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Sroubek J, Kramska L, Cesak T, Amlerova J, Keller J, Vojtech Z. Ultrasound-Navigated Multiple Hippocampal Transections: An Anatomical Study. J Neurol Surg A Cent Eur Neurosurg 2024; 85:444-450. [PMID: 38253328 PMCID: PMC11281836 DOI: 10.1055/s-0043-1771276] [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: 09/28/2022] [Accepted: 04/03/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Multiple hippocampal transection (MHT) is a surgical technique used for the treatment of drug-resistant mesial temporal lobe epilepsy in situations where standard procedures would pose a high risk for memory deterioration. During MHT, the longitudinal fibers of the hippocampus, implicated in epilepsy spreading, are interrupted, while the transverse memory circuits are spared. The extent of MHT is governed by intraoperative electrocorticography; abolition of epileptic discharges serves as an end point to terminate the transection. In other words, the aim of MHT is not the anatomical completeness of hippocampal transection. In contrast, we hypothesize that only the complete transection of hippocampal cross-section is needed to durably terminate epilepsy, avoiding possible postoperative reorganization of longitudinal pathways. Here, we report an anatomical study designed to evaluate the feasibility of complete transection of hippocampus with the aid of ultrasound neuronavigation and we propose new instruments to reach this goal. METHODS Five cadaveric brains were analyzed in this study. MHT was performed on both sides of each brain either with or without ultrasound neuronavigation. The percentage of transected cross-section of the hippocampus was measured using magnetic resonance imaging (MRI) and both sides were compared. RESULTS The ultrasound-guided MHTs were more likely to achieve complete hippocampal transection compared with the nonnavigated MHT transection (73 vs 58%; p < 0.01). Our study also allowed us to propose specialized transectors to minimize invasivity of this procedure. CONCLUSION Completeness of MHT can be better reached with the aid of an ultrasound neuronavigation system; modified instruments for this procedure were also designed.
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Affiliation(s)
- Jan Sroubek
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
- Department of Neurosurgery, Charles University Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Lenka Kramska
- Department of Clinical Psychology, Na Homolce Hospital, Prague, Czech Republic
| | - Tomas Cesak
- Department of Neurosurgery, Charles University Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jana Amlerova
- Department of Neurology, Motol University Hospital, Praha, Czech Republic
| | - Jiri Keller
- Department of Radiology, Na Homolce Hospital, Prague, Czech Republic
| | - Zdenek Vojtech
- Department of Neurology, Na Homolce Hospital, Prague, Czech Republic
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Abramov I, Jubran JH, Houlihan LM, Park MT, Howshar JT, Farhadi DS, Loymak T, Cole TS, Pitskhelauri D, Preul MC. Multiple hippocampal transection for mesial temporal lobe epilepsy: A systematic review. Seizure 2022; 101:162-176. [PMID: 36041364 DOI: 10.1016/j.seizure.2022.08.007] [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: 02/02/2022] [Revised: 08/02/2022] [Accepted: 08/19/2022] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Multiple hippocampal transection (MHT) is a surgical technique that offers adequate seizure control with minimal perioperative morbidity. However, there is little evidence available to guide neurosurgeons in selecting this technique for use in appropriate patients. This systematic review analyzes patient-level data associated with MHT for intractable epilepsy, focusing on postoperative seizure control and memory outcomes. METHODS The systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant articles were identified from 3 databases (PubMed, Medline, Embase) up to August 1, 2021. Inclusion criteria were that the majority of patients had received a diagnosis of intractable epilepsy, the article was written in English, MHT was the primary procedure, and patient-level metadata were included. RESULTS Fifty-nine unique patients who underwent MHT were identified across 11 studies. Ten (17%) of 59 patients underwent MHT alone. Forty-three (75%) of 57 patients who had a follow-up 12 months or longer were seizure free at last follow-up. With respect to postoperative verbal memory retention, 9 of 38 (24%) patient test scores did not change, 14 (37%) decreased, and 16 (42%) increased. With respect to postoperative nonverbal memory retention, 12 of 38 (34%) patient test scores did not change, 13 (34%) decreased, and 13 (33%) increased. CONCLUSION There are few reported patients analyzed after MHT. Although the neurocognitive benefits of MHT are unproven, this relatively novel technique has shown promise in the management of seizures in patients with intractable epilepsy. However, structured trials assessing MHT in isolation are warranted.
