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Cicutti SE, Cuello JF, Villamil F, Gromadzyn GP, Bartuluchi M. Surgical Anatomy and Technique of Peri-Insular Hemispherotomy in Pediatric Epilepsy. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01138. [PMID: 38651858 DOI: 10.1227/ons.0000000000001161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/28/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Hemispherotomy is a highly complex procedure that demands a steep learning curve. An incomplete brain disconnection often results in failure of seizure control. The purpose of this article was to present a step-by-step guide to the surgical anatomy of this procedure. It is composed of a 7-stage approach, enhancing access to and improving visualization of deep structures. METHODS A retrospective analysis of 39 pediatric patients with refractory epilepsy who underwent this technique was conducted. Engel scores were assessed 1 year postsurgery. Cadaveric dissections were performed to illustrate the procedure. RESULTS Between 2015 and 2022, 39 patients were surgically treated using the peri-insular technique. The technique involved 7 stages: patient positioning, operative approach, opercular resection, transventricular callosotomy, fronto-orbital disconnection, anterior temporal disconnection, and posterior temporal disconnection. Most of the patients (92.30%) were seizure-free (Engel class I) at 1 year postoperative, 5.13% were nearly seizure-free (Engel II), and 2.56% showed significant improvement (Engel III). Complications occurred in 8% of cases, including 1 infection, 2 cases of aseptic meningitis, and 1 non-shunt-requiring acute hydrocephalus. CONCLUSION The peri-insular hemispherotomy technique offers excellent seizure control with a low complication rate. Our visual documentation of surgical anatomy, complemented by detailed descriptions of surgical nuances, significantly contributes to a comprehensive understanding of this technique.
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Affiliation(s)
- Santiago E Cicutti
- Neurosurgery Department, Juan P. Garrahan Hospital, Buenos Aires, Argentina
| | - Javier F Cuello
- Neurosurgery Department, Hospital Provincial Petrona V. de Cordero, San Fernando, Buenos Aires, Argentina
| | | | - Guido P Gromadzyn
- Neurosurgery Department, Juan P. Garrahan Hospital, Buenos Aires, Argentina
| | - Marcelo Bartuluchi
- Neurosurgery Department, Juan P. Garrahan Hospital, Buenos Aires, Argentina
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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] [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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3
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Weil AG, Dimentberg E, Lewis E, Ibrahim GM, Kola O, Tseng CH, Chen JS, Lin KM, Cai LX, Liu QZ, Lin JL, Zhou WJ, Mathern GW, Smyth MD, O'Neill BR, Dudley R, Ragheb J, Bhatia S, Delev D, Ramantani G, Zentner J, Wang AC, Dorfer C, Feucht M, Czech T, Bollo RJ, Issabekov G, Zhu H, Connolly M, Steinbok P, Zhang JG, Zhang K, Hidalgo ET, Weiner HL, Wong-Kisiel L, Lapalme-Remis S, Tripathi M, Sarat Chandra P, Hader W, Wang FP, Yao Y, Champagne PO, Brunette-Clément T, Guo Q, Li SC, Budke M, Pérez-Jiménez MA, Raftopoulos C, Finet P, Michel P, Schaller K, Stienen MN, Baro V, Cantillano Malone C, Pociecha J, Chamorro N, Muro VL, von Lehe M, Vieker S, Oluigbo C, Gaillard WD, Al Khateeb M, Al Otaibi F, Krayenbühl N, Bolton J, Pearl PL, Fallah A. Development of an online calculator for the prediction of seizure freedom following pediatric hemispherectomy using the Hemispherectomy Outcome Prediction Scale (HOPS). Epilepsia 2024; 65:46-56. [PMID: 37347512 DOI: 10.1111/epi.17689] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 06/23/2023]
Abstract
OBJECTIVES Although hemispheric surgeries are among the most effective procedures for drug-resistant epilepsy (DRE) in the pediatric population, there is a large variability in seizure outcomes at the group level. A recently developed HOPS score provides individualized estimation of likelihood of seizure freedom to complement clinical judgement. The objective of this study was to develop a freely accessible online calculator that accurately predicts the probability of seizure freedom for any patient at 1-, 2-, and 5-years post-hemispherectomy. METHODS Retrospective data of all pediatric patients with DRE and seizure outcome data from the original Hemispherectomy Outcome Prediction Scale (HOPS) study were included. The primary outcome of interest was time-to-seizure recurrence. A multivariate Cox proportional-hazards regression model was developed to predict the likelihood of post-hemispheric surgery seizure freedom at three time points (1-, 2- and 5- years) based on a combination of variables identified by clinical judgment and inferential statistics predictive of the primary outcome. The final model from this study was encoded in a publicly accessible online calculator on the International Network for Epilepsy Surgery and Treatment (iNEST) website (https://hops-calculator.com/). RESULTS The selected variables for inclusion in the final model included the five original HOPS variables (age at seizure onset, etiologic substrate, seizure semiology, prior non-hemispheric resective surgery, and contralateral fluorodeoxyglucose-positron emission tomography [FDG-PET] hypometabolism) and three additional variables (age at surgery, history of infantile spasms, and magnetic resonance imaging [MRI] lesion). Predictors of shorter time-to-seizure recurrence included younger age at seizure onset, prior resective surgery, generalized seizure semiology, FDG-PET hypometabolism contralateral to the side of surgery, contralateral MRI lesion, non-lesional MRI, non-stroke etiologies, and a history of infantile spasms. The area under the curve (AUC) of the final model was 73.0%. SIGNIFICANCE Online calculators are useful, cost-free tools that can assist physicians in risk estimation and inform joint decision-making processes with patients and families, potentially leading to greater satisfaction. Although the HOPS data was validated in the original analysis, the authors encourage external validation of this new calculator.
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Affiliation(s)
- Alexander G Weil
- Department of Neurosurgery, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Evan Dimentberg
- Department of Neurosurgery, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Evan Lewis
- Neurology Center of Toronto by Numinus, Toronto, Ontario, Canada
| | - George M Ibrahim
- Division of Pediatric Neurosurgery, Sick Kids Toronto, University of Toronto, Toronto, Ontorio, Canada
| | - Olivia Kola
- Department of Neurosurgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Chi-Hong Tseng
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Jia-Shu Chen
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Kao-Min Lin
- Department of Functional Neurosurgery, Xiamen Humanity Hospital, Xiamen, China
| | - Li-Xin Cai
- Department of Pediatric Epilepsy Center, Peking University First Hospital, Beijing, China
| | - Qing-Zhu Liu
- Department of Pediatric Epilepsy Center, Peking University First Hospital, Beijing, China
| | - Jiu-Luan Lin
- Department of Epilepsy Center, Yuquan Hospital, Tsinghua University, Beijing, China
| | - Wen-Jing Zhou
- Department of Epilepsy Center, Yuquan Hospital, Tsinghua University, Beijing, China
| | - Gary W Mathern
- Department of Neurosurgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Matthew D Smyth
- Department of Neurological Surgery, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Brent R O'Neill
- Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Roy Dudley
- Division of Neurosurgery, Department of Pediatric Surgery, McGill University Health Centre, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - John Ragheb
- Department of Neurosurgery, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Sanjiv Bhatia
- Department of Neurosurgery, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Daniel Delev
- Department of Neurosurgery, University Medical Center Freiburg & Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Georgia Ramantani
- Department of Neurosurgery, University Medical Center Freiburg & Medical Faculty, University of Freiburg, Freiburg, Germany
- Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland
| | - Josef Zentner
- Department of Neurosurgery, University Medical Center Freiburg & Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Anthony C Wang
- Department of Neurosurgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Christian Dorfer
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Martha Feucht
- Department of Pediatrics, Medical University Vienna and ERN EpiCare, Vienna, Austria
| | - Thomas Czech
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Robert J Bollo
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Galymzhan Issabekov
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongwei Zhu
- Division of Neurosurgery, Department of Surgery, BC Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Mary Connolly
- Division of Neurosurgery, Department of Surgery, BC Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Paul Steinbok
- Division of Neurosurgery, Department of Surgery, BC Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Jian-Guo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kai Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Eveline Teresa Hidalgo
- Division of Pediatric Neurosurgery, Department of Surgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, New York, USA
| | - Howard L Weiner
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Lily Wong-Kisiel
- Division of Child Neurology and Epilepsy, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Samuel Lapalme-Remis
- Division of Neurology, Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Manjari Tripathi
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Poodipedi Sarat Chandra
- Department of Neurosurgery (COE for Epilepsy & Magnetoencephalography), All India Institute of Medical Sciences and National Brain Research Center, New Delhi, India
| | - Walter Hader
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Feng-Peng Wang
- Department of Functional Neurosurgery, Xiamen Humanity Hospital, Xiamen, China
| | - Yi Yao
- Department of Neurosurgery, Guangdong Shenzhen Children Hospital, Shenzhen, Guangdong, China
| | - Pierre Olivier Champagne
- Department of Neurosurgery, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Tristan Brunette-Clément
- Department of Neurosurgery, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Qiang Guo
- Department of Neurosurgery, Guangdong Sanjiu Brain Hospital, Guangzhou Shi, Guangdong Sheng, China
| | - Shao-Chun Li
- Department of Neurosurgery, Guangdong Sanjiu Brain Hospital, Guangzhou Shi, Guangdong Sheng, China
| | - Marcelo Budke
- Department of Neurosurgery, Niño Jesus University Children's Hospital, Madrid, Spain
| | | | - Christian Raftopoulos
- Department of Neurophysiology, Niño Jesus University Children's Hospital, Madrid, Spain
| | - Patrice Finet
- Department of Neurosurgery, Brussels Saint-Luc University Hospital, Brussels, Belgium
| | - Pauline Michel
- Department of Neurosurgery, Brussels Saint-Luc University Hospital, Brussels, Belgium
| | - Karl Schaller
- Department of Clinical Neurosciences, Division of Neurosurgery, Hospitaux Universitaire Genève, Genève, Switzerland
| | - Martin N Stienen
- Department of Neurosurgery, Kantonsspital St.Gallen, Medical School of St.Gallen, St.Gallen, Switzerland
| | - Valentina Baro
- Pediatric and Functional Neurosurgery, Department of Neurosciences, University of Padova, Padova, Italy
| | - Christian Cantillano Malone
- Department of Neurosurgery, Pontificia Universidad Catolica de Chile, Hospital Sotero del Rio, Santiago, Región Metropolitana, Chile
| | - Juan Pociecha
- Epilepsy Department, Neurologia Neurofisiologia Servicio de Epilepsia FLENI, Buenos Aires, Argentina
| | - Noelia Chamorro
- Epilepsy Department, Neurologia Neurofisiologia Servicio de Epilepsia FLENI, Buenos Aires, Argentina
| | - Valeria L Muro
- Epilepsy Department, Neurologia Neurofisiologia Servicio de Epilepsia FLENI, Buenos Aires, Argentina
| | - Marec von Lehe
- Department of Neurosurgery, Brandenburg Medical School, University Hospital Ruppin-Brandenburg, Neuruppin, Germany
| | - Silvia Vieker
- Department of Neurosurgery, Neurosurgical Clinic, Bochum, Germany
| | - Chima Oluigbo
- Department of Neurosurgery, Children's National Medical Center, Washington, DC, USA
| | - William D Gaillard
- Divisions of Child Neurology and Epilepsy and Neurophysiology, Children's National Hospital, Washington, DC, USA
| | - Mashael Al Khateeb
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre, Alfaisal University, Riyadh, Saudi Arabia
| | - Faisal Al Otaibi
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre, Alfaisal University, Riyadh, Saudi Arabia
| | - Niklaus Krayenbühl
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Jeffrey Bolton
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Phillip L Pearl
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
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Karagianni MD, Brotis AG, Tasiou A, Delev D, von Lehe M, Schijns OE, Fountas KN. Hemispherotomy Revised: A complication overview and a systematic review meta-analysis. BRAIN & SPINE 2023; 3:101766. [PMID: 38021002 PMCID: PMC10668062 DOI: 10.1016/j.bas.2023.101766] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/05/2023] [Accepted: 06/12/2023] [Indexed: 12/01/2023]
Abstract
Introduction Hemispherectomy/hemispherotomy has been employed in the management of catastrophic epilepsy. However, initial reports on the associated mortality and morbidity raised several concerns regarding the technique's safety. Their actual, current incidence needs to be systematically examined to redefine hemispherotomy's exact role. Research question Our current study examined their incidence and evaluated the association of the various hemispherotomy surgical techniques with the reported complications. Material & methods A PRISMA-compliant systematic review and meta-analysis was performed. We searched PubMed, Scopus, and Web of Science until December 2022. Fixed- and random-effects models were employed. Egger's regression test was used for estimating the publication bias, while subgroup analysis was utilized for defining the role of the different hemispherotomy techniques. Results We retrieved a total of 37 studies. The overall procedure mortality was 5%, with a reported mortality of 7% for hemispherectomy and 3% for hemispherotomy. The reported mortality has decreased over the last 30 years from 32% to 2%. Among the observed post-operative complications aseptic meningitis and/or fever occurred in 33%. Hydrocephalus requiring a shunt insertion occurred in 16%. Hematoma evacuation was necessary in 8%, while subgaleal effusion in another 8%. Infections occurred in 11%. A novel post-operative cranial nerve deficit occurred in 11%, while blood transfusion was necessary in 28% of the cases. Discussion and conclusion Our current analysis demonstrated that the evolution from hemispherectomy to hemispherotomy along with neuroanesthesia advances, had a tremendous impact on the associated mortality and morbidity. Hemispherotomy constitutes a safe surgical procedure in the management of catastrophic epilepsies.
