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Electrocorticographic Patterns in Frontal Epilepsy and Long-Term Outcomes [RETRACTED]. J Clin Neurophysiol 2024:00004691-990000000-00145. [PMID: 38916879 DOI: 10.1097/wnp.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024] Open
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Guo J, Wang Z, van 't Klooster MA, Van Der Salm SM, Leijten FS, Braun KP, Zijlmans M. Seizure Outcome After Intraoperative Electrocorticography-Tailored Epilepsy Surgery: A Systematic Review and Meta-Analysis. Neurology 2024; 102:e209430. [PMID: 38768406 PMCID: PMC11175635 DOI: 10.1212/wnl.0000000000209430] [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: 08/28/2023] [Accepted: 03/12/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Tailoring epilepsy surgery using intraoperative electrocorticography (ioECoG) has been debated, and modest number of epilepsy surgery centers apply this diagnostic method. We assessed the current evidence to use ioECoG-tailored epilepsy surgery for improving postsurgical outcome. METHODS PubMed and Embase were searched for original studies reporting on ≥10 cases who underwent ioECoG-tailored surgery for epilepsy, with a follow-up of at least 6 months. We used a random-effects model to calculate the overall rate of patients achieving favorable seizure outcome (FSO), defined as Engel class I, ILAE class 1, or seizure-free status. Meta-regression was used to investigate potential sources of heterogeneity. We calculated the odds ratio (OR) for estimating variables on FSO:ioECoG vs non-ioECoG-tailored surgery (if included studies contained patients with non-ioECoG-tailored surgery), ioECoG-tailored epilepsy surgery in children vs adults, temporal (TL) vs extratemporal lobe (eTL), MRI-positive vs MRI-negative, and complete vs incomplete resection of tissue that generated interictal epileptiform discharges (IEDs). A Bayesian network meta-analysis was conducted for underlying pathologies. We assessed the evidence certainty using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). RESULTS Eighty-three studies (82 observational studies, 1 trial) comprising 3,631 patients with ioECoG-tailored surgery were included. The overall pooled rate of patients who attained FSO after ioECoG-tailored surgery was 74% (95% CI 71-77) with significant heterogeneity, which was predominantly attributed to pathologies and seizure outcome classifications. Twenty-two studies contained non-ioECoG-tailored surgeries. IoECoG-tailored surgeries reached a higher rate of FSO than non-ioECoG-tailored surgeries (OR 2.10 [95% CI 1.37-3.24]; p < 0.01; very low certainty). Complete resection of tissue that displayed IEDs in ioECoG predicted FSO better compared with incomplete resection (OR 3.04 [1.76-5.25]; p < 0.01; low certainty). We found insignificant difference in FSO after ioECoG-tailored surgery in children vs adults, TL vs eTL, or MRI-positive vs MRI-negative. The network meta-analysis showed that the odds of FSO was lower for malformations of cortical development than for tumors (OR 0.47 95% credible interval 0.25-0.87). DISCUSSION Although limited by low-quality evidence, our meta-analysis shows a relatively good surgical outcome (74% FSO) after epilepsy surgery with ioECoG, especially in tumors, with better outcome for ioECoG-tailored surgeries in studies describing both and better outcome after complete removal of IED areas.
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Affiliation(s)
- Jiaojiao Guo
- From the Department of Neurology and Neurosurgery (J.G., Z.W., M.A.K., S.M.V.D.S., F.S.L., K.P.B., M.Z.), University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Part of ERN EpiCARE; and Stichting Epilepsie Instellingen Nederland (SEIN) (M.Z.), the Netherlands
| | - Ziyi Wang
- From the Department of Neurology and Neurosurgery (J.G., Z.W., M.A.K., S.M.V.D.S., F.S.L., K.P.B., M.Z.), University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Part of ERN EpiCARE; and Stichting Epilepsie Instellingen Nederland (SEIN) (M.Z.), the Netherlands
| | - Maryse A van 't Klooster
- From the Department of Neurology and Neurosurgery (J.G., Z.W., M.A.K., S.M.V.D.S., F.S.L., K.P.B., M.Z.), University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Part of ERN EpiCARE; and Stichting Epilepsie Instellingen Nederland (SEIN) (M.Z.), the Netherlands
| | - Sandra M Van Der Salm
- From the Department of Neurology and Neurosurgery (J.G., Z.W., M.A.K., S.M.V.D.S., F.S.L., K.P.B., M.Z.), University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Part of ERN EpiCARE; and Stichting Epilepsie Instellingen Nederland (SEIN) (M.Z.), the Netherlands
| | - Frans S Leijten
- From the Department of Neurology and Neurosurgery (J.G., Z.W., M.A.K., S.M.V.D.S., F.S.L., K.P.B., M.Z.), University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Part of ERN EpiCARE; and Stichting Epilepsie Instellingen Nederland (SEIN) (M.Z.), the Netherlands
| | - Kees P Braun
- From the Department of Neurology and Neurosurgery (J.G., Z.W., M.A.K., S.M.V.D.S., F.S.L., K.P.B., M.Z.), University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Part of ERN EpiCARE; and Stichting Epilepsie Instellingen Nederland (SEIN) (M.Z.), the Netherlands
| | - Maeike Zijlmans
- From the Department of Neurology and Neurosurgery (J.G., Z.W., M.A.K., S.M.V.D.S., F.S.L., K.P.B., M.Z.), University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Part of ERN EpiCARE; and Stichting Epilepsie Instellingen Nederland (SEIN) (M.Z.), the Netherlands
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Schaft EV, Sun D, van 't Klooster MA, van Blooijs D, Smits PL, Zweiphenning WJEM, Gosselaar PH, Ferrier CH, Zijlmans M. Spatial and temporal properties of intra-operatively recorded spikes and high frequency oscillations in focal cortical dysplasia. Clin Neurophysiol 2024; 162:210-218. [PMID: 38643614 DOI: 10.1016/j.clinph.2024.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 03/04/2024] [Accepted: 03/26/2024] [Indexed: 04/23/2024]
Abstract
OBJECTIVE Focal cortical dysplasias (FCD) are characterized by distinct interictal spike patterns and high frequency oscillations (HFOs; ripples: 80-250 Hz; fast ripples: 250-500 Hz) in the intra-operative electrocorticogram (ioECoG). We studied the temporal relation between intra-operative spikes and HFOs and their relation to resected tissue in people with FCD with a favorable outcome. METHODS We included patients who underwent ioECoG-tailored epilepsy surgery with pathology confirmed FCD and long-term Engel 1A outcome. Spikes and HFOs were automatically detected and visually checked in 1-minute pre-resection-ioECoG. Channels covering resected and non-resected tissue were compared using a logistic mixed model, assessing event numbers, co-occurrence ratios, and time-based properties. RESULTS We found pre-resection spikes, ripples in respectively 21 and 20 out of 22 patients. Channels covering resected tissue showed high numbers of spikes and HFOs, and high ratios of co-occurring events. Spikes, especially with ripples, have a relatively sharp rising flank with a long descending flank and early ripple onset over resected tissue. CONCLUSIONS A combined analysis of event numbers, ratios, and temporal relationships between spikes and HFOs may aid identifying epileptic tissue in epilepsy surgery. SIGNIFICANCE This study shows a promising method for clinically relevant properties of events, closely associated with FCD.
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Affiliation(s)
- Eline V Schaft
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Dongqing Sun
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Maryse A van 't Klooster
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Dorien van Blooijs
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Hoofddorp, the Netherlands
| | - Paul L Smits
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Willemiek J E M Zweiphenning
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter H Gosselaar
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Cyrille H Ferrier
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Maeike Zijlmans
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Hoofddorp, the Netherlands
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Rajeev SP, Darshan HR, Vilanilam GC, Abraham M, Keshavapisharady K, Venkat EH, Stanley A, Menon RN, Radhakrishnan A, Cherian A, Narasimaiah D, Thomas B, Kesavadas C, Vimala S. Is intraoperative electrocorticography (ECoG) for long-term epilepsy-associated tumors (LEATs) more useful in children?-A Randomized Controlled Trial. Childs Nerv Syst 2024; 40:839-854. [PMID: 38010434 DOI: 10.1007/s00381-023-06216-4] [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: 08/31/2023] [Accepted: 11/03/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVES The utility of intraoperative electrocorticography (ECoG)-guided resective surgery for pediatric long-term epilepsy-associated tumors (LEATs) with antiseizure medication (ASM) resistant epilepsy is not supported by robust evidence. As epilepsy networks and their ramifications are different in children from those in adults, the impact of intraoperative ECoG-based tailored resections in predicting prognosis and influencing outcomes may also differ. We evaluated this hypothesis by comparing the outcomes of resections with and without the use of ECoG in children and adults by a randomized study. METHODS From June 2020 to January 2022, 42 patients (17 children and 25 adults) with LEATs and antiseizure medication (ASM)-resistant epilepsy were randomly assigned to one of the 2 groups (ECoG or no ECoG), prior to surgical resection. The 'no ECoG' arm underwent gross total lesion resection (GTR) without ECoG guidance and the ECoG arm underwent GTR with ECoG guidance and further additional tailored resections, as necessary. Factors evaluated were tumor location, size, lateralization, seizure duration, preoperative antiepileptic drug therapy, pre- and postresection ECoG patterns and tumor histology. Postoperative Engel score and adverse event rates were compared in the pediatric and adult groups of both arms. Eloquent cortex lesions and re-explorations were excluded to avoid confounders. RESULTS Forty-two patients were included in the study of which 17 patients were in the pediatric cohort (age < 18 years) and 25 in the adult cohort. The mean age in the pediatric group was 11.11 years (SD 4.72) and in the adult group was 29.56 years (SD 9.29). The mean duration of epilepsy was 9.7 years (SD 4.8) in the pediatric group and 10.96 (SD 8.8) in the adult group. The ECoG arm of LEAT resections had 23 patients (9 children and 14 adults) and the non-ECoG arm had 19 patients (8 children and 11 adults). Three children and 3 adults from the ECoG group further underwent ECoG-guided tailored resections (average 1.33 additional tailored resections/per patient.).The histology of the tailored resection specimen was unremarkable in 3/6 (50%).Overall, the commonest histology in both groups was ganglioglioma and the temporal lobe, the commonest site of the lesion. 88.23% of pediatric cases (n = 15/17) had an excellent outcome (Engel Ia) following resection, compared to 84% of adult cases (n = 21/25) at a mean duration of follow-up of 25.76 months in children and 26.72 months in adults (p = 0.405).There was no significant difference in seizure outcomes between the ECoG and no ECoG groups both in children and adults, respectively (p > 0.05). Additional tailored resection did not offer any seizure outcome benefit when compared to the non-tailored resections. CONCLUSIONS The use of intraoperative electrocorticography in LEATs did not contribute to postoperative seizure outcome benefit in children and adults. No additional advantage or utility was offered by ECoG in children when compared to its use in adults. ECoG-guided additional tailored resections did not offer any additional seizure outcome benefit both in children and adults.
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Affiliation(s)
- Sreenath Prabha Rajeev
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - H R Darshan
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - George Chandy Vilanilam
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India.
- R Madhavan Nair Centre For Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India.
| | - Mathew Abraham
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Krishnakumar Keshavapisharady
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Easwer Hariharan Venkat
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Antony Stanley
- Regional Technical Resource Centre for Health Technology Assessment, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ramshekhar N Menon
- R Madhavan Nair Centre For Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ashalatha Radhakrishnan
- R Madhavan Nair Centre For Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ajith Cherian
- R Madhavan Nair Centre For Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Deepti Narasimaiah
- Department of Neuropathology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Bejoy Thomas
- Department of Neuroimaging and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Chandrasekhar Kesavadas
- Department of Neuroimaging and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Smita Vimala
- Department of Neuroanaesthesiology and Critical Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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de Font-Réaulx E, Solis-Santamaria A, Arch-Tirado E, González-Astiazarán A. Thermosensitive/thermochromic silicone and infrared thermography mapping in 60 consecutive cases of epilepsy surgery. Surg Neurol Int 2024; 15:63. [PMID: 38468653 PMCID: PMC10927215 DOI: 10.25259/sni_763_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 02/07/2024] [Indexed: 03/13/2024] Open
Abstract
Background Epilepsy surgery represents a therapeutic opportunity for those patients who do not respond to drug therapy. However, an important challenge is the precise identification of the epileptogenic area during surgery. Since it can be hard to delineate, it makes it necessary to use auxiliary tools as a guide during the surgical procedure. Electrocorticography (ECoG), despite having shown favorable results in terms of reducing post-surgical seizures, have certain limitations. Brain mapping using infrared thermography mapping and a new thermosensitive/thermochromic silicone (TTS) in epilepsy surgery has introduced a new resource of noninvasive and real-time devices that allow the localization of irritative zones. Methods Sixty consecutive patients with drug-resistant epilepsy with surgical indications who decided to participate voluntarily in the study were included in the study. We measured brain temperature using two quantitative methods and a qualitative method: the TTS sheet. In all cases, we used ECoG as the gold standard to identify irritative areas, and all brain tissue samples obtained were sent to pathology for diagnosis. Results In the subgroup in which the ECoG detected irritative areas (n = 51), adding the results in which there was a correlation with the different methods, the efficiency obtained to detect irritative areas is 94.11% (n = 48/51, P ≤ 0.0001) while the infrared thermography mapping method independently has an efficiency of 91.66% (P ≤ 0.0001). The TTS has a sensitivity of 95.71% and a specificity of 97.9% (P ≤ 0.0001) to detect hypothermic areas that correlate with the irritative zones detected by ECoG. No postoperative infections or wound dehiscence were documented, so the different methodologies used do not represent an additional risk for the surgical proceedings. Conclusion We consider that the infrared thermography mapping using high-resolution infrared thermography cameras and the TTS are both accurate and safe methods to identify irritative areas in epilepsy surgeries.
