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Del Gaudio N, Ferrao Santos S, Raftopoulos C. Modified Vertical Parasagittal Sub-Insular Hemispherotomy-Case Series and Technical Note. Brain Sci 2023; 13:1395. [PMID: 37891764 PMCID: PMC10605112 DOI: 10.3390/brainsci13101395] [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: 09/06/2023] [Revised: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
(1) Background: Hemispherotomy is the generally accepted treatment for hemispheric drug-resistant epilepsy (DRE). Lateral or vertical approaches are performed according to the surgeon's preference. Multiple technical variations have been proposed since Delalande first described his vertical technique. We propose a sub-insular variation of the vertical parasagittal hemispherotomy (VPH) and describe our case series of patients operated on using this procedure. (2) Methods: Data from a continuous series of patients with hemispheric DRE who were operated on by the senior author (CR) using the modified sub-insular VPH technique were analyzed retrospectively. Pre-operative demographic and epilepsy characteristics, functional outcome, and surgical complications were extracted from medical charts. (3) Results: Twenty-five patients were operated on between August 2008 and August 2023; 23 have at least 3 months of follow-up. Of this group, 20 (86.9%) patients are seizure-free. Only two patients developed postoperative hydrocephalus (8.7%). All patients who were able to walk autonomously preoperatively and 20 (86.9%) of those with follow-up were able to walk without assistance. A total of 17 (74%) patients were able to perform adapted social activities at the latest follow-up. (4) Conclusions: Modified sub-insular VPH is a successful surgical technique for hemispheric DRE with seizure freedom rates similar to the largest series reported in the literature. Compared to other series, patients who were operated on with our modified technique had a lower rate of postoperative hydrocephalus and excellent long-term motor and cognitive outcomes.
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Affiliation(s)
- Nicole Del Gaudio
- Neurosurgery Department, University Hospital Saint Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200 Brussels, Belgium;
| | - Susana Ferrao Santos
- Neurology Department, University Hospital Saint Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200 Brussels, Belgium;
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Chen JS, Harris WB, Wu KJ, Phillips HW, Tseng CH, Weil AG, Fallah A. Comparison of Hemispheric Surgery Techniques for Pediatric Drug-Resistant Epilepsy: An Individual Patient Data Meta-analysis. Neurology 2023; 101:e410-e424. [PMID: 37202158 PMCID: PMC10435062 DOI: 10.1212/wnl.0000000000207425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 04/03/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Hemispheric surgery effectively treats unihemispheric pediatric drug-resistant epilepsy (DRE) by resecting and/or disconnecting the epileptic hemisphere. Modifications to the original anatomic hemispherectomy have generated multiple functionally equivalent, disconnective techniques for performing hemispheric surgery, termed functional hemispherotomy. While a myriad of hemispherotomy variants exist, all of them can be categorized according to the anatomic plane they are performed in, which includes vertical approaches at or near the interhemispheric fissure and lateral approaches at or near the Sylvian fissure. This meta-analysis of individual patient data (IPD) aimed to compare seizure outcomes and complications between the hemispherotomy approaches to better characterize their relative efficacy and safety in the modern neurosurgical treatment of pediatric DRE, given emerging evidence that outcomes may differ between them. METHODS CINAHL, Embase, PubMed, and Web of Science were searched from inception to September 9, 2020, for studies reporting IPD from pediatric patients with DRE who underwent hemispheric surgery. Outcomes of interest were seizure freedom at last follow-up, time-to-seizure recurrence, and complications including hydrocephalus, infection, and mortality. The χ2 test compared the frequency of seizure freedom and complications. Multivariable mixed-effects Cox regression controlling for predictors of seizure outcome was performed on propensity score-matched patients to compare time-to-seizure recurrence between approaches. Kaplan-Meier curves were made to visualize differences in time-to-seizure recurrence. RESULTS Fifty-five studies reporting on 686 unique pediatric patients treated with hemispheric surgery were included for meta-analysis. Among the hemispherotomy subgroup, vertical approaches resulted in a greater proportion of seizure free patients (81.2% vs 70.7%, p = 0.014) than lateral approaches. While there were no differences in complications, lateral hemispherotomy had higher rates of revision hemispheric surgery due to incomplete disconnection and/or recurrent seizures than vertical hemispherotomy (16.3% vs 1.2%, p < 0.001). After propensity score matching, vertical hemispherotomy approaches independently conferred longer time-to-seizure recurrence than lateral hemispherotomy approaches (hazard ratio 0.44, 95% CI 0.19-0.98). DISCUSSION Among functional hemispherotomy techniques, vertical hemispherotomy approaches confer more durable seizure freedom than lateral approaches without compromising safety. Future prospective studies are required to definitively determine whether vertical approaches are indeed superior and how it should influence clinical guidelines for performing hemispheric surgery.
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Affiliation(s)
- Jia-Shu Chen
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles
| | - William B Harris
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles
| | - Katherine J Wu
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles
| | - H Westley Phillips
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles
| | - Chi-Hong Tseng
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles
| | - Alexander G Weil
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles
| | - Aria Fallah
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles.