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Affiliation(s)
- Irakliy Abramov
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Jubran H Jubran
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Lena Mary Houlihan
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Marian T Park
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Jacob T Howshar
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Dara S Farhadi
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Thanapong Loymak
- Department of Neurosurgery, Srisawan Hospital, Nakhonsawan, Thailand
| | - Tyler S Cole
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - David Pitskhelauri
- Department of Neuro-Oncology, Burdenko Neurosurgical Center, Moscow, Russia
| | - Mark C Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ.
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Koubeissi MZ, Joshi S, Eid A, Emami M, Jaafar N, Syed T, Foreman PJ, Sheth A, Amdur R, Bou Nasif M, Puente AN, Aly R, Chen H, Becker A, Gholipour T, Makke Y, Elmashad A, Gagnon L, Durand DM, Gaillard WD, Shields DC. Low-frequency stimulation of a fiber tract in bilateral temporal lobe epilepsy. Epilepsy Behav 2022; 130:108667. [PMID: 35344808 DOI: 10.1016/j.yebeh.2022.108667] [Citation(s) in RCA: 10] [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: 02/01/2022] [Revised: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Pharmacoresistant bilateral mesial temporal lobe epilepsy often implies poor resective surgical candidacy. Low-frequency stimulation of a fiber tract connected to bilateral hippocampi, the fornicodorsocommissural tract, has been shown to be safe and efficacious in reducing seizures in a previous short-term study. Here, we report a single-blinded, within-subject control, long-term deep-brain stimulation trial of low-frequency stimulation of the fornicodorsocommissural tract in bilateral mesial temporal lobe epilepsy. Outcomes of interest included safety with respect to verbal memory scores and reduction of seizure frequency. METHODS Our enrollment goal was 16 adult subjects to be randomized to 2-Hz or 5-Hz low-frequency stimulation of the fornicodorsocommissural tract starting at 2 mA. The study design consisted of four two-month blocks of stimulation with a 50%-duty cycle, alternating with two-month blocks of no stimulation. RESULTS We terminated the study after enrollment of five subjects due to slow accrual. Fornicodorsocommissural tract stimulation elicited bilateral hippocampal evoked responses in all subjects. Three subjects underwent implantation of pulse generators and long-term low-frequency stimulation with mean monthly seizures of 3.14 ± 2.67 (median 3.0 [IQR 1-4.0]) during stimulation-off blocks, compared with 0.96 ± 1.23 (median 1.0 [IQR 0-1.0]) during stimulation-on blocks (p = 0.0005) during the blinded phase. Generalized Estimating Equations showed that low-frequency stimulation reduced monthly seizure-frequency by 0.71 per mA (p < 0.001). Verbal memory scores were stable with no psychiatric complications or other adverse events. SIGNIFICANCE The results demonstrate feasibility of stimulating both hippocampi using a single deep-brain stimulation electrode in the fornicodorsocommissural tract, efficacy of low-frequency stimulation in reducing seizures, and safety as regards verbal memory.
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Affiliation(s)
- Mohamad Z Koubeissi
- Department of Neurology, The George Washington University, Washington, DC 20052, USA.