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Affiliation(s)
- Maria D. Karagianni
- Department of Neurosurgery, General University Hospital of Larissa, Mezourlo, Larissa, 41110, Greece
| | - Alexandros G. Brotis
- Department of Neurosurgery, General University Hospital of Larissa, Mezourlo, Larissa, 41110, Greece
| | - Anastasia Tasiou
- Department of Neurosurgery, General University Hospital of Larissa, Mezourlo, Larissa, 41110, Greece
| | - Daniel Delev
- Department of Neurosurgery, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
- Neurosurgical Artificial Intelligence Laboratory Aachen (NAILA), RWTH Aachen University Hospital, Aachen, Germany
- Center for Integrated Oncology, Universities Aachen, Bonn, Cologne, Duesseldorf (CIO ABCD), Germany
| | - Marec von Lehe
- Department of Neurosurgery, Brandenburg Medical School, University Hospital Ruppin Brandenburg, Fehrbelliner Str. 38, Neuruppin, Germany
| | - Olaf E.M.G. Schijns
- Department of Neurosurgery, Maastricht University Medical Center, Maatricht, the Netherlands
- Academic Center for Epileptology, Maastricht, Kempenhaeghe, the Netherlands
- School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Konstantinos N. Fountas
- Department of Neurosurgery, General University Hospital of Larissa, Mezourlo, Larissa, 41110, Greece
- Faculty of Medicine, University of Thessaly, Biopolis, Larissa, 41110, Greece
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Almojuela A, Xu Q, O'Carroll A, Ritchie L, Serletis D. Paediatric epilepsy surgery: Techniques and outcomes. J Paediatr Child Health 2022; 58:1952-1957. [PMID: 36197046 DOI: 10.1111/jpc.16236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 07/23/2022] [Accepted: 09/21/2022] [Indexed: 11/28/2022]
Abstract
Epilepsy is a neurological condition characterised by recurrent and persistent seizures. For paediatric patients, achieving early seizure freedom can have positive impacts on cognition, development, social integration and mental health, leading to improved quality of life. In general, one third of patients with epilepsy are refractory to medication; for these patients, epilepsy surgery may offer the only chance for improved seizure control. Epilepsy surgery as a therapeutic intervention has become increasingly accepted in the past few decades, with more diverse options available (including neuromodulatory and minimally invasive techniques). In this context, we discuss here the pre-operative workup for paediatric patients with medically refractory epilepsy and provide an updated review on current and emerging surgical therapies for this condition. We also discuss the clinical, neuropsychological, quality of life and economic impacts of epilepsy surgery.
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Affiliation(s)
- Alysa Almojuela
- Section of Neurosurgery, Department of Surgery, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Qi Xu
- Section of Pediatric Neurology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada
| | - Aoife O'Carroll
- Section of Pediatric Neurology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada
| | - Lesley Ritchie
- Department of Clinical Health Psychology, University of Manitoba, Winnipeg, Canada
| | - Demitre Serletis
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, United States.,Cleveland Clinic Epilepsy Center, Neurological Institute, Cleveland, Ohio, United States
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Ordóñez-Rubiano EG, Figueredo LF, Gamboa-Oñate CA, Kehayov I, Rengifo-Hipus JA, Romero-Castillo IJ, Rodríguez-Medina AP, Patiño-Gomez JG, Zorro O. The reverse question mark and L.G. Kempe incisions for decompressive craniectomy: A case series and narrative review of the literature. Surg Neurol Int 2022; 13:295. [PMID: 35855131 PMCID: PMC9282772 DOI: 10.25259/sni_59_2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 06/22/2022] [Indexed: 11/09/2022] Open
Abstract
Background: Decompressive craniectomy (DC) is a lifesaving procedure, relieving intracranial hypertension. Conventionally, DCs are performed by a reverse question mark (RQM) incision. However, the use of the L. G. Kempe’s (LGK) incision has increased in the last decade. We aim to describe the surgical nuances of the LGK and the standard RQM incisions to treat patients with severe traumatic brain injury (TBI), intracranial hemorrhage (ICH), empyema, and malignant ischemic stroke. Furthermore, to describe, surgical limitations, wound healing, and neurological outcomes related to each technique. Methods: To describe a prospective acquired, case series including patients who underwent a DC using either an RQM or an LGK incision in our institution between 2019 and 2020. Results: A total of 27 patients underwent DC. Of those, ten patients were enrolled. The mean age was 42.1 years (26–71), and 60% were male. Five patients underwent DC using a large RQM incision; three had severe TBI, one ICH, and one ischemic stroke. The other five patients underwent DC using an LGK incision (one ICH, one subdural empyema, and one ischemic stroke). About 50% of patients presented severe headaches associated with vomiting, and six presented altered mental status (drowsy or stuporous). Motor deficits were present in four cases. In patients with ischemic or hemorrhagic stroke, symptoms were directly related to the stroke location. Hospital stays varied between 13 and 22 days. No readmissions were recorded, and no fatal outcome was documented during the follow-up. Conclusion: The utility of the LGK incision is comparable with the classic RQM incision to treat acute brain injuries, where an urgent decompression must be performed. Some of these cases include malignant ischemic strokes, ICH, and empyema. No differences were observed between both techniques in terms of prevention of scalp necrosis and general cosmetic outcomes.
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Affiliation(s)
- Edgar G. Ordóñez-Rubiano
- Department of Neurosurgery, Hospital de San José - Fundación Universitaria de Ciencias de la Salud, Bogota, Colombia,
| | | | - Carlos A. Gamboa-Oñate
- Department of Neurosurgery, Hospital de San José - Fundación Universitaria de Ciencias de la Salud, Bogota, Colombia,
| | - Ivo Kehayov
- Department of Neurosurgery, Faculty of Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria,
| | - Jorge A. Rengifo-Hipus
- Department of Neurosurgery, School of Medicine, Hospital de San José - Fundación Universitaria de Ciencias de la Salud, Bogota, Colombia
| | - Ingrid J. Romero-Castillo
- Department of Neurosurgery, School of Medicine, Hospital de San José - Fundación Universitaria de Ciencias de la Salud, Bogota, Colombia
| | - Angie P. Rodríguez-Medina
- Department of Neurosurgery, School of Medicine, Hospital de San José - Fundación Universitaria de Ciencias de la Salud, Bogota, Colombia
| | - Javier G. Patiño-Gomez
- Department of Neurosurgery, Hospital de San José - Fundación Universitaria de Ciencias de la Salud, Bogota, Colombia,
| | - Oscar Zorro
- Department of Neurosurgery, Hospital de San José - Fundación Universitaria de Ciencias de la Salud, Bogota, Colombia,
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7
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Phillips HW, Maniquis CA, Chen JS, Duby SL, Nagahama Y, Bergeron D, Ibrahim GM, Weil AG, Fallah A. Midline Brain Shift After Hemispheric Surgery: Natural History, Clinical Significance, and Association With Cerebrospinal Fluid Diversion. Oper Neurosurg (Hagerstown) 2022; 22:269-276. [PMID: 35315814 PMCID: PMC9514754 DOI: 10.1227/ons.0000000000000134] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/28/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hemispherectomy and its modern variants are effective surgical treatments for medically intractable unihemispheric epilepsy. Although some complications such as posthemispherectomy hydrocephalus are well documented, midline brain shift (MLBS) after hemispheric surgery has only been described anecdotally and never formally studied. OBJECTIVE To assess the natural history and clinical relevance of MLBS and determine whether cerebrospinal fluid (CSF) shunting of the ipsilateral surgical cavity exacerbates MLBS posthemispheric surgery. METHODS A retrospective review of consecutive pediatric patients who underwent hemispheric surgery for intractable epilepsy and at least 6 months of follow-up at UCLA between 1994 and 2018 was performed. Patients were grouped by MLBS severity, shunt placement, valve type, and valve opening pressure (VOP). MLBS was evaluated using the paired samples t-test and analysis of covariance adjusting for follow-up time and baseline postoperative MLBS. RESULTS Seventy patients were analyzed, of which 23 (33%) required CSF shunt placement in the ipsilateral surgical cavity for posthemispherectomy hydrocephalus. MLBS increased between first and last follow-up for nonshunted (5.3 ± 4.9-9.7 ± 6.6 mm, P < .001) and shunted (6.6 ± 3.5-16.3 ± 9.4 mm, P < .001) patients. MLBS progression was greater in shunted patients (P = .001). Shunts with higher VOPs did not increase MLBS relative to nonshunted patients (P = .834), whereas MLBS increased with lower VOPs (P = .001). Severe MLBS was associated with debilitating headaches (P = .048). CONCLUSION Patients undergoing hemispheric surgery often develop postoperative MLBS, ie, exacerbated by CSF shunting of the ipsilateral surgical cavity, specifically when using lower VOP settings. MLBS exacerbation may be related to overshunting. Severe MLBS is associated with debilitating headaches.
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Affiliation(s)
- H. Westley Phillips
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA;
| | - Cassia A.B. Maniquis
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA;
| | - Jia-Shu Chen
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA;
| | - Shannon L. Duby
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA;
| | - Yasunori Nagahama
- Department of Neurosurgery, Rutgers—Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA;
| | - David Bergeron
- Division of Neurosurgery, University of Montreal, Montreal, Canada;
| | - George M. Ibrahim
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada;
| | - Alexander G. Weil
- Division of Neurosurgery, Ste. Justine Hospital, University of Montreal, Montreal, Canada;
| | - Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA;
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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8
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Weil AG, Lewis EC, Ibrahim GM, Kola O, Tseng CH, Zhou X, Lin KM, Cai LX, Liu QZ, Lin JL, Zhou WJ, Mathern GW, Smyth MD, O'Neill BR, Dudley R, Ragheb J, Bhatia S, Delev D, Ramantani G, Zentner J, Ojemann J, Wang AC, Dorfer C, Feucht M, Czech T, Bollo RJ, Issabekov G, Zhu H, Connelly M, Steinbok P, Zhang JG, Zhang K, Hidalgo ET, Weiner HL, Wong-Kisiel L, Lapalme-Remis S, Tripathi M, Sarat Chandra P, Hader W, Wang FP, Yao Y, Olivier Champagne P, Guo Q, Li SC, Budke M, Pérez-Jiménez MA, Raftapoulos C, Finet P, Michel P, Schaller K, Stienen MN, Baro V, Cantillano Malone C, Pociecha J, Chamorro N, Muro VL, von Lehe M, Vieker S, Oluigbo C, Gaillard WD, Al Khateeb M, Al Otaibi F, Krayenbühl N, Bolton J, Pearl PL, Fallah A. Hemispherectomy Outcome Prediction Scale: Development and validation of a seizure freedom prediction tool. Epilepsia 2021; 62:1064-1073. [PMID: 33713438 DOI: 10.1111/epi.16861] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To develop and validate a model to predict seizure freedom in children undergoing cerebral hemispheric surgery for the treatment of drug-resistant epilepsy. METHODS We analyzed 1267 hemispheric surgeries performed in pediatric participants across 32 centers and 12 countries to identify predictors of seizure freedom at 3 months after surgery. A multivariate logistic regression model was developed based on 70% of the dataset (training set) and validated on 30% of the dataset (validation set). Missing data were handled using multiple imputation techniques. RESULTS Overall, 817 of 1237 (66%) hemispheric surgeries led to seizure freedom (median follow-up = 24 months), and 1050 of 1237 (85%) were seizure-free at 12 months after surgery. A simple regression model containing age at seizure onset, presence of generalized seizure semiology, presence of contralateral 18-fluoro-2-deoxyglucose-positron emission tomography hypometabolism, etiologic substrate, and previous nonhemispheric resective surgery is predictive of seizure freedom (area under the curve = .72). A Hemispheric Surgery Outcome Prediction Scale (HOPS) score was devised that can be used to predict seizure freedom. SIGNIFICANCE Children most likely to benefit from hemispheric surgery can be selected and counseled through the implementation of a scale derived from a multiple regression model. Importantly, children who are unlikely to experience seizure control can be spared from the complications and deficits associated with this surgery. The HOPS score is likely to help physicians in clinical decision-making.
