1
|
Bergman L, Shofty B, Agur A, Sibony SU, Treiber JM, Curry DJ, Fried I, Weiner HL, Roth J. Hippocampal resection during hemispherotomy: is it needed? Childs Nerv Syst 2024:10.1007/s00381-024-06604-4. [PMID: 39243333 DOI: 10.1007/s00381-024-06604-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 08/29/2024] [Indexed: 09/09/2024]
Abstract
PURPOSE Hemispherotomy is an effective surgery for intractable pediatric hemispheric epilepsy. Over the years, the surgical goal has shifted from a complete hemispheric resection (anatomical hemispherectomy) to a disconnective hemispherotomy (DH). Multiple techniques for DH have been described, and often, anterior temporal lobectomy (ATL, with hippocampal resection) is performed. The goal of the current study is to assess the role of hippocampal resection in DH. METHODS We retrospectively collected all clinical data of children (< 18 years old) who underwent DH between 2001 and 2022 at two tertiary large centers. Epilepsy status and surgical outcome were compared, based on whether the hippocampus was resected (as part of an ATL) or disconnected at the amygdala and atrial segment of the fornix (with no ATL). RESULTS A total of 86 patients (32 females) were included. The most common epilepsy etiologies were stroke (31), Rasmussen's encephalitis (16), cortical dysplasia (10), and hemimegaloencephaly (9). The mean age at surgery was 7 (± 4.9) years. The average number of anti-seizure medications (ASMs) at surgery was 3 (± 1.2). Hemispherotomy techniques included peri-insular (54), vertical (23 [19 endoscopic + 4 parasagittal]), and trans-sylvian (9). The mean follow-up was 41.5 (± 38) months. Forty-three patients had hippocampal resection, and 43 patients had a hippocampal disconnection. Both groups had similar Engel outcome scores (p = 0.53). CONCLUSIONS Disconnective hemispherotomy is highly effective for pediatric intractable hemispheric epilepsy. Our data suggest that the inclusion of hippocampal resection does not provide additional benefit.
Collapse
Affiliation(s)
- Lottem Bergman
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, 6 Weizman Street, 64239, Tel Aviv, Israel
| | - Ben Shofty
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, 6 Weizman Street, 64239, Tel Aviv, Israel
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - Ariel Agur
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, 6 Weizman Street, 64239, Tel Aviv, Israel
| | - Shimrit Uliel Sibony
- Pediatric Epilepsy Unit, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Jeffrey M Treiber
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Daniel J Curry
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Itzhak Fried
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, 6 Weizman Street, 64239, Tel Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Howard L Weiner
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Jonathan Roth
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, 6 Weizman Street, 64239, Tel Aviv, Israel.
- Tel Aviv University, Tel Aviv, Israel.
| |
Collapse
|
2
|
Pilioneta M, Chen HH, Losito E, Bourgeois M, Chémaly N, Eiserman M, Guida L, Dangouloff-Ros V, Fumagalli L, Kaminska A, Boddaert N, Auvin S, Nabbout R, Sainte-Rose C, Blauwblomme T. Interhemispheric Vertical Hemispherotomy: Technique, Outcome, and Pitfalls-A Bicentric Retrospective Case Series of 39 Cases. Oper Neurosurg (Hagerstown) 2024; 26:413-422. [PMID: 37994857 DOI: 10.1227/ons.0000000000000992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/23/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND AND OBJECTIVES When seizure onset affects a whole hemisphere, hemispheric disconnections are efficient and safe procedures. However, both lateral peri-insular hemispherotomy and vertical paramedian hemispherotomy approaches report a failure rate around 20%, which can be explained by residual connections giving rise to persistent seizures. In this study, we present the interhemispheric vertical hemispherotomy (IVH), a technical variation of the vertical paramedian hemispherotomy approach, that aims to increase seizure control avoiding residual connections while exposing the corpus callosum. METHODS This is a retrospective study of IVH in two centers, with analysis of clinical and MRI data and outcomes. A detailed description of the technique is provided with a video. RESULTS IVH was performed in 39 children. The mean age at surgery was 7.2 years, and etiologies were as follows: malformations of cortical development (n = 14), Rasmussen's encephalitis (n = 10), stroke (n = 10), post-traumatic (3), and Sturge-Weber Syndrome (2). Hemispheric disconnection was complete on postoperative MRI in 34 cases. There was no mortality, hydrocephalus occurred in one case, and subdural collection occurred in four cases. A second surgery was performed in four cases because of seizure relapse (n = 3) and/or incomplete disconnection on MRI (n = 4). With a mean follow-up of 3.2 years, International League Against Epilepsy class I epilepsy outcome was obtained for 37/39 patients. CONCLUSION IVH is a safe and effective variation of the vertical approaches for hemispheric disconnection. It allows a good exposure and anatomic control of the corpus callosum, which is a frequent site of incomplete disconnection. IVH may be limited by the thalamic volume and the ventricular size, notably in hemimegalencephaly cases.