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Karagianni MD, Brotis AG, Tasiou A, Delev D, von Lehe M, Schijns OE, Fountas KN. Hemispherotomy Revised: A complication overview and a systematic review meta-analysis. BRAIN & SPINE 2023; 3:101766. [PMID: 38021002 PMCID: PMC10668062 DOI: 10.1016/j.bas.2023.101766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/05/2023] [Accepted: 06/12/2023] [Indexed: 12/01/2023]
Abstract
Introduction Hemispherectomy/hemispherotomy has been employed in the management of catastrophic epilepsy. However, initial reports on the associated mortality and morbidity raised several concerns regarding the technique's safety. Their actual, current incidence needs to be systematically examined to redefine hemispherotomy's exact role. Research question Our current study examined their incidence and evaluated the association of the various hemispherotomy surgical techniques with the reported complications. Material & methods A PRISMA-compliant systematic review and meta-analysis was performed. We searched PubMed, Scopus, and Web of Science until December 2022. Fixed- and random-effects models were employed. Egger's regression test was used for estimating the publication bias, while subgroup analysis was utilized for defining the role of the different hemispherotomy techniques. Results We retrieved a total of 37 studies. The overall procedure mortality was 5%, with a reported mortality of 7% for hemispherectomy and 3% for hemispherotomy. The reported mortality has decreased over the last 30 years from 32% to 2%. Among the observed post-operative complications aseptic meningitis and/or fever occurred in 33%. Hydrocephalus requiring a shunt insertion occurred in 16%. Hematoma evacuation was necessary in 8%, while subgaleal effusion in another 8%. Infections occurred in 11%. A novel post-operative cranial nerve deficit occurred in 11%, while blood transfusion was necessary in 28% of the cases. Discussion and conclusion Our current analysis demonstrated that the evolution from hemispherectomy to hemispherotomy along with neuroanesthesia advances, had a tremendous impact on the associated mortality and morbidity. Hemispherotomy constitutes a safe surgical procedure in the management of catastrophic epilepsies.
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Affiliation(s)
- Maria D. Karagianni
- Department of Neurosurgery, General University Hospital of Larissa, Mezourlo, Larissa, 41110, Greece
| | - Alexandros G. Brotis
- Department of Neurosurgery, General University Hospital of Larissa, Mezourlo, Larissa, 41110, Greece
| | - Anastasia Tasiou
- Department of Neurosurgery, General University Hospital of Larissa, Mezourlo, Larissa, 41110, Greece
| | - Daniel Delev
- Department of Neurosurgery, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
- Neurosurgical Artificial Intelligence Laboratory Aachen (NAILA), RWTH Aachen University Hospital, Aachen, Germany
- Center for Integrated Oncology, Universities Aachen, Bonn, Cologne, Duesseldorf (CIO ABCD), Germany
| | - Marec von Lehe
- Department of Neurosurgery, Brandenburg Medical School, University Hospital Ruppin Brandenburg, Fehrbelliner Str. 38, Neuruppin, Germany
| | - Olaf E.M.G. Schijns
- Department of Neurosurgery, Maastricht University Medical Center, Maatricht, the Netherlands
- Academic Center for Epileptology, Maastricht, Kempenhaeghe, the Netherlands
- School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Konstantinos N. Fountas
- Department of Neurosurgery, General University Hospital of Larissa, Mezourlo, Larissa, 41110, Greece
- Faculty of Medicine, University of Thessaly, Biopolis, Larissa, 41110, Greece
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De Benedictis A, Marasi A, Rossi-Espagnet MC, Napolitano A, Parrillo C, Fracassi D, Baldassari G, Borro L, Bua A, de Palma L, Luisi C, Pepi C, Savioli A, Luglietto D, Marras CE. Vertical Hemispherotomy: Contribution of Advanced Three-Dimensional Modeling for Presurgical Planning and Training. J Clin Med 2023; 12:jcm12113779. [PMID: 37297974 DOI: 10.3390/jcm12113779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/22/2023] [Accepted: 04/22/2023] [Indexed: 06/12/2023] Open
Abstract
Vertical hemispherotomy is an effective treatment for many drug-resistant encephalopathies with unilateral involvement. One of the main factors influencing positive surgical results and long-term seizure freedom is the quality of disconnection. For this reason, perfect anatomical awareness is mandatory during each step of the procedure. Although previous groups attempted to reproduce the surgical anatomy through schematic representations, cadaveric dissections, and intraoperative photographs and videos, a comprehensive understanding of the approach may still be difficult, especially for less experienced neurosurgeons. In this work, we reported the application of advanced technology for three-dimensional (3D) modeling and visualization of the main neurova-scular structures during vertical hemispherotomy procedures. In the first part of the study, we built a detailed 3D model of the main structures and landmarks involved during each disconnection phase. In the second part, we discussed the adjunctive value of augmented reality systems for the management of the most challenging etiologies, such as hemimegalencephaly and post-ischemic encephalopathy. We demonstrated the contribution of advanced 3D modeling and visualization to enhance the quality of anatomical representation and interaction between the operator and model according to a surgical perspective, optimizing the quality of presurgical planning, intraoperative orientation, and educational training.
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Affiliation(s)
- Alessandro De Benedictis
- Neurosurgery Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Alessandra Marasi
- Neurosurgery Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | | | - Antonio Napolitano
- Medical Physics Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Chiara Parrillo
- Medical Physics Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Donatella Fracassi
- Medical Physics Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Giulia Baldassari
- Medical Physics Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Luca Borro
- Multimodal Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Antonella Bua
- Neurosurgery Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Luca de Palma
- Clinical and Experimental Neurology, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Concetta Luisi
- Clinical and Experimental Neurology, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Chiara Pepi
- Clinical and Experimental Neurology, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Alessandra Savioli
- Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Davide Luglietto
- Neurosurgery Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
| | - Carlo E Marras
- Neurosurgery Unit, Bambino Gesù Children's Hospital, IRCCS, 4, Piazza S. Onofrio, 00165 Rome, Italy
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Ramantani G, Bulteau C, Cserpan D, Otte WM, Dorfmüller G, Cross JH, Zentner J, Tisdall M, Braun KPJ. Not surgical technique, but etiology, contralateral MRI, prior surgery, and side of surgery determine seizure outcome after pediatric hemispherotomy. Epilepsia 2023; 64:1214-1224. [PMID: 36869851 DOI: 10.1111/epi.17574] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/02/2023] [Accepted: 03/02/2023] [Indexed: 03/05/2023]
Abstract
OBJECTIVE We aimed to assess determinants of seizure outcome following pediatric hemispherotomy in a contemporary cohort. METHODS We retrospectively analyzed the seizure outcomes of 457 children who underwent hemispheric surgery in five European epilepsy centers between 2000 and 2016. We identified variables related to seizure outcome through multivariable regression modeling with missing data imputation and optimal group matching, and we further investigated the role of surgical technique by Bayes factor (BF) analysis. RESULTS One hundred seventy seven children (39%) underwent vertical and 280 children (61%) underwent lateral hemispherotomy. Three hundred forty-four children (75%) achieved seizure freedom at a mean follow-up of 5.1 years (range 1 to 17.1). We identified acquired etiology other than stroke (odds ratio [OR] 4.4, 95% confidence interval (CI) 1.1-18.0), hemimegalencephaly (OR 2.8, 95% CI 1.1-7.3), contralateral magnetic resonance imaging (MRI) findings (OR 5.5, 95% CI 2.7-11.1), prior resective surgery (OR 5.0, 95% CI 1.8-14.0), and left hemispherotomy (OR 2.3, 95% CI 1.3-3.9) as significant determinants of seizure recurrence. We found no evidence of an impact of the hemispherotomy technique on seizure outcome (the BF for a model including the hemispherotomy technique over the null model was 1.1), with comparable overall major complication rates for different approaches. SIGNIFICANCE Knowledge about the independent determinants of seizure outcome following pediatric hemispherotomy will improve the counseling of patients and families. In contrast to previous reports, we found no statistically relevant difference in seizure-freedom rates between the vertical and horizontal hemispherotomy techniques when accounting for different clinical features between groups.