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Affiliation(s)
- Alexander G Weil
- Department of Neurosurgery, Saint Justine University Hospital Centre, Montreal, Quebec, Canada
| | - Evan C Lewis
- Neurology Centre of Toronto, Toronto, Ontario, Canada
| | - George M Ibrahim
- Division of Pediatric Neurosurgery, Sick Kids Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Olivia Kola
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Chi-Hong Tseng
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Xinkai Zhou
- Department of Biostatistics, Fielding School of Public Health at, University of California, Los Angeles, Los Angeles, CA, USA
| | - Kao-Min Lin
- Department of Functional Neurosurgery, Xiamen Humanity Hospital, Xiamen, China
| | - Li-Xin Cai
- Pediatric Epilepsy Center, Peking University First Hospital, Beijing, China
| | - Qing-Zhu Liu
- Pediatric Epilepsy Center, Peking University First Hospital, Beijing, China
| | - Jiu-Luan Lin
- Department of Epilepsy Center, Yuquan Hospital, Tsinghua University, Beijing, China
| | - Wen-Jing Zhou
- Department of Epilepsy Center, Yuquan Hospital, Tsinghua University, Beijing, China
| | - Gary W Mathern
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Matthew D Smyth
- Department of Neurological Surgery, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Brent R O'Neill
- Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Roy Dudley
- Division of Neurosurgery, Department of Pediatric Surgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - John Ragheb
- Department of Neurosurgery, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Sanjiv Bhatia
- Department of Neurosurgery, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Daniel Delev
- Department of Neurosurgery, University Medical Center Freiburg and Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Georgia Ramantani
- Department of Neurosurgery, University Medical Center Freiburg and Medical Faculty, University of Freiburg, Freiburg, Germany.,Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland
| | - Josef Zentner
- Department of Neurosurgery, University Medical Center Freiburg and Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Jeffrey Ojemann
- Department of Neurosurgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Anthony C Wang
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Christian Dorfer
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Martha Feucht
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Thomas Czech
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Robert J Bollo
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Galymzhan Issabekov
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongwei Zhu
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Mary Connelly
- Department of Pediatrics, BC Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Paul Steinbok
- Department of Pediatrics, BC Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Jian-Guo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kai Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Eveline Teresa Hidalgo
- Division of Pediatric Neurosurgery, Department of Surgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, New York, USA
| | - Howard L Weiner
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Lily Wong-Kisiel
- Division of Child Neurology and Epilepsy, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Samuel Lapalme-Remis
- Division of Neurology, Department of Medicine, University of Montreal Hospital Centre, Montreal, Quebec, Canada
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences and National Brain Research Center, New Delhi, India
| | - Poodipedi Sarat Chandra
- Department of Neurosurgery (Center of Excellence for Epilepsy & Magnetoencephalography), All India Institute of Medical Sciences and National Brain Research Center, New Delhi, India
| | - Walter Hader
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Feng-Peng Wang
- Department of Functional Neurosurgery, Xiamen Humanity Hospital, Xiamen, China
| | - Yi Yao
- Division of Epilepsy Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | | | - Qiang Guo
- Department of Neurosurgery, Guangdong Sanjiu Brain Hospital, Guangzhou Shi, China
| | - Shao-Chun Li
- Department of Neurosurgery, Guangdong Sanjiu Brain Hospital, Guangzhou Shi, China
| | - Marcelo Budke
- Department of Neurosurgery, Niño Jesus University Children's Hospital, Madrid, Spain
| | | | - Christian Raftapoulos
- Department of Neurosurgery, Brussels Saint-Luc University Hospital, Brussels, Belgium
| | - Patrice Finet
- Department of Neurosurgery, Brussels Saint-Luc University Hospital, Brussels, Belgium
| | - Pauline Michel
- Department of Neurosurgery, Brussels Saint-Luc University Hospital, Brussels, Belgium
| | - Karl Schaller
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Martin N Stienen
- Department of Neurosurgery, Zurich University Hospital and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Valentina Baro
- Academic Neurosurgery, Department of Neurosciences, University of Padua, Padua, Italy
| | - Christian Cantillano Malone
- Department of Neurosurgery, Pontifical Catholic University of Chile, Sotero del Rio Hospital, Santiago, Chile
| | - Juan Pociecha
- Epilepsy Department, Fleni Epilepsy Neurology and Neurophysiology Service, Buenos Aires, Argentina
| | - Noelia Chamorro
- Epilepsy Department, Fleni Epilepsy Neurology and Neurophysiology Service, Buenos Aires, Argentina
| | - Valeria L Muro
- Epilepsy Department, Fleni Epilepsy Neurology and Neurophysiology Service, Buenos Aires, Argentina
| | - Marec von Lehe
- Department of Neurosurgery, University Hospital Bochum, Bochum, Germany.,Department of Neurosurgery, Brandenburg Medical School, Neuruppin, Germany
| | - Silvia Vieker
- Department of Neurosurgery, University Hospital Bochum, Bochum, Germany.,Department of Neurosurgery, Brandenburg Medical School, Neuruppin, Germany
| | - Chima Oluigbo
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA
| | - William D Gaillard
- Divisions of Child Neurology and Epilepsy and Neurophysiology, Children's National Medical Center, Washington, District of Columbia, USA
| | - Mashael Al Khateeb
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Alfaisal University, Riyadh, Saudi Arabia
| | - Faisal Al Otaibi
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Alfaisal University, Riyadh, Saudi Arabia
| | - Niklaus Krayenbühl
- Department of Neurosurgery, Zurich University Hospital and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Jeffrey Bolton
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Phillip L Pearl
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
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9
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Li YH, Li DS, Wang MQ, Zhao K, Gao BL. Modified hemispherectomy for infantile hemiparesis and epilepsy. Transl Neurosci 2020; 11:380-390. [PMID: 33335778 PMCID: PMC7718624 DOI: 10.1515/tnsci-2020-0145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/17/2020] [Accepted: 09/28/2020] [Indexed: 11/15/2022] Open
Abstract
Objective To investigate the effect and medical imaging of modified hemispherectomy on patients with infantile hemiparesis and medically refractory epilepsy. Patients and methods Forty-three patients with infantile hemiparesis and refractory epilepsy who underwent hemispherectomy were enrolled. The treatment effect and medical imaging were analyzed. Results Anatomical hemispherectomy was successfully performed in all patients (100%). In all patients, the muscular tension decreased and the contracted limbs relaxed. In the pathological examination of the resected brain tissue, secondary cicatricial gyri with concomitant cortical dysplasia was present in 36 cases and polycerebellar gyrus malformation and porencephalia in the other 7 cases. Followed up for 7-15 years (mean 11.3), all patients were alive without a long-term sequela. Epilepsy was satisfactorily controlled, with complete seizure relief in 39 cases (91%) classified as Engel I and basic control in the other 4 (9%) defined as Engel II. The posthemispherectomy medical imaging demonstrated that the intracranial space on the operative side shrank, and the healthy cerebral hemisphere shifted markedly toward the hemispherectomy side, with expanded lateral ventricle on the healthy side and thickened skull and enlarged frontal sinus on the operative side. After 4-5 years, the intracranial space on the operative side disappeared in 75% of the patients, demonstrating enlarged cerebral peduncle on the healthy side. Conclusion Further modified hemispherectomy in patients with infantile hemiparesis and medically refractory epilepsy demonstrated markedly ameliorated effects on epilepsy control and the prevention of superficial cerebral hemosiderosis in the long-term follow-up.
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Affiliation(s)
- Yu-Hui Li
- Department of Neurosurgery, Shijiazhuang People's Hospital, Xian Jiaotong University, 365 South Jianhua Street, Shijiazhuang, Hebei Province 050030, China
| | - Dong-Sheng Li
- Department of Neurosurgery, Shijiazhuang People's Hospital, Xian Jiaotong University, 365 South Jianhua Street, Shijiazhuang, Hebei Province 050030, China
| | - Mei-Qing Wang
- Department of Neurosurgery, Shijiazhuang People's Hospital, Xian Jiaotong University, 365 South Jianhua Street, Shijiazhuang, Hebei Province 050030, China
| | - Kai Zhao
- Department of Neurosurgery, Shijiazhuang People's Hospital, Xian Jiaotong University, 365 South Jianhua Street, Shijiazhuang, Hebei Province 050030, China
| | - Bu-Lang Gao
- Department of Neurosurgery, Shijiazhuang People's Hospital, Xian Jiaotong University, 365 South Jianhua Street, Shijiazhuang, Hebei Province 050030, China
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10
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Abstract
Hemispherectomy is a unique epilepsy surgery procedure that has undergone significant modification and evolution since Dandy's early description. This procedure is mainly indicated to treat early childhood and infancy medically intractable epilepsy. Various epileptic syndromes have been treated with this procedure, including hemimegalencephaly (HME), Rasmussen's encephalitis, Sturge-Weber syndrome (SWS), perinatal stroke, and hemispheric cortical dysplasia. In terms of seizure reduction, hemispherectomy remains one of the most successful epilepsy surgery procedures. The modification of this procedure over many years has resulted in lower mortality and morbidity rates. HME might increase morbidity and lower the success rate. Future studies should identify the predictors of outcomes based on the pathology and the type of hemispherectomy. Here, based on a literature review, we discuss the evolution of hemispherectomy techniques and their outcomes and complications.
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11
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Weil AG, Fallah A, Wang S, Ibrahim GM, Elkaim LM, Jayakar P, Miller I, Bhatia S, Niazi TN, Ragheb J. Functional hemispherectomy: can preoperative imaging predict outcome? J Neurosurg Pediatr 2020; 25:567-573. [PMID: 33988937 DOI: 10.3171/2019.12.peds19370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although hemispherectomy is an effective treatment for children with intractable hemispheric epilepsy syndromes, as many as 40% of patients eventually develop seizure recurrence. The causes of seizure recurrence in these patients are incompletely understood. The authors sought to evaluate the efficacy of hemispherectomy at their center and determine whether contralateral MRI abnormalities can predict seizure recurrence. METHODS A retrospective review of consecutive hemispherectomies performed at Miami Children's Hospital between January 2000 and June 2014 was performed. Time-to-event analysis was performed. The "event" was defined as any seizures following resective epilepsy surgery (not including seizures in the first postoperative week and auras). Several preoperative variables were analyzed to determine their suitability to predict seizure recurrence following surgery. RESULTS Sixty-nine patients (44 boys) with a mean age of 8.2 ± 5.9 years (range 0.1-20.8 years) underwent 72 hemispherectomies; 67 of these were functional hemispherectomies, while another 5 were completion of a previous functional hemispherectomy (2 completions of functional hemispherectomies, 3 anatomical hemispherectomies). The duration of epilepsy was 5.8 ± 5.5 years with 66 cases (91.7%) having daily seizures. Etiology included stroke (n = 28), malformation of cortical development (n = 11), hemimegalencephaly (n = 11), encephalitis (n = 13), and other (n = 7). Engel class I outcome was achieved in 59 (86%) and 56 (81%) patients at 1 and 2 years of follow-up, respectively. The mean time to seizure recurrence was 33.5 ± 31.1 months. In univariate analyses, the absence of contralateral abnormalities on MRI (HR 4.09, 95% CI 1.41-11.89, p = 0.009) was associated with a longer duration of seizure freedom. The presence of contralateral MRI abnormalities was associated with contralateral ictal seizures on preoperative scalp EEG (p = 0.002). Fifteen patients experienced 20 complications (20/72, 27.8%), including the development of hydrocephalus necessitating CSF diversion in 9 cases (13%), hygroma in 1, hemispheric edema in 1, aseptic meningitis in 2, postoperative hemorrhage in 2, infection in 2, ischemic stroke in 2, and blood transfusion-contracted hepatitis C in 1 case. CONCLUSIONS Patients with bihemispheric abnormalities, as evidenced by contralateral MRI abnormalities, have a higher risk of earlier seizure recurrence following functional hemispherectomy. ABBREVIATIONS EVD = external ventricular drain; MCD = malformation of cortical development; MEG = magnetoencephalography; PVWM = periventricular white matter; TTE = time-to-event; VPS = ventriculoperitoneal shunt.