Collapse
Affiliation(s)
- Martin Pilioneta
- Hôpital Necker, Assistance Publique Hôpitaux de Paris, Paris , France
| | | | - Emma Losito
- Hôpital Necker, Assistance Publique Hôpitaux de Paris, Paris , France
| | - Marie Bourgeois
- Hôpital Necker, Assistance Publique Hôpitaux de Paris, Paris , France
| | - Nicole Chémaly
- Hôpital Necker, Assistance Publique Hôpitaux de Paris, Paris , France
| | - Monika Eiserman
- Hôpital Necker, Assistance Publique Hôpitaux de Paris, Paris , France
| | - Lelio Guida
- Hôpital Necker, Assistance Publique Hôpitaux de Paris, Paris , France
- Université de Paris Cité, Paris , France
| | - Volodia Dangouloff-Ros
- Hôpital Necker, Assistance Publique Hôpitaux de Paris, Paris , France
- Université de Paris Cité, Paris , France
| | - Luca Fumagalli
- Hôpital Necker, Assistance Publique Hôpitaux de Paris, Paris , France
| | - Anna Kaminska
- Hôpital Necker, Assistance Publique Hôpitaux de Paris, Paris , France
| | - Nathalie Boddaert
- Hôpital Necker, Assistance Publique Hôpitaux de Paris, Paris , France
- Université de Paris Cité, Paris , France
| | - Stéphane Auvin
- Université de Paris Cité, Paris , France
- Hôpital Robert Debré, Assistance Publique Hôpitaux de Paris, Paris , France
| | - Rima Nabbout
- Hôpital Necker, Assistance Publique Hôpitaux de Paris, Paris , France
- Université de Paris Cité, Paris , France
| | | | - Thomas Blauwblomme
- Hôpital Necker, Assistance Publique Hôpitaux de Paris, Paris , France
- Université de Paris Cité, Paris , France
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
De Benedictis A, Marasi A, Rossi-Espagnet MC, Napolitano A, Parrillo C, Fracassi D, Baldassari G, Borro L, Bua A, de Palma L, Luisi C, Pepi C, Savioli A, Luglietto D, Marras CE. Vertical Hemispherotomy: Contribution of Advanced Three-Dimensional Modeling for Presurgical Planning and Training. J Clin Med 2023; 12:jcm12113779. [PMID: 37297974 DOI: 10.3390/jcm12113779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/22/2023] [Accepted: 04/22/2023] [Indexed: 06/12/2023] Open
Abstract
Vertical hemispherotomy is an effective treatment for many drug-resistant encephalopathies with unilateral involvement. One of the main factors influencing positive surgical results and long-term seizure freedom is the quality of disconnection. For this reason, perfect anatomical awareness is mandatory during each step of the procedure. Although previous groups attempted to reproduce the surgical anatomy through schematic representations, cadaveric dissections, and intraoperative photographs and videos, a comprehensive understanding of the approach may still be difficult, especially for less experienced neurosurgeons. In this work, we reported the application of advanced technology for three-dimensional (3D) modeling and visualization of the main neurova-scular structures during vertical hemispherotomy procedures. In the first part of the study, we built a detailed 3D model of the main structures and landmarks involved during each disconnection phase. In the second part, we discussed the adjunctive value of augmented reality systems for the management of the most challenging etiologies, such as hemimegalencephaly and post-ischemic encephalopathy. We demonstrated the contribution of advanced 3D modeling and visualization to enhance the quality of anatomical representation and interaction between the operator and model according to a surgical perspective, optimizing the quality of presurgical planning, intraoperative orientation, and educational training.