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Affiliation(s)
- Georgia Ramantani
- Department of Neuropediatrics, University Children's Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Christine Bulteau
- Member of ERN EpiCare, Department of Pediatric Neurosurgery, Hospital Fondation Adolphe de Rothschild, Paris, France
| | - Dorottya Cserpan
- Department of Neuropediatrics, University Children's Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Willem M Otte
- Member of ERN EpiCare, Department of Child Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, and Utrecht University, Utrecht, The Netherlands
| | - Georg Dorfmüller
- Member of ERN EpiCare, Department of Pediatric Neurosurgery, Hospital Fondation Adolphe de Rothschild, Paris, France
| | - J Helen Cross
- Department of Neurology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street & UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK
| | - Josef Zentner
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Martin Tisdall
- Department of Neurosurgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Kees P J Braun
- Member of ERN EpiCare, Department of Child Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, and Utrecht University, Utrecht, The Netherlands
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Pepi C, De Benedictis A, Rossi-Espagnet MC, Cappelletti S, Da Rold M, Falcicchio G, Vigevano F, Marras CE, Specchio N, De Palma L. Hemispherotomy in Infants with Hemimegalencephaly: Long-Term Seizure and Developmental Outcome in Early Treated Patients. Brain Sci 2022; 13:brainsci13010073. [PMID: 36672056 PMCID: PMC9856354 DOI: 10.3390/brainsci13010073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 12/21/2022] [Accepted: 12/26/2022] [Indexed: 01/01/2023] Open
Abstract
Hemimegalencephaly (HME) is a rare brain congenital malformation, consisting in altered neuronal migration and proliferation within one hemisphere, which is responsible for early onset drug-resistant epilepsy. Hemispherotomy is an effective treatment option for patients with HME and drug-resistant epilepsy. Surgical outcome may be variable among different surgical series, and the long-term neuropsychological trajectory has been rarely defined using a standardized neurocognitive test. We report the epileptological and neuropsychological long-term outcomes of four consecutive HME patients, operated on before the age of three years. All patients were seizure-free and drug-free, and the minimum follow-up duration was of five years. Despite the excellent post-surgical seizure outcome, the long-term developmental outcome is quite variable between patients, ranging from mild to severe intellectual disabilities. Patients showed improvement mainly in communication skills, while visuo-perceptive and coordination abilities were more impaired. Epileptological outcome seems to be improved in early treated patients; however, neuropsychological outcome in HME patients may be highly variable despite early surgery.
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Affiliation(s)
- Chiara Pepi
- Rare and Complex Epilepsies Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, IRCCS, Full Member of European Reference Network EpiCARE, 00165 Rome, Italy
| | | | | | - Simona Cappelletti
- Unit of Clinical Psychology, Department of Neuroscience, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Martina Da Rold
- Scientific Institute, IRCCS “E. Medea”, Association “La Nostra Famiglia”, 31015 Conegliano, Italy
| | - Giovanni Falcicchio
- Department of Basic Medical Sciences, Neurosciences and Sense Organs—University of Bari Aldo Moro, 70121 Bari, Italy
| | - Federico Vigevano
- Rare and Complex Epilepsies Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, IRCCS, Full Member of European Reference Network EpiCARE, 00165 Rome, Italy
| | - Carlo Efisio Marras
- Neurosurgery Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Nicola Specchio
- Rare and Complex Epilepsies Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, IRCCS, Full Member of European Reference Network EpiCARE, 00165 Rome, Italy
- Correspondence: ; Tel.: +39-06-68592645; Fax: +39-06-68592463
| | - Luca De Palma
- Rare and Complex Epilepsies Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, IRCCS, Full Member of European Reference Network EpiCARE, 00165 Rome, Italy
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Can Presurgical Interhemispheric EEG Connectivity Predict Outcome in Hemispheric Surgery? A Brain Machine Learning Approach. Brain Sci 2022; 13:brainsci13010071. [PMID: 36672052 PMCID: PMC9856795 DOI: 10.3390/brainsci13010071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/21/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Hemispherotomy (HT) is a surgical option for treatment of drug-resistant seizures due to hemispheric structural lesions. Factors affecting seizure outcome have not been fully clarified. In our study, we used a brain Machine Learning (ML) approach to evaluate the possible role of Inter-hemispheric EEG Connectivity (IC) in predicting post-surgical seizure outcome. METHODS We collected 21 pediatric patients with drug-resistant epilepsy; who underwent HT in our center from 2009 to 2020; with a follow-up of at least two years. We selected 5-s windows of wakefulness and sleep pre-surgical EEG and we trained Artificial Neuronal Network (ANN) to estimate epilepsy outcome. We extracted EEG features as input data and selected the ANN with best accuracy. RESULTS Among 21 patients, 15 (71%) were seizure and drug-free at last follow-up. ANN showed 73.3% of accuracy, with 85% of seizure free and 40% of non-seizure free patients appropriately classified. CONCLUSIONS The accuracy level that we reached supports the hypothesis that pre-surgical EEG features may have the potential to predict epilepsy outcome after HT. SIGNIFICANCE The role of pre-surgical EEG data in influencing seizure outcome after HT is still debated. We proposed a computational predictive model, with an ML approach, with a high accuracy level.