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Affiliation(s)
- Enrique de Font-Réaulx
- Head, Department of Epilepsy Surgery, Neurological Center, Centro Médico ABC, Mexico City, Mexico
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Freund BE, Sherman WJ, Sabsevitz DS, Middlebrooks EH, Feyissa AM, Garcia DM, Grewal SS, Chaichana KL, Quinones-Hinojosa A, Tatum WO. Can we improve electrocorticography using a circular grid array in brain tumor surgery? Biomed Phys Eng Express 2023; 9:065027. [PMID: 37871586 DOI: 10.1088/2057-1976/ad05dd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 10/23/2023] [Indexed: 10/25/2023]
Abstract
Intraoperative electrocorticography (iECoG) is used as an adjunct to localize the epileptogenic zone during surgical resection of brain tumors in patients with focal epilepsies. It also enables monitoring of after-discharges and seizures with EEG during functional brain mapping with electrical stimulation. When seizures or after-discharges are present, they complicate accurate interpretation of the mapping strategy to outline the brain's eloquent function and can affect the surgical procedure. Recurrent seizures during surgery requires urgent treatment and, when occurring during awake craniotomy, often leads to premature termination of brain mapping due to post-ictal confusion or sedation from acute rescue therapy. There are mixed results in studies on efficacy with iECoG in patients with epilepsy and brain tumors influencing survival and functional outcomes following surgery. Commercially available electrode arrays have inherent limitations. These could be improved with customization potentially leading to greater precision in safe and maximal resection of brain tumors. Few studies have assessed customized electrode grid designs as an alternative to commercially available products. Higher density electrode grids with intercontact distances less than 1 cm improve spatial delineation of electrophysiologic sources, including epileptiform activity, electrographic seizures, and afterdischarges on iECoG during functional brain mapping. In response to the shortcomings of current iECoG grid technologies, we designed and developed a novel higher-density hollow circular electrode grid array. The 360-degree iECoG monitoring capability allows continuous EEG recording during surgical intervention through the aperture with and without electrical stimulation mapping. Compared with linear strip electrodes that are commonly used for iECoG during surgery, the circular grid demonstrates significant benefits in brain tumor surgery. This includes quicker recovery of post-operative motor deficits (2.4 days versus 9 days, p = 0.05), more extensive tumor resection (92.0% versus 77.6%, p = 0.003), lesser reduction in Karnofsky Performance scale postoperatively (-2 versus -11.6, p = 0.007), and more sensitivity to recording afterdischarges. In this narrative review, we discuss the advantages and disadvantages of commercially available recording devices in the operating room and focus on the usefulness of the higher-density circular grid.
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Affiliation(s)
- Brin E Freund
- Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic, Jacksonville, FL, United States of America
| | - Wendy J Sherman
- Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic, Jacksonville, FL, United States of America
| | - David S Sabsevitz
- Department of Psychiatry, Division of Neuropsychology, Mayo Clinic College of Medicine, Mayo Clinic, Jacksonville, FL, United States of America
| | - Erik H Middlebrooks
- Department of Radiology, Division of Neuroradiology, Mayo Clinic College of Medicine, Mayo Clinic, Jacksonville, FL, United States of America
- Department of Neurosurgery, Mayo Clinic College of Medicine, Mayo Clinic, Jacksonville, FL, United States of America
| | - Anteneh M Feyissa
- Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic, Jacksonville, FL, United States of America
| | - Diogo Moniz Garcia
- Department of Neurosurgery, Mayo Clinic College of Medicine, Mayo Clinic, Jacksonville, FL, United States of America
| | - Sanjeet S Grewal
- Department of Neurosurgery, Mayo Clinic College of Medicine, Mayo Clinic, Jacksonville, FL, United States of America
| | - Kaisorn L Chaichana
- Department of Neurosurgery, Mayo Clinic College of Medicine, Mayo Clinic, Jacksonville, FL, United States of America
| | - Alfredo Quinones-Hinojosa
- Department of Neurosurgery, Mayo Clinic College of Medicine, Mayo Clinic, Jacksonville, FL, United States of America
| | - William O Tatum
- Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic, Jacksonville, FL, United States of America
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Sharma D, Tripathi M, Doddamani R, Sharma MC, Lalwani S, Sarat Chandra P, Banerjee Dixit A, Banerjee J. Correlation of age at seizure onset with GABA A receptor subunit and chloride Co-transporter configuration in Focal cortical dysplasia (FCD). Neurosci Lett 2023; 796:137065. [PMID: 36638954 DOI: 10.1016/j.neulet.2023.137065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/23/2022] [Accepted: 01/09/2023] [Indexed: 01/12/2023]
Abstract
Focal cortical dysplasia (FCD) represents a group of malformations of cortical development, which are speculated to be related to early developmental defects in the cerebral cortex. According to dysmature cerebral development hypothesis of FCD altered GABAA receptor function is known to contribute to abnormal neuronal network. Here, we studied the possible association between age at seizure onset in FCD with the subunit configuration of GABAA receptors in resected brain specimens obtained from patients with FCD. We observed a significantly higher ratio of α4/α1 subunit-containing GABAA receptors in patients with early onset (EO) FCD as compared to those with late onset (LO) FCD as is seen during the course of development where α4-containing GABAA receptors expression is high as compared to α1-containing GABAA receptors expression. Likewise, the influx to efflux chloride co-transporter expression of NKCC1/KCC2 was also increased in patients with EO FCD as seen during brain development. In addition, we observed that the ratio of GABA/Glutamate neurotransmitters was lower in patients with EO FCD as compared to that in patients with LO FCD. Our findings suggest altered configuration of GABAA receptors in FCD which could be contributing to aberrant depolarizing GABAergic activity. In particular, we observed a correlation of age at seizure onset in FCD with subunit configuration of GABAA receptors, levels of NKCC1/KCC2 and the ratio of GABA/Glutamate neurotransmitters such that the patients with EO FCD exhibited a more critically modulated GABAergic network.
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Affiliation(s)
- Devina Sharma
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ramesh Doddamani
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - M C Sharma
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Lalwani
- Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, New Delhi, India
| | - P Sarat Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Aparna Banerjee Dixit
- Dr. B.R Ambedkar Center for Biomedical Research, University of Delhi, New Delhi, India
| | - Jyotirmoy Banerjee
- Department of Biophysics, All India Institute of Medical Sciences, New Delhi, India.
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Goel K, Pek V, Shlobin NA, Chen JS, Wang A, Ibrahim GM, Hadjinicolaou A, Roessler K, Dudley RW, Nguyen DK, El-Tahry R, Fallah A, Weil AG. Clinical utility of intraoperative electrocorticography for epilepsy surgery: A systematic review and meta-analysis. Epilepsia 2023; 64:253-265. [PMID: 36404579 DOI: 10.1111/epi.17472] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022]
Abstract
Despite the widespread use of intraoperative electrocorticography (iECoG) during resective epilepsy surgery, there are conflicting data on its overall efficacy and inability to predict benefit per pathology. Given the heterogeneity of iECoG use in resective epilepsy surgery, it is important to assess the utility of interictal-based iECoG. This individual patient data (IPD) meta-analysis seeks to identify the benefit of iECoG during resective epilepsy surgery in achieving seizure freedom for various pathologies. Embase, Scopus, and PubMed were searched from inception to January 31, 2021 using the following terms: "ecog", "electrocorticography", and "epilepsy". Articles were included if they reported seizure freedom at ≥12-month follow-up in cohorts with and without iECoG for epilepsy surgery. Non-English articles, noncomparative iECoG cohorts, and studies with <10% iECoG use were excluded. This meta-analysis followed the PRISMA 2020 guidelines. The primary outcome was seizure freedom at last follow-up and time to seizure recurrence, if applicable. Forest plots with random effects modeling assessed the relationship between iECoG use and seizure freedom. Cox regression of IPD was performed to identify predictors of longer duration of seizure freedom. Kaplan-Meier curves with log-rank test were created to visualize differences in time to seizure recurrence. Of 7504 articles identified, 18 were included for study-level analysis. iECoG was not associated with higher seizure freedom at the study level (relative risk = 1.09, 95% confidence interval [CI] = 0.96-1.23, p = .19, I2 = 64%), but on IPD (n = 7 studies, 231 patients) iECoG use was independently associated with more favorable seizure outcomes (hazard ratio = 0.47, 95% CI = .23-.95, p = .037). In Kaplan-Meier analysis of specific pathologies, iECoG use was significantly associated with longer seizure freedom only for focal cortical dysplasia (FCD; p < .001) etiology. Number needed to treat for iECoG was 8.8, and for iECoG in FCD it was 4.7. We show iECoG seizure freedom is not achieved uniformly across centers. iECoG is particularly beneficial for FCD etiology in improving seizure freedom.
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Affiliation(s)
- Keshav Goel
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Valérie Pek
- Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jia-Shu Chen
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Andrew Wang
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
- College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, Los Angeles, California, USA
| | - George M Ibrahim
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Aristides Hadjinicolaou
- Division of Neurology, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, Quebec, Canada
- Brain and Development Research Axis, Sainte-Justine Research Centre, Montreal, Quebec, Canada
| | - Karl Roessler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Roy W Dudley
- Division of Pediatric Neurosurgery, Department of Pediatric Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Dang K Nguyen
- Department of Neurology, University of Montreal Hospital Centre, Montreal, Quebec, Canada
| | - Riëm El-Tahry
- Saint Luc University Hospital, Brussels, Belgium
- Institute of Neuroscience, Neurology pole, Catholic University of Louvain, Brussels, Belgium
| | - Aria Fallah
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Alexander G Weil
- Brain and Development Research Axis, Sainte-Justine Research Centre, Montreal, Quebec, Canada
- Division of Neurosurgery, Department of Surgery, Sainte-Justine University Hospital Centre, Montreal, Quebec, Canada
- Division of Neurosurgery, Department of Surgery, University of Montreal Hospital Centre, Montreal, Quebec, Canada
- Department of Neuroscience, University of Montreal, Montreal, Quebec, Canada
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9
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Zweiphenning W, Klooster MAV', van Klink NEC, Leijten FSS, Ferrier CH, Gebbink T, Huiskamp G, van Zandvoort MJE, van Schooneveld MMJ, Bourez M, Goemans S, Straumann S, van Rijen PC, Gosselaar PH, van Eijsden P, Otte WM, van Diessen E, Braun KPJ, Zijlmans M. Intraoperative electrocorticography using high-frequency oscillations or spikes to tailor epilepsy surgery in the Netherlands (the HFO trial): a randomised, single-blind, adaptive non-inferiority trial. Lancet Neurol 2022; 21:982-993. [PMID: 36270309 PMCID: PMC9579052 DOI: 10.1016/s1474-4422(22)00311-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 07/04/2022] [Accepted: 07/19/2022] [Indexed: 11/27/2022]
Abstract
Background Intraoperative electrocorticography is used to tailor epilepsy surgery by analysing interictal spikes or spike patterns that can delineate epileptogenic tissue. High-frequency oscillations (HFOs) on intraoperative electrocorticography have been proposed as a new biomarker of epileptogenic tissue, with higher specificity than spikes. We prospectively tested the non-inferiority of HFO-guided tailoring of epilepsy surgery to spike-guided tailoring on seizure freedom at 1 year. Methods The HFO trial was a randomised, single-blind, adaptive non-inferiority trial at an epilepsy surgery centre (UMC Utrecht) in the Netherlands. We recruited children and adults (no age limits) who had been referred for intraoperative electrocorticography-tailored epilepsy surgery. Participants were randomly allocated (1:1) to either HFO-guided or spike-guided tailoring, using an online randomisation scheme with permuted blocks generated by an independent data manager, stratified by epilepsy type. Treatment allocation was masked to participants and clinicians who documented seizure outcome, but not to the study team or neurosurgeon. Ictiform spike patterns were always considered in surgical decision making. The primary endpoint was seizure outcome after 1 year (dichotomised as seizure freedom [defined as Engel 1A–B] vs seizure recurrence [Engel 1C–4]). We predefined a non-inferiority margin of 10% risk difference. Analysis was by intention to treat, with prespecified subgroup analyses by epilepsy type and for confounders. This completed trial is registered with the Dutch Trial Register, Toetsingonline ABR.NL44527.041.13, and ClinicalTrials.gov, NCT02207673. Findings Between Oct 10, 2014, and Jan 31, 2020, 78 individuals were enrolled to the study and randomly assigned (39 to HFO-guided tailoring and 39 to spike-guided tailoring). There was no loss to follow-up. Seizure freedom at 1 year occurred in 26 (67%) of 39 participants in the HFO-guided group and 35 (90%) of 39 in the spike-guided group (risk difference –23·5%, 90% CI –39·1 to –7·9; for the 48 patients with temporal lobe epilepsy, the risk difference was –25·5%, –45·1 to –6·0, and for the 30 patients with extratemporal lobe epilepsy it was –20·3%, –46·0 to 5·4). Pathology associated with poor prognosis was identified as a confounding factor, with an adjusted risk difference of –7·9% (90% CI –20·7 to 4·9; adjusted risk difference –12·5%, –31·0 to 5·9, for temporal lobe epilepsy and 5·8%, –7·7 to 19·5, for extratemporal lobe epilepsy). We recorded eight serious adverse events (five in the HFO-guided group and three in the spike-guided group) requiring hospitalisation. No patients died. Interpretation HFO-guided tailoring of epilepsy surgery was not non-inferior to spike-guided tailoring on intraoperative electrocorticography. After adjustment for confounders, HFOs show non-inferiority in extratemporal lobe epilepsy. This trial challenges the clinical value of HFOs as an epilepsy biomarker, especially in temporal lobe epilepsy. Further research is needed to establish whether HFO-guided intraoperative electrocorticography holds promise in extratemporal lobe epilepsy. Funding UMCU Alexandre Suerman, EpilepsieNL, RMI Talent Fellowship, European Research Council, and MING Fund.
