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Goel K, Ghadiyaram A, Krishnakumar A, Morden FTC, Higashihara TJ, Harris WB, Shlobin NA, Wang A, Karunungan K, Dubey A, Phillips HW, Weil AG, Fallah A. Hemimegalencephaly: A Systematic Comparison of Functional and Anatomic Hemispherectomy for Drug-Resistant Epilepsy. Neurosurgery 2024; 94:666-678. [PMID: 37975663 DOI: 10.1227/neu.0000000000002759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 09/19/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Hemimegalencephaly (HME) is a rare diffuse malformation of cortical development characterized by unihemispheric hypertrophy, drug-resistant epilepsy (DRE), hemiparesis, and developmental delay. Definitive treatment for HME-related DRE is hemispheric surgery through either anatomic (AH) or functional hemispherectomy (FH). This individual patient data meta-analysis assessed seizure outcomes of AH and FH for HME with pharmacoresistant epilepsy, predictors of Engel I, and efficacy of different FH approaches. METHODS PubMed, Web of Science, and Cumulative Index to Nursing and Allied Health Literature were searched from inception to Jan 13th, 2023, for primary literature reporting seizure outcomes in >3 patients with HME receiving AH or FH. Demographics, neurophysiology findings, and Engel outcome at the last follow-up were extracted. Postsurgical seizure outcomes were compared through 2-tailed t -test and Fisher exact test. Univariate and multivariate Cox regression analyses were performed to identify independent predictors of Engel I outcome. RESULTS Data from 145 patients were extracted from 26 studies, of which 89 underwent FH (22 vertical, 33 lateral), 47 underwent AH, and 9 received an unspecified hemispherectomy with a median last follow-up of 44.0 months (FH cohort) and 45.0 months (AH cohort). Cohorts were similar in preoperative characteristics and at the last follow-up; 77% (n = 66) of the FH cohort and 81% (n = 38) and of the AH cohort were Engel I. On multivariate analysis, only the presence of bilateral ictal electroencephalography abnormalities (hazard ratio = 11.5; P = .002) was significantly associated with faster time-to-seizure recurrence. A number-needed-to-treat analysis to prevent 1 additional case of posthemispherectomy hydrocephalus reveals that FH, compared with AH, was 3. There was no statistical significance for any differences in time-to-seizure recurrence between lateral and vertical FH approaches (hazard ratio = 2.59; P = .101). CONCLUSION We show that hemispheric surgery is a highly effective treatment for HME-related DRE. Unilateral ictal electroencephalography changes and using the FH approach as initial surgical management may result in better outcomes due to significantly lower posthemispherectomy hydrocephalus probability. However, larger HME registries are needed to further delineate the predictors of seizure outcomes.
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Affiliation(s)
- Keshav Goel
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles , California , USA
| | - Ashwin Ghadiyaram
- Virginia Commonwealth University School of Medicine, Richmond , Virginia , USA
| | - Asha Krishnakumar
- Virginia Commonwealth University School of Medicine, Richmond , Virginia , USA
| | - Frances T C Morden
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu , Hawaii , USA
| | - Tate J Higashihara
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu , Hawaii , USA
| | - William B Harris
- Department of Neurosurgery, University of Colorado, Boulder , Colorado , USA
| | - Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago , Illinois , USA
| | - Andrew Wang
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles , California , USA
| | - Krystal Karunungan
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles , California , USA
| | - Anwesha Dubey
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles , California , USA
| | - H Westley Phillips
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Alexander G Weil
- Division of Neurosurgery, Department of Surgery, Sainte-Justine University Hospital Centre, Montréal , Québec , Canada
- Division of Neurosurgery, Department of Surgery, University of Montreal Hospital Centre (CHUM), Montréal , Québec , Canada
- Brain and Development Research Axis, Sainte-Justine Research Center, Montréal , Québec , Canada
- Department of Neuroscience, University of Montreal, Montréal , Québec , Canada
| | - Aria Fallah
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles , California , USA
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles , California , USA
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Goel K, Phillips HW, Chen JS, Ngo J, Edmonds B, Ha PX, Wang A, Weil A, Russell BE, Salamon N, Nariai H, Fallah A. Hemispheric epilepsy surgery for hemimegalencephaly: The UCLA experience. Epilepsia 2024; 65:57-72. [PMID: 37873610 DOI: 10.1111/epi.17807] [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: 08/09/2023] [Revised: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 10/25/2023]
Abstract