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Tassi L, Specchio N, Mecarelli O, Tinuper P, Vigevano F, Perucca E. The 50th anniversary of the Italian League Against Epilepsy (Lega Italiana Contro l’Epilessia). Epilepsy Behav Rep 2022; 19:100553. [PMID: 35664663 PMCID: PMC9157453 DOI: 10.1016/j.ebr.2022.100553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 05/11/2022] [Accepted: 05/15/2022] [Indexed: 11/17/2022] Open
Abstract
We describe the 50-year history of the Italian League Against Epilepsy (LICE). LICE promotes high-quality epilepsy care, education and research into epilepsy. LICE maintains close relations with ILAE and other professional societies.
This article was prepared to outline the article collection submitted on behalf of Lega Italiana Contro l’Epilepsia, or LICE, for the 50th anniversary of the founding of the ILAE Italian Chapter, and provides a brief summary of the history, with its landmark achievements and challenges. LICE is a multidisciplinary, inclusive, educational, informative and multifaceted organization. Initially in 1955 and then formally in 1972, LICE was born in Milano, with the mission to devote itself to people suffering with epilepsy and by promoting appropriate treatment and care, integration into society, to promote and pursue all kinds of activities designed to achieve those aims. The LICE is currently composed of more than 1000 members including neurologists, pediatric neurologists, neurosurgeons, neurophysiologists, and neuropsychologists who function throughout Italy dealing mainly or exclusively with the diagnosis and treatment of people with epilepsy.
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Wang S, Pan J, Zhao M, Wang X, Zhang C, Li T, Wang M, Wang J, Zhou J, Liu C, Sun Y, Zhu M, Qi X, Luan G, Guan Y. Characteristics, surgical outcomes, and influential factors of epilepsy in Sturge-Weber syndrome. Brain 2021; 145:3431-3443. [PMID: 34932802 DOI: 10.1093/brain/awab470] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 11/19/2021] [Accepted: 11/28/2021] [Indexed: 02/05/2023] Open
Abstract
Abstract
Few studies have reported the clinical presentation, surgical treatment, outcomes, and influential factors for patients with epilepsy and Sturge-Weber syndrome.
This large-scale retrospective study continuously enrolled 132 patients with Sturge-Weber syndrome and epilepsy from January 2008 to December 2018 at our hospital to analyze their characteristics. Among these patients, 90 underwent epilepsy surgery, and their postoperative 2-year follow-up seizure, cognitive, and motor functional outcomes were assessed and analyzed. Univariable and multivariable logistic analyses were conducted to explore the influential factors.
Among the Sturge-Weber syndrome patients for whom characteristics were analyzed (n = 132), 76.52% of patients had their first epileptic seizures within their first year of life. The risk factors for cognitive decline were seizure history≥2 years (adjusted odds ratio [aOR] = 3.829, 95% confidence interval [CI]: 1.810-9.021, p = 0.008), bilateral leptomeningeal angiomas (aOR = 3.173, 95% CI: 1.970-48.194, p = 0.013), age at onset < 1 year (aOR = 2.903, 95% CI: 1.230-6.514, p = 0.013), brain calcification (aOR = 2.375, 95% CI: 1.396-5.201, p = 0.021) and left leptomeningeal angiomas (aOR = 2.228, 95% CI: 1.351-32.571, p = 0.030). Of the patients who underwent epilepsy surgery (n = 90), 44 were subject to focal resection, and 46 underwent hemisphere surgery (19 anatomical hemispherectomies and 27 modified hemispherotomies). A postoperative seizure-free status, favorable cognitive outcomes, and favorable motor outcomes were achieved in 83.33%, 44.44%, and 43.33% of surgical patients, respectively. The modified hemispherotomy group had similar surgical outcomes, less intraoperative blood loss and shorter postoperative hospital stays than the anatomical hemispherectomy group. Regarding seizure outcomes, full resection (aOR = 11.115, 95% CI: 1.260-98.067, p = 0.020) and age at surgery < 2 years (aOR = 6.040, 95% CI: 1.444-73.367, p = 0.031) were positive influential factors for focal resection. Age at surgery < 2 years (aOR = 15.053, 95% CI: 1.050-215.899, p = 0.036) and infrequent seizures (aOR = 8.426, 95% CI: 1.086-87.442, p = 0.042; monthly vs. weekly) were positive influential factors for hemisphere surgery.
In conclusion, epilepsy surgery resulted in a good postoperative seizure-free rate and favorable cognitive and motor functional outcomes and showed acceptable safety for patients with epilepsy and Sturge-Weber syndrome. Modified hemispherotomy is a less invasive and safer type of hemisphere surgery than traditional anatomic hemispherectomy with similar surgical outcomes. Early surgery may be helpful to achieve better seizure outcomes and cognitive protection, while the risk of surgery for young children should also be considered.
