was demonstrated in the other two. All the remaining children, even though maintaining a moderate retardation, definitely improved their abilities; in particular, one of them reached an almost borderline level. The three patients with unchanged neurodevelopmental delay presented also persistent seizures. On the other hand, two children with persistent seizures presented neurodevelopmental improvement. CONCLUSIONS Simple surgical excision of the cyst "membrane" of epileptogenic poroencephalic cysts can represent an excellent means to control epilepsy in affected children. However, postoperative seizure persistence and late recurrences, although rare, do not allow to exclude that hemispherectomy or partial resections (based on electrocorticography findings) might represent the good answer at least in some cases.
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Affiliation(s)
- Francesco Guzzetta
- Division of Child Neurology, Catholic University Medical School, Rome, Italy
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de Almeida AN, Marino R, Marie SK, Aguiar PH, Teixeira MJ. Factors of morbidity in hemispherectomies: surgical technique x pathology. Brain Dev 2006; 28:215-22. [PMID: 16371245 DOI: 10.1016/j.braindev.2005.08.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2005] [Revised: 07/30/2005] [Accepted: 08/01/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The objective of this paper is to evaluate factors of surgical morbidity from different techniques of hemispherectomy with emphasis on causative pathology. PATIENTS AND METHODS Thirty patients underwent hemispherectomy in our institution from 1987 to 2003, two presented with Sturge-Weber Syndrome (SWS), sixteen with Rasmussen's Syndrome (RS), eight with established hemispheric lesions (EHL), and four with cortical development malformations (CDM). Six surgeons operated on three patients using anatomical hemispherectomies (AH), 11 patients using functional hemispherectomy (FH), and 16 patients employing hemispherotomy (HT). Surgical technique and causative pathology were studied independently as factors of morbidity in hemispherectomy. RESULTS Overall mean surgical time was 11:50+/-3:20 h and increased proportionately in pathologies with larger hemispheres. Blood transfusion was particularly influenced by the approach adopted by our team of anesthesiologists, independently of technique or pathology. Pathology was the most important factor related to hydrocephalus as two out of four patients with CDM needed ventriculoperitoneal shunt whilst none with EHL or SWS. Four patients undergoing HT and one FH presented residual bridges connecting the hemispheres, three were reoperated and are seizure free. Two patients with CDM did not improve their seizures worthwhile with surgery and other two (one with RS and other with CDM) were waiting a second procedure due to incomplete inter-hemispheric disconnection. Five patients presented infection and one died after developing meningoencephalitis. CONCLUSION Hemispherectomies are procedures where pathology and surgical technique interact narrowly. Therefore, in order to study surgical morbidity or outcome, both pathology and technique have to be analyzed independently.
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Affiliation(s)
- Antonio Nogueira de Almeida
- Departamento de Neurologia, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
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O'Brien DF, Basu S, Williams DH, May PL. Anatomical hemispherectomy for intractable seizures: excellent seizure control, low morbidity and no superficial cerebral haemosiderosis. Childs Nerv Syst 2006; 22:489-98; discussion 499. [PMID: 16470390 DOI: 10.1007/s00381-005-0023-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2005] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This current study was performed to evaluate whether superficial cerebral haemosiderosis (SCH) is still a complication of modern day anatomical hemispherectomy. METHODS We report a 13-year institutional experience with anatomical hemispherectomy for intractable epilepsy. Seizure control at a mean follow-up interval of 7 years was 83%. Though one patient died post-operatively from a non-neurosurgical complication, mortality was otherwise zero and morbidity minimal. The much-described complication of SCH following anatomical hemispherectomy was non-existent. We explain the history of SCH as a complication of anatomical hemispherectomy, and the measures that are presently taken to prevent it. CONCLUSIONS We suggest that the importance of SCH in modern epilepsy surgery is probably over-emphasised.
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Affiliation(s)
- Donncha F O'Brien
- Department of Neurosurgery, Royal Liverpool Children's Hospital NHS Trust, Alder Hey and the Walton Centre for Neurology and Neurosurgery NHS Trust, Eaton Road, Liverpool, L12 2AP, UK.