Collapse
Affiliation(s)
- Alessandro De Benedictis
- Neurosurgery Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Alessandra Marasi
- Neurosurgery Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | | | - Antonio Napolitano
- Medical Physics Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Chiara Parrillo
- Medical Physics Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Donatella Fracassi
- Medical Physics Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Giulia Baldassari
- Medical Physics Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Luca Borro
- Multimodal Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Antonella Bua
- Neurosurgery Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Luca de Palma
- Clinical and Experimental Neurology, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Concetta Luisi
- Clinical and Experimental Neurology, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Chiara Pepi
- Clinical and Experimental Neurology, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Alessandra Savioli
- Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Davide Luglietto
- Neurosurgery Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Carlo E Marras
- Neurosurgery Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| |
Collapse
|
5
|
Baltus C, El M’Kaddem B, Ferrao Santos S, Ribeiro Vaz JG, Raftopoulos C. Second surgery after vertical paramedian hemispherotomy for epilepsy recurrence. Heliyon 2023; 9:e14326. [PMID: 36950565 PMCID: PMC10025104 DOI: 10.1016/j.heliyon.2023.e14326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 02/02/2023] [Accepted: 03/01/2023] [Indexed: 03/13/2023] Open
Abstract
Background Vertical Paramedian Hemispherotomy (VPH) is considered an effective surgical treatment for drug-resistant epilepsy with 80% of patients experiencing seizure freedom or worthwhile improvement. Identifying persistent connective tracts is challenging in failed VPH. Methods We reviewed our series of consecutive patients undergoing VPH for hemispheric drug-resistant epilepsy and included cases with recurrent epileptic seizures undergoing second surgery with at least 6 months of postoperative follow-up. The cases were extensively assessed to propose a targeted complementary resection. Results Two children suffering from seizure recurrence following hemispherotomy leading to second surgery were included. After complete assessment, persisting amygdala residue was suspected responsible for the epilepsy recurrence in both patients. Complementary resection of the amygdala residue led to seizure freedom for both patients (Engel IA/ILAE Class 1) without complication. Different diagnostic tools are used to assess patients after failed hemispherotomy including routine EEG, prolonged video EEG, MRI (particularly DTI sequences), SPECT or PET scans and clinical evaluation. These tools allow to rule out epileptic foci in the contralateral hemisphere and to localize a potentially persisting epileptogenic zone. Assessment of these patients should be as systematic and integrated as the initial workup. Although our two patients suffered from Rasmussen's encephalitis, seizure recurrence after VPH has been described in other pathologies. Conclusion Lying deep and medially in the surgical corridor of VPH, the amygdala can be incompletely resected and cause recurrent epilepsy. Complementary selective resection of the amygdala residue may safely lead to success in epilepsy control.
Collapse
Affiliation(s)
- Cedric Baltus
- Department of Neurosurgery, University Hospital St-Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200, Brussels, Belgium
| | - Bouchra El M’Kaddem
- Department of Pediatric Neurology, University Hospital St-Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200, Brussels, Belgium
| | - Susana Ferrao Santos
- Refractory Epilepsy Center, University Hospital St-Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200, Brussels, Belgium
| | - José Géraldo Ribeiro Vaz
- Department of Neurosurgery, University Hospital St-Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200, Brussels, Belgium
| | - Christian Raftopoulos
- Department of Neurosurgery, University Hospital St-Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200, Brussels, Belgium
- Corresponding author.
| |
Collapse
|
6
|
Matsuo T, Fujimoto S. Surgical Strategy for Hemispherotomy. Neurol Med Chir (Tokyo) 2023; 63:131-136. [PMID: 36682794 PMCID: PMC10166605 DOI: 10.2176/jns-nmc.2022-0279] [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: 01/20/2023] Open
Abstract
Hemispherotomy is a radical treatment for drug-resistant epilepsy that targets developmental, acquired, and progressive diseases with widespread epileptogenic regions in one cerebral hemisphere. Currently, two main approaches are utilized after repeated improvements: lateral and vertical approaches. With the lateral approach, the surgical field is wide, and the approach to the lateral ventricle is relatively easy. On the other hand, the vertical approach has the advantage of reducing intraoperative bleeding and operating time as the resection line of the radial fiber is short, and understanding the three-dimensional anatomy is relatively easy. The lateral approach is generally used for atrophic lesions, whereas the vertical approach is for hypertrophic lesions. Hemispherotomy is expected to not only suppress epileptic seizures but also improve psychomotor development by protecting the unaffected cerebral hemisphere. However, this method is one of the most invasive surgeries in epilepsy surgery, and it is important to fully consider its indications. Furthermore, understanding the neural fiber pathway is important for actual surgery.
Collapse
Affiliation(s)
- Takeshi Matsuo
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital
| | - So Fujimoto
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital
| |
Collapse
|
7
|
Candela-Cantó S, Muchart J, Valera C, Jou C, Culebras D, Alamar M, Becerra V, Artés D, Armero G, Aparicio J, Hinojosa J, Rumià J. Completion of disconnective surgery for refractory epilepsy in pediatric patients using robot-assisted MRI-guided laser interstitial thermal therapy. J Neurosurg Pediatr 2023; 31:61-70. [PMID: 36272116 DOI: 10.3171/2022.9.peds22258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/08/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Since 2007, the authors have performed 34 hemispherotomies and 17 posterior quadrant disconnections (temporoparietooccipital [TPO] disconnections) for refractory epilepsy at Sant Joan de Déu Barcelona Children's Hospital. Incomplete disconnection is the main cause of surgical failure in disconnective surgery, and reoperation is the treatment of choice. In this study, 6 patients previously treated with hemispherotomy required reoperation through open surgery. After the authors' initial experience with real-time MRI-guided laser interstitial thermal therapy (MRIgLITT) for hypothalamic hamartomas, they decided to use this technique instead of open surgery to complete disconnective surgeries. The objective was to report the feasibility, safety, and efficacy of MRIgLITT to complete hemispherotomies and TPO disconnections for refractory epilepsy in pediatric patients. METHODS Eight procedures were performed on 6 patients with drug-resistant epilepsy. Patient ages ranged between 4 and 18 years (mean 10 ± 4.4 years). The patients had previously undergone hemispherotomy (4 patients) and TPO disconnection (2 patients) at the hospital. The Visualase system assisted by a Neuromate robotic arm was used. The ablation trajectory was planned along the residual connection. The demographic and epilepsy characteristics of the patients, precision of the robot, details of the laser ablation, complications, and results were prospectively collected. RESULTS Four patients underwent hemispherotomy and 2 underwent TPO disconnection. Two patients, including 1 who underwent hemispherotomy and 1 who underwent TPO disconnection, received a second laser ablation because of persistent seizures and connections after the first treatment. The average precision of the system (target point localization error) was 1.7 ± 1.4 mm. The average power used was 6.58 ± 1.53 J. No complications were noted. Currently, 5 of the 6 patients are seizure free (Engel class I) after a mean follow-up of 20.2 ± 5.6 months. CONCLUSIONS According to this preliminary experience, laser ablation is a safe method for complete disconnective surgeries and allowed epilepsy control in 5 of the 6 patients treated. A larger sample size and longer follow-up periods are necessary to better assess the efficacy of MRIgLITT to complete hemispherotomy and TPO disconnection, but the initial results are encouraging.