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Affiliation(s)
- Willemiek Zweiphenning
- Department of Neurology and Neurosurgery, Utrecht Brain Center, University Medical Center Utrecht (Part of ERN EpiCARE), Utrecht, Netherlands
| | - Maryse A van 't Klooster
- Department of Neurology and Neurosurgery, Utrecht Brain Center, University Medical Center Utrecht (Part of ERN EpiCARE), Utrecht, Netherlands
| | - Nicole E C van Klink
- Department of Neurology and Neurosurgery, Utrecht Brain Center, University Medical Center Utrecht (Part of ERN EpiCARE), Utrecht, Netherlands
| | - Frans S S Leijten
- Department of Neurology and Neurosurgery, Utrecht Brain Center, University Medical Center Utrecht (Part of ERN EpiCARE), Utrecht, Netherlands
| | - Cyrille H Ferrier
- Department of Neurology and Neurosurgery, Utrecht Brain Center, University Medical Center Utrecht (Part of ERN EpiCARE), Utrecht, Netherlands
| | - Tineke Gebbink
- Department of Neurology and Neurosurgery, Utrecht Brain Center, University Medical Center Utrecht (Part of ERN EpiCARE), Utrecht, Netherlands
| | - Geertjan Huiskamp
- Department of Neurology and Neurosurgery, Utrecht Brain Center, University Medical Center Utrecht (Part of ERN EpiCARE), Utrecht, Netherlands
| | - Martine J E van Zandvoort
- Department of Neurology and Neurosurgery, Utrecht Brain Center, University Medical Center Utrecht (Part of ERN EpiCARE), Utrecht, Netherlands
| | - Monique M J van Schooneveld
- Department of Pediatric Psychology, Wilhelmina's Children Hospital, University Medical Center Utrecht, Netherlands
| | - M Bourez
- Stichting Epilepsie Instellingen Nederland, Heemstede, Netherlands
| | - Sophie Goemans
- Department of Neurology and Neurosurgery, Utrecht Brain Center, University Medical Center Utrecht (Part of ERN EpiCARE), Utrecht, Netherlands
| | - Sven Straumann
- Department of Neurology and Neurosurgery, Utrecht Brain Center, University Medical Center Utrecht (Part of ERN EpiCARE), Utrecht, Netherlands
| | - Peter C van Rijen
- Department of Neurology and Neurosurgery, Utrecht Brain Center, University Medical Center Utrecht (Part of ERN EpiCARE), Utrecht, Netherlands
| | - Peter H Gosselaar
- Department of Neurology and Neurosurgery, Utrecht Brain Center, University Medical Center Utrecht (Part of ERN EpiCARE), Utrecht, Netherlands
| | - Pieter van Eijsden
- Department of Neurology and Neurosurgery, Utrecht Brain Center, University Medical Center Utrecht (Part of ERN EpiCARE), Utrecht, Netherlands
| | - Willem M Otte
- Department of Neurology and Neurosurgery, Utrecht Brain Center, University Medical Center Utrecht (Part of ERN EpiCARE), Utrecht, Netherlands
| | - Eric van Diessen
- Department of Neurology and Neurosurgery, Utrecht Brain Center, University Medical Center Utrecht (Part of ERN EpiCARE), Utrecht, Netherlands
| | - Kees P J Braun
- Department of Neurology and Neurosurgery, Utrecht Brain Center, University Medical Center Utrecht (Part of ERN EpiCARE), Utrecht, Netherlands
| | - Maeike Zijlmans
- Department of Neurology and Neurosurgery, Utrecht Brain Center, University Medical Center Utrecht (Part of ERN EpiCARE), Utrecht, Netherlands; Stichting Epilepsie Instellingen Nederland, Heemstede, Netherlands.
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10
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Kumar K, Banerjee Dixit A, Tripathi M, Dubey V, Siraj F, Sharma MC, Lalwani S, Chandra PS, Banerjee J. Transcriptomic profiling of nonneoplastic cortical tissues reveals epileptogenic mechanisms in dysembryoplastic neuroepithelial tumors. Funct Integr Genomics 2022; 22:905-917. [PMID: 35633443 DOI: 10.1007/s10142-022-00869-1] [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: 09/19/2021] [Revised: 05/09/2022] [Accepted: 05/09/2022] [Indexed: 11/29/2022]
Abstract
Low-grade dysembryoplastic neuroepithelial tumors (DNTs) are a frequent cause of drug-refractory epilepsy. Molecular mechanisms underlying seizure generation in these tumors are poorly understood. This study was conducted to identify altered genes in nonneoplastic epileptogenic cortical tissues (ECTs) resected from DNT patients during electrocorticography (ECoG)-guided surgery. RNA sequencing (RNAseq) was used to determine the differentially expressed genes (DEGs) in these high-spiking ECTs compared to non-epileptic controls. A total of 477 DEGs (180 upregulated; 297 downregulated) were observed in the ECTs compared to non-epileptic controls. Gene ontology analysis revealed enrichment of genes belonging to the following Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways: (i) glutamatergic synapse; (ii) nitrogen metabolism; (iii) transcriptional misregulation in cancer; and (iv) protein digestion and absorption. The glutamatergic synapse pathway was enriched by DEGs such as GRM4, SLC1A6, GRIN2C, GRM2, GRM5, GRIN3A, and GRIN2B. Enhanced glutamatergic activity was observed in the pyramidal neurons of ECTs, which could be attributed to altered synaptic transmission in these tissues compared to non-epileptic controls. Besides glutamatergic synapse, altered expression of other genes such as GABRB1 (synapse formation), SLIT2 (axonal growth), and PROKR2 (neuron migration) could be linked to epileptogenesis in ECTs. Also, upregulation of GABRA6 gene in ECTs could underlie benzodiazepine resistance in these patients. Neural cell-type-specific gene set enrichment analysis (GSEA) revealed transcriptome of ECTs to be predominantly contributed by microglia and neurons. This study provides first comprehensive gene expression profiling of nonneoplastic ECTs of DNT patients and identifies genes/pathways potentially linked to epileptogenesis.
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Affiliation(s)
- Krishan Kumar
- Dr. B.R. Ambedkar Center for Biomedical Research, University of Delhi, Delhi, India
| | | | | | - Vivek Dubey
- Department of Biophysics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India
| | - Fouzia Siraj
- ICMR-National Institute of Pathology, New Delhi, India
| | | | - Sanjeev Lalwani
- Department of Forensic Medicine and Toxicology, AIIMS, New Delhi, India
| | | | - Jyotirmoy Banerjee
- Department of Biophysics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India.
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11
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Validity of intraoperative ECoG in the parahippocampal gyrus as an indicator of hippocampal epileptogenicity. Epilepsy Res 2022; 184:106950. [DOI: 10.1016/j.eplepsyres.2022.106950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 05/01/2022] [Accepted: 05/25/2022] [Indexed: 11/20/2022]
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12
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Zhu Q, Liang Y, Fan Z, Liu Y, Zhou C, Zhang H, Li T, Zhou Y, Yang J, Wang L. The utility of intraoperative ECoG in tumor-related epilepsy: Systematic review. Clin Neurol Neurosurg 2021; 212:107054. [PMID: 34896866 DOI: 10.1016/j.clineuro.2021.107054] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/14/2021] [Accepted: 11/15/2021] [Indexed: 11/03/2022]
Abstract
OBJECT Epilepsy is one of the most common clinical manifestations of primary brain tumors. Intraoperative electrocorticography (ECoG) has been widely used in tumor resection. We aim to describe the indication and utility of ECoG during brain tumor surgery. METHODS We performed a systematic review of the literature on the prognosis of tumor-related epilepsy surgery guided by intraoperative ECoG. The published studies were searched in PubMed, Embase, and Web of Science using the keyword 'seizure' or 'epilepsy' and 'electrocorticography' or 'ECoG'. Two reviewer authors screened studies and extracted data independently. RESULTS Thirteen studies included 569 patients were finally selected, of which eight investigated medically intractable epilepsy. Three publications described temporal tumor-related epilepsy. All included studies were retrospective, and the age of all patients ranged from 1 to 71 years. The duration of epilepsy ranged from 1 month to 30 years. Patients with tumor-related epilepsy underwent surgical treatment with Engel I outcomes ranging from 56.5%-100%. CONCLUSION Intraoperative ECoG is generally considered a useful technique in delineating epileptogenic areas and improving the prognosis of surgical treatment of tumor-related epilepsy. However, large-scale randomized control trials are still needed to verify these findings and formulate appropriate surgical strategies.
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Affiliation(s)
- Qiang Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Yuchao Liang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Ziwen Fan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Yukun Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Chunyao Zhou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Hong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Tianshi Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Yanpeng Zhou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Jianing Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Lei Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China.
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13
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Madaan P, Gupta A, Gulati S. Pediatric Epilepsy Surgery: Indications and Evaluation. Indian J Pediatr 2021; 88:1000-1006. [PMID: 33740232 DOI: 10.1007/s12098-021-03668-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 01/12/2021] [Indexed: 12/26/2022]
Abstract
Epilepsy is a common neurological condition in children. It is usually amenable to drug therapy. However, nearly one-third of patients may be refractory to antiseizure drugs. Poor compliance and nonepileptic events should be ruled out as possible causes of drug-resistant epilepsy (DRE). After failing adequate trials of two appropriate antiseizure drugs, patients with focal DRE or poorly classifiable epilepsy or epileptic encephalopathy with focal electro-clinical features should be worked up for surgical candidacy. A randomized controlled trial provided a class I evidence for epilepsy surgery in pediatric DRE. Pre-surgical screening workup typically includes a high-resolution epilepsy protocol brain magnetic resonance imaging (MRI) and a high-quality in-patient video electroencephalography evaluation. Advanced investigations such as positron emission tomography (PET), single-photon emission computed tomography (SPECT), and magnetoencephalography (MEG) may be required in selected cases especially when brain MRI is normal, and further evidence for anatomo-electro-clinical concordance is necessary to refine candidacy for surgery and surgical strategy. Some children may also need functional MRI to map eloquent regions of interest such as motor, sensory, and language functions to avoid unacceptable neurological deficits after surgery. Selected children may need invasive long-term electroencephalographic monitoring using stereotactically implanted intracranial depth electrodes or subdural grids. Surgical options include resective surgeries (lesionectomy, lobectomy, multilobar resections) and disconnective surgeries (corpus callosotomy, etc.) with the potential to obtain seizure freedom. Other surgical procedures, typically considered to be palliative are neuromodulation [deep brain stimulation (DBS), vagal nerve stimulation (VNS), and responsive neural stimulation (RNS)]. DBS and RNS are currently not approved in children. Pediatric DRE should be evaluated early considering the risk of epileptic encephalopathy and negative impact on cognition.
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Affiliation(s)
- Priyanka Madaan
- Pediatric Neurology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Gupta
- Pediatric Epilepsy, Epilepsy Center, Department of Neurology/Neurological Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Sheffali Gulati
- Center of Excellence & Advanced Research on Childhood Neurodevelopmental Disorders, Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
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14
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Abstract
BACKGROUND A large number of patients have epilepsy that is intractable and adversely affects a child's lifelong experience with addition societal burden that is disabling and expensive. The last two decades have seen a major explosion of new antiseizure medication options. Despite these advances, children with epilepsy continue to have intractable seizures. An option that has been long available but little used is epilepsy surgery to control intractable epilepsy. METHODS This article is a review of the literature as well as published opinions. RESULTS Epilepsy surgery in pediatrics is an underused modality to effectively treat children with epilepsy. Adverse effects of medication should be weighed against risks of surgery as well as risks of nonefficacy. CONCLUSIONS We discuss an approach to selecting the appropriate pediatric patient for consideration, a detailed evaluation including necessary evaluation, and the creation of an algorithm to approach patients with both generalized and focal epilepsy. We then discuss surgical options available including outcome data. New modalities are also addressed including high-frequency ultrasound and co-registration techniques including magnetic resonance imaging-guided laser therapy.
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15
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Srivastava A, Kumar K, Banerjee J, Tripathi M, Dubey V, Sharma D, Yadav N, Sharma MC, Lalwani S, Doddamani R, Chandra PS, Dixit AB. Transcriptomic profiling of high- and low-spiking regions reveals novel epileptogenic mechanisms in focal cortical dysplasia type II patients. Mol Brain 2021; 14:120. [PMID: 34301297 PMCID: PMC8305866 DOI: 10.1186/s13041-021-00832-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 07/14/2021] [Indexed: 11/15/2022] Open
Abstract
Focal cortical dysplasia (FCD) is a malformation of the cerebral cortex with poorly-defined epileptogenic zones (EZs), and poor surgical outcome in FCD is associated with inaccurate localization of the EZ. Hence, identifying novel epileptogenic markers to aid in the localization of EZ in patients with FCD is very much needed. High-throughput gene expression studies of FCD samples have the potential to uncover molecular changes underlying the epileptogenic process and identify novel markers for delineating the EZ. For this purpose, we, for the first time performed RNA sequencing of surgically resected paired tissue samples obtained from electrocorticographically graded high (MAX) and low spiking (MIN) regions of FCD type II patients and autopsy controls. We identified significant changes in the MAX samples of the FCD type II patients when compared to non-epileptic controls, but not in the case of MIN samples. We found significant enrichment for myelination, oligodendrocyte development and differentiation, neuronal and axon ensheathment, phospholipid metabolism, cell adhesion and cytoskeleton, semaphorins, and ion channels in the MAX region. Through the integration of both MAX vs non-epileptic control and MAX vs MIN RNA sequencing (RNA Seq) data, PLP1, PLLP, UGT8, KLK6, SOX10, MOG, MAG, MOBP, ANLN, ERMN, SPP1, CLDN11, TNC, GPR37, SLC12A2, ABCA2, ABCA8, ASPA, P2RX7, CERS2, MAP4K4, TF, CTGF, Semaphorins, Opalin, FGFs, CALB2, and TNC were identified as potential key regulators of multiple pathways related to FCD type II pathology. We have identified novel epileptogenic marker elements that may contribute to epileptogenicity in patients with FCD and could be possible markers for the localization of EZ.
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Affiliation(s)
| | - Krishan Kumar
- Dr B R Ambedkar Centre for Biomedical Research, University of Delhi, Delhi, 110007, India
| | | | | | - Vivek Dubey
- Department of Biophysics, AIIMS, New Delhi, India
| | - Devina Sharma
- Department of Neurosurgery, AIIMS, New Delhi, 110029, India
| | - Nitin Yadav
- Dr B R Ambedkar Centre for Biomedical Research, University of Delhi, Delhi, 110007, India
| | - M C Sharma
- Department of Pathology, AIIMS, New Delhi, India
| | - Sanjeev Lalwani
- Department of Forensic Medicine and Toxicology, AIIMS, New Delhi, India
| | | | - P Sarat Chandra
- Department of Neurosurgery, AIIMS, New Delhi, 110029, India.
| | - Aparna Banerjee Dixit
- Dr B R Ambedkar Centre for Biomedical Research, University of Delhi, Delhi, 110007, India.