| | - Sweta Joshi
- Department of Neurology, The George Washington University, Washington, DC 20052, USA
| | - Alexandra Eid
- Department of Neurology, The George Washington University, Washington, DC 20052, USA
| | - Mehrdad Emami
- Department of Neurology, The George Washington University, Washington, DC 20052, USA
| | - Nadim Jaafar
- Department of Neurology, The George Washington University, Washington, DC 20052, USA
| | | | - Perry J Foreman
- Department of Neurology, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA
| | - Anumeha Sheth
- Department of Neurology, The George Washington University, Washington, DC 20052, USA
| | - Richard Amdur
- Department of Surgery, George Washington University School of Medicine, Washington, DC 20052, USA
| | - Mei Bou Nasif
- Department of Neurology, The George Washington University, Washington, DC 20052, USA
| | - Antonio N Puente
- Department of Psychiatry, George Washington University School of Medicine, Washington, DC 20052, USA
| | - Radwa Aly
- Department of Neurology, The George Washington University, Washington, DC 20052, USA
| | - Hai Chen
- Department of Neurology, The George Washington University, Washington, DC 20052, USA
| | - Andrew Becker
- Department of Neurology, The George Washington University, Washington, DC 20052, USA
| | - Taha Gholipour
- Department of Neurology, The George Washington University, Washington, DC 20052, USA
| | - Yamane Makke
- Department of Neurology, The George Washington University, Washington, DC 20052, USA
| | - Ahmed Elmashad
- Department of Neurology, The George Washington University, Washington, DC 20052, USA
| | - Linda Gagnon
- Department of Neurology, The George Washington University, Washington, DC 20052, USA
| | - Dominique M Durand
- Neural Engineering Center, Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, USA
| | - William D Gaillard
- Center for Neuroscience and Behavioral Health, Children's National Hospital, Washington, DC 20010, USA
| | - Donald C Shields
- Department of Neurosurgery, The George Washington University, Washington, DC 20052, USA
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Kozlova A, Korsakova M, Pitskhelauri D, Kudieva E, Dombaanai B, Vlasov P, Kamenetskaya M. Neurophysiological aspects of multiple hippocampal transection in intractable temporal lobe epilepsy. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:104-111. [DOI: 10.17116/jnevro2022122011104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Pitskhelauri D, Kudieva E, Kamenetskaya M, Kozlova A, Vlasov P, Dombaanai B, Eliseeva N, Shishkina L, Sanikidze A, Shults E, Moshev D, Pronin I, Melikyan A. Multiple hippocampal transections for mesial temporal lobe epilepsy. Surg Neurol Int 2021; 12:372. [PMID: 34513139 PMCID: PMC8422472 DOI: 10.25259/sni_350_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: 04/09/2021] [Accepted: 06/25/2021] [Indexed: 11/16/2022] Open
Abstract
Background: The purpose of this study was to evaluate the effectiveness of multiple hippocampal transections (MHT) in the treatment of drug-resistant mesial temporal lobe epilepsy. Methods: Six patients underwent MHT at Burdenko Neurosurgery Center in 2018. The age of the patients varied from 18 to 43 years. All patients suffered from refractory epilepsy caused by focal lesions of the mesial temporal complex or temporal pole in dominant side. Postoperative pathology revealed neuronal-glial tumors in two patients, focal cortical dysplasia (FCD) of the temporal pole – in two patients, cavernous angioma – in one patient, and encephalocele of the preuncal area – in one patient. Results: All patients underwent surgery satisfactorily. There were no postoperative complications except for homonymous superior quadrantanopia. This kind of visual field loss was noted in four cases out of six. During the follow-up period five patients out of six had Engel Class I outcome (83.3%). In one case, seizures developed after 1 month in a patient with FCD in the uncus (Engel IVA). After surgery, three out of six patients developed significant nominative aphasia. Two patients relative to the preoperative level demonstrated improvement in delayed verbal memory after MHT. Two patients showed a decrease level in delayed verbal memory. In preoperative period, visual memory was below the normal in one patient. Delayed visual memory in two cases impaired compared to the preoperative level. Conclusion: MHT can be considered as an effective method of drug-resistant mesial temporal lobe epilepsy caused by tumors of the medial temporal complex. At the same time, MHT makes it possible to preserve memory in patients with structurally preserved hippocampus. However, MHT do not guarantee the preservation of memory after surgery.