Collapse
Affiliation(s)
- Santiago Candela-Cantó
- Departments of1Neurosurgery
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
| | - Jordi Muchart
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
- 3Diagnostic Imaging
| | - Carlos Valera
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
| | - Cristina Jou
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
- 4Pathology, and
| | - Diego Culebras
- Departments of1Neurosurgery
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
| | | | | | | | | | - Javier Aparicio
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
| | - José Hinojosa
- Departments of1Neurosurgery
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
| | - Jordi Rumià
- Departments of1Neurosurgery
- 2Epilepsy Surgery Unit, full member of the ERN EpiCARE, Sant Joan de Déu Barcelona Children's Hospital, University of Barcelona, Spain
| |
Collapse
|
8
|
Lu VM, Brown EC, Ragheb J, Wang S. Repeat surgery for pediatric epilepsy: a systematic review and meta-analysis of resection and disconnection approaches. J Neurosurg Pediatr 2022; 30:616-623. [PMID: 36242580 DOI: 10.3171/2022.9.peds22344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 09/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Resection and disconnection surgeries for epilepsy in the pediatric demographic (patients ≤ 18 years of age) are two separate, definitive intervention options in medically refractory cases. Questions remain regarding the role of surgery when seizures persist after an initial incomplete surgery. The aim of this study was to review the contemporary literature and summarize the metadata on the outcomes of repeat surgery in this specific demographic. METHODS Searches of seven electronic databases from inception to July 2022 were conducted using PRISMA guidelines. Articles were screened using prespecified criteria. Metadata from the articles were abstracted and pooled by random-effects meta-analysis of proportions. RESULTS Eleven studies describing 12 cohorts satisfied all criteria, reporting outcomes of 170 pediatric patients with epilepsy who underwent repeat resection or disconnection surgery. Of these patients, 55% were male, and across all studies, median ages at initial and repeat surgeries were 7.2 and 9.4 years, respectively. The median follow-up duration after repeat surgery was 47.7 months. The most commonly reported etiology for epilepsy was cortical dysplasia. Overall, the estimated incidence of complete seizure freedom (Engel class I) following repeat surgery was 48% (95% CI 40%-56%, p value for heterogeneity = 0.93), and the estimated incidence of postoperative complications following repeat surgery was 25% (95% CI 12%-39%, p = 0.04). There were six cohorts each that described outcomes for repeat resection and repeat disconnection surgeries. There was no statistical difference between these two subgroups with respect to estimated incidence of complete seizure freedom (p value for interaction = 0.92), but postoperative complications were statistically more common following repeat resection (p ≤ 0.01). CONCLUSIONS For both resection and disconnection surgeries, repeat epilepsy surgery in children is likely to confer complete seizure freedom in approximately half of the patients who experience unsuccessful initial incomplete epilepsy surgery. More data are needed to elucidate the impact on efficacy based on surgical approach selection. Judicious discussion and planning between the patient, family, and a multidisciplinary team of epilepsy specialists is recommended to optimize expectations and outcomes in this setting.