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30
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Mani J, Gupta A, Mascha E, Lachhwani D, Prakash K, Bingaman W, Wyllie E. Postoperative seizures after extratemporal resections and hemispherectomy in pediatric epilepsy. Neurology 2006; 66:1038-43. [PMID: 16606916 DOI: 10.1212/01.wnl.0000204236.96232.1c] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives: To estimate frequency and risk factors for acute postoperative seizures (APOS) within the first week after extratemporal cortical resection (ETR) and hemispherectomy (HS) in children and to assess the predictive value of APOS on long-term seizure outcome in this group.Methods: The authors conducted a retrospective analysis of children (<18 years), who underwent ETR or HS for intractable epilepsy between 1995 and 2002. APOS features and seizure outcome after ETR or HS were obtained at 6, 12, and 24 months. Univariate logistic regression was used for risk factors of APOS and life table analysis and log rank tests for seizure outcome at 0 to 6, 6 to 12, and 12 to 24 months.Results: Of 132 patients, 34 (26%) had APOS. APOS were more frequent after ETR (26/71) than HS (8/61) (p < 0.01). APOS, irrespective of their timing, number, semiology, or other perioperative complications, were an independent predictor of poor postoperative seizure outcome at 2 years (p < 0.001). The estimated odds of postoperative Engel class I outcome in the APOS vs non-APOS categories was 0.27 (73% less likely) for 0- to 6-month, 0.22 (78% less likely) for 6- to 12-month, and 0.13 (87% less likely) for the 12- to 24-month intervals.Conclusions: Acute postoperative seizures (APOS) occur in 26% children, and the risk is higher after extratemporal cortical resection than hemispherectomy. APOS predict a poor postoperative seizure outcome at 6, 12, and 24 months. This study is useful for counseling families after epilepsy surgery. It also suggests that APOS may not be discounted as “benign” in research studies that evaluate seizure outcomes after epilepsy surgery.
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Affiliation(s)
- J Mani
- Department of Neurology, Cleveland Clinic Foundation, OH 44195, USA
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Jiao QF, You C. [Modified hemispherectomy for intractable epilepsy in patients with infantile hemiplegia]. Zhonghua Wai Ke Za Zhi 2005; 43:1410-3. [PMID: 16318783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To explore the effectiveness of modified hemispherectomy for intractable epilepsy in patients with infantile hemiplegia. METHODS Eighteen cases of patients were treated with modified hemispherectomy and the effectiveness was studied and followed up. RESULTS The seizures in all 18 cases of patients were controlled effectively and stopped completely in 16 cases of them, without nervous disfunction worsened. The patients' cerebral peduncles on healthy side were much thicker than those on sick side (t = 58.32, P < 0.001) and healthy peoples' (t = 14.63, P < 0.001) and the patients' cerebral peduncles on sick side were much thinner than those of healthy peoples' (t = 51.27, P < 0.001). CONCLUSION The modified hemispherectomy can effectively control the seizures of patients with infantile hemiplegia without superficial cerebral hemosiderosis happened.
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Affiliation(s)
- Qing-fang Jiao
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610041, China
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Abstract
Fifteen posthemispherectomy children were examined to assess residual motor function of the paretic side using the 74-point Fugl-Meyer Assessment of Motor Recovery scale. The degree of residual motor control differed for upper and lower extremities, with hand function being most severely impaired. Posthemispherectomy motor outcomes also differed as a function of etiology: cortical dysplasia, perinatal infarct, and Rasmussen's encephalitis. Children whose intractable seizures resulted from perinatal middle cerebral artery stroke demonstrated the most spared motor function. To detect cortical areas that represented motor control of the hemiparetic side, we focused on voluntary control of the affected lower extremity. Seven of our patients were able to carry out a foot dorsiflexion paradigm during functional magnetic resonance imaging, and these results were compared with activations found in normal controls. All children showed activations in the sensorimotor network ipsilateral to the affected side. The perinatal infarct group demonstrated greater activity in the cingulate cortex, whereas the Rasmussen's encephalitis group had significant activations in the insula, suggesting etiology-specific differences in reorganization. These findings are discussed in the framework of our understanding of mechanisms of cortical plasticity in the injured brain and its relevance to neurologic rehabilitation. We suggest that imaging techniques are important tools in identifying cortical regions underlying functional reorganization. Furthermore, detection of such areas might become a basis for specific training promoting the optimal reorganization of cortical networks to enhance motor control.
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Affiliation(s)
- Stella de Bode
- Department of Neurology, UCLA School of Medicine, Reed Neurologic Research Center, Los Angeles, CA 90095, USA.