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Affiliation(s)
- David Pitskhelauri
- Department of Neurosurgery, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Elina Kudieva
- Department of Neurosurgery, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Maria Kamenetskaya
- Department of Neuropsychiatric Research, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Antonina Kozlova
- Department of Neurophysiological Research, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Pavel Vlasov
- Department of Pediatric Neurosurgery, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Baiyr Dombaanai
- Department of Neurosurgery, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Natalia Eliseeva
- Department of Neuroophthalmological Research, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Lyudmila Shishkina
- Department of Neuropathology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Alexander Sanikidze
- Department of Neurosurgery, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Evgeniy Shults
- Department of X-ray and Radioisotope Research, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Dmitriy Moshev
- Department of Neuroanesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Igor Pronin
- Department of X-ray and Radioisotope Research, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Armen Melikyan
- Department of Pediatric Neurosurgery, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
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Shivacharan RS, Chiang CC, Wei X, Subramanian M, Couturier NH, Pakalapati N, Durand DM. Neural recruitment by ephaptic coupling in epilepsy. Epilepsia 2021; 62:1505-1517. [PMID: 33979453 DOI: 10.1111/epi.16903] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 03/30/2021] [Accepted: 03/30/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE One of the challenges in treating patients with drug-resistant epilepsy is that the mechanisms of seizures are unknown. Most current interventions are based on the assumption that epileptic activity recruits neurons and progresses by synaptic transmission. However, several experimental studies have shown that neural activity in rodent hippocampi can propagate independently of synaptic transmission. Recent studies suggest these waves are self-propagating by electric field (ephaptic) coupling. In this study, we tested the hypothesis that neural recruitment during seizures can occur by electric field coupling. METHODS 4-Aminopyridine was used in both in vivo and in vitro preparation to trigger seizures or epileptiform activity. A transection was made in the in vivo hippocampus and in vitro hippocampal and cortical slices to study whether the induced seizure activity can recruit neurons across the gap. A computational model was built to test whether ephaptic coupling alone can account for neural recruitment across the transection. The model prediction was further validated by in vitro experiments. RESULTS Experimental results show that electric fields generated by seizure-like activity in the hippocampus both in vitro and in vivo can recruit neurons locally and through a transection of the tissue. The computational model suggests that the neural recruitment across the transection is mediated by electric field coupling. With in vitro experiments, we show that a dielectric material can block the recruitment of epileptiform activity across a transection, and that the electric fields measured within the gap are similar to those predicted by model simulations. Furthermore, this nonsynaptic neural recruitment is also observed in cortical slices, suggesting that this effect is robust in brain tissue. SIGNIFICANCE These results indicate that ephaptic coupling, a nonsynaptic mechanism, can underlie neural recruitment by a small electric field generated by seizure activity and could explain the low success rate of surgical transections in epilepsy patients.
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Affiliation(s)
- Rajat S Shivacharan
- Neural Engineering, Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - Chia-Chu Chiang
- Neural Engineering, Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - Xile Wei
- School of Electrical and Information Engineering, Tianjin University, Tianjin, China
| | - Muthumeenakshi Subramanian
- Neural Engineering, Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - Nicholas H Couturier
- Neural Engineering, Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - Nrupen Pakalapati
- Neural Engineering, Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - Dominique M Durand
- Neural Engineering, Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
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Marashly A, Koop J, Loman M, Kim I, Maheshwari M, Lew SM. Multiple hippocampal transections for refractory pediatric mesial temporal lobe epilepsy: seizure and neuropsychological outcomes. J Neurosurg Pediatr 2020; 26:379-388. [PMID: 32590352 DOI: 10.3171/2020.4.peds19760] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 04/13/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Temporal lobe epilepsy (TLE) is the most common focal epilepsy across adult and pediatric age groups. It is also the most amenable to surgery, with excellent long-term seizure outcome. Most TLE cases have an epileptogenic zone in the mesial temporal structures, namely the hippocampus. Resecting the dominant hippocampus has been shown to be associated with significant verbal memory deficits, especially in patients with intact verbal memory scores presurgically. Multiple hippocampal transection (MHT) is a relatively new surgical technique designed to interrupt the longitudinal hippocampal circuitry involved in seizure propagation yet preserve the circular fibers involved in memory function. This technique has been used to treat mesial TLE in both dominant- and nondominant-hemisphere cases, almost exclusively in adults. It has been applied to normal and sclerotic hippocampi. METHODS In this study, information on 3 pediatric patients who underwent MHT for mesial TLE at Children's Wisconsin between 2017 and 2018 is included. Clinical, electroencephalographic, and neuropsychological features and outcomes are described in detail. RESULTS MRI revealed a tumor in the amygdala with a normal hippocampus in 1 patient and hippocampal sclerosis in 2 patients. All patients underwent stereoelectroencephalography confirming the involvement of the hippocampus in seizure onset. MHTs were completed under intraoperative monitoring, with amygdala and temporal tip resection in all patients due to early spread to these regions. All patients had excellent seizure outcomes at 1 year, and 2 of the 3 patients remain seizure free at last follow-up (range 20-36 months), all with stable or improved neuropsychological profiles, including verbal memory. CONCLUSIONS MHT is a relatively new surgical procedure designed to preserve essential memory circuitry while disrupting seizure propagation pathways in the hippocampus. A growing body of literature shows good seizure and neuropsychological results, but mainly in adults. This is the first series of MHTs used exclusively in children at one medical center, showcasing excellent seizure control and preservation of neuropsychological functioning. One of the patients is also the first described to have MHT in the setting of an amygdalar tumor abutting the hippocampus, further expanding the pathological setting in which MHT can be used effectively.