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16
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Warsi NM, Narvacan K, Donner E, Go C, Strantzas S, Ochi A, Otsubo H, Sharma R, Snead OC, Ibrahim GM. Supplementing Extraoperative Electrocorticography With Real-Time Intraoperative Recordings Using the Same Chronically Implanted Electrodes. Oper Neurosurg (Hagerstown) 2021; 20:559-564. [PMID: 33555026 DOI: 10.1093/ons/opab019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 12/11/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The practice of intraoperative electrocorticography (iECoG) to guide resective epilepsy surgery is variable. Limitations of iECoG include variability in recordings from previously unsampled cortex, increased operative time and cost, and a lack of clear benefit to surgical decision-making. OBJECTIVE To describe a simple technique to supplement extraoperative intracranial recordings with real-time iECoG using the same chronically implanted electrodes that overcome some of these limitations. METHODS We describe the technical procedure, intraoperative findings, and outcomes of 7 consecutive children undergoing 2-stage resective epilepsy surgery with invasive subdural grid monitoring between January 2017 and December 2019. All children underwent placement of subdural grids, strips, and depth electrodes. Planned neocortical resection was based on extraoperative mapping of ictal and interictal recordings. During resection in the second stage, the same electrodes were used to perform real-time iECoG. RESULTS Real-time iECoG using this technique leads to modification of resection for 2 of the 7 children. The first was extended due to an electroencephalographic seizure from a distant electrode not part of the original resection plan. The second was restricted due to attenuation of epileptiform activity following a partial resection, thereby limiting the extent of a Rolandic resection. No infections or other adverse events were encountered. CONCLUSION We report a simple technique to leverage chronically implanted electrodes for real-time iECoG during 2-stage resective surgery. This technique presents fewer limitations than traditional approaches and may alter intraoperative decision-making.
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Affiliation(s)
- Nebras M Warsi
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Karl Narvacan
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elizabeth Donner
- Department of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cristina Go
- Department of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Samuel Strantzas
- Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ayako Ochi
- Department of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hiroshi Otsubo
- Department of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Roy Sharma
- Department of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - O Carter Snead
- Department of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - George M Ibrahim
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
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Kobayashi Y, Sato Y, Sugiyama T, Mizutani T. Intraoperative epileptogenic network visualization using gamma oscillation regularity correlation analysis in epilepsy surgery. Surg Neurol Int 2021; 12:254. [PMID: 34221585 PMCID: PMC8247660 DOI: 10.25259/sni_298_2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 04/29/2021] [Indexed: 11/10/2022] Open
Abstract
Background: We have recently demonstrated that gamma oscillation (30–70 Hz) regularity (GOR) analysis accurately localized epileptogenic focus using intraoperative electrocorticographic data. In this report, we assessed whether GOR correlation analysis could depict epileptogenic networks intraoperatively. Dual foci in temporal lobe epilepsy without hippocampal structural abnormalities are difficult to diagnose. Using our GOR correlation analysis, we aimed to intraoperatively visualize such dual foci and epileptogenic networks. Case Description: A 56-year-old man suffered from pharmacoresistant focal impaired awareness seizures. Magnetic resonance imaging demonstrated an 8 × 12-mm cavernoma in the right inferior temporal gyrus without any structural changes in the hippocampus. Since ictal semiology indicated a high probability of epileptogenicity in the right hippocampus, we reached the hippocampus using a transsylvian approach and assessed intraoperative GOR correlation analysis in the lateral temporal lobe where the cavernoma was located and the hippocampus, simultaneously. High GORs suggestive of epileptogenicity were identified in both the lateral temporal lobe and the hippocampus. Furthermore, they were connected using GOR correlation networks. When the high GOR locations in the lateral temporal lobe and the cavernoma were removed, high GORs and those networks were found within the hippocampus only. After additional hippocampal transection, high GORs and these networks were absent. The patient became seizure-free after the surgery. Conclusion: Our GOR correlation analysis may be a powerful tool for intraoperative evaluation of epileptogenic networks in epilepsy surgery.
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Affiliation(s)
- Yuta Kobayashi
- Department of Neurosurgery, Showa University School of Medicine, Tokyo, Japan
| | - Yosuke Sato
- Department of Neurosurgery, Showa University School of Medicine, Tokyo, Japan
| | - Tatsuya Sugiyama
- Department of Neurosurgery, Showa University School of Medicine, Tokyo, Japan
| | - Tohru Mizutani
- Department of Neurosurgery, Showa University School of Medicine, Tokyo, Japan
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18
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Peng SJ, Wong TT, Huang CC, Chang H, Hsieh KLC, Tsai ML, Yang YS, Chen CL. Quantitative analysis of intraoperative electrocorticography mirrors histopathology and seizure outcome after epileptic surgery in children. J Formos Med Assoc 2020; 120:1500-1511. [PMID: 33214033 DOI: 10.1016/j.jfma.2020.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/21/2020] [Accepted: 11/01/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Epileptic surgery is the potentially curative treatment for children with refractory seizures. The study aimed to quantify and analyze high frequency oscillation (HFO) ripples and interictal epileptiform discharges (EDs) in intraoperative electrocorticography (ECoG) between malformation of cortical dysplasia (MCD) and non-MCD children with MRI-lesional focal epilepsy, and evaluate of seizure outcomes after epileptic surgery. METHODS The intraoperative ECoG was performed before and after lesionectomy. Quantifications of HFO ripples and interictal EDs of ECoG by frequency, amplitude, and foci of intraoperative ECoG were performed based on electrode location, and the characteristics of ECoG recordings were analyzed in each patient based on their histopathology. Seizure outcome after surgery according to their quantitative ECoG findings was analyzed. RESULTS Frequency of EDs and HFO ripple rates in preresection ECoG were significantly higher in children with MCD compared with non-MCD (p = 0.018 and p = 0.002, respectively). Higher frequencies of EDs and ripple rates in preresection ECoG were observed in residual seizures than in seizure-free children (p = 0.045 and p = 0.005, respectively). Clinically, children with residual seizures after surgery were significantly younger at the onset, had a trend of higher seizure frequency and higher spike frequency of presurgical videoEEG. CONCLUSION Our results suggested that quantification of intraoperative ECoG predicted seizure outcomes and reflected different ED pattern and frequencies between MCD and non-dysplastic histopathology among children who underwent resective epileptic surgery. The results of our study were encouraging and indicated that intraoperative ECoG improved the outcomes of surgery in children with epilepsy.
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Affiliation(s)
- Syu-Jyun Peng
- Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tai-Tong Wong
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Neuroscience Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chao-Ching Huang
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsi Chang
- Neuroscience Research Center, Taipei Medical University Hospital, Taipei, Taiwan; Division of Pediatric Neurology, Department of Pediatrics, Taipei Medical University Hospital, Taipei Medical University, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Kevin Li-Chun Hsieh
- Neuroscience Research Center, Taipei Medical University Hospital, Taipei, Taiwan; Department of Medical Imaging, Taipei Medical University Hospital, Taipei, Taiwan; Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Min-Lan Tsai
- Neuroscience Research Center, Taipei Medical University Hospital, Taipei, Taiwan; Division of Pediatric Neurology, Department of Pediatrics, Taipei Medical University Hospital, Taipei Medical University, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| | - Yi-Shang Yang
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chi-Long Chen
- Department of Pathology, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan; Department of Pathology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Effects of sevoflurane anesthesia on intraoperative high-frequency oscillations in patients with temporal lobe epilepsy. Seizure 2020; 82:44-49. [DOI: 10.1016/j.seizure.2020.08.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/08/2020] [Accepted: 08/28/2020] [Indexed: 11/24/2022] Open
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Lesko R, Benova B, Jezdik P, Liby P, Jahodova A, Kudr M, Tichy M, Zamecnik J, Krsek P. The clinical utility of intraoperative electrocorticography in pediatric epilepsy surgical strategy and planning. J Neurosurg Pediatr 2020; 26:533-542. [PMID: 32736347 DOI: 10.3171/2020.4.peds20198] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 04/29/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In this study, the authors aimed to determine 1) whether the use of intraoperative electrocorticography (ECoG) affects outcomes and complication rates of children undergoing resective epilepsy surgery; 2) which patient- and epilepsy-related variables might influence ECoG-based surgical strategy; and 3) what the predictors of epilepsy surgery outcomes are. METHODS Over a period of 12 years, data were collected on pediatric patients who underwent tailored brain resections in the Motol Epilepsy Center. In patients in whom an abnormal ECoG pattern (e.g., spiking, suppression burst, or recruiting rhythm) was not observed beyond presurgically planned resection margins, the authors did not modify the surgical plan (group A). In those with significant abnormal ECoG findings beyond resection margins, the authors either did (group B) or did not (group C) modify the surgical plan, depending on the proximity of the eloquent cortex or potential extent of resection. Using Fisher's exact test and the chi-square test, the 3 groups were compared in relation to epilepsy surgery outcomes and complication rate. Next, multivariate models were constructed to identify variables associated with each of the groups and with epilepsy surgery outcomes. RESULTS Patients in group C achieved significantly lower rates of seizure freedom compared to groups A (OR 30.3, p < 0.001) and B (OR 35.2, p < 0.001); groups A and B did not significantly differ (p = 0.78). Patients in whom the surgical plan was modified suffered from more frequent complications (B vs A+C, OR 3.8, p = 0.01), but these were mostly minor (duration < 3 months; B vs A+C, p = 0.008). In all cases, tissue samples from extended resections were positive for the presence of the original pathology. Patients with intended modification of the surgical plan (groups B+C) suffered more often from daily seizures, had a higher age at first seizure, had intellectual disability, and were regarded as MR-negative (p < 0.001). Unfavorable surgical outcome (Engel class II-IV) was associated with focal cortical dysplasia, incomplete resection based on MRI and/or ECoG findings, negative MRI finding, and inability to modify the surgical plan when indicated. CONCLUSIONS Intraoperative ECoG serves as a reliable tool to guide resection and may inform the prognosis for seizure freedom in pediatric patients undergoing epilepsy surgery. ECoG-based modification of the surgical plan is associated with a higher rate of minor complications. Children in whom ECoG-based modification of the surgical plan is indicated but not feasible achieve significantly worse surgical outcomes.
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Affiliation(s)
| | | | - Petr Jezdik
- 3Department of Circuit Theory, Faculty of Electrical Engineering, Czech Technical University of Prague, Czech Republic
| | | | | | | | | | - Josef Zamecnik
- 4Pathology and Molecular Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital; and
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Banerjee J, Dey S, Dixit AB, Doddamani R, Sharma MC, Garg A, Chandra PS, Tripathi M. GABA A Receptor-Mediated Epileptogenicity in Focal Cortical Dysplasia (FCD) Depends on Age at Epilepsy Onset. Front Cell Neurosci 2020; 14:562811. [PMID: 33192309 PMCID: PMC7556289 DOI: 10.3389/fncel.2020.562811] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 09/01/2020] [Indexed: 11/13/2022] Open
Abstract
Enhanced spontaneous GABAA receptor activity is associated with focal cortical dysplasia (FCD), a developmental malformation of the cerebral cortex. Clinical manifestations in FCD vary with age at epilepsy onset with a more favorable prognosis in patients with late-onset (LO) compared to that in cases with early-onset (EO). This study was designed to test the hypothesis in FCD that spontaneous GABAA receptor-mediated epileptogenicity depends on the age at epilepsy onset and varies between patients with early and late-onset age in FCD. To this end, brain specimens were obtained from the maximal spiking region (MAX) and minimal spiking region (MIN) of the epileptic foci of EO (n = 14, mean age = 10.6 ± 2.9 years) and LO (n = 10, mean age = 27 ± 5.6 years) patients undergoing electrocorticography (ECoG) guided surgery. The whole-cell patch-clamp technique was used to record spontaneous GABAergic currents from normal-looking pyramidal neurons in slice preparations of resected brain samples. We detected higher frequency and amplitude of GABAergic events in MAX samples compared to MIN samples of LO patients, while they were comparable in MIN and MAX samples of EO patients. Further GABAergic activity in the MIN and MAX samples of EO patients was higher than the MIN samples of LO patients. This suggests that in LO patients, GABAA receptor-mediated epileptogenicity is confined only to the high spiking areas, but in EO patients, it affects low spiking regions as well.
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Affiliation(s)
- Jyotirmoy Banerjee
- Department of Biophysics, All India Institute of Medical Sciences, New Delhi, India
| | - Soumil Dey
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Aparna Banerjee Dixit
- Dr. B R Ambedkar Centre for Biomedical Research, University of Delhi, New Delhi, India
| | - Ramesh Doddamani
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Meher Chand Sharma
- Department of Neuropathology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Garg
- Department of Neuroimaging and Interventional Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - P Sarat Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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22
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Demuru M, Kalitzin S, Zweiphenning W, van Blooijs D, Van't Klooster M, Van Eijsden P, Leijten F, Zijlmans M. The value of intra-operative electrographic biomarkers for tailoring during epilepsy surgery: from group-level to patient-level analysis. Sci Rep 2020; 10:14654. [PMID: 32887896 PMCID: PMC7474097 DOI: 10.1038/s41598-020-71359-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 04/23/2020] [Indexed: 01/08/2023] Open
Abstract
Signal analysis biomarkers, in an intra-operative setting, may be complementary tools to guide and tailor the resection in drug-resistant focal epilepsy patients. Effective assessment of biomarker performances are needed to evaluate their clinical usefulness and translation. We defined a realistic ground-truth scenario and compared the effectiveness of different biomarkers alone and combined to localize epileptogenic tissue during surgery. We investigated the performances of univariate, bivariate and multivariate signal biomarkers applied to 1 min inter-ictal intra-operative electrocorticography to discriminate between epileptogenic and non-epileptogenic locations in 47 drug-resistant people with epilepsy (temporal and extra-temporal) who had been seizure-free one year after the operation. The best result using a single biomarker was obtained using the phase-amplitude coupling measure for which the epileptogenic tissue was localized in 17 out of 47 patients. Combining the whole set of biomarkers provided an improvement of the performances: 27 out of 47 patients. Repeating the analysis only on the temporal-lobe resections we detected the epileptogenic tissue in 29 out of 30 combining all the biomarkers. We suggest that the assessment of biomarker performances on a ground-truth scenario is required to have a proper estimate on how biomarkers translate into clinical use. Phase-amplitude coupling seems the best performing single biomarker and combining biomarkers improves localization of epileptogenic tissue. Performance achieved is not adequate as a tool in the operation theater yet, but it can improve the understanding of pathophysiological process.