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Jonas R, Nguyen S, Hu B, Asarnow RF, LoPresti C, Curtiss S, de Bode S, Yudovin S, Shields WD, Vinters HV, Mathern GW. Cerebral hemispherectomy: hospital course, seizure, developmental, language, and motor outcomes. Neurology 2004; 62:1712-21. [PMID: 15159467 DOI: 10.1212/01.wnl.0000127109.14569.c3] [Citation(s) in RCA: 209] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare hemispherectomy patients with different pathologic substrates for hospital course, seizure, developmental, language, and motor outcomes. METHODS The authors compared hemispherectomy patients (n = 115) with hemimegalencephaly (HME; n = 16), hemispheric cortical dysplasia (hemi CD; n = 39), Rasmussen encephalitis (RE; n = 21), infarct/ischemia (n = 27), and other/miscellaneous (n = 12) for differences in operative management, postsurgery seizure control, and antiepilepsy drug (AED) usage. In addition, Vineland Adaptive Behavior Scale (VABS) developmental quotients (DQ), language, and motor assessments were performed pre- or postsurgery, or both. RESULTS Surgically, HME patients had the greatest perioperative blood loss, and the longest surgery time. Fewer HME patients were seizure free or not taking AEDs 1 to 5 years postsurgery, but the differences between pathologic groups were not significant. Postsurgery, 66% of HME patients had little or no language and worse motor scores in the paretic limbs. By contrast, 40 to 50% of hemi CD children showed near normal language and motor assessments, similar to RE and infarct/ischemia cases. VABS DQ scores showed +5 points or more improvement postsurgery in 57% of patients, and hemi CD (+12.7) and HME (+9.1) children showed the most progress compared with RE (+4.6) and infarct/ischemia (-0.6) cases. Postsurgery VABS DQ scores correlated with seizure duration, seizure control, and presurgery DQ scores. CONCLUSIONS The pathologic substrate predicted pre- and postsurgery differences in outcomes, with hemimegalencephaly (but not hemispheric cortical dysplasia) patients doing worse in several domains. Furthermore, shorter seizure durations, seizure control, and greater presurgery developmental quotients predicted better postsurgery developmental quotients in all patients, irrespective of pathology.
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Affiliation(s)
- R Jonas
- Division of Pediatric Neurology, David Geffen School of Medicine, University of California, Los Angeles, USA
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Abstract
Using the International Classification of Functioning Disability and Health (ICF) (WHO, 2001), impairments, activities and social participation are reported in 12 children (mean age at surgery 5.9 years) who were investigated before and three times over a 2-year period after hemispherectomy. Impairments were assessed (i) in terms of seizure frequency (Engel classification) and seizure severity (HASS) and (ii) with respect to muscle strength (MRC), range of motion (JAM score) and muscle tone (modified Ashworth scale). Activities were assessed in terms of gross motor functioning (GMFM) and self-care, mobility and social function (PEDI). Participation was assessed in terms of epilepsy-related restrictions and quantified by means of the Hague Restrictions in Childhood Epilepsy Scale (HARCES). Nine out of 12 children could be classified as free of seizures (Engel class I), and in the remaining three seizure frequency was Engel class III. HASS scores showed maximum improvement in 10 out of 12 children and near-maximum improvement in the two remaining children. Muscle strength and muscle tone on the side of the body contralateral to the hemispherectomy, which were already decreased preoperatively, decreased even further in the first 6 months after surgery, but returned to the presurgical baseline thereafter, except for the distal part of the arm. Range of motion was abnormal prior to operation and remained so after operation. Mean GMFM increase was 20% after 2 years (95% confidence interval 10-33); all five dimensions improved statistically significantly (P < 0.05). Mean PEDI increase was more than 20 scale points (95% confidence interval 10-35); again, all domains improved significantly (P < 0.05). In nearly all children, HARCES scores had normalized 2 years after surgery. In conclusion, decrease of seizure frequency and severity widens the scope of motor and social functioning, which overrides the effects of remaining motor impairments.
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Affiliation(s)
- R van Empelen
- Department of Paediatric Physical Therapy and Exercise Physiology, University Medical Centre, Wilhelmina Children's Hospital, RM. KB 02.056.0, P.O. Box 85090, 3508 AB Utrecht, The Netherlands.