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Affiliation(s)
- Alexander G Weil
- 1Division of Neurosurgery, Sainte Justine Hospital, Montreal, Quebec, Canada
| | - Aria Fallah
- 2Department of Neurosurgery, UCLA Mattel Children's Hospital, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Shelly Wang
- 3Division of Pediatric Neurosurgery, Department of Neurosurgery, Brain Institute, Miami Children's Hospital, Miami, Florida
| | - George M Ibrahim
- 4Division of Neurosurgery, The Hospital for Sick Children, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada; and
| | - Lior M Elkaim
- 5Department of Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Prasanna Jayakar
- 3Division of Pediatric Neurosurgery, Department of Neurosurgery, Brain Institute, Miami Children's Hospital, Miami, Florida
| | - Ian Miller
- 3Division of Pediatric Neurosurgery, Department of Neurosurgery, Brain Institute, Miami Children's Hospital, Miami, Florida
| | - Sanjiv Bhatia
- 3Division of Pediatric Neurosurgery, Department of Neurosurgery, Brain Institute, Miami Children's Hospital, Miami, Florida
| | - Toba N Niazi
- 3Division of Pediatric Neurosurgery, Department of Neurosurgery, Brain Institute, Miami Children's Hospital, Miami, Florida
| | - John Ragheb
- 3Division of Pediatric Neurosurgery, Department of Neurosurgery, Brain Institute, Miami Children's Hospital, Miami, Florida
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12
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Volpon Santos M, Teixeira TL, Ioriatti ES, Thome U, Paula de Andrade Hamad A, Machado HR. Risk factors and results of hemispherotomy reoperations in children. Neurosurg Focus 2020; 48:E5. [DOI: 10.3171/2020.1.focus19944] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 01/27/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe goal of this study was to perform an analysis of a single-center experience with hemispherotomy reoperations for refractory hemispheric pediatric epilepsy due to persistence of seizures after initial surgery. The authors also identify possible anatomical and neurophysiological reasons for hemispherotomy failure, as well as risk factors and surgical options for this subgroup of patients.METHODSA review was performed of the medical records in 18 consecutive cases in which candidates for redo hemispherotomy were treated between 2003 and 2018 at the authors’ epilepsy surgery center. Fourteen patients underwent reoperation due to seizure recurrence and were studied herein, whereas in 3 the initial surgical procedure was stopped because of uncontrollable bleeding, and the remaining patient refused to undergo a reoperation in spite of seizure recurrence and went on to have a vagus nerve stimulation device placed.RESULTSAmong the 14 patients whose seizures recurred and in whom reoperations were done, the etiology of epilepsy consisted of 7 cases with malformations of cortical development (50%), 5 cases of Rasmussen encephalitis (35.8%), 1 case of porencephaly (7.1%), and 1 case of Sturge-Weber syndrome (7.1%). Eleven patients had radiological evidence of incomplete disconnection. After reoperation, 6 patients were Engel class IA, 1 was Engel II, 5 were Engel III, and 2 were Engel IV, within a mean follow-up of 48.4 months.CONCLUSIONSPatients with malformations of cortical development have a higher risk of seizure recurrence, and these malformations comprised the main etiology in the reoperation series. Failure of an initial hemispherotomy usually occurs due to incomplete disconnection and needs to be extensively assessed. Outcomes of reoperation are most often favorable, with acceptable complication rates.
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Affiliation(s)
- Marcelo Volpon Santos
- 1Division of Pediatric Neurosurgery, Ribeirao Preto Medical School; and
- 2Center for Pediatric Epilepsy Surgery, University Hospital, Ribeirao Preto Medical School, University of São Paulo, Brazil
| | | | | | - Ursula Thome
- 2Center for Pediatric Epilepsy Surgery, University Hospital, Ribeirao Preto Medical School, University of São Paulo, Brazil
| | - Ana Paula de Andrade Hamad
- 2Center for Pediatric Epilepsy Surgery, University Hospital, Ribeirao Preto Medical School, University of São Paulo, Brazil
| | - Helio Rubens Machado
- 1Division of Pediatric Neurosurgery, Ribeirao Preto Medical School; and
- 2Center for Pediatric Epilepsy Surgery, University Hospital, Ribeirao Preto Medical School, University of São Paulo, Brazil
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13
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Pindrik J, Hoang N, Smith L, Halverson M, Wojnaroski M, McNally K, Gedela S, Ostendorf AP. Preoperative evaluation and surgical management of infants and toddlers with drug-resistant epilepsy. Neurosurg Focus 2019; 45:E3. [PMID: 30173613 DOI: 10.3171/2018.7.focus18220] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Despite perioperative risks, epilepsy surgery represents a legitimate curative or palliative treatment approach for children with drug-resistant epilepsy (DRE). Several factors characterizing infants and toddlers with DRE create unique challenges regarding optimal evaluation and management. Epilepsy surgery within children < 3 years of age has received moderate attention in the literature, including mainly case series and retrospective studies. This article presents a systematic literature review and explores multidisciplinary considerations for the preoperative evaluation and surgical management of infants and toddlers with DRE. METHODS The study team conducted a systematic literature review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, targeting studies that investigated children < 3 years of age undergoing surgical treatment of DRE. Using the PubMed database, investigators selected peer-reviewed articles that reported seizure outcomes with or without developmental outcomes and/or perioperative complications. Studies were eliminated based on the following exclusion criteria: sample size < 5 patients; and inclusion of patients > 3 years of age, when demographic and outcomes data could not be separated from the cohort of patients < 3 years of age. RESULTS The study team identified 20 studies published between January 1990 and May 2017 that satisfied eligibility criteria. All selected studies represented retrospective reviews, observational studies, and uncontrolled case series. The compiled group of studies incorporated 465 patients who underwent resective or disconnective surgery (18 studies, 444 patients) or vagus nerve stimulator insertion (2 studies, 21 patients). Patient age at surgery ranged between 28 days and 36 months, with a mean of 16.8 months (1.4 years). DISCUSSION The study team provided a detailed summary of the literature review, focusing on the etiologies, preoperative evaluation, surgical treatments, seizure and developmental outcomes, and potential for functional recovery of infants and toddlers with DRE. Additionally, the authors discussed special considerations in this vulnerable age group from the perspective of multiple disciplines. CONCLUSIONS While presenting notable challenges, pediatric epilepsy surgery within infants and toddlers (children < 3 years of age) offers significant opportunities for improved seizure frequency, neuro-cognitive development, and quality of life. Successful evaluation and treatment of young children with DRE requires special consideration of multiple aspects related to neurological and physiological immaturity and surgical morbidity.
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Affiliation(s)
- Jonathan Pindrik
- 1Division of Pediatric Neurosurgery, Department of Neurosurgery.,2Department of Neurological Surgery, The Ohio State University College of Medicine; and
| | - Nguyen Hoang
- 2Department of Neurological Surgery, The Ohio State University College of Medicine; and
| | - Luke Smith
- 2Department of Neurological Surgery, The Ohio State University College of Medicine; and
| | - Mark Halverson
- 3Division of Pediatric Neuroradiology, Department of Radiology, and
| | - Mary Wojnaroski
- 4Section of Pediatric Psychology and Neuropsychology, Department of Pediatrics, Nationwide Children's Hospital
| | - Kelly McNally
- 4Section of Pediatric Psychology and Neuropsychology, Department of Pediatrics, Nationwide Children's Hospital
| | - Satyanarayana Gedela
- 5Division of Child Neurology, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Adam P Ostendorf
- 5Division of Child Neurology, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
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14
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Anatomical hemispherectomy revisited-outcome, blood loss, hydrocephalus, and absence of chronic hemosiderosis. Childs Nerv Syst 2019; 35:1341-1349. [PMID: 31243582 DOI: 10.1007/s00381-019-04256-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 06/06/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate microsurgical trans-sylvian trans-ventricular anatomical hemispherectomy with regard to seizure outcome, risk of hydrocephalus, blood loss, and risk of chronic hemosiderosis in patients with intractable seizures selected for surgery using current preoperative assessment techniques. METHODS Out of 86 patients who underwent hemispherectomy between February 2000 and April 2019, by a single surgeon, at a tertiary care referral center, 77 patients (ages 0.2-20 years; 40 females) who had an anatomical hemispherectomy were analyzed. Five of these were 'palliative' surgeries. One-stage anatomical hemispherectomy was performed in 55 children, two-stage anatomical hemispherectomy after extraoperative intracranial monitoring in 16, and six hemispherectomies were done following failed previous resection. Mean follow-up duration was 5.7 years (range 1-16.84 years). Forty-six patients had postoperative MRI scans. RESULTS Ninety percent of children with non-palliative hemispherectomy achieved ILAE Class-1 outcome. Twenty-seven patients were no longer taking anticonvulsant medications. Surgical failures (n = 4) included one patient with previous meningoencephalitis, one with anti-GAD antibody encephalitis, one with idiopathic neonatal thalamic hemorrhage, and one with extensive tuberous sclerosis. There were no failures among patients with malformations of cortical development. Estimated average blood loss during surgery was 387 ml. Ten (21%) children developed hydrocephalus and required a shunt following one-stage hemispherectomy, whereas 10 (50%) patients developed hydrocephalus among those who had extraoperative intracranial monitoring. Only 20% of the shunts malfunctioned in the first year. Early malfunctions were related to the valve and later to fracture disconnection of the shunt. One patent had a traumatic subdural hematoma. None of the patients developed clinical signs of chronic 'superficial cerebral hemosiderosis' nor was there evidence of radiologically persistent chronic hemosiderosis in patients who had postoperative MRI imaging. CONCLUSION Surgical results of anatomical hemispherectomy are excellent in carefully selected cases. Post-operative complications of hydrocephalus and intraoperative blood loss are comparable to those reported for hemispheric disconnective surgery (hemispherotomy). The rate of shunt malfunction was less than that reported for patients with hydrocephalus of other etiologies Absence of chronic 'superficial hemosiderosis', even on long-term follow-up, suggests that anatomical hemispherectomy should be revisited as a viable option in patients with intractable seizures and altered anatomy such as in malformations of cortical development, a group that has a reported high rate of seizure recurrence related to incomplete disconnection following hemispheric disconnective surgery.
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Neurosurgical approaches to pediatric epilepsy: Indications, techniques, and outcomes of common surgical procedures. Seizure 2018; 77:76-85. [PMID: 30473268 DOI: 10.1016/j.seizure.2018.11.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/07/2018] [Accepted: 11/14/2018] [Indexed: 01/01/2023] Open
Abstract
Epilepsy is a common pediatric neurological condition, and approximately one-third of children with epilepsy are refractory to medical management. For these children neurosurgery may be indicated, but operative success is dependent on complete delineation of the epileptogenic zone. In this review, surgical techniques for pediatric epilepsy are considered. First, potentially-curative operations are discussed and broadly divided into resections and disconnections. Then, two palliative approaches to seizure control are reviewed. Finally, future neurosurgical approaches to epilepsy are considered.
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Du XY, Chen SC, Guan YG, Gu JJ, Zhao M, Li TF, Pan JH, Luan GM. Asymmetry of Cerebral Peduncles for Predicting Motor Function Restoration in Young Patients Before Hemispherectomy. World Neurosurg 2018; 116:e634-e639. [PMID: 29777895 DOI: 10.1016/j.wneu.2018.05.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Hemispherectomy has been used successfully for patients with medically intractable epilepsy. However, it is difficult to predict postoperative motor function. The aim of the present study was to analyze whether the preoperative asymmetry of cerebral peduncles could be used to predict motor function restoration before hemispherectomy for young patients with medically intractable epilepsy. METHODS The clinical record and magnetic resonance imaging data of 53 patients were analyzed retrospectively. The correlation between preoperative cerebral peduncle asymmetry ratio (pCPAR) and pre- and postoperative changes in motor function was evaluated, as well as the influencing factors for pCPAR, such as duration and etiology factors. The restoration of motor function was defined as changes in pre- and postoperative hemiparesis. RESULTS The pCPARs of patients with improved and unchanged hemiparesis were significantly greater than that of worsened patients. Patients with a pCPAR of more than 1.5 had an obvious restorative capacity of motor function of the intact hemisphere, and these patients had a lower risk of worsening hemiparesis. The duration in the improved/unchanged and worsened groups was 5.84 ± 3.85 years and 2.67 ± 2.03 years, respectively. Furthermore, there were more patients with no-progressive pathology in the group in whom pCPAR was more than 1.5. CONCLUSIONS pCPAR is a useful and objective indicator for predicting the restoration of motor function in pediatric patients with medically intractable epilepsy before hemispherectomy. Most patients with nonprogressive pathology and a duration of more than 5 years presented with greater pCPARs, exhibited better restoration of motor function, and had less risk of worsening hemiparesis.
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Affiliation(s)
- Xiu-Yu Du
- Department of Neurosurgery, Epilepsy Center, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Si-Chang Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yu-Guang Guan
- Department of Neurosurgery, Epilepsy Center, Sanbo Brain Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of Epilepsy, Beijing, China; Beijing Institute for Brain Disorders, Beijing, China
| | - Jing-Jing Gu
- Department of Neurosurgery, Epilepsy Center, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Meng Zhao
- Department of Neurosurgery, Epilepsy Center, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Tian-Fu Li
- Department of Neurology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jun-Hong Pan
- Department of Neurosurgery, Epilepsy Center, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Guo-Ming Luan
- Department of Neurosurgery, Epilepsy Center, Sanbo Brain Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of Epilepsy, Beijing, China; Beijing Institute for Brain Disorders, Beijing, China.