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Affiliation(s)
- Matteo Demuru
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands.
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Stiliyan Kalitzin
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Willemiek Zweiphenning
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Dorien van Blooijs
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maryse Van't Klooster
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pieter Van Eijsden
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frans Leijten
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maeike Zijlmans
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
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Brodnick SK, Ness JP, Richner TJ, Thongpang S, Novello J, Hayat M, Cheng KP, Krugner-Higby L, Suminski AJ, Ludwig KA, Williams JC. μECoG Recordings Through a Thinned Skull. Front Neurosci 2019; 13:1017. [PMID: 31632232 PMCID: PMC6779785 DOI: 10.3389/fnins.2019.01017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 09/06/2019] [Indexed: 12/12/2022] Open
Abstract
The studies described in this paper for the first time characterize the acute and chronic performance of optically transparent thin-film micro-electrocorticography (μECoG) grids implanted on a thinned skull as both an electrophysiological complement to existing thinned skull preparation for optical recordings/manipulations, and a less invasive alternative to epidural or subdurally placed μECoG arrays. In a longitudinal chronic study, μECoG grids placed on top of a thinned skull maintain impedances comparable to epidurally placed μECoG grids that are stable for periods of at least 1 month. Optogenetic activation of cortex is also reliably demonstrated through the optically transparent μECoG grids acutely placed on the thinned skull. Finally, spatially distinct electrophysiological recordings were evident on μECoG electrodes placed on a thinned skull separated by 500–750 μm, as assessed by stimulation evoked responses using optogenetic activation of cortex as well as invasive and epidermal stimulation of the sciatic and median nerve at chronic time points. Neural signals were collected through a thinned skull in mice and rats, demonstrating potential utility in neuroscience research applications such as in vivo imaging and optogenetics.
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Affiliation(s)
- Sarah K Brodnick
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States
| | - Jared P Ness
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States
| | - Thomas J Richner
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States
| | - Sanitta Thongpang
- Department of Biomedical Engineering, Mahidol University, Salaya, Thailand
| | - Joseph Novello
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States
| | - Mohammed Hayat
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States
| | - Kevin P Cheng
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States
| | - Lisa Krugner-Higby
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - Aaron J Suminski
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States.,Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI, United States
| | - Kip A Ludwig
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States.,Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI, United States
| | - Justin C Williams
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States.,Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI, United States
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Bhaskar N, Thakkar KD, Sharma S, Hrishi AP. Dexmedetomidine for Electrocorticography in Patients With Lennox-Gastaut Syndrome Presenting for Epilepsy Surgery: A Case Report. A A Pract 2019; 13:148-150. [PMID: 31008722 DOI: 10.1213/xaa.0000000000001020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report the anesthetic management of 2 patients with Lennox-Gastaut syndrome presenting for respective epilepsy surgery with intraoperative electrocorticography. Electrocorticography is a useful tool to guide the localization of the epileptogenic focus for surgical resection in epilepsy surgery. Drug interactions, proconvulsant or anticonvulsant activity of the anesthetics, and anesthetic influence on intraoperative electrocorticography are the primary concerns to be addressed in these patients. We observed that dexmedetomidine-based anesthesia facilitates intraoperative electrocorticography monitoring. Dexmedetomidine, by decreasing the requirements of other anesthetic agents, offers better recovery profile and pain relief with minimal respiratory depression in patients undergoing disconnective epilepsy surgeries.
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Affiliation(s)
- Nisha Bhaskar
- From the Division of Neuroanesthesia, Department of Anaesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
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Alkawadri R. Brain-Computer Interface (BCI) Applications in Mapping of Epileptic Brain Networks Based on Intracranial-EEG: An Update. Front Neurosci 2019; 13:191. [PMID: 30971871 PMCID: PMC6446441 DOI: 10.3389/fnins.2019.00191] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 02/18/2019] [Indexed: 01/20/2023] Open
Abstract
The main applications of the Brain-Computer Interface (BCI) have been in the domain of rehabilitation, control of prosthetics, and in neuro-feedback. Only a few clinical applications presently exist for the management of drug-resistant epilepsy. Epilepsy surgery can be a life-changing procedure in the subset of millions of patients who are medically intractable. Recording of seizures and localization of the Seizure Onset Zone (SOZ) in the subgroup of "surgical" patients, who require intracranial-EEG (icEEG) evaluations, remain to date the best available surrogate marker of the epileptogenic tissue. icEEG presents certain risks and challenges making it a frontier that will benefit from optimization. Despite the presentation of several novel biomarkers for the localization of epileptic brain regions (HFOs-spikes vs. Spikes for instance), integration of most in practices is not at the prime time as it requires a degree of knowledge about signal and computation. The clinical care remains inspired by the original practices of recording the seizures and expert visual analysis of rhythms at onset. It is becoming increasingly evident, however, that there is more to infer from the large amount of EEG data sampled at rates in the order of less than 1 ms and collected over several days of invasive EEG recordings than commonly done in practice. This opens the door for interesting areas at the intersection of neuroscience, computation, engineering and clinical care. Brain-Computer interface (BCI) has the potential of enabling the processing of a large amount of data in a short period of time and providing insights that are not possible otherwise by human expert readers. Our practices suggest that implementation of BCI and Real-Time processing of EEG data is possible and suitable for most standard clinical applications, in fact, often the performance is comparable to a highly qualified human readers with the advantage of producing the results in real-time reliably and tirelessly. This is of utmost importance in specific environments such as in the operating room (OR) among other applications. In this review, we will present the readers with potential targets for BCI in caring for patients with surgical epilepsy.
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Affiliation(s)
- Rafeed Alkawadri
- Human Brain Mapping Laboratory, Department of Neurology, University of Pittsburgh, Pittsburgh, PA, United States
- Yale Human Brain Mapping Program, Yale University, New Haven, CT, United States
- The Department of Neurology, School of Medicine, Yale University, New Haven, CT, United States
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Chandra PS, Subianto H, Bajaj J, Girishan S, Doddamani R, Ramanujam B, Chouhan MS, Garg A, Tripathi M, Bal CS, Sarkar C, Dwivedi R, Sapra S, Tripathi M. Endoscope-assisted (with robotic guidance and using a hybrid technique) interhemispheric transcallosal hemispherotomy: a comparative study with open hemispherotomy to evaluate efficacy, complications, and outcome. J Neurosurg Pediatr 2019; 23:187-197. [PMID: 30497135 DOI: 10.3171/2018.8.peds18131] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 08/09/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEEndoscope-assisted hemispherotomy (EH) has emerged as a good alternative option for hemispheric pathologies with drug-resistant epilepsy.METHODSThis was a prospective observational study. Parameters measured included primary outcome measures (frequency, severity of seizures) and secondary outcomes (cognition, behavior, and quality of life). Blood loss, operating time, complications, and hospital stay were also taken into account. A comparison was made between the open hemispherotomy (OH) and endoscopic techniques performed by the senior author.RESULTSOf 59 cases (42 males), 27 underwent OH (8 periinsular, the rest vertical) and 32 received EH. The mean age was 8.65 ± 5.41 years (EH: 8.6 ± 5.3 years; OH: 8.6 ± 5.7 years). Seizure frequency per day was 7 ± 5.9 (EH: 7.3 ± 4.6; OH: 15.0 ± 6.2). Duration of disease (years since first episode) was 3.92 ± 1.24 years (EH: 5.2 ± 4.3; OH: 5.8 ± 4.5 years). Number of antiepileptic drugs per patient was 3.9 ± 1.2 (EH: 4.2 ± 1.2; OH: 3.8 ± 0.98). Values for the foregoing variables are expressed as the mean ± SD. Pathologies included the following: postinfarct encephalomalacia in 19 (EH: 11); Rasmussen's syndrome in 14 (EH: 7); hemimegalencephaly in 12 (EH: 7); hemispheric cortical dysplasia in 7 (EH: 4); postencephalitis sequelae in 6 (EH: 2); and Sturge-Weber syndrome in 1 (EH: 1). The mean follow-up was 40.16 ± 17.3 months. Thirty-nine of 49 (79.6%) had favorable outcomes (International League Against Epilepsy class I and II): in EH the total was 19/23 (82.6%) and in OH it was 20/26 (76.9%). There was no difference in the primary outcome between EH and OH (p = 0.15). Significant improvement was seen in the behavioral/quality of life performance, but not in IQ scores in both EH and OH (p < 0.01, no intergroup difference). Blood loss (p = 0.02) and hospital stay (p = 0.049) were less in EH.CONCLUSIONSEH was as effective as the open procedure in terms of primary and secondary outcomes. It also resulted in less blood loss and a shorter postoperative hospital stay.
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Affiliation(s)
- P Sarat Chandra
- Departments of1Neurosurgery
- 3COE, Epilepsy, National Brain Research Centre and All India Institute of Medical Sciences, New Delhi; and
| | - Heri Subianto
- Departments of1Neurosurgery
- 3COE, Epilepsy, National Brain Research Centre and All India Institute of Medical Sciences, New Delhi; and
| | - Jitin Bajaj
- Departments of1Neurosurgery
- 3COE, Epilepsy, National Brain Research Centre and All India Institute of Medical Sciences, New Delhi; and
| | - Shabari Girishan
- Departments of1Neurosurgery
- 3COE, Epilepsy, National Brain Research Centre and All India Institute of Medical Sciences, New Delhi; and
| | | | - Bhargavi Ramanujam
- 2Neurology
- 3COE, Epilepsy, National Brain Research Centre and All India Institute of Medical Sciences, New Delhi; and
| | | | | | | | | | | | | | - Savita Sapra
- 8Pediatric Neuropsychology, All India Institute of Medical Sciences, New Delhi
| | - Manjari Tripathi
- 2Neurology
- 3COE, Epilepsy, National Brain Research Centre and All India Institute of Medical Sciences, New Delhi; and
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Roessler K, Heynold E, Buchfelder M, Stefan H, Hamer HM. Current value of intraoperative electrocorticography (iopECoG). Epilepsy Behav 2019; 91:20-24. [PMID: 30420228 DOI: 10.1016/j.yebeh.2018.06.053] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 06/28/2018] [Accepted: 06/29/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Intraoperative electrocorticography (iopECoG) can contribute to delineate the resection borders of the anticipated epileptogenic zone in epilepsy surgery. However, it has several caveats that should be considered to avoid incorrect interpretation during intraoperative monitoring. METHODS The literature on iopECoG application was reviewed, and pros and cons as well as obstacles to this technique were analyzed. RESULTS The literature of the first half of the nineties was very enthusiastic in using iopECoG for tailoring the resection in temporal as well as extratemporal epilepsy surgery. Mostly, this resulted in a good correlation of postresection ECoG and excellent seizure outcome. In the second half of the nineties, many authors demonstrated lack of correlation between iopECoG and postoperative seizure outcome, especially in surgery for temporal lobe epilepsy with hippocampal sclerosis. In the noughties, investigators found that ECoG was significantly useful in neocortical lesional temporal lobe epilepsy as well as in extratemporal lesional epilepsies. Extratemporal epilepsy without lesions proved to be more a domain of chronic extraoperative ECoG, especially using depth electrode recordings. In recent years, iopECoG detecting high-frequency oscillations (ripples, 80-250 Hz, fast ripples, 250-500 Hz) for tailored resection was found to allow intraoperative prediction of postoperative seizure outcome. CONCLUSION After a period of scepticism, iopECoG seems back in the focus of interest for intraoperative guidance of resecting epileptogenic tissue to raise postoperative favorable seizure outcome. In temporal and extratemporal lesional epilepsies, especially in cases of focal cortical dysplasia, tuberous sclerosis, or cavernous malformations, an excellent correlation between iopECoG-guided resection and postoperative seizure relief was found.
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Affiliation(s)
- Karl Roessler
- Neurosurgical Clinic, University Hospital Erlangen, Germany.
| | | | | | - Hermann Stefan
- Epilepsy Center, Neurological Clinic, University Hospital Erlangen, Germany
| | - Hajo M Hamer
- Epilepsy Center, Neurological Clinic, University Hospital Erlangen, Germany
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Tatum W, Rubboli G, Kaplan P, Mirsatari S, Radhakrishnan K, Gloss D, Caboclo L, Drislane F, Koutroumanidis M, Schomer D, Kasteleijn-Nolst Trenite D, Cook M, Beniczky S. Clinical utility of EEG in diagnosing and monitoring epilepsy in adults. Clin Neurophysiol 2018; 129:1056-1082. [DOI: 10.1016/j.clinph.2018.01.019] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 12/28/2017] [Accepted: 01/09/2018] [Indexed: 12/20/2022]
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Electrocorticographic Patterns in Epilepsy Surgery and Long-Term Outcome. J Clin Neurophysiol 2017; 34:520-526. [DOI: 10.1097/wnp.0000000000000407] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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30
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Rossini L, Garbelli R, Gnatkovsky V, Didato G, Villani F, Spreafico R, Deleo F, Lo Russo G, Tringali G, Gozzo F, Tassi L, de Curtis M. Seizure activity per se does not induce tissue damage markers in human neocortical focal epilepsy. Ann Neurol 2017; 82:331-341. [PMID: 28749594 DOI: 10.1002/ana.25005] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 07/10/2017] [Accepted: 07/17/2017] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The contribution of recurring seizures to the progression of epileptogenesis is debated. Seizure-induced brain damage is not conclusively demonstrated either in humans or in animal models of epilepsy. We evaluated the expression of brain injury biomarkers on postsurgical brain tissue obtained from 20 patients with frequent seizures and a long history of drug-resistant focal epilepsy. METHODS The expression patterns of specific glial, neuronal, and inflammatory molecules were evaluated by immunohistochemistry in the core of type II focal cortical dysplasias (FCD-II), at the FCD boundary (perilesion), and in the adjacent normal-appearing area included in the epileptogenic region. We also analyzed surgical specimens from cryptogenic patients not presenting structural alterations at imaging. RESULTS Astroglial and microglial activation, reduced neuronal density, perivascular CD3-positive T-lymphocyte clustering, and fibrinogen extravasation were demonstrated in the core of FCD-II lesions. No pathological immunoreactivity was observed outside the FCD-II or in cryptogenetic specimens, where the occurrence of interictal and ictal epileptiform activity was confirmed by either stereo-electroencephalography or intraoperative electrocorticography. INTERPRETATION Recurrent seizures do not induce the expression of brain damage markers in nonlesional epileptogenic cortex studied in postsurgical tissue from cryptogenic and FCD patients. This evidence argues against the hypothesis that epileptiform activity per se contributes to focal brain injury, at least in the neocortical epilepsies considered here. Ann Neurol 2017;82:331-341.