OBJECTIVES Hemimegalencephaly (HME) is a rare congenital brain malformation presenting predominantly with drug-resistant epilepsy. Hemispheric disconnective surgery is the mainstay of treatment; however, little is known about how postoperative outcomes compare across techniques. Thus we present the largest single-center cohort of patients with HME who underwent epilepsy surgery and characterize outcomes. METHODS This observational study included patients with HME at University of California Los Angeles (UCLA) from 1984 to 2021. Patients were stratified by surgical intervention: anatomic hemispherectomy (AH), functional hemispherectomy (FH), or less-than-hemispheric resection (LTH). Seizure freedom, functional outcomes, and operative complications were compared across surgical approaches. Regression analysis identified clinical and intraoperative variables that predict seizure outcomes. RESULTS Of 56 patients, 43 (77%) underwent FH, 8 (14%) underwent AH, 2 (4%) underwent LTH, 1 (2%) underwent unknown hemispherectomy type, and 2 (4%) were managed non-operatively. At median last follow-up of 55 months (interquartile range [IQR] 20-92 months), 24 patients (49%) were seizure-free, 17 (30%) required cerebrospinal fluid (CSF) shunting for hydrocephalus, 9 of 43 (21%) had severe developmental delay, 8 of 38 (21%) were non-verbal, and 15 of 38 (39%) were non-ambulatory. There was one (2%) intraoperative mortality due to exsanguination earlier in this cohort. Of 12 patients (29%) requiring revision surgery, 6 (50%) were seizure-free postoperatively. AH, compared to FH, was not associated with statistically significant improved seizure freedom (hazard ratio [HR] = .48, p = .328), although initial AH trended toward greater odds of seizure freedom (75% vs 46%, p = .272). Younger age at seizure onset (HR = .29, p = .029), lack of epilepsia partialis continua (EPC) (HR = .30, p = .022), and no contralateral seizures on electroencephalography (EEG) (HR = .33, p = .039) independently predicted longer duration of seizure freedom. SIGNIFICANCE This study helps inform physicians and parents of children who are undergoing surgery for HME by demonstrating that earlier age at seizure onset, absence of EPC, and no contralateral EEG seizures were associated with longer postoperative seizure freedom. At our center, initial AH for HME may provide greater odds of seizure freedom with complications and functional outcomes comparable to those of FH.
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Affiliation(s)
- Keshav Goel
- David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - H Westley Phillips
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jia-Shu Chen
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Jacqueline Ngo
- Department of Pediatrics, Division of Pediatric Neurology, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Benjamin Edmonds
- Department of Pediatrics, Division of Pediatric Neurology, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Phong X Ha
- Department of Radiology, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Andrew Wang
- David Geffen School of Medicine at the University of California, Los Angeles, California, USA
- College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California, USA
| | - Alexander Weil
- Brain and Development Research Axis, Sainte-Justine Research Center, Montréal, Québec, Canada
- Department of Surgery, Division of Neurosurgery, Sainte-Justine University Hospital Centre, Montréal, Québec, Canada
- Department of Surgery, Division of Neurosurgery, University of Montreal Hospital Centre (CHUM), Montréal, Québec, Canada
- Department of Neuroscience, University of Montreal, Montréal, Québec, Canada
| | - Bianca E Russell
- Department of Human Genetics, Division of Clinical Genetics, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Noriko Salamon
- Department of Radiology, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Hiroki Nariai
- Department of Pediatrics, Division of Pediatric Neurology, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Aria Fallah
- David Geffen School of Medicine at the University of California, Los Angeles, California, USA
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
- Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, California, USA
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Liu X, Zhu Y, Liu Q, Zhang S, Wu P, Sun Y, Zhang J, Wang R, Ji T, Wang S, Liu X, Jiang Y, Cai L, Wu Y. Clinical characteristics and surgical outcomes in children with mild malformation of cortical development and oligodendroglial hyperplasia in epilepsy. Epilepsia Open 2023; 8:898-911. [PMID: 37144544 PMCID: PMC10472402 DOI: 10.1002/epi4.12755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 05/01/2023] [Indexed: 05/06/2023] Open
Abstract