Collapse
Affiliation(s)
- Victor M Lu
- 1Department of Neurological Surgery, University of Miami, Jackson Memorial Hospital; and
- 2Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, Florida
| | - Erik C Brown
- 2Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, Florida
| | - John Ragheb
- 1Department of Neurological Surgery, University of Miami, Jackson Memorial Hospital; and
- 2Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, Florida
| | - Shelly Wang
- 1Department of Neurological Surgery, University of Miami, Jackson Memorial Hospital; and
- 2Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, Florida
| |
Collapse
|
9
|
Vertical parasagittal hemispherotomy: a case report of postoperative mesio-temporal seizures via amygdalofugal pathway. Acta Neurochir (Wien) 2021; 163:2833-2836. [PMID: 34291381 DOI: 10.1007/s00701-021-04836-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/26/2021] [Indexed: 10/20/2022]
Abstract
Vertical parasagittal hemispherotomy (VPH) is a well-established surgical treatment which is proposed for children with widespread unilateral onset of intractable epileptic seizures. VPH allows to disconnect from a vertical transventricular approach all white matter fibers of the hemisphere around a central core including the thalamus. We present the case of a girl who underwent VPH for hemimegalencephaly in early infancy. Postoperatively, she developed unexpected seizures of mesio-temporal origin. Stereo-EEG provided arguments for an amygdalar origin. High-resolution MRI with tractography confirmed the presence of the amygdalo-fugal pathway to be responsible of epileptic discharges propagation. She became seizure-free after temporal resection.
Collapse
|
10
|
Fallah A, Lewis E, Ibrahim GM, Kola O, Tseng CH, Harris WB, Chen JS, Lin KM, Cai LX, Liu QZ, Lin JL, Zhou WJ, Mathern GW, Smyth MD, O'Neill BR, Dudley RWR, 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, Weil AG. Comparison of the real-world effectiveness of vertical versus lateral functional hemispherotomy techniques for pediatric drug-resistant epilepsy: A post hoc analysis of the HOPS study. Epilepsia 2021; 62:2707-2718. [PMID: 34510448 PMCID: PMC9290517 DOI: 10.1111/epi.17021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/24/2021] [Accepted: 07/15/2021] [Indexed: 11/26/2022]
Abstract
Objective This study was undertaken to determine whether the vertical parasagittal approach or the lateral peri‐insular/peri‐Sylvian approach to hemispheric surgery is the superior technique in achieving long‐term seizure freedom. Methods We conducted a post hoc subgroup analysis of the HOPS (Hemispheric Surgery Outcome Prediction Scale) study, an international, multicenter, retrospective cohort study that identified predictors of seizure freedom through logistic regression modeling. Only patients undergoing vertical parasagittal, lateral peri‐insular/peri‐Sylvian, or lateral trans‐Sylvian hemispherotomy were included in this post hoc analysis. Differences in seizure freedom rates were assessed using a time‐to‐event method and calculated using the Kaplan–Meier survival method. Results Data for 672 participants across 23 centers were collected on the specific hemispherotomy approach. Of these, 72 (10.7%) underwent vertical parasagittal hemispherotomy and 600 (89.3%) underwent lateral peri‐insular/peri‐Sylvian or trans‐Sylvian hemispherotomy. Seizure freedom was obtained in 62.4% (95% confidence interval [CI] = 53.5%–70.2%) of the entire cohort at 10‐year follow‐up. Seizure freedom was 88.8% (95% CI = 78.9%–94.3%) at 1‐year follow‐up and persisted at 85.5% (95% CI = 74.7%–92.0%) across 5‐ and 10‐year follow‐up in the vertical subgroup. In contrast, seizure freedom decreased from 89.2% (95% CI = 86.3%–91.5%) at 1‐year to 72.1% (95% CI = 66.9%–76.7%) at 5‐year to 57.2% (95% CI = 46.6%–66.4%) at 10‐year follow‐up for the lateral subgroup. Log‐rank test found that vertical hemispherotomy was associated with durable seizure‐free progression compared to the lateral approach (p = .01). Patients undergoing the lateral hemispherotomy technique had a shorter time‐to‐seizure recurrence (hazard ratio = 2.56, 95% CI = 1.08–6.04, p = .03) and increased seizure recurrence odds (odds ratio = 3.67, 95% CI = 1.05–12.86, p = .04) compared to those undergoing the vertical hemispherotomy technique. Significance This pilot study demonstrated more durable seizure freedom of the vertical technique compared to lateral hemispherotomy techniques. Further studies, such as prospective expertise‐based observational studies or a randomized clinical trial, are required to determine whether a vertical approach to hemispheric surgery provides superior long‐term seizure outcomes.