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Mullin JP, Soni P, Lee S, Jehi L, Naduvil Valappi AM, Bingaman W, Gonzalez-Martinez J. Volumetric Analysis of Cerebral Peduncles and Cerebellar Hemispheres for Predicting Hemiparesis After Hemispherectomy. Neurosurgery 2017; 79:499-507. [PMID: 27322806 DOI: 10.1227/neu.0000000000001307] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In some cases of refractory epilepsy, hemispherectomy is the final invasive treatment option. However, predictors of postoperative hemiparesis in these patients have not been widely studied. OBJECTIVE To investigate how the volumetric analysis of cerebral peduncles and cerebellar hemispheres in patients who have undergone hemispherectomy may determine prognostic implications for postoperative hemiparesis. METHODS Twenty-two patients who underwent hemispherectomy at our institution were retrospectively included. Using iPlan/BrainLAB (BrainLAB, Feldkirchen, Germany) imaging software and a semiautomatic voxel-based segmentation method, we calculated the preoperative cerebral peduncle and cerebellar hemisphere volumes. Cerebral peduncle and cerebellar hemisphere ratios were compared between patients with worsened or unchanged/better hemiparesis postoperatively. RESULTS The ratios of ipsilateral/contralateral cerebral peduncles (0.570 vs 0.828; P = .02) and contralateral/ipsilateral cerebellar hemispheres (0.885 vs 1.031; P = .009) were significantly lower in patients who had unchanged/improved hemiparesis postoperatively compared with patients who had worsened hemiparesis. Relative risk of worsening hemiparesis was significantly higher in patients with a cerebral peduncle ratio < 0.7 (relative risk, 4.3; P = .03) or a cerebellar ratio < 1.0 (relative risk, 6.4; P = .006). CONCLUSION Although patients who undergo hemispherectomy are heterogeneous, we report a method of predicting postoperative hemiparesis using only standard volumetric magnetic resonance imaging. This information could be used in preoperative discussions with patients and families to help better understand that chance of retaining baseline motor function. ABBREVIATIONS CST, corticospinal tractfMRI, functional magnetic resonance imagingTMS, transcranial magnetic stimulation.
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Affiliation(s)
- Jeffrey P Mullin
- *Department of Neurosurgery, Epilepsy Center, and §Department of Neurology, Section of Pediatric Epilepsy, Neurological Institute, Cleveland Clinic, Cleveland, Ohio; ‡Case Western Reserve University Medical School, Cleveland, Ohio
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18
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Iyer RS, Rao RM, Muthukalathi K, Kumar P. Trapped ipsilateral lateral ventricle: a delayed complication of hemispherotomy for Rasmussen's encephalitis. BMJ Case Rep 2017; 2017:bcr-2017-222040. [PMID: 29054955 DOI: 10.1136/bcr-2017-222040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Hemispherotomy is the currently preferred surgical treatment option for refractory unihemispheric epilepsies. The incidence of hydrocephalus is greatly reduced in this disconnective procedure when compared with the resective procedure of anatomical hemispherectomy. We describe the occurrence of ipsilateral trapped lateral ventricle months after hemispherotomy for Rasmussen's encephalitis. There is enough evidence to suggest that this rare and interesting complication is due to the local inflammatory changes associated with the surgical trauma.
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Affiliation(s)
| | - Ravi Mohan Rao
- Department of Neurosurgery, Apollo Hospitals, Bangalore, Karnataka, India
| | | | - Praveen Kumar
- Department of Radiology, KG Hospital, Coimbatore, Tamil nadu, India
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Fukuda M, Masuda H, Shirozu H, Ito Y, Nakayama Y, Higashijima T, Fujii Y. Additional resective surgery after the failure of initial surgery in patients with intractable epilepsy. Neurol Res 2017; 39:1049-1055. [PMID: 28889791 DOI: 10.1080/01616412.2017.1376471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Objectives There are three conceivable reasons for the failure of resective surgery for intractable epilepsy: incomplete resection of the epileptogenic zone including or overlapping with eloquent area (group A); incorrect determination of the epileptogenic zone prior to the first surgery (group B); and the development of a new epileptic focus after the first surgery (group C). We examined the relationship between the reason for failure of initial surgery and patient outcomes after repeated surgical resection. Methods The study included 18 patients (5.1%) underwent additional surgery after failure of the initial operation. Post-operative outcomes, complications and other clinical data were collected by retrospective chart review. Results Four patients (22.2%) were assigned to group A, 13 (72.2%) were assigned to group B, and 1 patient was assigned to group C (5.6%). Six patients (40.0%) were seizure-free for 2 or more years after additional surgery. In group B, 11 patients underwent additional resection of the cortex adjacent to the previously resected area and 2 underwent re-operation involving a site distant from the previously resected area; notably, the latter 2 patients did not achieve seizure-free status post-surgery. After the first operation, only one patient (group A) experienced transient paresis; after additional surgery, 10 of 18 patients (56%; 3 group A, 6 group B, and 1 group C) experienced various complications. Discussion Although additional resective surgery provided freedom from seizures in about 40% of the patients, it is important to weigh a high risk of complications against possible benefits when considering additional surgery.
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Affiliation(s)
- Masafumi Fukuda
- a Department of Neurosurgery , Nishi-Niigata National Chuo Hospital , Niigata-City , Japan
| | - Hiroshi Masuda
- a Department of Neurosurgery , Nishi-Niigata National Chuo Hospital , Niigata-City , Japan
| | - Hiroshi Shirozu
- a Department of Neurosurgery , Nishi-Niigata National Chuo Hospital , Niigata-City , Japan
| | - Yosuke Ito
- a Department of Neurosurgery , Nishi-Niigata National Chuo Hospital , Niigata-City , Japan
| | - Yoko Nakayama
- a Department of Neurosurgery , Nishi-Niigata National Chuo Hospital , Niigata-City , Japan
| | - Takefumi Higashijima
- a Department of Neurosurgery , Nishi-Niigata National Chuo Hospital , Niigata-City , Japan
| | - Yukihiko Fujii
- b Department of Neurosurgery , Brain Research Institute, University of Niigata , Niigata-City , Japan
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Bartoli A, El Hassani Y, Jenny B, Momjian S, Korff CM, Seeck M, Vulliemoz S, Schaller K. What to do in failed hemispherotomy? Our clinical series and review of the literature. Neurosurg Rev 2017; 41:125-132. [DOI: 10.1007/s10143-017-0888-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 07/20/2017] [Accepted: 07/31/2017] [Indexed: 10/19/2022]
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Sebastianelli L, Versace V, Taylor A, Brigo F, Nothdurfter W, Saltuari L, Trinka E, Nardone R. Functional reorganization after hemispherectomy in humans and animal models: What can we learn about the brain's resilience to extensive unilateral lesions? Brain Res Bull 2017; 131:156-167. [PMID: 28414105 DOI: 10.1016/j.brainresbull.2017.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 04/05/2017] [Accepted: 04/11/2017] [Indexed: 01/18/2023]
Abstract
Hemispherectomy (HS) is an effective surgical procedure aimed at managing otherwise intractable epilepsy in cases of diffuse unihemispheric pathologies. Neurological recovery in subjects treated with HS is not limited to seizure reduction, rather, sensory-motor and behavioral improvement is often observed. This outcome highlights the considerable capability of the brain to react to such an extensive lesion, by functionally reorganizing and rewiring the cerebral cortex, especially early in life. In this narrative review, we summarize the animal studies as well as the human neurophysiological and neuroimaging studies dealing with the reorganizational processes that occur after HS. These topics are of particular interest in understanding mechanisms of functional recovery after brain injury. HS offers the chance to investigate contralesional hemisphere activity in controlling ipsilateral limb movements, and the role of transcallosal interactions, before and after the surgical procedure. These post-injury neuroplastic phenomena actually differ from those observed after less extensive brain damage. Therefore, they illustrate how different lesions could lead the contralesional hemisphere to play the "good" or "bad" role in functional recovery. These issues may have clinical implications and could inform rehabilitation strategies aiming to improve functional recovery following unilateral hemispheric lesions. Future studies, involving large cohorts of hemispherectomized patients, will be necessary in order to obtain a greater understanding of how cerebral reorganization can contribute to residual sensorimotor, visual and auditory functions.
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Affiliation(s)
- Luca Sebastianelli
- Department of Neurorehabilitation, Hospital of Vipiteno, Italy, and Research Unit for Neurorehabilitation of South Tyrol, Bolzano, Italy
| | - Viviana Versace
- Department of Neurorehabilitation, Hospital of Vipiteno, Italy, and Research Unit for Neurorehabilitation of South Tyrol, Bolzano, Italy
| | - Alexandra Taylor
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Francesco Brigo
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy; Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Wolfgang Nothdurfter
- Department of Neurorehabilitation, Hospital of Vipiteno, Italy, and Research Unit for Neurorehabilitation of South Tyrol, Bolzano, Italy
| | - Leopold Saltuari
- Department of Neurorehabilitation, Hospital of Vipiteno, Italy, and Research Unit for Neurorehabilitation of South Tyrol, Bolzano, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria; Centre of Cognitive Neuroscience, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Raffaele Nardone
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Franz Tappeiner Hospital, Merano, Italy.
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22
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An observational study on outcome of hemispherotomy in children with refractory epilepsy. Int J Surg 2016; 36:477-482. [DOI: 10.1016/j.ijsu.2015.05.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 05/15/2015] [Accepted: 05/29/2015] [Indexed: 11/24/2022]
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Kiehna EN, Widjaja E, Holowka S, Carter Snead O, Drake J, Weiss SK, Ochi A, Thompson EM, Go C, Otsubo H, Donner EJ, Rutka JT. Utility of diffusion tensor imaging studies linked to neuronavigation and other modalities in repeat hemispherotomy for intractable epilepsy. J Neurosurg Pediatr 2016; 17:483-90. [PMID: 26651159 DOI: 10.3171/2015.7.peds15101] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Hemispherectomy for unilateral, medically refractory epilepsy is associated with excellent long-term seizure control. However, for patients with recurrent seizures following disconnection, workup and investigation can be challenging, and surgical options may be limited. Few studies have examined the role of repeat hemispherotomy in these patients. The authors hypothesized that residual fiber connections between the hemispheres could be the underlying cause of recurrent epilepsy in these patients. Diffusion tensor imaging (DTI) was used to test this hypothesis, and to target residual connections at reoperation using neuronavigation. METHODS The authors identified 8 patients with recurrent seizures following hemispherectomy who underwent surgery between 1995 and 2012. Prolonged video electroencephalography recordings documented persistent seizures arising from the affected hemisphere. In all patients, DTI demonstrated residual white matter association fibers connecting the hemispheres. A repeat craniotomy and neuronavigation-guided targeted disconnection of these residual fibers was performed. Engel class was used to determine outcome after surgery at a minimum of 2 years of follow-up. RESULTS Two patients underwent initial hemidecortication and 6 had periinsular hemispherotomy as their first procedures at a median age of 9.7 months. Initial pathologies included hemimegalencephaly (n = 4), multilobar cortical dysplasia (n = 3), and Rasmussen's encephalitis (n = 1). The mean duration of seizure freedom for the group after the initial procedure was 32.5 months (range 6-77 months). In all patients, DTI showed limited but definite residual connections between the 2 hemispheres, primarily across the rostrum/genu of the corpus callosum. The median age at reoperation was 6.8 years (range 1.3-14 years). The average time taken for reoperation was 3 hours (range 1.8-4.3 hours), with a mean blood loss of 150 ml (range 50-250 ml). One patient required a blood transfusion. Five patients are seizure free, and the remaining 3 patients are Engel Class II, with a minimum follow-up of 24 months for the group. CONCLUSIONS Repeat hemispherotomy is an option for consideration in patients with recurrent intractable epilepsy following failed surgery for catastrophic epilepsy. In conjunction with other modalities to establish seizure onset zones, advanced MRI and DTI sequences may be of value in identifying patients with residual connectivity between the affected and unaffected hemispheres. Targeted disconnection of these residual areas of connectivity using neuronavigation may result in improved seizure outcomes, with minimal and acceptable morbidity.
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Affiliation(s)
- Erin N Kiehna
- Division of Neurosurgery, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California and
| | | | | | | | - James Drake
- Pediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | | | | | - Eric M Thompson
- Pediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | | | | | | | - James T Rutka
- Pediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
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Giordano F, Spacca B, Barba C, Mari F, Pisano T, Guerrini R, Genitori L. Vertical extraventricular functional hemispherotomy: a new variant for hemispheric disconnection. Technical notes and results in three patients. Childs Nerv Syst 2015; 31:2151-60. [PMID: 26099230 DOI: 10.1007/s00381-015-2788-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 06/09/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE Hemispherectomy and disconnective hemispherotomy are the most effective epilepsy surgical procedures for the treatment of epilepsy due to hemispheric pathologies such as Sturge-Weber syndrome, diffuse hemispheric cortical dysplasia, and posttraumatic and postischemic focal lesions. Disconnective hemispherotomy is nowadays preferred to reduce surgical morbidity in term of early and late complications (i.e., cerebral superficial hemosiderosis). Despite the number of existing technical variants conceived to further reduce the amount of brain tissue to be removed, postoperative hydrocephalus still persists and may account for an average incidence of 15-41% according to different series and reviews. A new variant of disconnective vertical hemispherotomy we termed vertical extraventricular parasagittal hemispherotomy is described aiming to further reduce the amount of removed brain tissue and so the risk of postoperative hydrocephalus in favor of a pure hemispheric disconnection. METHODS Three patients affected by drug-resistant epilepsy due to different hemispheric pathologies (posttraumatic epilepsy, Sturge-Weber syndrome, diffuse hemispheric cortical dysplasia) were considered to be candidates for vertical extraventricular parasagittal hemispherotomy disconnective based on presurgical evaluation protocol. The oldest patient was 15 years old, the two youngest were both 2 years old. RESULTS None of the patients experienced early and late surgical complications. After a mean follow-up of 36 months (range 12-60 months), two patients were seizure free, one relapsed seizures 18 months later. Postoperative hydrocephalus never occurred. CONCLUSION Vertical extraventricular parasagittal hemispherotomy may be an efficacious and less invasive technique as it consists in a pure disconnection of the hemisphere with less amount of brain tissue removed and a theoretical reduced risk of postoperative hydrocephalus.