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Piastra M, Pietrini D, Caresta E, Chiaretti A, Viola L, Cota F, Pusateri A, Polidori G, Di Rocco C. Hemispherectomy procedures in children: haematological issues. Childs Nerv Syst 2004; 20:453-8. [PMID: 15503368 DOI: 10.1007/s00381-004-0957-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTS In literature, excessive perioperative haemorrhage and related haemodynamic instability have been described as major risk factors in hemispherectomy. In this report we analyse the impact of neurosurgical operation on both the haematological and coagulative patterns of these children, especially focusing on younger patients. METHODS From 1993 to 2003, 18 consecutive children suffering from intractable epilepsia and treated by hemispherectomy were admitted to the Pediatric Intensive Care Unit (PICU) of Catholic University Medical School, Policlinico Gemelli, Rome. Eight children had an entire hemisphere removed (anatomical hemispherectomy), whereas the remaining 10 underwent disconnective procedures (functional hemispherectomy) or cerebral cortex ablations (e.g. hemicorticectomy). Eleven out of these 18 children underwent hemispherectomy because of hemimegalencephaly (HME): their mean age was 14.5 months (range 3-56 months); non-HME patients underwent surgery for epileptogenic lesions involving the cerebral hemisphere to a great extent or diffusely. Data have been compared with an historical cohort of 13 children operated on before 1992 at the same institution comparable for age, aetiology of epilepsy and the modalities of surgical operation. CONCLUSIONS Blood losses and haemotransfusions showed a profound influence on the haematologic/coagulative status of the children operated upon. A strict correlation was demonstrated between estimated red cell volume (ERCV) loss and haemostatic impairment in this series. Recent surgical techniques appear to reduce blood losses and related haemocoagulative risks even in younger patients.
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Affiliation(s)
- M Piastra
- Paediatric Intensive Care Unit, Catholic University Medical School, 00168 Rome, Italy.
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de Ribaupierre S, Villemure JG, Chalaron M, Cotting J, Pollo C. Contralateral frontal and cerebellar haemorrhages after peri-insular hemispherotomy. Acta Neurochir (Wien) 2004; 146:743-4. [PMID: 15197620 DOI: 10.1007/s00701-004-0255-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Guénot M. [Indications and risk of neurosurgical techniques in the adult presenting with drug-resistant partial epilepsy (radiosurgery included)]. Rev Neurol (Paris) 2004; 160 Spec No 1:5S185-94. [PMID: 15331966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
To be considered for resective (curative) surgery, most seizures have to been proved to arise exclusively from one area of the brain that is functionally silent. The drug-resistance must be certain, and the patient must be strongly motivated to undergo surgery. Temporal lobectomy for drug-resistant temporo-mesial epilepsy is now scientifically validated by a randomized controlled trial. Hemispherotomy, which consists in complete disconnection of one hemisphere, is a curative technique, which may be considered where there is a pre-existing hemiplegia associated with a structural abnormality of the contralateral hemisphere. Therefore, it is rarely performed in adult patients. Stereotactic radiosurgery is also a curative technique, which shares most of its indications with those of temporo-mesial resections. Callosotomy is a palliative technique, which consists in disconnecting the hemispheres, one from the other. It may be considered in individuals having frequent atonic seizures (drop attacks). Multiple subpial transection involves transection of transverse fibers, leaving longitudinal fibers intact. It may be performed if the epileptogenic focus is located in an eloquent brain area. The complication rate of resective surgery is low. Controlateral motor impairement is the main permanent complication related to cortical resection. It is a rare occurrence (1 to 2 percent of cases) due to peroperative lesions of the sylvian vasculature, or of the anterior choroidal artery, or even of the motor area. Postoperative hematomas, infections, or hydrocephalus may also occur in 2 to 6 percent of cases, depending on the authors. Some postoperative neuropsychological complications are reported in the literature, especially after surgery on the dominant side. Hydrocephalus and infection are the most frequent complications occurring after hemispherotomy (10 percent of cases). Dysconnexion syndrome is a rare complication, which can be seen after total callosotomy. It is unusual for the effects of disconnection after anterior callosotomy to represent significant handicap. Permanent postoperative worsening of a pre-existing neurological impairement, as well as hematomas, are seen in less than 10 percent of the cases after multiple subpial transection. In conclusion, surgery is an important therapeutic option, which has to be considered as soon as the epileptic disease appears to be drug-resistant, particularly in case of temporo-mesial epilepsy.
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Affiliation(s)
- M Guénot
- Service de Neurochirurgie et Stéréotaxie Fonctionnelles (Pr Sindou), Hôpital P. Wertheimer, 59 Boulevard Pinel, 69003 Lyon, France.
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Loddenkemper T, Dinner DS, Kubu C, Prayson R, Bingaman W, Dagirmanjian A, Wyllie E. Aphasia after hemispherectomy in an adult with early onset epilepsy and hemiplegia. J Neurol Neurosurg Psychiatry 2004; 75:149-51. [PMID: 14707328 PMCID: PMC1757473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
A 55 year old left handed man with left hemisphere subcortical encephalomalacia, seizures, language impairment, and right hemiparesis from a motor vehicle accident at age five was evaluated for epilepsy surgery. The patient continued to speak and followed commands during a left intracarotid amobarbital test (IAT). Left functional hemispherectomy resulted in expressive aphasia. Based on postoperative outcome, language was bilateral. The injury after primary development of language function, the predominantly subcortical lesion, and the late timing of surgical intervention well past development and plasticity may have been factors in the emergence of postoperative aphasia.