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Affiliation(s)
- Laura Rossini
- Epilepsy Unit, C. Besta Neurological Institute Foundation
| | - Rita Garbelli
- Epilepsy Unit, C. Besta Neurological Institute Foundation
| | | | | | - Flavio Villani
- Epilepsy Unit, C. Besta Neurological Institute Foundation
| | | | | | | | - Giovanni Tringali
- Neurosurgery Unit, C. Besta Neurological Institute Foundation, Milan, Italy
| | | | - Laura Tassi
- C. Munari Epilepsy Surgery Center, Niguarda Hospital
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van 't Klooster MA, van Klink NEC, Zweiphenning WJEM, Leijten FSS, Zelmann R, Ferrier CH, van Rijen PC, Otte WM, Braun KPJ, Huiskamp GJM, Zijlmans M. Tailoring epilepsy surgery with fast ripples in the intraoperative electrocorticogram. Ann Neurol 2017; 81:664-676. [PMID: 28380659 DOI: 10.1002/ana.24928] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 03/09/2017] [Accepted: 03/26/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Intraoperative electrocorticography (ECoG) can be used to delineate the resection area in epilepsy surgery. High-frequency oscillations (HFOs; 80-500 Hz) seem better biomarkers for epileptogenic tissue than spikes. We studied how HFOs and spikes in combined pre- and postresection ECoG predict surgical outcome in different tailoring approaches. METHODS We, retrospectively, marked HFOs, divided into fast ripples (FRs; 250-500 Hz) and ripples (80-250 Hz), and spikes in pre- and postresection ECoG sampled at 2,048 Hz in people with refractory focal epilepsy. We defined four groups of electroencephalography (EEG) event occurrence: pre+post- (+/-), pre+post+ (+/+), pre-post+ (-/+) and pre-post- (-/-). We subcategorized three tailoring approaches: hippocampectomy with tailoring for neocortical involvement; lesionectomy of temporal lesions with tailoring for mesiotemporal involvement; and lesionectomy with tailoring for surrounding neocortical involvement. We compared the percentage of resected pre-EEG events, time to recurrence, and the different tailoring approaches to outcome (seizure-free vs recurrence). RESULTS We included 54 patients (median age, 15.5 years; 25 months of follow-up; 30 seizure free). The percentage of resected FRs, ripples, or spikes in pre-ECoG did not predict outcome. The occurrence of FRs in post-ECoG, given FRs in pre-ECoG (+/-, +/+), predicted outcome (hazard ratio, 3.13; confidence interval = 1.22-6.25; p = 0.01). Seven of 8 patients without spikes in pre-ECoG were seizure free. The highest predictive value for seizure recurrence was presence of FRs in post-ECoG for all tailoring approaches. INTERPRETATION FRs that persist before and after resection predict poor postsurgical outcome. These findings hold for different tailoring approaches. FRs can thus be used for tailoring epilepsy surgery with repeated intraoperative ECoG measurements. Ann Neurol 2017;81:664-676.
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Affiliation(s)
- Maryse A van 't Klooster
- Brain Center Rudolf Magnus, Department of Neurology & Neurosurgery, UMC Utrecht, Utrecht, The Netherlands
| | - Nicole E C van Klink
- Brain Center Rudolf Magnus, Department of Neurology & Neurosurgery, UMC Utrecht, Utrecht, The Netherlands
| | | | - Frans S S Leijten
- Brain Center Rudolf Magnus, Department of Neurology & Neurosurgery, UMC Utrecht, Utrecht, The Netherlands
| | - Rina Zelmann
- Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Cyrille H Ferrier
- Brain Center Rudolf Magnus, Department of Neurology & Neurosurgery, UMC Utrecht, Utrecht, The Netherlands
| | - Peter C van Rijen
- Brain Center Rudolf Magnus, Department of Neurology & Neurosurgery, UMC Utrecht, Utrecht, The Netherlands
| | - Willem M Otte
- Brain Center Rudolf Magnus, Department of Child Neurology, UMC Utrecht, Utrecht, The Netherlands.,Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, UMC Utrecht, Utrecht, The Netherlands.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
| | - Kees P J Braun
- Brain Center Rudolf Magnus, Department of Child Neurology, UMC Utrecht, Utrecht, The Netherlands
| | - Geertjan J M Huiskamp
- Brain Center Rudolf Magnus, Department of Neurology & Neurosurgery, UMC Utrecht, Utrecht, The Netherlands
| | - Maeike Zijlmans
- Brain Center Rudolf Magnus, Department of Neurology & Neurosurgery, UMC Utrecht, Utrecht, The Netherlands.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
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Ray S, Tripathi M, Chandra SP, Chakravarty K. Protocols in contemporary epilepsy surgery-a short communication. Int J Surg 2017. [PMID: 28648797 DOI: 10.1016/j.ijsu.2017.06.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Sucharita Ray
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.
| | - Sarat P Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Altered glutamatergic tone reveals two distinct resting state networks at the cellular level in hippocampal sclerosis. Sci Rep 2017; 7:319. [PMID: 28336943 PMCID: PMC5428248 DOI: 10.1038/s41598-017-00358-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 02/21/2017] [Indexed: 11/08/2022] Open
Abstract
Hippocampal sclerosis (HS), the most common subset of drug-resistant epilepsy (DRE), is associated with large-scale network abnormalities, even under resting state. We studied the excitatory postsynaptic currents (EPSCs) recorded from pyramidal neurons in resected samples under resting conditions from the hippocampal and anterior temporal lobe (ATL) obtained from patients with HS (n = 14) undergoing resective surgery. We observed higher frequency and amplitude of spontaneous EPSCs in both the samples compared to non-seizure control samples. Application of tetrodotoxin (TTX) reduced the frequency of spontaneous EPSCs by 49.6 ± 4.3% and 61.8 ± 6.2% in the hippocampal and ATL samples, respectively. The magnitude of reduction caused by TTX with respect to non-seizure controls was significantly higher in the ATL samples than in the hippocampal samples. The magnitude of the change in the expression of the NR2A subunit of the NMDA receptors also varied in these two regions. Thus, the mechanism of hyperexcitabilty mediated by glutamatergic network reorganization in the hippocampal region is different from that in the ATL region of patients with HS, suggesting two independent resting-state networks at the cellular level. Taken together, these findings will improve the understanding of the broadly distributed resting-state networks in HS.
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Jayakar P, Gotman J, Harvey AS, Palmini A, Tassi L, Schomer D, Dubeau F, Bartolomei F, Yu A, Kršek P, Velis D, Kahane P. Diagnostic utility of invasive EEG for epilepsy surgery: Indications, modalities, and techniques. Epilepsia 2016; 57:1735-1747. [PMID: 27677490 DOI: 10.1111/epi.13515] [Citation(s) in RCA: 178] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2016] [Indexed: 12/21/2022]
Abstract
Many patients with medically refractory epilepsy now undergo successful surgery based on noninvasive diagnostic information, but intracranial electroencephalography (IEEG) continues to be used as increasingly complex cases are considered surgical candidates. The indications for IEEG and the modalities employed vary across epilepsy surgical centers; each modality has its advantages and limitations. IEEG can be performed in the same intraoperative setting, that is, intraoperative electrocorticography, or through an independent implantation procedure with chronic extraoperative recordings; the latter are not only resource intensive but also carry risk. A lack of understanding of IEEG limitations predisposes to data misinterpretation that can lead to denying surgery when indicated or, worse yet, incorrect resection with adverse outcomes. Given the lack of class 1 or 2 evidence on IEEG, a consensus-based expert recommendation on the diagnostic utility of IEEG is presented, with emphasis on the application of various modalities in specific substrates or locations, taking into account their relative efficacy, safety, ease, and incremental cost-benefit. These recommendations aim to curtail outlying indications that risk the over- or underutilization of IEEG, while retaining substantial flexibility in keeping with most standard practices at epilepsy centers and addressing some of the needs of resource-poor regions around the world.
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Affiliation(s)
- Prasanna Jayakar
- Brain Institute, Nicklaus Children's Hospital, Miami, Florida, U.S.A
| | - Jean Gotman
- Montreal Neurological Hospital and Institute, McGill University, Montréal, Quebec, Canada
| | - A Simon Harvey
- The Royal Children's Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - André Palmini
- Services of Neurology and Neurosurgery, Hospital São Lucas, Porto Alegre, Brazil
| | - Laura Tassi
- Claudio Munari Epilepsy Surgery Center, Niguarda Hospital, Milan, Italy
| | | | - Francois Dubeau
- Montreal Neurological Hospital and Institute, McGill University, Montréal, Quebec, Canada
| | - Fabrice Bartolomei
- Service of Neurophysiology Clinic, Public Hospital of Marseille, Marseille, France
| | - Alice Yu
- Neurology Department, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Pavel Kršek
- Department of Pediatric Neurology, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Demetrios Velis
- Epilepsy Surgery Program, Free University Medical Center (VUmc), Amsterdam, The Netherlands
| | - Philippe Kahane
- GIN INSERM U1216, Grenoble-Alpes Hospital and University, Grenoble, France
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Post-resection electrocorticography has no added value in epilepsy surgery. Acta Neurol Belg 2016; 116:279-85. [PMID: 27095099 DOI: 10.1007/s13760-016-0641-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 04/06/2016] [Indexed: 10/21/2022]
Abstract
Intra-operative electrocorticography (ECoG) has been traditionally used in the surgical management of medically refractory partial epilepsies to identify the limits of the epileptogenic zone. This retrospective study had as goal to evaluate whether tailored surgery based on the presurgical evaluation completed by intra-operative post-resection ECoG improves outcome. We reviewed 94 cases of epilepsy surgery with intra-operative ECoG and determined how many had an ECoG-guided surgical procedure in addition to the initial planned surgery. We also reviewed the presence of specific recurrent ECoG patterns of interictal epileptiform discharges (IED) in the exposed cortical surface, such as: electrographic seizures, bursts, intermittent spike waves, polyspikes or fast rhythms and continuous or quasi-continuous spiking. When performing a post-resection ECoG-tailored surgery, outcome did not improve in lesional or non-lesional epilepsy. Postoperative residual IED did not correlate with a poorer outcome. In our study, the persistence of post-resection IED on ECoG is not correlated with outcome in patients with lesional or non-lesional epilepsy.
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Dixit AB, Banerjee J, Ansari A, Tripathi M, Chandra SP. Mutations in GABRG2 receptor gene are not a major factor in the pathogenesis of mesial temporal lobe epilepsy in Indian population. Ann Indian Acad Neurol 2016; 19:236-41. [PMID: 27293336 PMCID: PMC4888688 DOI: 10.4103/0972-2327.182304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
AIM This study is focused on GABRG2 gene sequence variations in patients with mesial temporal lobe epilepsy (mTLE). The GABAAreceptor is a heteropentameric receptor and alpha-1 beta-2 gamma-2 subunits combination is most abundant and present in almost all regions of the brain. The gamma-2 subunit (GABRG2) gene mutations have been reported in different epilepsy pathologies. In the present study we have looked for GABRG2 gene sequence variations in patients with mTLE. MATERIALS AND METHODS Twenty patients (12 females and eight males, age 4.6-38 years) with MTLE were recruited for this investigation. Patients were recommended for epilepsy surgery after all clinical investigations as per the epilepsy protocol. Ethnically matched glioma or meningioma patients were considered as nonepileptic controls. During temporal lobectomy of amygdalohippocampectomy, hippocampal brain tissue samples were resected guided by intraoperative electrocorticography (ECoG) activity. All 11 exons of GABRG2 gene with their flanking intronic regions were amplified by polymerase chain reaction (PCR) and screened by DNA sequencing analysis for sequence variations. STATISTICAL ANALYSIS USED Comparison of allele frequencies between patient and control groups was determined using a c(2) test. RESULTS AND CONCLUSIONS Total five DNA sequence variations were identified, three in exonic regions (c.643A > G, rs211035), (c.T > A, rs424740), and (c.C > T, rs418210) and two in intronic regions (c.751 + 41A > G, rs211034) and (c.751 + 52G > A, rs 34281163). Allele frequencies of variants identified in this study did not differ between patients and normal controls. Thus, we conclude that GABRG2 gene may not be playing significant role in the development of epilepsy or as a susceptibility gene in patients with MTLE in Indian population.
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Affiliation(s)
- Aparna Banerjee Dixit
- Center for Excellence in Epilepsy, A joint National Brain Research Centre-All Institute of Medical Sciences Collaboration, National Brain Research Centre, Manesar, Haryana, India
| | - Jyotirmoy Banerjee
- Center for Excellence in Epilepsy, A joint National Brain Research Centre-All Institute of Medical Sciences Collaboration, National Brain Research Centre, Manesar, Haryana, India
| | - Abuzar Ansari
- Department of Neurosurgery, All Institute of Medical Sciences, New Delhi, India
| | - Manjari Tripathi
- Department of Neurology, All Institute of Medical Sciences, New Delhi, India
| | - Sarat P Chandra
- Department of Neurosurgery, All Institute of Medical Sciences, New Delhi, India
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Rolston JD, Englot DJ, Knowlton RC, Chang EF. Rate and complications of adult epilepsy surgery in North America: Analysis of multiple databases. Epilepsy Res 2016; 124:55-62. [PMID: 27259069 DOI: 10.1016/j.eplepsyres.2016.05.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 04/05/2016] [Accepted: 05/05/2016] [Indexed: 11/28/2022]
Abstract
Epilepsy surgery is under-utilized, but recent studies reach conflicting conclusions regarding whether epilepsy surgery rates are currently declining, increasing, or remaining steady. However, data in these prior studies are biased toward high-volume epilepsy centers, or originate from sources that do not disaggregate various procedure types. All major epilepsy surgery procedures were extracted from the Centers for Medicare and Medicaid Services Part B National Summary Data File and the American College of Surgeons National Surgical Quality Improvement Program. Procedure rates, trends, and complications were analyzed, and patient-level predictors of postoperative adverse events were identified. Between 2000-2013, 6200 cases of epilepsy surgery were identified. Temporal lobectomy was the most common procedure (59% of cases), and most did not utilize electrocorticography (63-64%). Neither temporal nor extratemporal lobe epilepsy surgery rates changed significantly during the study period, suggesting no change in utilization. Adverse events, including major and minor complications, occurred in 15.3% of temporal lobectomies and 55.6% of hemispherectomies. Our findings suggest stagnant rates of both temporal and extratemporal lobe epilepsy surgery across U.S. surgical centers over the past decade. This finding contrasts with prior reports suggesting a recent dramatic decline in temporal lobectomy rates at high-volume epilepsy centers. We also observed higher rates of adverse events when both low- and high-volume centers were examined together, as compared to reports from high-volume centers alone. This is consistent with the presence of a volume-outcome relationship in epilepsy surgery.