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Affiliation(s)
- Flavio Giordano
- Neurosurgery - Department of Neurosciences, Anna Meyer Pediatric Hospital, Viale Pieraccini 24, 50139, Florence, Italy.
| | - Barbara Spacca
- Neurosurgery - Department of Neurosciences, Anna Meyer Pediatric Hospital, Viale Pieraccini 24, 50139, Florence, Italy
| | - Carmen Barba
- Pediatric Neurology Clinic - Department of Neurosciences, Anna Meyer Pediatric Hospital, Florence, Italy
| | - Francesco Mari
- Pediatric Neurology Clinic - Department of Neurosciences, Anna Meyer Pediatric Hospital, Florence, Italy
| | - Tiziana Pisano
- Pediatric Neurology Clinic - Department of Neurosciences, Anna Meyer Pediatric Hospital, Florence, Italy
| | - Renzo Guerrini
- Pediatric Neurology Clinic - Department of Neurosciences, Anna Meyer Pediatric Hospital, Florence, Italy
| | - Lorenzo Genitori
- Neurosurgery - Department of Neurosciences, Anna Meyer Pediatric Hospital, Viale Pieraccini 24, 50139, Florence, Italy
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Yoshikawa A, Nakamachi T, Shibato J, Rakwal R, Shioda S. Comprehensive analysis of neonatal versus adult unilateral decortication in a mouse model using behavioral, neuroanatomical, and DNA microarray approaches. Int J Mol Sci 2014; 15:22492-517. [PMID: 25490135 PMCID: PMC4284721 DOI: 10.3390/ijms151222492] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 11/17/2014] [Accepted: 11/20/2014] [Indexed: 01/29/2023] Open
Abstract
Previously, studying the development, especially of corticospinal neurons, it was concluded that the main compensatory mechanism after unilateral brain injury in rat at the neonatal stage was due in part to non-lesioned ipsilateral corticospinal neurons that escaped selection by axonal elimination or neuronal apoptosis. However, previous results suggesting compensatory mechanism in neonate brain were not correlated with high functional recovery. Therefore, what is the difference among neonate and adult in the context of functional recovery and potential mechanism(s) therein? Here, we utilized a brain unilateral decortication mouse model and compared motor functional recovery mechanism post-neonatal brain hemisuction (NBH) with adult brain hemisuction (ABH). Three analyses were performed: (1) Quantitative behavioral analysis of forelimb movements using ladder walking test; (2) neuroanatomical retrograde tracing analysis of unlesioned side corticospinal neurons; and (3) differential global gene expressions profiling in unlesioned-side neocortex (rostral from bregma) in NBH and ABH on a 8 × 60 K mouse whole genome Agilent DNA chip. Behavioral data confirmed higher recovery ability in NBH over ABH is related to non-lesional frontal neocortex including rostral caudal forelimb area. A first inventory of differentially expressed genes genome-wide in the NBH and ABH mouse model is provided as a resource for the scientific community.
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Affiliation(s)
- Akira Yoshikawa
- Department of Anatomy, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo 142-8555, Japan.
| | - Tomoya Nakamachi
- Department of Anatomy, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo 142-8555, Japan.
| | - Junko Shibato
- Department of Anatomy, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo 142-8555, Japan.
| | - Randeep Rakwal
- Department of Anatomy, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo 142-8555, Japan.
| | - Seiji Shioda
- Department of Anatomy, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo 142-8555, Japan.
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Lew SM, Koop JI, Mueller WM, Matthews AE, Mallonee JC. Fifty consecutive hemispherectomies: outcomes, evolution of technique, complications, and lessons learned. Neurosurgery 2014; 74:182-94; discussion 195. [PMID: 24176954 DOI: 10.1227/neu.0000000000000241] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Techniques for achieving hemispheric disconnection in patients with epilepsy continue to evolve. OBJECTIVE To review the outcomes of the first 50 hemispherectomy surgeries performed by a single surgeon with an emphasis on outcomes, complications, and how these results led to changes in practice. METHODS The first 50 hemispherectomy cases performed by the lead author were identified from a prospectively maintained database. Patient demographics, surgical details, clinical outcomes, and complications were critically reviewed. RESULTS From 2004 to 2012, 50 patients underwent hemispherectomy surgery (mean follow-up time, 3.5 years). Modified lateral hemispherotomy became the preferred technique and was performed on 44 patients. Forty patients (80%) achieved complete seizure freedom (Engel I). Presurgical and postsurgical neuropsychological evaluations demonstrated cognitive stability. Two cases were performed for palliation only. Previous hemispherectomy surgery was associated with worsened seizure outcome (2 of 6 seizure free; P .005). The use of Avitene was associated with a higher incidence of postoperative hydrocephalus (56% vs 18%; P = .03). In modified lateral hemispherotomy patients without the use of Avitene, the incidence of hydrocephalus was 13%. Complications included infection (n = 3), incomplete disconnection requiring reoperation (n = 1), reversible ischemic neurological deficit (n = 1), and craniosynostosis (n = 1). There were no (unanticipated) permanent neurological deficits or deaths. Minor technique modifications were made in response to specific complications. CONCLUSION The modified lateral hemispherotomy is effective and safe for both initial and revision hemispherectomy surgery. Avitene use appears to result in a greater incidence of postoperative hydrocephalus.
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Affiliation(s)
- Sean M Lew
- *Department of Neurosurgery, and ‡Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Toda K, Baba H, Ono T, Ono K. The utility of diffusion tensor imaging tractography for post-operative evaluation of a patient with hemispherotomy performed for intractable epilepsy. Brain Dev 2014; 36:641-4. [PMID: 23981348 DOI: 10.1016/j.braindev.2013.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 08/03/2013] [Accepted: 08/04/2013] [Indexed: 11/27/2022]
Abstract
Hemispherotomy is an effective treatment for patients with severe epilepsy caused by hemispheric abnormalities such as hemimegalencephaly or other dysplastic malformations. Here, we report a 5-year-old boy who experienced right-side hemiconvulsion due to left hemispheric cortical dysplasia. He presented with mild right hemiparesis that had been present since seizure onset. Ictal electroencephalogram obtained during the hemiconvulsion showed localized epileptic discharges in the left hemisphere. He underwent a left peri-insular hemispherotomy. Three months after surgery, clonic convulsions returned in the left leg and EEG-video monitoring showed localized epileptic discharges in the frontal region. Magnetic resonance images showed that the genu of corpus callosum was unsectioned and diffusion tensor imaging tractography confirmed the presence of callosal fibers in the genu of the corpus callosum. Clonic convulsion disappeared after additional section of the corpus callosum. Further studies are warranted to determine the utility of diffusion tensor imaging tractography on the assessment of subcortical fibers following disconnective epilepsy surgery.
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Affiliation(s)
- Keisuke Toda
- Department of Neurosurgery, Nagasaki Medical Center, National Hospital Organization, Japan.
| | - Hiroshi Baba
- Department of Neurosurgery, Nagasaki Medical Center, National Hospital Organization, Japan
| | - Tomonori Ono
- Department of Neurosurgery, Nagasaki Medical Center, National Hospital Organization, Japan
| | - Kenji Ono
- Department of Neurosurgery, Nagasaki Medical Center, National Hospital Organization, Japan
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Abstract
The term hemispherectomy refers to the complete removal or functional disconnection of a cerebral hemisphere. The technique was initially developed over 85 years ago to treat infiltrating brain tumors but is now used exclusively for medically refractory epilepsy. Hemispherectomy surgery has progressed from an extremely morbid procedure fraught with complications to a fairly routine one performed at most pediatric epilepsy centers with relatively low risk and great efficacy. The author reviews the history and evolution of hemispherectomy surgery, the relevant pathological conditions, as well as outcomes and complications.
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Affiliation(s)
- Sean M Lew
- Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI 53226, USA
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Epilepsy surgery series: a study of 502 consecutive patients from a developing country. EPILEPSY RESEARCH AND TREATMENT 2014; 2014:286801. [PMID: 24627805 PMCID: PMC3929285 DOI: 10.1155/2014/286801] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 10/17/2013] [Accepted: 11/08/2013] [Indexed: 11/28/2022]
Abstract
Purpose. To review the postoperative seizure outcomes of patients that underwent surgery for epilepsy at King Faisal Specialist Hospital & Research Centre (KFSHRC). Methods. A descriptive retrospective study for 502 patients operated on for medically intractable epilepsy between 1998 and 2012. The surgical outcome was measured using the ILAE criteria. Results. The epilepsy surgery outcome for temporal lobe epilepsy surgery (ILAE classes 1, 2, and 3) at 12, 36, and 60 months is 79.6%, 74.2%, and 67%, respectively. The favorable 12- and 36-month outcomes for frontal lobe epilepsy surgery are 62% and 52%, respectively. For both parietal and occipital epilepsy lobe surgeries the 12- and 36-month outcomes are 67%. For multilobar epilepsy surgery, the 12- and 36-month outcomes are 65% and 50%, respectively. The 12- and 36-month outcomes for functional hemispherectomy epilepsy surgery are 64.2% and 63%, respectively. According to histopathology diagnosis, mesiotemporal sclerosis (MTS) and benign CNS tumors had the best favorable outcome after surgery at 1 year (77.27% and 84.3%, resp.,) and 3 years (76% and 75%, resp.,). The least favorable seizure-free outcome after 3 years occurred in cases with dual pathology (66.6%). Thirty-four epilepsy patients with normal magnetic resonance imaging (MRI) brain scans were surgically treated. The first- and third-year epilepsy surgery outcome of 17 temporal lobe surgeries were (53%) and (47%) seizure-free, respectively. The first- and third-year epilepsy surgery outcomes of 15 extratemporal epilepsy surgeries were (47%) and (33%) seizure-free. Conclusion. The best outcomes are achieved with temporal epilepsy surgery, mesial temporal sclerosis, and benign CNS tumor. The worst outcomes are from multilobar surgery, dual pathology, and normal MRI.
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Umeda T, Funakoshi K. Reorganization of motor circuits after neonatal hemidecortication. Neurosci Res 2014; 78:30-7. [DOI: 10.1016/j.neures.2013.08.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 08/21/2013] [Accepted: 08/23/2013] [Indexed: 11/15/2022]
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Hamad AP, Caboclo LO, Centeno R, Costa LV, Ladeia-Frota C, Carrete H, Gomez NG, Marinho M, Yacubian EMT, Sakamoto AC. Hemispheric surgery for refractory epilepsy in children and adolescents: Outcome regarding seizures, motor skills and adaptive function. Seizure 2013; 22:752-6. [DOI: 10.1016/j.seizure.2013.06.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 05/31/2013] [Accepted: 06/03/2013] [Indexed: 11/26/2022] Open
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Dorfer C, Czech T, Dressler A, Gröppel G, Mühlebner-Fahrngruber A, Novak K, Reinprecht A, Reiter-Fink E, Traub-Weidinger T, Feucht M. Vertical perithalamic hemispherotomy: A single-center experience in 40 pediatric patients with epilepsy. Epilepsia 2013; 54:1905-12. [DOI: 10.1111/epi.12394] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Christian Dorfer
- Department of Neurosurgery; Medical University of Vienna; Vienna Austria
| | - Thomas Czech
- Department of Neurosurgery; Medical University of Vienna; Vienna Austria
| | - Anastasia Dressler
- Epilepsy Monitoring Unit; Department of Pediatrics and Adolescence Medicine; Medical University of Vienna; Vienna Austria
| | - Gudrun Gröppel
- Epilepsy Monitoring Unit; Department of Pediatrics and Adolescence Medicine; Medical University of Vienna; Vienna Austria
| | - Angelika Mühlebner-Fahrngruber
- Epilepsy Monitoring Unit; Department of Pediatrics and Adolescence Medicine; Medical University of Vienna; Vienna Austria
| | - Klaus Novak
- Department of Neurosurgery; Medical University of Vienna; Vienna Austria
| | - Andrea Reinprecht
- Department of Neurosurgery; Medical University of Vienna; Vienna Austria
| | - Edith Reiter-Fink
- Epilepsy Monitoring Unit; Department of Pediatrics and Adolescence Medicine; Medical University of Vienna; Vienna Austria
| | | | - Martha Feucht
- Epilepsy Monitoring Unit; Department of Pediatrics and Adolescence Medicine; Medical University of Vienna; Vienna Austria
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Erba G, Messina P, Pupillo E, Beghi E. Acceptance of epilepsy surgery in the pediatric age - what the parents think and what the doctors can do. Epilepsy Behav 2013; 29:112-20. [PMID: 23939035 DOI: 10.1016/j.yebeh.2013.05.039] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 05/30/2013] [Accepted: 05/31/2013] [Indexed: 10/26/2022]
Abstract
Epilepsy surgery (ES) in pediatrics is safe and effective but can be underutilized. Possible barriers could be parental resistance and doctor inertia. We surveyed 138 parents of pediatric patients with epilepsy and found that 25.2% were opposed to this treatment. However, upon completing the questionnaire that contained factual information about ES, 50.4% of the responders stated that they had become more favorable vs. 3.3% more contrary and 46.3% unchanged. Parents of prepubescent patients were most receptive (p=0.0343) and more likely to shift to a more favorable attitude. Thus, pediatric neurologists should not hesitate to discuss ES as soon as indicated, providing all necessary information to increase acceptance. However, among 60 child neurologists surveyed, 60% did not fully comply with guidelines or follow accepted standards of practice, indicating that they may not be apt to provide proper parental guidance. We conclude that education of both practicing neurologists and parents is needed to facilitate the process.