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Affiliation(s)
- T Loddenkemper
- Department of Neurology, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Yang ZX, Luan GM. [Treatment of intractable epilepsy with hemispherectomy]. Zhonghua Wai Ke Za Zhi 2003; 41:359-61. [PMID: 12892590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
OBJECTIVE To explore the clinical effectiveness of hemispherectomy for patients with intractable epilepsy. METHODS Thirty-six patients with intractable epilepsy were treated by modified hemispherectomy and their clinical results were followed up after operation. RESULTS The seizures of the 36 patients were effectively controlled and 34 (94.4%) were thoroughly controlled. Meanwhile, the dysfunction of the central nervous system in 30 patients (83.3%) was aggravated, and 5 patients (13.9%) showed better improvement than before. Neuropsychological assessment revealed much improvement in the patients. CONCLUSIONS Modified hemispherectomy is advisable for patients with wide-range lesion of the half-brain associated with intractable epilepsy.
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Affiliation(s)
- Zhong-xu Yang
- Neurosurgical Department, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
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Abstract
PURPOSE OF REVIEW Recent advances in epilepsy surgery have developed a resurgence of interest in the use of surgical techniques for the treatment of intractable epilepsy. RECENT FINDINGS More invasive procedures such as hemispherectomy and multiple subpial transection have become more popular. Disconnective techniques such as multiple subpial transection have provided a surgical option for patients whose epileptogenic zone resides in the eloquent cortex. Alternatively, new minimally invasive neurostimulation therapies have been introduced to preserve maximal cerebral tissue. Radiosurgery has been recently utilized in the treatment of epilepsy with preliminary promising results. SUMMARY In this analysis, the authors will attempt to review the more recent surgical approaches and their indications for the treatment of medically intractable epilepsy. For patients with the epileptogenic zone in the noneloquent cortex, seizure focus resection remains the most reasonable approach to therapy.
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Affiliation(s)
- Aaron A Cohen-Gadol
- Department of Neurological Surgery, Yale University School of Medicine, New Haven, CT 06520-8082, USA
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Abstract
A 15-year-old girl with a 3-year history of Rasmussen syndrome (RS) underwent left functional hemispherectomy by central disconnection. Clinical seizures then ceased. Five months postoperatively, ictal EEG discharges were associated with focal hyperperfusion on SPECT within the disconnected hypoperfused left hemisphere, suggesting that the basic mechanisms of RS may continue, only to remit later. EEG and SPECT may complement studies of these in seizure-free surgically treated patients in whom clinical follow-up may be unrevealing.
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Affiliation(s)
- Pierre Thomas
- Service de Neurologie, Hôpital Pasteur, Nice, France.
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Kossoff EH, Vining EPG, Pyzik PL, Kriegler S, Min KS, Carson BS, Avellino AM, Freeman JM. The postoperative course and management of 106 hemidecortications. Pediatr Neurosurg 2002; 37:298-303. [PMID: 12422044 DOI: 10.1159/000066309] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
RATIONALE The excellent long-term outcome for most children undergoing hemispherectomy is well documented. However, the condition of these children in the immediate postoperative period is poorly described. The purpose of this study was to evaluate the short-term issues surrounding hemispherectomy and their management in a series of patients from our institution. METHODS 106 hemispherectomies were performed at our institution from 1975 to 2001 (102 hemidecortications). Medical records were retrospectively examined for information regarding immediate postoperative problems and care. RESULTS Three children died in the immediate perioperative period, while 3 others had significant postoperative morbidity. 82% of these children had postoperative fevers (temperature >38.5 degrees C). Of these children, 62% had lumbar punctures. Ten cases had positive CSF growth, of which 6 cases were felt to have actual meningitis. Patients with CSF growth had a significantly longer prior duration of steroid therapy and higher maximum temperature peaks. CSF pleocytosis and an ill clinical appearance neared significance for prediction of CSF growth. Shunting was performed in 19% of all children and was associated with CSF growth. CONCLUSIONS Postoperative fevers are common after hemidecortication, but meningitis is not. Children with CSF growth tended to appear more ill and have higher temperature spikes and CSF pleocytosis. Shunting was related to CSF growth.
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Affiliation(s)
- E H Kossoff
- Department of Neurology and Pediatrics, The Pediatric Epilepsy Center, Johns Hopkins Medicla Institutions, Baltimore, Md, USA.
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