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Affiliation(s)
- John D Rolston
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.
| | - Dario J Englot
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Robert C Knowlton
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Edward F Chang
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
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Greiner HM, Horn PS, Tenney JR, Arya R, Jain SV, Holland KD, Leach JL, Miles L, Rose DF, Fujiwara H, Mangano FT. Should spikes on post-resection ECoG guide pediatric epilepsy surgery? Epilepsy Res 2016; 122:73-8. [DOI: 10.1016/j.eplepsyres.2016.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 02/11/2016] [Accepted: 02/28/2016] [Indexed: 10/22/2022]
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Greiner HM, Horn PS, Tenney JR, Arya R, Jain SV, Holland KD, Leach JL, Miles L, Rose DF, Fujiwara H, Mangano FT. Preresection intraoperative electrocorticography (ECoG) abnormalities predict seizure-onset zone and outcome in pediatric epilepsy surgery. Epilepsia 2016; 57:582-9. [DOI: 10.1111/epi.13341] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Hansel M. Greiner
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio U.S.A
| | - Paul S. Horn
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio U.S.A
| | - Jeffrey R. Tenney
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio U.S.A
| | - Ravindra Arya
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio U.S.A
| | - Sejal V. Jain
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio U.S.A
| | - Katherine D. Holland
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio U.S.A
| | - James L. Leach
- Division of Neuroradiology; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio U.S.A
| | - Lili Miles
- Division of Pathology; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio U.S.A
| | - Douglas F. Rose
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio U.S.A
| | - Hisako Fujiwara
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio U.S.A
| | - Francesco T. Mangano
- Division of Pediatric Neurosurgery; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio U.S.A
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Ravat S, Iyer V, Panchal K, Muzumdar D, Kulkarni A. Surgical outcomes in patients with intraoperative Electrocorticography (EcoG) guided epilepsy surgery-experiences of a tertiary care centre in India. Int J Surg 2016; 36:420-428. [PMID: 26892714 DOI: 10.1016/j.ijsu.2016.02.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 01/30/2016] [Accepted: 02/11/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The Comprehensive Epilepsy Surgery Program was started in 2001 at K.E.M. Hospital, Mumbai with the aim of performing epilepsy surgeries at highly concessional rates. We have started using intraoperative Electrocorticography (EcoG) since 2009 in patients with tumors, Mesial Temporal Sclerosis (MTS) plus and focal cortical dysplasia (FCD). This study highlights our experience with EcoG and it's utility in epilepsy surgery.introduction METHODS: 51 patients with drug resistant epilepsy due to temporal and extra-temporal tumors, MTS plus and FCD underwent pre-surgical evaluation and ECoG guided epilepsy surgery through our program. The surgical procedures employed included intraoperative EcoG guided lesionectomy or a lesionectomy with Anterior Temporal Lobectomy (ATL). Postoperative MRI and EEG were done. Seizure freedom was categorized as per Engel's classification. RESULTS At a mean follow up of 33 months (range: 14-69 months), 43 out of 51(84.31%) patients were completely seizure free post-surgery (Engel's Class I). Among the patients who were not seizure free, 3 patients were in Engel's Class II and 5 patients were in Engel's Class III. Presence of a residual lesion on postoperative MRI (p < 0.001), abnormal postoperative EEG (p < 0.001) and persistent spikes on post-resection EcoG (p < 0.05) had a significant statistical association with poor seizure freedom post-surgery. CONCLUSION The success of epilepsy surgery depends upon accurate localization and complete resection of the epileptogenic tissue, both of which are aided by intraoperative EcoG.Thus, intraoperative EcoG is a useful adjunct in epilepsy surgery to achieve optimal seizure freedom in cases of MTS plus, focal cortical dysplasia and tumors. Even the patients who are not seizure free can achieve worthwhile improvement post surgery.
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Affiliation(s)
- Sangeeta Ravat
- Comprehensive Epilepsy Care Centre, Seth GSMC & KEM Hospital, Parel, Mumbai, 400012, India.
| | - Vivek Iyer
- Dept. of Neurology, Comprehensive Epilepsy Care Centre, Seth GSMC & KEM Hospital, Parel, Mumbai, 400012, India.
| | - Keyurkumar Panchal
- Dept. of Neurology, Comprehensive Epilepsy Care Centre, Seth GSMC & KEM Hospital, Parel, Mumbai, 400012, India.
| | - Dattatraya Muzumdar
- Dept. of Neurosurgery, Comprehensive Epilepsy Care Centre, Seth GSMC & KEM Hospital, Parel, Mumbai, 400012, India.
| | - Abhijit Kulkarni
- Department of Neurosurgery, Seth GSMC & KEM Hospital, Parel, Mumbai, 400012, India.
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Tandon V, Bansal S, Chandra PS, Suri A, Tripathi M, Sharma MC, Sarkari A, Mahapatra AK. Ganglioglioma: Single-institutional experience of 24 cases with review of literature. Asian J Neurosurg 2016; 11:407-411. [PMID: 27695546 PMCID: PMC4974967 DOI: 10.4103/1793-5482.153500] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Ganglioglioma is a common seizure associated tumor. The goal of this study was to observe the postoperative outcome in patients with gangliogliomas. Material and Methods: A total 24 patients with gangliogliomas who underwent surgery at our institute from 2008 to 2011 were included. There were 13 males (54%) in our study. A retrospective analysis for the demographic profile, surgery and outcome was performed using STATA software. Literature on this subject was also reviewed, MEDLINE and PUBMED databases were searched. Observations: Sixteen patients presented with signs and symptoms of raised intracranial pressure and 12 patients had seizure disorder. Average age at surgery was 20 years (range 7-50 years). Twelve each were located in the temporal lobe and extra-temporal location. Intra-operative electrocorticography (ECoG) alone in three and image guidance alone were used in two patients, respectively. Both ECoG and image guidance were used in one patient and none of them was used in 18 patients. Gross total resection was achieved in 17 patients. After a mean follow-up of 1.6 years (range 3 months to 2.5 years), out of 12 patients with preoperative seizures, 10 (83.3%) were seizure free (Engel class-I) and 2 (16.6%) belonged to Engel class-II. None of the factors, including age at surgery, seizure duration prior to surgery, type of seizures, use of intra-operative ECoG and image guidance, extent of tumor resection, and surgical strategy proved to have significant correlation with postoperative seizure outcome. Conclusions: Surgical treatment is effective and safe for patients with gangliogliomas. Neither intra-operative ECoG nor image guidance necessarily leads to better seizure control, although they are useful adjunct for achieving safe and complete tumor resection.
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Affiliation(s)
- Vivek Tandon
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sumit Bansal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - P Sarat Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Suri
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Mehar C Sharma
- Department of Neuropathology, All India Institute of Medical Sciences, New Delhi, India
| | - Avijit Sarkari
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Ashok K Mahapatra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Chandra SP, Kurwale NS, Chibber SS, Banerji J, Dwivedi R, Garg A, Bal C, Tripathi M, Sarkar C, Tripathi M. Endoscopic-Assisted (Through a Mini Craniotomy) Corpus Callosotomy Combined With Anterior, Hippocampal, and Posterior Commissurotomy in Lennox-Gastaut Syndrome. Neurosurgery 2015; 78:743-51. [DOI: 10.1227/neu.0000000000001060] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Corpus callosotomy is a palliative procedure especially for Lennox-Gastaut semiology without localization with drop attacks.
OBJECTIVE:
To describe endoscopic-assisted complete corpus callosotomy combined with anterior, hippocampal, and posterior commissurotomy.
METHODS:
Patients with drug refractory epilepsy having drop attacks as the predominant seizure type, bilateral abnormalities on imaging, and moderate to severe mental retardation were included. All underwent a complete workup (including magnetic resonance imaging).
RESULTS:
Patients (n = 16, mean age 11.4 ± 6.4 years, range 6-19 years) had a mean seizure frequency of 24.5 ± 19.8/days (range 1-60) and a mean intelligence quotient of 25.23 ± 10.71. All had syndromic diagnosis of Lennox-Gastaut syndrome, with the following etiologies: hypoxic insult (10), lissencephaly (2), bilateral band heterotropia (2), and microgyria and pachygyria (2). Surgery included complete callosotomy and the section of anterior and posterior commissure by microscopic approach through a mini craniotomy (11) and endoscopic-assisted approach (5). Complications included meningitis (1), hyperammonemic encephalopathy (2), and acute transient disconnection (5). There was no mortality or long-term morbidity. Mean follow-up was 18 ± 4.7 months (range 16-27 months). Drop attacks stopped in all. Seizure frequency/duration decreased >90% in 10 patients and >50% in 5 patients, and increased in 1 patient. All patients attained presurgical functional levels in 3 to 6 months. Child behavior checklist scores showed no deterioration. Parental questionnaires reported 90% satisfaction attributed to the control of drop attacks. The series was compared retrospectively with an age/sex-matched cohort (where a callosotomy only was performed), and showed better outcome for drop attacks (P < .003).
CONCLUSION:
This preliminary study demonstrated the efficacy and safety of complete callosotomy with anterior, hippocampal, and posterior commissurotomy in Lennox-Gastaut syndrome (drop attacks) with moderate to severe mental retardation.
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Affiliation(s)
- Sarat P. Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
- Centre of Excellence for Epilepsy, New Delhi, India
| | - Nilesh S. Kurwale
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
- Centre of Excellence for Epilepsy, New Delhi, India
| | - Sarabjit Singh Chibber
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
- Centre of Excellence for Epilepsy, New Delhi, India
| | | | - Rekha Dwivedi
- Centre of Excellence for Epilepsy, New Delhi, India
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Garg
- Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Chandrashekhar Bal
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Madhavi Tripathi
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Chitra Sarkar
- Department of Neuropathology, All India Institute of Medical Sciences, New Delhi, India
| | - Manjari Tripathi
- Centre of Excellence for Epilepsy, New Delhi, India
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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van 't Klooster MA, Leijten FSS, Huiskamp G, Ronner HE, Baayen JC, van Rijen PC, Eijkemans MJC, Braun KPJ, Zijlmans M. High frequency oscillations in the intra-operative ECoG to guide epilepsy surgery ("The HFO Trial"): study protocol for a randomized controlled trial. Trials 2015; 16:422. [PMID: 26399310 PMCID: PMC4581519 DOI: 10.1186/s13063-015-0932-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 08/28/2015] [Indexed: 11/16/2022] Open
Abstract
Background Intra-operative electrocorticography, based on interictal spikes and spike patterns, is performed to optimize delineation of the epileptogenic tissue during epilepsy surgery. High frequency oscillations (HFOs, 80–500 Hz) have been identified as more precise biomarkers for epileptogenic tissue. The aim of the trial is to determine prospectively if ioECoG-tailored surgery using HFOs, instead of interictal spikes, is feasible and will lead to an equal or better seizure outcome. Methods\Design We present a single-blinded multi-center randomized controlled trial “The HFO Trial” including patients with refractory focal epilepsy of all ages who undergo surgery with intra-operative electrocorticography. Surgery is tailored by HFOs (arm 1) or interictal spikes (arm 2) in the intra-operative electrocorticography. Primary outcome is post-operative outcome after 1 year, dichotomized in seizure freedom (Engel 1A and 1B) versus seizure recurrence (Engel 1C-4). Secondary outcome measures are the volume of resected tissue, neurologic deficits, surgical duration and complications, cognition and quality of life. The trial has a non-inferiority design to test feasibility and at least equal performance in terms of surgical outcome. We aim to include 78 patients within 3 years including 1 year follow-up. Results are expected in 2018. Discussion This trial provides a transition from observational research towards clinical interventions using HFOs. We address methodological difficulties in designing this trial. We expect that the use of HFOs as a biomarker for tailoring will increase the success rate of epilepsy surgery while reducing resection volume. This may reduce neurological deficits and yield a better quality of life. Future technical developments, such as validated automatic online HFO identification, could, together with the attained clinical knowledge, lead to a new objective tailoring approach in epilepsy surgery. Trial registration This trial is registered at the US National Institutes of Health (ClinicalTrials.gov) #NCT02207673 (31 July 2014) and the Central Committee on Research Involving Human Subjects, The Netherlands #NL44257.041.13 (18 March 2014).
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Affiliation(s)
- Maryse A van 't Klooster
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO Box 85500, 3504, Utrecht, GA, The Netherlands.
| | - Frans S S Leijten
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO Box 85500, 3504, Utrecht, GA, The Netherlands.
| | - Geertjan Huiskamp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO Box 85500, 3504, Utrecht, GA, The Netherlands.
| | - Hanneke E Ronner
- Department of Clinical Neurophysiology and Magnetoencephalography Center, VU University Medical Center, Amsterdam, The Netherlands.
| | - Johannes C Baayen
- Neurosurgical Center Amsterdam, VU University Medical Center Amsterdam, Amsterdam, The Netherlands.
| | - Peter C van Rijen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO Box 85500, 3504, Utrecht, GA, The Netherlands.
| | - Martinus J C Eijkemans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Kees P J Braun
- Department of Child Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Maeike Zijlmans
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO Box 85500, 3504, Utrecht, GA, The Netherlands. .,SEIN-Stichting Epilepsie Instellingen Nederland, Heemstede, The Netherlands.