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Affiliation(s)
- Giuseppe Erba
- Strong Epilepsy Center, Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Abstract
The surgical options available for intractable hemispheric epilepsy have evolved since their initial description in the early 20th century. Surgical techniques have advanced, as has the ability to predict good surgical outcomes with noninvasive diagnostics. The authors review the history of hemispherectomy and detail the novel imaging and surgical strategies used to confer seizure freedom.
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Affiliation(s)
- Alexandra D. Beier
- 1Division of Pediatric Neurological Surgery, University of Florida Health Science Center Jacksonville, Florida; and
| | - James T. Rutka
- 2Division of Neurosurgery, The Hospital for Sick Children and Department of Surgery, University of Toronto, Ontario, Canada
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Abstract
BACKGROUND Fevers and leukocytosis after pediatric craniotomy trigger diagnostic evaluation and antimicrobial therapy for possible brain infection. This study determined the incidence and predictors of infection in infants and children undergoing epilepsy neurosurgery. METHODS We reviewed the postoperative course of 100 consecutive surgeries for pediatric epilepsy, comparing those with and without infections for clinical variables and daily maximum temperatures, blood white blood cell (WBC) and differential and cerebrospinal fluid (CSF) studies. RESULTS Infections were the most common adverse events after these surgeries. Four patients (4%) had CSF infections and 12 had non-CSF infections (including 1 with distinct CSF and bloodstream infections). Most (88%) infections occurred before postoperative day 12 and were associated with larger resections involving ventriculostomies. Fevers (T ≥ 38.5°C) were observed in the first 12 days postsurgery in 43% of cases, and were associated with patients undergoing hemispherectomy and multilobar resections. Fevers in the first 3 days postsurgery identified infections with 73% sensitivity, 69% specificity and 70% accuracy; 2 (13%) patients with infections never developed fevers. Peripheral blood WBC >15,000 was found in 49% of patients and 5 cases of infections never had elevated WBC counts. WBC differential, CSF protein, red blood cell, WBC and red blood cell/WBC ratios were poor predictors of infections. Longer hospital stays were associated with infections and hemispherectomy and multilobar resections. Patients with and without infections were equally likely to be seizure free after surgery. CONCLUSIONS Fevers and elevated blood WBC counts were common after pediatric epilepsy surgery, but CSF infections were uncommon. Positive cultures and other confirmatory microbiologic tests should drive changes in antimicrobial therapy after surgery.
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36
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Saneto R, Wyllie E. Surgically Treatable Epilepsy Syndromes in Infancy and Childhood. ACTA ACUST UNITED AC 2013. [DOI: 10.1201/b14113-11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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Zhang J, Mei S, Liu Q, Liu W, Chen H, Xia H, Zhou Z, Wang L, Li Y. fMRI and DTI assessment of patients undergoing radical epilepsy surgery. Epilepsy Res 2013; 104:253-63. [PMID: 23340329 DOI: 10.1016/j.eplepsyres.2012.10.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Revised: 10/19/2012] [Accepted: 10/30/2012] [Indexed: 10/27/2022]
Abstract
Hemispherectomy is effective for young patients suffered from unilateral cortical disease and severe drug-resistant epilepsy, but a major concern for hemispherectomy is the remaining brain functions and function recovery in patients after such surgery. In this study, seven patients were evaluated with clinical and imaging assessment pre- and post-surgery. Among them, four underwent anatomic hemispherectomy (AH) and three underwent subtotal hemispherectomy (functional hemispherectomy, FH). After the surgery, 71.4% (5/7) patients [(4/4) with AH and (1/3) with FH] became seizure free (Engel class I). Motor function of the paretic upper extremity unchanged in 4 patients and deteriorated in 3. Functional imaging results indicated that relocation of hand motor function (to the ipsilateral hemisphere) could take place before or after the surgery, or did not occur. Similar observations were made in the motor cortex activation on the paretic foot movement. In addition, both the affected and unaffected hemispheres underwent post-surgical changes in the corticospinal tracks (CST) in various degrees, but significant reinforcement of the CST in the remaining unaffected hemisphere was not evident. Further research is needed to reveal the true functional and structural changes of the remaining brain after surgery and to explore the mechanisms of such functional relocation and reorganization in patients underwent hemispherectomy.
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Affiliation(s)
- Jing Zhang
- School of Biomedical Engineering, Capital Medical University, Beijing 100069, PR China.
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38
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Pediatric functional hemispherectomy: outcome in 92 patients. Acta Neurochir (Wien) 2012; 154:2017-28. [PMID: 22941395 DOI: 10.1007/s00701-012-1481-3] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 08/10/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The revival of epilepsy surgery after the introduction of modern presurgical evaluation procedures has led to an increase in hemispherectomy or hemispherotomy procedures. Since a large part of our pediatric series was done using a newer hemispherotomy technique, we focus mainly on the outcomes after a recently developed hemispherotomy technique (transsylvian keyhole). METHODS Ninety-six pediatric patients (aged 4 months to 18 years, mean 7.3) were operated on between 1990 and 2009; 92 were available with follow-up. RESULTS The most frequent diagnosis was porencephaly in 46 % of all patients. Progressive etiologies were present in 20 % and developmental etiologies in 22 %. At last available outcome (LAO), 85 % of the patients were seizure free (ILAE class 1). Year-to-year outcome was rather stable; usually over 80 % were class 1 for up to 13 years (n = 24). Of 92 assessable patients, 71 were treated with the transsylvian keyhole technique, with 89 % being seizure free. The overall shunt rate was 5.3 % for the whole series and 3 % for the keyhole technique subgroup. Mortality was 1 of 96 patients. Excluding patients with hemimegalencephaly (HME), patients with the shortest duration of epilepsy and the lowest age at seizure onset had the highest rates of seizure freedom. The etiology does influence outcome, with HME patients having the poorest seizure outcome and patients with Sturge-Weber syndrome and porencephaly having excellent seizure control. CONCLUSION Hemispherotomies/functional hemispherectomies are very effective and safe procedures for treating drug-resistant epilepsy with extensive unihemispheric pathology. Etiology and surgery type clearly influence seizure outcome.
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Lew SM, Matthews AE, Hartman AL, Haranhalli N. Posthemispherectomy hydrocephalus: results of a comprehensive, multiinstitutional review. Epilepsia 2012; 54:383-9. [PMID: 23106378 DOI: 10.1111/epi.12010] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Hemispherectomy surgery for medically intractable epilepsy is known to cause hydrocephalus in a subset of patients. Existing data regarding the incidence of, and risk factors for, developing posthemispherectomy hydrocephalus have been limited by the relatively small number of cases performed by any single center. Our goal was to better understand this phenomenon and to identify risk factors that may predispose patients to developing hydrocephalus after hemispherectomy surgery. METHODS Fifteen pediatric epilepsy centers participated in this study. A retrospective chart review was performed on all available patients who had hemispherectomy surgery. Data collected included surgical techniques, etiology of seizures, prior brain surgery, symptoms and signs of hydrocephalus, timing of shunt placement, and basic demographics. KEY FINDINGS Data were collected from 736 patients who underwent hemispherectomy surgery between 1986 and 2011. Forty-six patients had preexisting shunted hydrocephalus and were excluded from analysis, yielding 690 patients for this study. One hundred sixty-two patients (23%) required hydrocephalus treatment. The timing of hydrocephalus ranged from the immediate postoperative period to 8.5 years after surgery, with 43 patients (27%) receiving shunts >90 days after surgery. Multivariate regression analysis revealed anatomic hemispherectomies (odds ratio [OR] 4.1, p < 0.0001) and previous brain surgery (OR 1.7, p = 0.04) as independent significant risk factors for developing hydrocephalus. There was a trend toward significance for the use of hemostatic agents (OR 2.2, p = 0.07) and the involvement of basal ganglia or thalamus in the resection (OR 2.2, p = 0.08) as risk factors. SIGNIFICANCE Hydrocephalus is a common sequela of hemispherectomy surgery. Surgical technique and prior brain surgery influence the occurrence of posthemispherectomy hydrocephalus. A significant portion of patients develop hydrocephalus on a delayed basis, indicating the need for long-term surveillance.
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Affiliation(s)
- Sean M Lew
- Department of Neurosurgery, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.
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40
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Vadera S, Moosa AN, Jehi L, Gupta A, Kotagal P, Lachhwani D, Wyllie E, Bingaman W. Reoperative Hemispherectomy for Intractable Epilepsy. Neurosurgery 2012; 71:388-92; discussion 392-3. [DOI: 10.1227/neu.0b013e31825979bb] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
BACKGROUND:
In patients with medically intractable epilepsy and diffuse unilateral hemispheric disease, functional or disconnective hemispherectomy is a widely accepted and successful treatment option. If recurrent seizures develop after disconnective hemispherectomy, management options become more complex and include conversion to anatomic hemispherectomy.
OBJECTIVE:
To present the outcomes of all patients undergoing reoperative hemispherectomy in 1 institution by 1 surgeon since 1998.
METHODS:
The medical records, operative reports, and imaging studies for 36 patients undergoing reoperative hemispherectomy for continuing medically intractable epilepsy from 1998 to 2011 at Cleveland Clinic were reviewed. Patient characteristics, cause of seizure, imaging findings, surgery-related complications, and long-term seizure outcomes were evaluated.
RESULTS:
Patients presented with a variety of seizure origins, including Rasmussen encephalitis, perinatal infarction, cortical dysplasia, and hemimegalencephaly. Overall, 19% of patients were seizure free after conversion to anatomic hemispherectomy, and 45% reported a decrease in seizure frequency by ≥ 90%. An additional 36% reported no improvement. Generalized ictal electroencephalography tended to confer a poorer prognosis, as did cortical dysplasia as the underlying diagnosis.
CONCLUSION:
The possibility that residual epileptogenic tissue in the operated hemisphere remains connected should be considered after failed functional hemispherectomy because our data suggest that improvement in seizure frequency is possible after reoperative hemispherectomy, although the chance of obtaining seizure freedom is relatively low. The decision to proceed with reoperative hemispherectomy should be made after proper discussion with the patient and family and informed consent is given.
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Affiliation(s)
- Sumeet Vadera
- Department of Neurosurgery and Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ahsan N.V. Moosa
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lara Jehi
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ajay Gupta
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Prakash Kotagal
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Deepak Lachhwani
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Elaine Wyllie
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - William Bingaman
- Department of Neurosurgery and Cleveland Clinic Foundation, Cleveland, Ohio
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Rangel-Castilla L, Hwang SW, Al-Shamy G, Jea A, Curry DJ. The periinsular functional hemispherotomy. Neurosurg Focus 2012; 32:E7. [DOI: 10.3171/2012.1.focus11331] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The surgical treatment of refractory epilepsy has evolved as new innovations have been created. Disconnective procedures such as hemispherectomy have evolved. Presently, hemispherotomy has replaced hemispherectomy to reduce complication rates while maintaining good seizure control. Several disconnective techniques have been described including the Rasmussen, vertical, and lateral approaches. The lateral approach, or periinsular hemispherectomy, was derived from modifications on the functional hemispherectomy and involves removal of the temporal lobe mesial structures, exposure of the atrium via the circular sulcus, internal capsule transection under the central sulcus, intraventricular callosotomy, and frontobasal disconnection. The purpose of this article is to describe and illustrate in detail the anatomy and operative technique for periinsular hemispherotomy, as well as to discuss the nuances and issues involved with this procedure.