Collapse
Affiliation(s)
- Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Evan Lewis
- Neurology Center of Toronto, Toronto, Ontario, Canada
| | - George M Ibrahim
- Division of Neurosurgery, The Hospital for Sick Children, 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
| | - William B Harris
- Department of Medicine, John A. Burns School of Medicine at University of Hawaii, Honolulu, Hawaii, 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 W R 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
| | - 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, 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
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - 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
- 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, University of Montreal Hospital Centre, Montreal, Quebec, Canada
| | - Manjari Tripathi
- Department of Neurosurgery, All India Institute of Medical Sciences, 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
- Department of Neurosurgery, Guangdong Shenzhen Children 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 Raftopoulos
- 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, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Valentina Baro
- Academic Neurosurgery, Department of Neuroscience, University of Padova, Padova, Italy
| | - Christian Cantillano Malone
- Department of Neurosurgery, Pontifical Catholic University of Chile, Sotero del Rio Hospital, Santiago, Chile
| | - Juan Pociecha
- Epilepsy Department, Neurology Neurophysiology Epilepsy Service Foundation Against Childhood Neurological Diseases, Buenos Aires, Argentina
| | - Noelia Chamorro
- Epilepsy Department, Neurology Neurophysiology Epilepsy Service Foundation Against Childhood Neurological Diseases, Buenos Aires, Argentina
| | - Valeria L Muro
- Epilepsy Department, Neurology Neurophysiology Epilepsy Service Foundation Against Childhood Neurological Diseases, Buenos Aires, Argentina
| | - Marec von Lehe
- Department of Neurosurgery, Brandenburg Medical School, Neuruppin, Germany
| | - Silvia Vieker
- 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, University Hospital Zurich 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
| | - Alexander G Weil
- Department of Neurosurgery, Saint Justine University Hospital Centre, Montreal, Quebec, Canada
| |
Collapse
|
11
|
Melikyan AG, Kushel YV, Sorokin VS, Vlasov PA, Demin MO, Shults EI, Shevchenko AM, Strunina YV. [Lessons learnt from 101 hemispheric pediatric epilepsy surgeries part ii: pitfalls and complications]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2021; 85:44-52. [PMID: 34951759 DOI: 10.17116/neiro20218506144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To evaluate the spectrum of pitfalls and complications after hemisherotomy basing on a retrospective study of a large consecutive pediatric cohort of patients from a single institution. MATERIAL AND METHODS One hundred and one patients (med. age - 43 months) with refractory seizures underwent hemispherotomy. Developmental pathology was the anatomical substrate of disorder in 42 patients. The infantile post-stroke scarring and gliosis was the origin of epilepsy in the majority of 43 cases with acquired etiology. The progressive pathology (RE, S-W and TS) was the etiology in the rest of children (16 cases). The lateral periinsular technique was used to isolate the sick hemisphere in 55 patients; the vertical parasagittal approach was employed in 46 cases. Median perioperative blood loss constituted 10.5 ml/kg, but was markedly larger in kids with hemimegaly (52.8 ml/kg); 57 patients needed hemotransfusion during surgery. Median length of stay in ICU was 14.7 hours, and the length of stay in the hospital until discharge - 6.5 days. Eight patients underwent second-look surgery to complete sectioning of undercut commissural fibers. FU is known in 91 patients (med. length - 1.5 years). RESULTS Major surgical complications with serious hemorrhage and/or surgery induced life-threatening events developed in 7 patients (one of them has died on the 5th day post-surgery for the causes of brain edema and uncontrolled hyponatremia). Various early and late infectious complications were noted in 4 cases. Ten patients experienced new not anticipated but temporary neurological deficit. Nine patients needed shunting for the causes of hydrocephalus within several first months post-hemispherotomy. Early seizure onset was associated with probability of all complications in general (p=0.02), and developmental etiology - with intraoperative bleeding and hemorrhagic complications (p=0.03). CONCLUSION Children with developmental etiology, particularly those with hemimegalencephaly, are most challengeable in terms of perioperative hemorrhage and serious complications. Patients with relapse or persisting seizures should be evaluated for the possibility of incomplete hemispheric isolation and have good chances to become SF by re-doing hemispherotomy.
Collapse
Affiliation(s)
| | - Yu V Kushel
- Burdenko Neurosurgical Center, Moscow, Russia
| | - V S Sorokin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - P A Vlasov
- Burdenko Neurosurgical Center, Moscow, Russia
| | - M O Demin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - E I Shults
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | |
Collapse
|
12
|
Kurwale NS, Patil SB, Jagtap SA, Joshi A, Nilegaonkar S, Bapat D, Chitnis S. Failed Hemispherotomy: Insights from Our Early Experience in 40 Patients. World Neurosurg 2020; 146:e685-e690. [PMID: 33171323 DOI: 10.1016/j.wneu.2020.10.170] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 10/29/2020] [Accepted: 10/29/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To study the factors responsible for failure of hemispherotomy and outcomes of revision surgery. The effect of the surgeon's learning curve on failures was also analyzed. METHODS Forty consecutive patients, who underwent functional hemispherotomy through a 4-year period, from the inception of the single-surgeon epilepsy surgery program, were analyzed. RESULTS A total of 47 functional hemispherotomies were performed in the study period in 40 patients (7 revision surgeries on 6 patients). Mean age of the cohort was 9.45 ± 14.84 years and it included 7 infants (<2 years). Of the 9 patients (23.5%) who failed the first procedure, 6 qualified for revision surgery, all of whom belonged to the cohort of the first 15 patients treated during the first 2 years of the program. Hemimegalencephaly was the most common disease (n = 4). Ipsilateral temporal stem (n = 3), frontobasal connections (n = 2), splenium of corpus callosum (n = 2), and posterior insula (n = 2) were residual undisconnected substrates identified for revision on imaging. The substrates for failure were obvious in 5/6 patients and resulted from incomplete disconnection, implying surgical inadequacy. At the mean follow-up of 30 ± 13.17 months (range, 13-55 months), 35 of 40 patients (87.5%) remained seizure free (Engel class Ia), including 4/6 patients who underwent redo surgery. Revision did not benefit the remaining 2 patients (Engel class III). There was no mortality. CONCLUSIONS Surgical revision is more common in hemimegalencephaly and in the early days of a surgical program. Affirmative neuroimaging improves the outcomes of subsequent revision surgery.