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Affiliation(s)
- Shu Wang
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Junhong Pan
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Meng Zhao
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Xiongfei Wang
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Chunsheng Zhang
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Tianfu Li
- Department of Neurology, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
- Beijing Key Laboratory of Epilepsy, Beijing 100093, China
- Center of Epilepsy, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing 100093, China
| | - Mengyang Wang
- Department of Neurology, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Jing Wang
- Department of Neurology, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Jian Zhou
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Changqing Liu
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Yongxing Sun
- Department of Anesthesiology, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
| | - Mingwang Zhu
- Department of Radiology, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
- Department of Pathology, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
| | | | - Guoming Luan
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
- Beijing Key Laboratory of Epilepsy, Beijing 100093, China
- Center of Epilepsy, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing 100093, China
| | - Yuguang Guan
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing 100093, China
- Beijing Key Laboratory of Epilepsy, Beijing 100093, China
- Center of Epilepsy, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing 100093, China
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10
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Bourdillon P, Bulteau C, Dorfmüller G, Ferrand-Sorbets S. Vertical hemispherotomy for drug-resistant epilepsy: Toward confirmation of the HOPS study. Epilepsia 2021; 62:3150-3151. [PMID: 34716924 DOI: 10.1111/epi.17111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Pierre Bourdillon
- Department of Neurosurgery, Foundation Adolphe de Rothschild Hospital, Paris, France
| | - Christine Bulteau
- Department of Pediatric Neurosurgery, Foundation Adolphe de Rothschild Hospital, Paris, France.,MC2Lab, Institute of Psychology, University of Paris, Paris, France
| | - Georg Dorfmüller
- Department of Pediatric Neurosurgery, Foundation Adolphe de Rothschild Hospital, Paris, France
| | - Sarah Ferrand-Sorbets
- Department of Pediatric Neurosurgery, Foundation Adolphe de Rothschild Hospital, Paris, France
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11
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Melikyan AG, Kozlova AB, Vlasov PA, Shishkina LV, Demin MO, Shults EI, Buklina SB, Nagorskaya IA, Strunina YV. [Lessons learnt from 101 hemispherotomies in children with symptomatic epilepsy. Part I: seizure outcome]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:15-21. [PMID: 34713999 DOI: 10.17116/neiro20218505115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate variables that may predict the outcome after hemispherotomy basing on a retrospective study of a large consecutive pediatric cohort of patients from a single institution. MATERIAL AND METHODS One hundred and one patients with refractory seizures and variable decline in development (n=78) underwent hemispherotomy (med. age - 43 months, med. epilepsy history - 30 months). Developmental pathology was the anatomical substrate of disorder in 42 patients, while the infantile post-stroke scarring and gliosis was its origin in the majority of 43 cases with acquired etiology. The progressive pathology (the Rasmussen encephalitis, Sturge-Weber angiomatosis and tuberous sclerosis) was the etiology in 16 children. Left-sided hemisphere was impaired in 54 cases; some contralateral anatomical and potentially epileptogenic MRI-abnormalities were noted also in «healthy» hemisphere in ¼ of all cases. Eight patients needed second surgery to complete sectioning of undercut commissural fibers. FU is known in 91 patients (med. - 1.5 years) and 73 of them were free of seizures (80.2%), but only 30 of 40 patients with FU > 2 years were still SF (75%). All but one of re-do hemispherotomies were successful. AED-treatment was discontinued in 46 cases and tapered in other 27 patients. Up to 90% of kids demonstrated some improvement in behavior and cognition. RESULTS AND CONCLUSION Developmental pathology, infantile spasms and younger age onset of seizures are negative predictors for achievement of SF-status (p<0.05). Neither bilateral epileptic EEG-signs, nor MRI-abnormalities in «healthy» hemisphere had any relation to outcome, but focal seizure onset was associated positively with further SF-status (p = 0.03). Kids with multiple lobe unilateral CD do somewhat worse than their counterparts with hemimegalencephaly and acquired etiology. Post-hemispherotomy hemiparesis (either new or worsening of already existed one) has no relation either to the age at surgery, or to the age onset (p = 0.41). Children with left-sided lesions were less successful in every neurodevelopmental domain except maintaining expressive language. Patients with relapse or persisting seizures have good chances to become SF by re-doing hemispherotomy and should be evaluated for the possibly incomplete hemispheric isolation.
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Affiliation(s)
| | - A B Kozlova
- Burdenko Neurosurgical Center, Moscow, Russia
| | - P A Vlasov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - M O Demin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - E I Shults
- Burdenko Neurosurgical Center, Moscow, Russia
| | - S B Buklina
- Pirogov Russian National Research Medical University, Moscow, Russia
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12
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Cossu M, Nichelatti M, De Benedictis A, Rizzi M. Lateral versus vertical hemispheric disconnection for epilepsy: a systematic review and meta-analysis. J Neurosurg 2021:1-11. [PMID: 34653979 DOI: 10.3171/2021.5.jns21949] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 05/18/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Lateral periinsular hemispherotomy (LPH) and vertical parasagittal hemispherotomy (VPH) are the most popular disconnective techniques for intractable epilepsies associated with unilateral hemispheric pathologies. The authors aimed to investigate possible differences in seizure outcome and complication rates between patients who underwent LPH and VPH. METHODS A comprehensive literature search of PubMed and Embase identified English-language articles published from database inception to December 2019 that reported series (minimum 12 patients with follow-up ≥ 12 months) on either LPH or VPH. Pooled rates of seizure freedom and complications (with a particular focus on hydrocephalus) were analyzed using meta-analysis to calculate both fixed and random effects. Heterogeneity (Cochran's Q test) and inconsistency (fraction of Q due to actual heterogeneity) were also calculated. RESULTS Twenty-five studies were included. Data from 825 patients were available for seizure outcome analysis (583 underwent LPH and 242 underwent VPH), and data from 692 patients were available for complication analysis (453 underwent LPH and 239 underwent VPH). No differences were found in the pooled rates of Engel class I seizure outcome between patients who underwent LPH (80.02% and 79.44% with fixed and random effects, respectively) and VPH (79.89% and 80.69% with fixed and random effects, respectively) (p = 0.953). No differences were observed in the pooled rates of shunted hydrocephalus between patients who underwent LPH (11.34% and 10.63% with fixed and random effects, respectively) and VPH (11.07% and 9.98% with fixed and random effects, respectively) (p = 0.898). Significant heterogeneity and moderate inconsistency were determined for hydrocephalus occurrence in patients who underwent both LPH and VPH. CONCLUSIONS LPH and VPH techniques present similar excellent seizure outcomes, with comparable and acceptable safety profiles.