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Affiliation(s)
| | - Steven W. Hwang
- 2Division of Pediatric Neurosurgery, Department of Neurosurgery, Floating Hospital for Children, Tufts Medical Center, Boston, Massachusetts; and
| | - George Al-Shamy
- 3Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Andrew Jea
- 3Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Daniel J. Curry
- 3Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Davies ESS, Volk HA, Behr S, Summers B, de Lahunta A, Syme H, Jull P, Garosi L. Porencephaly and hydranencephaly in six dogs. Vet Rec 2011; 170:179. [PMID: 22186380 DOI: 10.1136/vr.100109] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
A retrospective study was performed to identify dogs with cerebrospinal fluid-filled cavitatory lesions on MRI. Six dogs were included and the lesions were classified. In the three dogs in the present study with hydranencephaly, unilateral but complete loss of the temporal and parietal lobes was noted and had almost complete loss of the occipital and frontal lobes of a cerebral hemisphere. In the three dogs with porencephaly, there was unilateral incomplete loss of the parietal lobe and one dog had additional partial loss of the temporal and frontal lobes. Two of the dogs with porencephaly had seizures; the third showed no associated clinical signs. The dogs with hydranencephaly had mentation changes and circled compulsively. The two porencephalic dogs with seizures were treated with phenobarbitone. One of the dogs with hydranencephaly showed increased frequency and duration of circling; one dog's clinical signs did not progress and the third dog was euthanased due to increasing aggression. The dog with increased circling had ventriculoperitoneal shunt placement and the circling frequency reduced.
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Affiliation(s)
- E S S Davies
- Willows Veterinary Centre, Highlands Road, Shirley, Solihull, West Midlands B90 4NH, UK.
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Hemispherectomy in pediatric patients with epilepsy: a study of 45 cases with special emphasis on epileptic syndromes. Childs Nerv Syst 2011; 27:2131-6. [PMID: 21947090 DOI: 10.1007/s00381-011-1596-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 09/13/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVE In this study we report the clinical outcomes of hemispherectomy for epilepsy in pediatric patients with special emphasis on the epileptic syndromes and their etiologies. MATERIAL AND METHODS We retrospectively studied 45 patients with medically refractory epilepsy with hemispheric lesions who underwent hemispherectomy at the "Hospital de Pediatría Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina between February 1990 and February 2010. Patients had been assessed using a standard protocol involving clinical, neuroradiological, neurophysiological, and neuropsychological teams. RESULTS Twenty-seven males and 18 females with a mean age of 8.5 years (range, 2 months to 18 years) who underwent epilepsy surgery for refractory epilepsy were assessed. The mean time of follow-up was 9.5 years (range, 1 to 16 years). The following epileptic syndromes were recognized: West syndrome in 15 patients (33.5%), Rasmussen syndrome in 13 (29%), focal symptomatic epilepsy in 8 (17.5%), startle epilepsy in 6 (13.5%), Lennox-Gastaut syndrome in 2 (5%), and continuous spikes and waves during slow sleep in 1 (2%). The surgical specimens revealed malformations of cortical development in 18 patients (40%), Rasmussen encephalitis in 13 (29%), porencephalic lesions in 10 (22%), gliosis in 2 (4.4%), tumor in 1 (2.2%), and Sturge-Weber syndrome in 1 (2.2%). CONCLUSION The outcome of hemispherectomy in pediatric patients is good for those with refractory epilepsies, such as West syndrome, Lennox-Gastaut syndrome, epileptic encephalopathy with continuous spikes and waves during slow sleep, and startle epilepsy arising from a hemispheric lesion associated with hemiplegia.
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Kwan A, Ng WH, Otsubo H, Ochi A, Snead OC, Tamber MS, Rutka JT. Hemispherectomy for the control of intractable epilepsy in childhood: comparison of 2 surgical techniques in a single institution. Neurosurgery 2011; 67:429-36. [PMID: 21099569 DOI: 10.1227/neu.0b013e3181f743dc] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hemispherectomy is an established neurosurgical procedure for catastrophic epilepsy in childhood. However, the technique used to achieve an optimum outcome remains to be determined. OBJECTIVE We examined the influence of hemidecortication (HD) vs peri-insular hemispherotomy (PIH) on patient outcome. METHODS The medical records of 41 children undergoing hemispherectomy were reviewed for patient demographics, clinical criteria, and surgical outcomes. RESULTS HD and PIH were performed in 21 and 20 children, respectively. The mean age at surgery for HD was 54 months and 61 months for PIH. The median durations of surgery for HD and PIH were 5 hours and 7 hours, respectively (P < .001). For HD, 6 patients required a second surgery and 3 required a third. One PIH patient required a second procedure. Postoperative shunting was required in 5 HD patients, but only 1 PIH patient. All patients had increased hemiparesis after surgery. The overall mean follow-up time was 72 months. Engel class I or II outcomes after initial surgery were better after PIH (85%) compared with HD (48%) (P < .02). After subsequent surgeries for seizure control, 4 HD patients and 1 PIH patient improved to Engel class I or II. CONCLUSION Hemispherectomy is an effective surgical procedure for childhood intractable catastrophic epilepsy. In patients with diffuse hemispheric disorder, PIH tends to have fewer major complications, more favorable seizure outcomes, and a decreased need for subsequent surgical procedures, including shunting for hydrocephalus, compared with HD.
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Affiliation(s)
- Allison Kwan
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Jazayeri MA, Jensen JN, Lew SM. Craniosynostosis following hemispherectomy in a 2.5-month-old boy with intractable epilepsy. J Neurosurg Pediatr 2011; 8:450-4. [PMID: 22044367 DOI: 10.3171/2011.8.peds11176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report on the case of a 6-week-old boy who presented with infantile spasms. At 2.5 months of age, the patient underwent a right hemispherectomy. Approximately 3 months postoperatively, the patient presented with left coronal craniosynostosis. Subsequent cranial vault remodeling resulted in satisfactory cosmesis. Four years after surgery, the patient remains seizure free without the need for anticonvulsant medications. The authors believe this to be the first reported case of iatrogenic craniosynostosis due to hemispherectomy, and they describe 2 potential mechanisms for its development. This case suggests that, in the surgical treatment of infants with intractable epilepsy, minimization of brain volume loss through disconnection techniques should be considered, among other factors, when determining the best course of action.
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Affiliation(s)
- Mohammad-Ali Jazayeri
- Department of Neurosurgery, Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
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46
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Scalp EEG does not predict hemispherectomy outcome. Seizure 2011; 20:758-63. [PMID: 21813300 DOI: 10.1016/j.seizure.2011.07.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 07/08/2011] [Accepted: 07/10/2011] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Functional hemispherectomy is effective in carefully selected patients, resulting in a reduction of seizure burden up to complete resolution, improvement of intellectual development, and developmental benefit despite possible additional neurological deficit. Despite apparent hemispheric pathology on brain magnetic resonance imaging (MRI) or other imaging tests, scalp electroencephalography (EEG) could be suggestive of bilateral ictal onset or even ictal onset contralateral to the dominant imaging abnormality. We aimed to investigate the role of scalp EEG lateralization pre-operatively in predicting outcome. METHODS We retrospectively reviewed 54 patients who underwent hemispherectomy between 1991 and 2009 at Medical College of Georgia (1991-2006) and Cincinnati Children's Hospital Medical Center (2006-2009) and had at least one year post-operative follow-up. All preoperative EEGs were reviewed, and classified as either lateralizing or nonlateralizing, for both ictal and interictal EEG recordings. RESULTS Of 54 patients, 42 (78%) became seizure free. Twenty-four (44%) of 54 had a nonlateralizing ictal or interictal EEG. Further analysis was based on etiology of epilepsy, including malformation of cortical development (MCD), Rasmussen syndrome (RS), and stroke (CVA). EEG nonlateralization did not predict poor outcome in any of the etiology groups evaluated. CONCLUSION Scalp EEG abnormalities in contralateral or bilateral hemispheres do not, in isolation, predict a poor outcome from hemispherectomy. Results of other non-invasive and invasive evaluations should be used to determine candidacy.
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Gowda S, Salazar F, Bingaman WE, Kotagal P, Lachhwani DL, Gupta A, Davis S, Niezgoda J, Wyllie E. Surgery for catastrophic epilepsy in infants 6 months of age and younger. J Neurosurg Pediatr 2010; 5:603-7. [PMID: 20515334 DOI: 10.3171/2010.1.peds08301] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Few data are available concerning efficacy and safety of surgery for catastrophic epilepsy in the first 6 months of life. METHODS The authors retrospectively analyzed epilepsy surgeries in 15 infants ranging in age from 1.5 to 6 months (median 4 months) and weight from 4 to 10 kg (median 7 kg) who underwent anatomical (4 patients) or functional (7 patients) hemispherectomy, or frontal (1 patient), frontoparietal (2 patients), or parietooccipital (1 patient) resection for life-threatening catastrophic epilepsy due to malformation of cortical development. RESULTS No patient died. Intraoperative complications included an acute ischemic infarction with hemiparesis in our youngest, smallest infant. The most frequent complication was blood loss requiring transfusion, which was encountered in every case. The estimated blood loss was 3-214% (median 63%) of the total blood volume. At maximum follow-up of 6-121 months (median 60 months), 46% were seizure free. CONCLUSIONS Epilepsy surgery may be effective in young infants as it is in older children. However, intraoperative blood loss and risk of permanent postoperative neurological deficits present significant challenges.
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Affiliation(s)
- Shaila Gowda
- Department of Neurology, Providence Park Hospital, Novi, Michigan 48374, USA.
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Takahashi M, Vattanajun A, Umeda T, Isa K, Isa T. Large-scale reorganization of corticofugal fibers after neonatal hemidecortication for functional restoration of forelimb movements. Eur J Neurosci 2009; 30:1878-87. [PMID: 19895560 DOI: 10.1111/j.1460-9568.2009.06989.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
As an experimental model to study the mechanism of large-scale network plasticity of the juvenile brain, functional compensation after neonatal brain damage was studied in rats that received unilateral decortication at postnatal day 5. These animals exhibited a marked ability in reaching and grasping movements in the contralesional side of the forelimb when tested at 10-14 weeks of age. Additional lesion of the sensorimotor cortex in the remaining contralesional hemisphere at this stage resulted in severe impairment of both forelimbs. It was suggested that the sensorimotor cortex on the contralesional side was controlling the movements of both forelimbs. Following the injection of an anterograde tracer into the remaining sensorimotor cortex, the corticofugal axons from the remaining sensorimotor cortex were found to issue aberrant projections to the contralateral red nucleus, contralateral superior colliculus, contralateral pontine nuclei, ipsilateral dorsal column nucleus and ipsilateral gray matter of the cervical spinal cord, all of which appeared to be necessary for the control of contralesional forelimb movements. These results suggest that the forelimb movements on the contralesional side were compensated by large-scale reorganization of the corticofugal axons from the remaining sensorimotor cortex.
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Affiliation(s)
- Masahito Takahashi
- Department of Developmental Physiology, National Institute for Physiological Sciences, National Institutes of Natural Sciences, Myodaiji, Okazaki, Japan
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Hemispherectomy-associated complications from the Kids’ Inpatient Database. Epilepsy Res 2009; 87:47-53. [DOI: 10.1016/j.eplepsyres.2009.07.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2008] [Revised: 07/16/2009] [Accepted: 07/24/2009] [Indexed: 10/20/2022]
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Hallbook T, Ruggieri P, Adina C, Lachhwani DK, Gupta A, Kotagal P, Bingaman WE, Wyllie E. Contralateral MRI abnormalities in candidates for hemispherectomy for refractory epilepsy. Epilepsia 2009; 51:556-63. [PMID: 19817811 DOI: 10.1111/j.1528-1167.2009.02335.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE To assess the impact of contralateral magnetic resonance imaging (MRI) findings on seizure outcome after hemispherectomy for refractory epilepsy. METHODS We retrospectively reviewed 110 children, 0.4-18 (median 5.9) years of age, who underwent hemispherectomy for severe refractory epilepsy at Cleveland Clinic Children's Hospital. In children with contralateral (as well as ipsilateral) MRI findings appreciated preoperatively, the decision to proceed to surgery was based on other features concordant with the side with the most severe MRI abnormality, including ipsilateral epileptiform discharges, lateralizing seizure semiology, and side of hemiparesis. RESULTS We retrospectively observed contralateral MRI abnormalities (predominantly small hemisphere, white matter loss or abnormal signal, or sulcation abnormalities) in 81 patients (74%), including 31 of 43 (72%) with malformations of cortical development (MCD), 31 of 42 (73%) with perinatal injury from infarction or hypoxia, and 15 of 25 (60%) with Rasmussen's encephalitis, Sturge-Weber syndrome, or posttraumatic encephalomalacia. Among 84 children (76%) with lesions that were congenital or acquired pre- or perinatally, 67 (83%) had contralateral MRI abnormalities (p = 0.02). Contralateral findings were subjectively judged to be mild or moderate in 70 (86%). At follow-up 12-84 (median 24) months after surgery, 79% of patients with contralateral MRI abnormalities were seizure-free compared to 83% of patients without contralateral MRI findings, with no differences based on etiology group or type or severity of contralateral MRI abnormality. DISCUSSION MRI abnormalities, usually mild to moderate in severity, were seen in the contralateral hemisphere in the majority of children who underwent hemispherectomy for refractory epilepsy due to various etiologies, especially those that were congenital or early acquired. The contralateral MRI findings, always much less prominent than those in the ipsilateral hemisphere, did not correlate with seizure outcome and may not contraindicate hemispherectomy in otherwise favorable candidates.
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Affiliation(s)
- Tove Hallbook
- Department of Neurology, Cleveland Clinic, Children's Hospital, Cleveland, Ohio, USA.
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