Collapse
Affiliation(s)
- Nilesh S Kurwale
- Department of Neurosurgery, Deenanath Mangeshkar Hospital, Pune, India; Department of Neurosurgery, D. Y. Patil Medical College, Pune, India.
| | - Sandip B Patil
- Department of Pediatric Neurology, Deenanath Mangeshkar Hospital, Pune, India
| | - Sujit A Jagtap
- Department of Neurology, Deenanath Mangeshkar Hospital, Pune, India; Department of Neurology, Bharati Vidyapeeth Medical College, Pune, India
| | - Aniruddha Joshi
- Department of Radiology, Deenanath Mangeshkar Hospital, Pune, India
| | - Sujit Nilegaonkar
- Department of Nuclear Medicine, Deenanath Mangeshkar Hospital, Pune, India
| | - Deepa Bapat
- Department of Neuropsychology, Deenanath Mangeshkar Hospital, Pune, India
| | - Sonal Chitnis
- Department of Speech Pathology and Language, Deenanath Mangeshkar Hospital, Pune, India
| |
Collapse
|
13
|
Muthaffar OY. Treating epilepsy with options other than antiepileptic medications. NEUROSCIENCES (RIYADH, SAUDI ARABIA) 2020; 25:253-261. [PMID: 33130805 PMCID: PMC8015608 DOI: 10.17712/nsj.2020.4.20200010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Epilepsy is a common health burden worldwide. Epilepsy is linked to variety of factors, including infectious, vascular, immune, structural, genetic, and metabolic etiologies. Despite the existence of multiple antiepileptic drugs (AEDs), many patients are diagnosed with intractable epilepsy. Many nonpharmacological options are available for epilepsy. Some types of epilepsy respond to cofactors. Other patients may be candidates for a ketogenic diet. Inflammatory mediators, such as intravenous immunoglobulins (IVIgs) and steroids, are other options for epilepsy. Recently, cannabinoids have been approved for epilepsy treatment. Refractory epilepsy can be treated with surgical interventions. Focal resections, hemispherectomies, and corpus callosotomies are some common epilepsy surgery approaches. Neuromodulation techniques are another option. Thermal ablation is a minimally invasive approach for epilepsy treatment. Epilepsy outcomes are improving, and treatment modalities are expanding. Trials of nonpharmacological options for epilepsy patients are recommended. This article summarizes available nonpharmacological options other than AEDs for the treatment of epilepsy.
Collapse
Affiliation(s)
- Osama Y Muthaffar
- Department of Pediatrics, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia. E-mail:
| |
Collapse
|
14
|
Sturge-Weber syndrome: an update on the relevant issues for neurosurgeons. Childs Nerv Syst 2020; 36:2553-2570. [PMID: 32564157 DOI: 10.1007/s00381-020-04695-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/21/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Sturge-Weber syndrome (SWS) is a neurocutaneous facomatosis characterized by facial and leptomeningeal angioma, glaucoma, seizures, and neurological disability. Therefore, a challenging multidisciplinary interaction is required for its management. The goal of this paper is to review the main aspects of SWS and to present an illustrative pediatric series. METHODS The pertinent literature has been analyzed, focused mainly on etiopathogenesis, pathology, clinical features, diagnostic tools, management, and outcome of the disease. Moreover, a series of 11 children operated on for refractory epilepsy between 2005 and 2015 (minimum follow-up 5 years, mean follow-up 9.6 years) is reported. The series consists of six boys and five girls with 6.5-month and 16.2-month mean age at seizure onset and at surgery, respectively. Seizures affected all children, followed by hemiparesis and psychomotor delay (81%), glaucoma (54%), and other neurological deficits (45%). RESULTS All children underwent hemispherectomy (anatomical in three cases, functional in two cases, hemispherotomy in six cases); one patient needed a redo hemispherotomy. Mortality was nil; disseminated intravascular coagulation and interstitial pneumonia occurred in one patient each; three children had subdural fluid collection. Eight patients (72%) are in the ILAE Class 1 (completely seizure and aura free), two in Class 2 (only auras, no seizure), and one in Class 3 (1-3 seizure days per year). AEDs discontinuation was possible in 73% of cases. The most important news from the literature concerned the pathogenesis (role of the mutation of the GNAQ gene in the abnormal SWS vasculogenesis), the clinical findings (the features and pathogenesis of the stroke-like episodes are being understood), the diagnostic tools (quantitative MRI and EEG), and both the medical (migraine, seizures) and surgical management (epilepsy). The epileptic outcome of SWS patients is very good (80% are seizure-free), if compared with other hemispheric syndromes. The quality of life is affected by the neurological and cognitive deficits. CONCLUSIONS SWS still is an etiological and clinical challenge. However, the improvements over the time are consistent. In particular, the neurosurgical treatment of refractory epilepsy provides very good results as long as the indication to treatment is correct.