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Affiliation(s)
- Massimo Cossu
- 1"Claudio Munari" Epilepsy Surgery Centre, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Michele Nichelatti
- 2Service of Biostatistics, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano, Niguarda, Milan, Italy; and
| | - Alessandro De Benedictis
- 3Neurosurgery Unit, Department of Neurosciences, Bambino Gesù Children Hospital IRCCS, Rome, Italy
| | - Michele Rizzi
- 1"Claudio Munari" Epilepsy Surgery Centre, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
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13
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Beatty CW, Lockrow JP, Gedela S, Gehred A, Ostendorf AP. The Missed Value of Underutilizing Pediatric Epilepsy Surgery: A Systematic Review. Semin Pediatr Neurol 2021; 39:100917. [PMID: 34620465 DOI: 10.1016/j.spen.2021.100917] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 10/20/2022]
Abstract
Pediatric epilepsy surgery is underutilized. Only 1%-11% of children with drug resistant epilepsy (DRE) undergo surgical treatment, or less than half of those estimated to benefit. We conducted a systematic review of articles published in PubMed, EMBASE, and Web of Science in order to study the factors related to surgery underutilization as well as the impact on both the individual and the healthcare system. Our review demonstrates multiple factors leading to underutilization, including family misconceptions about epilepsy surgery, lack of provider knowledge, as well as systemic health disparities. While the upfront cost of epilepsy surgery is significant, the long-term financial benefits and reduced health resource utilization tilt the economic advantage in favor of surgery in children with DRE. Additionally, timely interventions improve seizure and cognitive outcomes with low risk of complications. Further interventions are needed at the levels of family, provider, and the healthcare system to increase access to pediatric epilepsy surgery.
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Affiliation(s)
- Christopher W Beatty
- The Ohio State University and Nationwide Children's Hospital, Division of Neurology, Department of Pediatrics, Columbus, OH
| | - Jason P Lockrow
- Department of Neurology, Section of Pediatric Neurology, University of Washington, Seattle, WA
| | - Satyanarayana Gedela
- Emory University and Children's Healthcare of Atlanta, Division of Neurology, Department of Pediatrics, Atlanta, GA
| | - Alison Gehred
- Medical Library Division, Nationwide Children's Hospital, Columbus, OH
| | - Adam P Ostendorf
- The Ohio State University and Nationwide Children's Hospital, Division of Neurology, Department of Pediatrics, Columbus, OH.
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14
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Guglielmi G, Eschbach KL, Alexander AL. Smaller Knife, Fewer Seizures? Recent Advances in Minimally Invasive Techniques in Pediatric Epilepsy Surgery. Semin Pediatr Neurol 2021; 39:100913. [PMID: 34620456 DOI: 10.1016/j.spen.2021.100913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 02/02/2023]
Abstract
Children with drug-resistant epilepsy are at high risk for developmental delay, increased mortality, psychiatric comorbidities, and requiring assistance with activities of daily living. Despite the advent of new and effective pharmacologic therapies, about one in 5 children will develop drug-resistant epilepsy, and most of these children continue to have seizures despite trials of other medication. Epilepsy surgery is often a safe and effective option which may offer seizure freedom or at least a significant reduction in seizure burden in many children. However, despite published evidence of safety and efficacy, epilepsy surgery remains underutilized in the pediatric population. Patient and family fears about the risks of surgery may contribute to this gap. Less invasive surgical techniques may be more palatable to children with epilepsy and their caregivers. In this review, we present recent advances in minimally invasive techniques for the surgical treatment of epilepsy as well as intriguing possibilities for the future. We describe the indications for, benefits of, and limits to minimally-invasive techniques including Stereo-encephalography, laser interstitial thermal ablation, deep brain stimulation, focused ultrasound, stereo-encephalography-guided radiofrequency ablation, endoscopic disconnections, and responsive neurostimulation.
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Affiliation(s)
- Gina Guglielmi
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO
| | - Krista L Eschbach
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO
| | - Allyson L Alexander
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO.
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15
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Fallah A, Lewis E, Ibrahim GM, Kola O, Tseng CH, Harris WB, Chen JS, Lin KM, Cai LX, Liu QZ, Lin JL, Zhou WJ, Mathern GW, Smyth MD, O'Neill BR, Dudley RWR, Ragheb J, Bhatia S, Delev D, Ramantani G, Zentner J, Wang AC, Dorfer C, Feucht M, Czech T, Bollo RJ, Issabekov G, Zhu H, Connolly M, Steinbok P, Zhang JG, Zhang K, Hidalgo ET, Weiner HL, Wong-Kisiel L, Lapalme-Remis S, Tripathi M, Sarat Chandra P, Hader W, Wang FP, Yao Y, Champagne PO, Brunette-Clément T, Guo Q, Li SC, Budke M, Pérez-Jiménez MA, Raftopoulos C, Finet P, Michel P, Schaller K, Stienen MN, Baro V, Cantillano Malone C, Pociecha J, Chamorro N, Muro VL, von Lehe M, Vieker S, Oluigbo C, Gaillard WD, Al-Khateeb M, Al Otaibi F, Krayenbühl N, Bolton J, Pearl PL, Weil AG. Comparison of the real-world effectiveness of vertical versus lateral functional hemispherotomy techniques for pediatric drug-resistant epilepsy: A post hoc analysis of the HOPS study. Epilepsia 2021; 62:2707-2718. [PMID: 34510448 PMCID: PMC9290517 DOI: 10.1111/epi.17021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/24/2021] [Accepted: 07/15/2021] [Indexed: 11/26/2022]
Abstract
Objective This study was undertaken to determine whether the vertical parasagittal approach or the lateral peri‐insular/peri‐Sylvian approach to hemispheric surgery is the superior technique in achieving long‐term seizure freedom. Methods We conducted a post hoc subgroup analysis of the HOPS (Hemispheric Surgery Outcome Prediction Scale) study, an international, multicenter, retrospective cohort study that identified predictors of seizure freedom through logistic regression modeling. Only patients undergoing vertical parasagittal, lateral peri‐insular/peri‐Sylvian, or lateral trans‐Sylvian hemispherotomy were included in this post hoc analysis. Differences in seizure freedom rates were assessed using a time‐to‐event method and calculated using the Kaplan–Meier survival method. Results Data for 672 participants across 23 centers were collected on the specific hemispherotomy approach. Of these, 72 (10.7%) underwent vertical parasagittal hemispherotomy and 600 (89.3%) underwent lateral peri‐insular/peri‐Sylvian or trans‐Sylvian hemispherotomy. Seizure freedom was obtained in 62.4% (95% confidence interval [CI] = 53.5%–70.2%) of the entire cohort at 10‐year follow‐up. Seizure freedom was 88.8% (95% CI = 78.9%–94.3%) at 1‐year follow‐up and persisted at 85.5% (95% CI = 74.7%–92.0%) across 5‐ and 10‐year follow‐up in the vertical subgroup. In contrast, seizure freedom decreased from 89.2% (95% CI = 86.3%–91.5%) at 1‐year to 72.1% (95% CI = 66.9%–76.7%) at 5‐year to 57.2% (95% CI = 46.6%–66.4%) at 10‐year follow‐up for the lateral subgroup. Log‐rank test found that vertical hemispherotomy was associated with durable seizure‐free progression compared to the lateral approach (p = .01). Patients undergoing the lateral hemispherotomy technique had a shorter time‐to‐seizure recurrence (hazard ratio = 2.56, 95% CI = 1.08–6.04, p = .03) and increased seizure recurrence odds (odds ratio = 3.67, 95% CI = 1.05–12.86, p = .04) compared to those undergoing the vertical hemispherotomy technique. Significance This pilot study demonstrated more durable seizure freedom of the vertical technique compared to lateral hemispherotomy techniques. Further studies, such as prospective expertise‐based observational studies or a randomized clinical trial, are required to determine whether a vertical approach to hemispheric surgery provides superior long‐term seizure outcomes.