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Affiliation(s)
- Ahmad Marashly
- 1Division of Pediatric Neurology, University of Washington/Seattle Children's Hospital, Seattle, Washington; and
| | | | | | | | - Mohit Maheshwari
- 4Pediatric Radiology, Children's Wisconsin/Medical College of Wisconsin, Milwaukee, Wisconsin
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Park JT, Fernandez Baca Vaca G, Tangen R, Miller J. Hippocampal transection for stereo-electroencephalography-proven dominant mesial temporal lobe epilepsy in a child: a detailed case report and critical review. J Neurosurg Pediatr 2018; 22:1-7. [PMID: 30095344 DOI: 10.3171/2018.5.peds1896] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/15/2018] [Indexed: 11/06/2022]
Abstract
Resection of the hippocampus ipsilateral to the verbal memory-dominant hemisphere frequently results in severe memory deficits. In adults with epilepsy, multiple hippocampal transections (MHTs) have resulted in excellent seizure outcome with preservation of verbal memory. The authors report the first detailed case of a child undergoing MHTs for mesial temporal lobe epilepsy. A 13-year-old right-handed boy had intractable seizures characterized by epigastric discomfort evolving to unresponsiveness and chewing automatisms, lasting 1 minute and occurring 2-3 times weekly, sometimes ending in a generalized tonic-clonic seizure. He had no seizure risk factors and nonfocal examination results. Interictal electroencephalography (EEG) showed frequent left temporal epileptiform discharges (maximum FT9) and intermittent slowing. Video EEG, FDG-PET, and 1.5-T MRI were nonlocalizing. Neuropsychological evaluation suggested left temporal lobe dysfunction. A stereo-EEG investigation using 8 electrodes localized the seizure onset zone to the anterior mesial temporal region, immediately involving the hippocampus. The temporal pole and amygdala were resected en bloc with 3 MHTs. Comparison of neuropsychological tests 4 months before and 6 months after the surgery showed a significant decline only in confrontational naming and no significant change in verbal memory. Six and a half years later, the patient remains seizure free with no antiepileptic drugs. In children with established hemispheric dominance suffering from mesial temporal lobe epilepsy, MHTs may be an option.
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Affiliation(s)
- Jun T Park
- 1Section of Pediatric Epilepsy, Department of Pediatrics, Rainbow Babies & Children's Hospital, Case Western University School of Medicine
- 2Epilepsy Center, Neurological Institute, Department of Neurology, University Hospital, Case Western University School of Medicine
| | - Guadalupe Fernandez Baca Vaca
- 2Epilepsy Center, Neurological Institute, Department of Neurology, University Hospital, Case Western University School of Medicine
| | - Rachel Tangen
- 3Division of Developmental and Behavioral Pediatrics and Psychology, Department of Pediatrics, Rainbow Babies & Children's Hospital, Case Western University School of Medicine; and
| | - Jonathan Miller
- 4Department of Neurosurgery, Neurological Institute, University Hospital, Case Western University School of Medicine, Cleveland, Ohio
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