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Englot DJ, Raygor KP, Molinaro AM, Garcia PA, Knowlton RC, Auguste KI, Chang EF. Factors associated with failed focal neocortical epilepsy surgery. Neurosurgery 2015; 75:648-5;discussion 655; quiz 656. [PMID: 25181435 DOI: 10.1227/neu.0000000000000530] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Seizure outcomes after focal neocortical epilepsy (FNE) surgery are less favorable than after temporal lobectomy, and the reasons for surgical failure are incompletely understood. Few groups have performed an in-depth examination of seizure recurrences to identify possible reasons for failure. OBJECTIVE To elucidate factors contributing to FNE surgery failures. METHODS We reviewed resections for drug-resistant FNE performed at our institution between 1998 and 2011. We performed a quantitative analysis of seizure outcome predictors and a detailed qualitative review of failed surgical cases. RESULTS Of 138 resections in 125 FNE patients, 91 (66%) resulted in freedom from disabling seizures (Engel I outcome). Mean ± SEM patient age was 20.0 ± 1.2 years; mean follow-up was 3.8 years (range, 1-17 years); and 57% of patients were male. Less favorable (Engel II-IV) seizure outcome was predicted by higher preoperative seizure frequency (odds ratio = 0.85; 95% confidence interval, 0.78-0.93), a history of generalized tonic-clonic seizures (odds ratio = 0.42; 95% confidence interval, 0.18-0.97), and normal magnetic resonance imaging (odds ratio = 0.30; 95% confidence interval, 0.09-1.02). Among 36 surgical failures examined, 26 (72%) were related to extent of resection, with residual epileptic focus at the resection margins, whereas 10 (28%) involved location of resection, with an additional epileptogenic zone distant from the resection. Of 16 patients who received reoperation after seizure recurrence, 10 (63%) achieved seizure freedom. CONCLUSION Insufficient extent of resection is the most common reason for recurrent seizures after FNE surgery, although some patients harbor a remote epileptic focus. Many patients with incomplete seizure control are candidates for reoperation.
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Affiliation(s)
- Dario J Englot
- *Department of Neurological Surgery, ‡UCSF Comprehensive Epilepsy Center, and §Department of Neurology, University of California, San Francisco, California
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Uda T, Morino M, Minami N, Matsumoto T, Uchida T, Kamei T. Abnormal discharges from the temporal neocortex after selective amygdalohippocampectomy and seizure outcomes. J Clin Neurosci 2015; 22:1797-801. [PMID: 26256064 DOI: 10.1016/j.jocn.2015.03.063] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Revised: 03/17/2015] [Accepted: 03/18/2015] [Indexed: 11/28/2022]
Abstract
The present study examined the relationship between residual discharges from the temporal neocortex postoperatively and seizure outcomes, in mesial temporal lobe epilepsy (MTLE) patients with hippocampal sclerosis (HS) who were treated with selective amygdalohippocampectomy (SelAH). Abnormal discharges from the temporal neocortex are often observed and remain postoperatively. However, no recommendations have been made regarding whether additional procedures to eliminate these discharges should be performed for seizure relief. We retrospectively analyzed 28 patients with unilateral MTLE and HS, who underwent transsylvian SelAH. The mean follow-up period was 29 months (range: 16-49). In the pre- and postresection states, electrocorticography (ECoG) was recorded for the temporal base and lateral temporal cortex. The extent of resection was not influenced by the results of the preresection ECoG. Even if residual abnormal discharges were identified on the temporal neocortex, no additional procedures were undertaken to eliminate these abnormalities. The postresection spike counts were examined to determine the postresective alterations in spike count, and the frequency of residual spike count. The seizure outcomes were evaluated in all patients using the Engel classification. The postoperative seizure-free rate was 92.9%. No significant correlations were seen between a decreasing spike count and seizure outcomes (p=0.9259), or between the absence of residual spikes and seizure outcomes (p=1.000). Residual spikes at the temporal neocortex do not appear to influence seizure outcomes. Only mesial temporal structures should be removed, and additional procedures to eliminate residual spikes are not required.
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Affiliation(s)
- Takehiro Uda
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan; Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan.
| | - Michiharu Morino
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Noriaki Minami
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Takahiro Matsumoto
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Tatsuya Uchida
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Takamasa Kamei
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
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van 't Klooster MA, van Klink NEC, Leijten FSS, Zelmann R, Gebbink TA, Gosselaar PH, Braun KPJ, Huiskamp GJM, Zijlmans M. Residual fast ripples in the intraoperative corticogram predict epilepsy surgery outcome. Neurology 2015; 85:120-8. [PMID: 26070338 DOI: 10.1212/wnl.0000000000001727] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 01/29/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We studied whether residual high-frequency oscillations (80-500 Hz; ripples, 80-250 Hz), especially fast ripples (FRs, 250-500 Hz), in post-resection intraoperative electrocorticography (ECoG) predicted seizure recurrence in comparison to residual interictal spikes and ictiform spike patterns. METHODS We studied, retrospectively, ECoG recorded at 2,048 Hz after resection in a cohort of patients with refractory focal epilepsy. We analyzed occurrence and number of residual FRs, ripples, interictal spikes, and ictiform spike patterns within the last minute of each recording and compared these to seizure recurrence. RESULTS We included 54 patients (median age 15.5 years) with 25 months median follow-up. Twenty-four patients had recurrent seizures. We found residual FRs, ripples, spikes, and ictiform spike patterns in 12, 51, 38, and 9 patients. Nine out of 12 patients with residual FRs had recurrent seizures (p = 0.016, positive predictive value 75%). Other ECoG events did not predict seizure recurrence. Patients with seizures had higher FR rates than seizure-free patients (p = 0.022). FRs near the resection and in distant pathologic areas could have changed the resection in 8 patients without harming functionally eloquent areas. One seizure-free patient had FRs in distant functionally eloquent areas. CONCLUSIONS Residual FRs in post-resection ECoG are prognostic markers for seizure recurrence, especially if their number is high. Tailoring could rely on FRs, but requires careful assessment of the ECoG, as FRs in functionally eloquent areas might not be pathologic.
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Affiliation(s)
- Maryse A van 't Klooster
- From the Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery (M.A.v.K., N.E.C.v.K., F.S.S.L., T.A.G., P.H.G., K.P.J.B., G.J.M.H., M.Z.), University Medical Center Utrecht; SEIN-Stichting Epilepsie Instellingen Nederland (M.Z.), Heemstede, the Netherlands; and Montreal Neurological Institute (R.Z.), McGill University, Montreal, Canada.
| | - Nicole E C van Klink
- From the Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery (M.A.v.K., N.E.C.v.K., F.S.S.L., T.A.G., P.H.G., K.P.J.B., G.J.M.H., M.Z.), University Medical Center Utrecht; SEIN-Stichting Epilepsie Instellingen Nederland (M.Z.), Heemstede, the Netherlands; and Montreal Neurological Institute (R.Z.), McGill University, Montreal, Canada
| | - Frans S S Leijten
- From the Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery (M.A.v.K., N.E.C.v.K., F.S.S.L., T.A.G., P.H.G., K.P.J.B., G.J.M.H., M.Z.), University Medical Center Utrecht; SEIN-Stichting Epilepsie Instellingen Nederland (M.Z.), Heemstede, the Netherlands; and Montreal Neurological Institute (R.Z.), McGill University, Montreal, Canada
| | - Rina Zelmann
- From the Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery (M.A.v.K., N.E.C.v.K., F.S.S.L., T.A.G., P.H.G., K.P.J.B., G.J.M.H., M.Z.), University Medical Center Utrecht; SEIN-Stichting Epilepsie Instellingen Nederland (M.Z.), Heemstede, the Netherlands; and Montreal Neurological Institute (R.Z.), McGill University, Montreal, Canada
| | - Tineke A Gebbink
- From the Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery (M.A.v.K., N.E.C.v.K., F.S.S.L., T.A.G., P.H.G., K.P.J.B., G.J.M.H., M.Z.), University Medical Center Utrecht; SEIN-Stichting Epilepsie Instellingen Nederland (M.Z.), Heemstede, the Netherlands; and Montreal Neurological Institute (R.Z.), McGill University, Montreal, Canada
| | - Peter H Gosselaar
- From the Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery (M.A.v.K., N.E.C.v.K., F.S.S.L., T.A.G., P.H.G., K.P.J.B., G.J.M.H., M.Z.), University Medical Center Utrecht; SEIN-Stichting Epilepsie Instellingen Nederland (M.Z.), Heemstede, the Netherlands; and Montreal Neurological Institute (R.Z.), McGill University, Montreal, Canada
| | - Kees P J Braun
- From the Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery (M.A.v.K., N.E.C.v.K., F.S.S.L., T.A.G., P.H.G., K.P.J.B., G.J.M.H., M.Z.), University Medical Center Utrecht; SEIN-Stichting Epilepsie Instellingen Nederland (M.Z.), Heemstede, the Netherlands; and Montreal Neurological Institute (R.Z.), McGill University, Montreal, Canada
| | - Geertjan J M Huiskamp
- From the Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery (M.A.v.K., N.E.C.v.K., F.S.S.L., T.A.G., P.H.G., K.P.J.B., G.J.M.H., M.Z.), University Medical Center Utrecht; SEIN-Stichting Epilepsie Instellingen Nederland (M.Z.), Heemstede, the Netherlands; and Montreal Neurological Institute (R.Z.), McGill University, Montreal, Canada
| | - Maeike Zijlmans
- From the Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery (M.A.v.K., N.E.C.v.K., F.S.S.L., T.A.G., P.H.G., K.P.J.B., G.J.M.H., M.Z.), University Medical Center Utrecht; SEIN-Stichting Epilepsie Instellingen Nederland (M.Z.), Heemstede, the Netherlands; and Montreal Neurological Institute (R.Z.), McGill University, Montreal, Canada
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Kurwale NS, Chandra SP, Chouksey P, Arora A, Garg A, Sarkar C, Bal C, Tripathi M. Impact of intraoperative MRI on outcomes in epilepsy surgery: preliminary experience of two years. Br J Neurosurg 2015; 29:380-5. [DOI: 10.3109/02688697.2014.1003034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Dexmedetomidine anesthesia enhances spike generation during intra-operative electrocorticography: A promising adjunct for epilepsy surgery. Epilepsy Res 2015; 109:65-71. [DOI: 10.1016/j.eplepsyres.2014.10.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 09/30/2014] [Accepted: 10/18/2014] [Indexed: 11/20/2022]
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Role of concordance between ictal-subtracted SPECT and PET in predicting long-term outcomes after epilepsy surgery. Epilepsy Res 2014; 108:1782-9. [DOI: 10.1016/j.eplepsyres.2014.09.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 09/02/2014] [Accepted: 09/13/2014] [Indexed: 11/24/2022]
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Englot DJ, Han SJ, Rolston JD, Ivan ME, Kuperman RA, Chang EF, Gupta N, Sullivan JE, Auguste KI. Epilepsy surgery failure in children: a quantitative and qualitative analysis. J Neurosurg Pediatr 2014; 14:386-95. [PMID: 25127098 PMCID: PMC4393949 DOI: 10.3171/2014.7.peds13658] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Resection is a safe and effective treatment option for children with pharmacoresistant focal epilepsy, but some patients continue experience seizures after surgery. While most studies of pediatric epilepsy surgery focus on predictors of postoperative seizure outcome, these factors are often not modifiable, and the reasons for surgical failure may remain unclear. METHODS The authors performed a retrospective cohort study of children and adolescents who received focal resective surgery for pharmacoresistant epilepsy. Both quantitative and qualitative analyses of factors associated with persistent postoperative seizures were conducted. RESULTS Records were reviewed from 110 patients, ranging in age from 6 months to 19 years at the time of surgery, who underwent a total of 115 resections. At a mean 3.1-year follow-up, 76% of patients were free of disabling seizures (Engel Class I outcome). Seizure freedom was predicted by temporal lobe surgery compared with extratemporal resection, tumor or mesial temporal sclerosis compared with cortical dysplasia or other pathologies, and by a lower preoperative seizure frequency. Factors associated with persistent seizures (Engel Class II-IV outcome) included residual epileptogenic tissue adjacent to the resection cavity (40%), an additional epileptogenic zone distant from the resection cavity (32%), and the presence of a hemispheric epilepsy syndrome (28%). CONCLUSIONS While seizure outcomes in pediatric epilepsy surgery may be improved by the use of high-resolution neuroimaging and invasive electrographic studies, a more aggressive resection should be considered in certain patients, including hemispherectomy if a hemispheric epilepsy syndrome is suspected. Family counseling regarding treatment expectations is critical, and reoperation may be warranted in select cases.
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Affiliation(s)
- Dario J. Englot
- UCSF Comprehensive Epilepsy Center, University of California, San Francisco,Department of Neurological Surgery, University of California, San Francisco
| | - Seunggu J. Han
- UCSF Comprehensive Epilepsy Center, University of California, San Francisco,Department of Neurological Surgery, University of California, San Francisco
| | - John D. Rolston
- UCSF Comprehensive Epilepsy Center, University of California, San Francisco,Department of Neurological Surgery, University of California, San Francisco
| | - Michael E. Ivan
- UCSF Comprehensive Epilepsy Center, University of California, San Francisco,Department of Neurological Surgery, University of California, San Francisco
| | - Rachel A. Kuperman
- Pediatric Epilepsy Program, Children’s Hospital and Research Center Oakland, California
| | - Edward F. Chang
- UCSF Comprehensive Epilepsy Center, University of California, San Francisco,Department of Neurological Surgery, University of California, San Francisco
| | - Nalin Gupta
- UCSF Comprehensive Epilepsy Center, University of California, San Francisco,Department of Neurological Surgery, University of California, San Francisco,Department of Pediatrics, University of California, San Francisco
| | - Joseph E. Sullivan
- UCSF Comprehensive Epilepsy Center, University of California, San Francisco,Department of Neurology, University of California, San Francisco,Department of Pediatrics, University of California, San Francisco
| | - Kurtis I. Auguste
- UCSF Comprehensive Epilepsy Center, University of California, San Francisco,Department of Neurological Surgery, University of California, San Francisco,Department of Pediatrics, University of California, San Francisco,Pediatric Epilepsy Program, Children’s Hospital and Research Center Oakland, California
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