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Affiliation(s)
- Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Evan Lewis
- Neurology Center of Toronto, Toronto, Ontario, Canada
| | - George M Ibrahim
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Olivia Kola
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Chi-Hong Tseng
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - William B Harris
- Department of Medicine, John A. Burns School of Medicine at University of Hawaii, Honolulu, Hawaii, USA
| | - Jia-Shu Chen
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Kao-Min Lin
- Department of Functional Neurosurgery, Xiamen Humanity Hospital, Xiamen, China
| | - Li-Xin Cai
- Department of Pediatric Epilepsy Center, Peking University First Hospital, Beijing, China
| | - Qing-Zhu Liu
- Department of Pediatric Epilepsy Center, Peking University First Hospital, Beijing, China
| | - Jiu-Luan Lin
- Department of Epilepsy Center, Yuquan Hospital, Tsinghua University, Beijing, China
| | - Wen-Jing Zhou
- Department of Epilepsy Center, Yuquan Hospital, Tsinghua University, Beijing, China
| | - Gary W Mathern
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Matthew D Smyth
- Department of Neurological Surgery, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Brent R O'Neill
- Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Roy W R Dudley
- Division of Neurosurgery, Department of Pediatric Surgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - John Ragheb
- Department of Neurosurgery, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Sanjiv Bhatia
- Department of Neurosurgery, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Daniel Delev
- Department of Neurosurgery, University Medical Center Freiburg and Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Georgia Ramantani
- Department of Neurosurgery, University Medical Center Freiburg and Medical Faculty, University of Freiburg, Freiburg, Germany.,Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland
| | - Josef Zentner
- Department of Neurosurgery, University Medical Center Freiburg and Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Anthony C Wang
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Christian Dorfer
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Martha Feucht
- Department of Pediatrics, Medical University Vienna, Vienna, Austria
| | - Thomas Czech
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Robert J Bollo
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Galymzhan Issabekov
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongwei Zhu
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Mary Connolly
- Division of Neurosurgery, Department of Surgery, BC Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Paul Steinbok
- Division of Neurosurgery, Department of Surgery, BC Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Jian-Guo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kai Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Eveline Teresa Hidalgo
- Division of Pediatric Neurosurgery, Department of Surgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, New York, USA
| | - Howard L Weiner
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Lily Wong-Kisiel
- Division of Child Neurology and Epilepsy, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Samuel Lapalme-Remis
- Division of Neurology, Department of Medicine, University of Montreal Hospital Centre, Montreal, Quebec, Canada
| | - Manjari Tripathi
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Poodipedi Sarat Chandra
- Department of Neurosurgery (Center of Excellence for Epilepsy & Magnetoencephalography), All India Institute of Medical Sciences and National Brain Research Center, New Delhi, India
| | - Walter Hader
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Feng-Peng Wang
- Department of Functional Neurosurgery, Xiamen Humanity Hospital, Xiamen, China
| | - Yi Yao
- Department of Neurosurgery, Guangdong Shenzhen Children Hospital, Shenzhen, China
| | | | | | - Qiang Guo
- Department of Neurosurgery, Guangdong Sanjiu Brain Hospital, Guangzhou Shi, China
| | - Shao-Chun Li
- Department of Neurosurgery, Guangdong Sanjiu Brain Hospital, Guangzhou Shi, China
| | - Marcelo Budke
- Department of Neurosurgery, Niño Jesus University Children's Hospital, Madrid, Spain
| | | | - Christian Raftopoulos
- Department of Neurosurgery, Brussels Saint-Luc University Hospital, Brussels, Belgium
| | - Patrice Finet
- Department of Neurosurgery, Brussels Saint-Luc University Hospital, Brussels, Belgium
| | - Pauline Michel
- Department of Neurosurgery, Brussels Saint-Luc University Hospital, Brussels, Belgium
| | - Karl Schaller
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Martin N Stienen
- Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Valentina Baro
- Academic Neurosurgery, Department of Neuroscience, University of Padova, Padova, Italy
| | - Christian Cantillano Malone
- Department of Neurosurgery, Pontifical Catholic University of Chile, Sotero del Rio Hospital, Santiago, Chile
| | - Juan Pociecha
- Epilepsy Department, Neurology Neurophysiology Epilepsy Service Foundation Against Childhood Neurological Diseases, Buenos Aires, Argentina
| | - Noelia Chamorro
- Epilepsy Department, Neurology Neurophysiology Epilepsy Service Foundation Against Childhood Neurological Diseases, Buenos Aires, Argentina
| | - Valeria L Muro
- Epilepsy Department, Neurology Neurophysiology Epilepsy Service Foundation Against Childhood Neurological Diseases, Buenos Aires, Argentina
| | - Marec von Lehe
- Department of Neurosurgery, Brandenburg Medical School, Neuruppin, Germany
| | - Silvia Vieker
- Department of Neurosurgery, Brandenburg Medical School, Neuruppin, Germany
| | - Chima Oluigbo
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA
| | - William D Gaillard
- Divisions of Child Neurology and Epilepsy and Neurophysiology, Children's National Medical Center, Washington, District of Columbia, USA
| | - Mashael Al-Khateeb
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Alfaisal University, Riyadh, Saudi Arabia
| | - Faisal Al Otaibi
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Alfaisal University, Riyadh, Saudi Arabia