OBJECTIVE Mild malformation of cortical development with oligodendroglial hyperplasia in epilepsy (MOGHE) is a new and rare histopathological entity of cortical developmental malformations. The clinical characteristics of MOGHE remain challenging. METHODS Children with histologically confirmed MOGHE were retrospectively studied. The clinical findings, electroclinical and imaging features, and postoperative outcomes were analyzed, and previously published studies were reviewed up to June 2022. RESULTS Thirty-seven children were included in our cohort. Clinical characteristics included early onset in infancy (94.6% before 3 years), multiple seizure types, and moderate or severe delay. Epileptic spasm is the most common seizure type and initial manifestation. The lesions were mainly multilobar (59.5% multiple lobes and 8.1% hemispheres), and predominance in the frontal lobe was observed. The interictal EEG pattern was circumscribed or widespread. The prominent MRI characteristics were cortical thickening, cortical/subcortical hyperintense T2/FLAIR signal, and blurring at the GM and WM transition. Among the 21 children followed up for more than 1 year after surgery, 76.2% were seizure-free. Preoperative interictal circumscribed discharges and larger resections were significantly associated with a good postoperative outcome. The clinical features of 113 patients in the reviewed studies were similar to those we reported, but the lesions were mainly unilobar (73.5%) and Engel I was achieved in only 54.2% after surgery. SIGNIFICANCE Distinct clinical characteristics in MOGHE, especially age at onset, epileptic spasm, and age-related MRI characteristics, can help in early diagnosis. Preoperative interictal discharge and surgical strategy may be predictors of postoperative outcomes.
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Affiliation(s)
- Xianyu Liu
- Department of PediatricsPeking University First HospitalBeijingChina
| | - Ying Zhu
- Department of RadiologyPeking University First HospitalBeijingChina
| | - Qingzhu Liu
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
| | - Shuang Zhang
- Department of PathologyPeking University First HospitalBeijingChina
| | - Pengxia Wu
- Department of PediatricsPeking University First HospitalBeijingChina
| | - Yu Sun
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
| | - Jie Zhang
- Department of PediatricsPeking University First HospitalBeijingChina
| | - Ruofan Wang
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
| | - Taoyun Ji
- Department of PediatricsPeking University First HospitalBeijingChina
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
| | - Shuang Wang
- Department of PediatricsPeking University First HospitalBeijingChina
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
| | - Xiaoyan Liu
- Department of PediatricsPeking University First HospitalBeijingChina
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
| | - Yuwu Jiang
- Department of PediatricsPeking University First HospitalBeijingChina
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
| | - Lixin Cai
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
| | - Ye Wu
- Department of PediatricsPeking University First HospitalBeijingChina
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
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Mozaffari K, Krishnakumar A, Chen JS, Goel K, Wang A, Shlobin NA, Weil AG, Fallah A. Seizure outcomes in children with Sturge-Weber syndrome undergoing epilepsy surgery: An individual participant data meta-analysis. Seizure 2023; 107:43-51. [PMID: 36958063 DOI: 10.1016/j.seizure.2023.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/06/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
BACKGROUND A subpopulation of patients with Sturge-Weber syndrome (SWS) develop medically intractable epilepsy. There is a paucity of literature on preoperative factors that predict postoperative seizure outcomes in these patients. An individual participant data meta-analysis (IPDMA) was performed to discern preoperative variables associated with favorable seizure outcomes in pediatric SWS patients undergoing epilepsy surgery. METHODS PubMed, Cochrane, Web of Science, and Scopus were independently queried following PRISMA guidelines. Studies that reported seizure outcomes in individual pediatric SWS patients were selected. Preoperative demographic variables and disease characteristics were recorded and evaluated in a time-to-event fashion via Cox regression and Kaplan-Meier analysis with log-rank test. RESULTS A total of 18 studies with 108 patients were included for meta-analysis. Median age at seizure onset was 4.5 months, and 85 patients (78.7%) were seizure-free at last follow-up (median: 72 months). On multivariable Cox regression, no variables were independent predictors of post-operative seizure freedom duration, including the extent of hemispheric resection. There were also no differences in time-to-seizure recurrence on Kaplan-Meier analysis when comparing those treated with hemispheric surgery and those with less than hemispheric surgery (p = 0.52). CONCLUSION This IPDMA showed that both resective and hemispheric epilepsy surgery achieve favorable and comparable seizure outcomes in pediatric SWS patients. The best available evidence using IPD suggests that resective surgery may be an appropriate alternative to hemispheric epilepsy surgery in well-selected patients. Prospective multi-institutional studies with greater follow-up are warranted to further investigate predictors of seizure outcome in pediatric SWS patients.