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Girishan S, Tripathi M, Garg A, Doddamani R, Bajaj J, Ramanujam B, Chandra PS. Enhancing outcomes of endoscopic vertical approach hemispherotomy: understanding the role of "temporal stem" residual connections causing recurrence of seizures. J Neurosurg Pediatr 2020; 25:159-167. [PMID: 31703206 DOI: 10.3171/2019.8.peds19148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 08/19/2019] [Indexed: 11/06/2022]
Abstract
Objective The authors sought to analyze the residual connections formed by the temporal stem as a cause for seizure recurrence following endoscopic vertical interhemispheric hemispherotomy and to review and compare lateral approach (perisylvian) with vertical approach surgical techniques to highlight the anatomical factors responsible for residual connections. METHODS This study was a retrospective analysis of patients who underwent endoscopic hemispherotomy for drug-resistant epilepsy. Postoperative MR images were analyzed. Specific attention was given to anatomical 3D-acquired thin-section T1 images to assess the extent of disconnection, which was confirmed with a diffusion tensor imaging sequence. Cadaver brain dissection was done to analyze the anatomical factors responsible for persistent connections. RESULTS Of 39 patients who underwent surgery, 80% (31/39) were seizure free (follow-up of 23.61 ± 8.25 months) following the first surgery. Thirty patients underwent postoperative MRI studies, which revealed persistent connections in 14 patients (11 temporal stem only; 3 temporal stem + amygdala + splenium). Eight of these 14 patients had persistent seizures. In 4 of these 8 patients, investigations revealed good concordance with the affected hemisphere, and repeat endoscopic disconnection of the residual connection was performed. Two of the 8 patients were lost to follow-up, and 2 had bihemispheric seizure onset. The 4 patients who underwent repeat endoscopic disconnection had seizure-free outcomes following the second surgery, increasing the good outcome total among all patients to 90% (35/39). Cadaveric brain dissection analysis revealed the anatomical factors responsible for the persistence of residual connections. CONCLUSIONS In endoscopic vertical approach interhemispheric hemispherotomy (and also vertical approach parasagittal hemispherotomy) the temporal stem, which lies deep and parallel to the plane of disconnection, is prone to be missed, which might lead to persistent or recurrent seizures. The recognition of this limitation can lead to improved seizure outcome. The amygdala and splenium are areas less commonly prone to be missed during surgery.
Collapse
Affiliation(s)
| | | | - Ajay Garg
- 3Neuroradiology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | | | | | | | | |
Collapse
|
17
|
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.
Collapse
|
18
|
Lee KH, Lee YJ, Seo JH, Baumgartner JE, Westerveld M. Epilepsy Surgery in Children versus Adults. J Korean Neurosurg Soc 2019; 62:328-335. [PMID: 31085959 PMCID: PMC6514317 DOI: 10.3340/jkns.2019.0026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 02/24/2019] [Indexed: 11/29/2022] Open
Abstract
Epilepsy is one of the most common chronic neurological disorder affecting 6–7 per 1000 worldwide. Nearly one-third of patients with newly diagnosed epilepsy continue to have recurrent seizures despite adequate trial of more than two anti-seizure drugs : drug-resistant epilepsy (DRE). Children with DRE often experience cognitive and psychosocial co-morbidities requiring more urgent and aggressive treatment than adults. Epilepsy surgery can result in seizure-freedom in approximately two-third of children with improvement in cognitive development and quality of life. Understanding fundamental differences in etiology, co-morbidity, and neural plasticity between children and adults is critical for appropriate selection of surgical candidates, appropriate presurgical evaluation and surgical approach, and improved overall outcome.
Collapse
Affiliation(s)
- Ki Hyeong Lee
- Comprehensive Epilepsy Center, Advent Health for Children, Orlando, FL, USA
| | - Yun-Jin Lee
- Comprehensive Epilepsy Center, Advent Health for Children, Orlando, FL, USA.,Department of Pediatrics, Pusan University College of Medicine, Yangsan, Korea
| | - Joo Hee Seo
- Comprehensive Epilepsy Center, Advent Health for Children, Orlando, FL, USA
| | | | - Michael Westerveld
- Comprehensive Epilepsy Center, Advent Health for Children, Orlando, FL, USA
| |
Collapse
|