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Affiliation(s)
- Khashayar Mozaffari
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, United States
| | - Asha Krishnakumar
- School of Medicine, Virginia Commonwealth University, Richmond, United States
| | - Jia-Shu Chen
- Warren Alpert Medical School of Brown University, Providence, United States
| | - Keshav Goel
- David Geffen School of Medicine at University of California, Los Angeles, United States
| | - Andrew Wang
- David Geffen School of Medicine at University of California, Los Angeles, United States
| | - Nathan A Shlobin
- Northwestern University Feinberg School of Medicine, Chicago, United States
| | - Alexander G Weil
- Department of Surgery, Division of Neurosurgery, Ste. Justine University Hospital, University of Montreal, Quebec, Canada; Department of Neuroscience, University of Montreal, Quebec, Canada; Division of Neurosurgery, Ste. Justine Hospital, University of Montreal, Quebec, Canada
| | - Aria Fallah
- Department of Neurosurgery and Pediatrics, Los Angeles (UCLA), University of California, 300 Stein Plaza Driveway, Suite 525, Los Angeles, CA 90095, United States.
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Li L, Lin S, Tan Z, Chen L, Zeng Q, Sun Y, Li C, Liu Z, Lin C, Ren X, Zhang T, Li Y, Su Q, Li Y, Cao D, Liao J, Zhu F, Chen Y. Resective epilepsy surgery for West syndrome: The Hypsarrhythmic Asymmetric Scoring Scheme is a determining predictor of seizure outcome. Seizure 2022; 101:205-210. [PMID: 36084526 DOI: 10.1016/j.seizure.2022.08.011] [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: 06/17/2022] [Revised: 08/25/2022] [Accepted: 08/27/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE It has been suggested that asymmetric hypsarrhythmia is associated with structural etiology. We devised the Hypsarrhythmic Asymmetric Scoring Scheme (HASS) to quantify the degree of hypsarrhythmic asymmetry in a retrospective series of patients who underwent surgical treatment at our center. The present study aimed to investigate the role of HASS in predicting the postsurgical seizure outcomes. METHODS We retrospectively analyzed the records of 46 children with hypsarrhythmia who underwent resective epilepsy surgery between 2018 and 2020 and were followed up for at least 1 year after surgery. Hypsarrhythmia severity in each hemisphere was quantified and scored. The HASS score was calculated as the difference between the two hemispheres. Univariate results were submitted to logistic regression models to identify independent predictors for favorable surgical outcomes. RESULTS Of the 46 patients who underwent resective surgery, Engel's class I-Ⅱ outcomes were achieved in 34 (73.9%). The Engel I-Ⅱ group had a significantly higher HASS score than the Engel Ⅲ-Ⅳ group (p<0.001). Multivariate analysis showed that the HASS score was the only significant predictor of good outcomes (p = 0.011). Further receiver operating characteristic analysis showed that a threshold of 7 yielded a better seizure outcome with a sensitivity of 97.06% and specificity of 83.33%. SIGNIFICANCE As the first hypsarrhythmia scoring system specially designed for presurgical evaluation, the HASS score may contribute to predicting the postsurgical seizure outcome from the electroencephalography perspective.
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Affiliation(s)
- Lin Li
- Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China
| | - Sufang Lin
- Department of Neurology, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China
| | - Zeshi Tan
- Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China
| | - Li Chen
- Department of Neurology, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China
| | - Qi Zeng
- Department of Neurology, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China
| | - Yang Sun
- Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China
| | - Cong Li
- Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China
| | - Zhenzhen Liu
- Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China
| | - Chun Lin
- Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China
| | - Xiaofan Ren
- Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China
| | - Tian Zhang
- Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China
| | - Ying Li
- Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China
| | - Qiru Su
- Department of Clinical Research, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China
| | - Yilian Li
- Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China
| | - Dezhi Cao
- Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China; Department of Neurology, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China
| | - Jianxiang Liao
- Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China; Department of Neurology, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China
| | - Fengjun Zhu
- Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China.
| | - Yan Chen
- Surgery Division, Epilepsy Center, Shenzhen Children's Hospital, Shenzhen, Guangdong Province 518038, China.
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