| | - Niklaus Krayenbühl
- Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Jeffrey Bolton
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Phillip L Pearl
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alexander G Weil
- Department of Neurosurgery, Saint Justine University Hospital Centre, Montreal, Quebec, Canada
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16
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Hemispherotomy for pediatric epilepsy: a systematic review and critical analysis. Childs Nerv Syst 2021; 37:2153-2161. [PMID: 33907902 DOI: 10.1007/s00381-021-05176-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/18/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Several variations of functional disconnection surgery have been described for the treatment of lateralized, hemispheric, drug-resistant epilepsy in children. The purpose of this study is to investigate the existing literature regarding patient selection, approach, and outcomes after hemispherotomy. METHODS A systematic review of the English literature through February 2019 was performed in accordance with the PRISMA statement. The articles were classified by level of evidence and summarized in an evidentiary table. Seizure outcomes, functional outcomes, surgical techniques, complications, and patient selection were critically analyzed. RESULTS A total of 173 papers were reviewed, of which 37 met criteria of inclusion and exclusion. Thirteen studies were classified as level III evidence, the remaining reached level IV. Vertical and lateral hemispherotomy achieve similar rates of seizure freedom and functional outcomes, though parasagittal and interhemispheric approaches may have shorter operative times and less blood loss. Etiology, bilateral MRI abnormalities, and nonlateralizing EEG did not predict worse seizure or functional outcomes. CONCLUSIONS Both vertical and lateral hemispherotomy approaches result in durable, reproducible benefits to epilepsy severity and functional status in appropriately selected pediatric patients.
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The Role of KRAS Mutations in Cortical Malformation and Epilepsy Surgery: A Novel Report of Nevus Sebaceous Syndrome and Review of the Literature. Brain Sci 2021; 11:brainsci11060793. [PMID: 34208656 PMCID: PMC8234150 DOI: 10.3390/brainsci11060793] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/27/2021] [Accepted: 06/11/2021] [Indexed: 12/12/2022] Open
Abstract
The rare nevus sebaceous (NS) syndrome (NSS) includes cortical malformations and drug-resistant epilepsy. Somatic RAS-pathway genetic variants are pathogenetic in NS, but not yet described within the brain of patients with NSS. We report on a 5-year-old boy with mild psychomotor delay. A brown-yellow linear skin lesion suggestive of NS in the left temporo-occipital area was evident at birth. Epileptic spasms presented at aged six months. EEG showed continuous left temporo-occipital epileptiform abnormalities. Brain MRI revealed a similarly located diffuse cortical malformation with temporal pole volume reduction and a small hippocampus. We performed a left temporo-occipital resection with histopathological diagnosis of focal cortical dysplasia type Ia in the occipital region and hippocampal sclerosis type 1. Three years after surgery, he is seizure-and drug-free (Engel class Ia) and showed cognitive improvement. Genetic examination of brain and skin specimens revealed the c.35G > T (p.Gly12Val) KRAS somatic missense mutation. Literature review suggests epilepsy surgery in patients with NSS is highly efficacious, with 73% probability of seizure freedom. The few histological analyses reported evidenced disorganized cortex, occasionally with cytomegalic neurons. This is the first reported association of a KRAS genetic variant with cortical malformations associated with epilepsy, and suggests a possible genetic substrate for hippocampal sclerosis.
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Consales A, Casciato S, Asioli S, Barba C, Caulo M, Colicchio G, Cossu M, de Palma L, Morano A, Vatti G, Villani F, Zamponi N, Tassi L, Di Gennaro G, Marras CE. The surgical treatment of epilepsy. Neurol Sci 2021; 42:2249-2260. [PMID: 33797619 DOI: 10.1007/s10072-021-05198-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 03/16/2021] [Indexed: 01/07/2023]
Abstract
In 2009, the Commission for Epilepsy Surgery of the Italian League Against Epilepsy (LICE) conducted an overview about the techniques used for the pre-surgical evaluation and the surgical treatment of epilepsies. The recognition that, in selected cases, surgery can be considered the first-line approach, suggested that the experience gained by the main Italian referral centers should be pooled in order to provide a handy source of reference. In light of the progress made over these past years, some parts of that first report have accordingly been updated. The present revision aims to harmonize the general principles regulating the patient selection and the pre-surgical work-up, as well as to expand the use of epilepsy surgery, that still represents an underutilized resource, regrettably. The objective of this contribution is drawing up a methodological framework within which to integrate the experiences of each group in this complex and dynamic sector of the neurosciences.
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Affiliation(s)
- Alessandro Consales
- Division of Neurosurgery, IRCCS Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Sara Casciato
- Epilepsy Surgery Centre, IRCCS Neuromed, Via Atinense, 18, 86170, Pozzilli, IS, Italy
| | - Sofia Asioli
- Department of Biomedical and Neuromotor Sciences, Section of Anatomic Pathology "M. Malpighi", Bellaria Hospital, Bologna, Italy
| | - Carmen Barba
- Neuroscience Department, Meyer Children's Hospital-University of Florence, Florence, Italy
| | - Massimo Caulo
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | | | - Massimo Cossu
- "C. Munari" Epilepsy Surgery Center, Niguarda Hospital, Milan, Italy
| | - Luca de Palma
- Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children Hospital, Rome, Italy
| | - Alessandra Morano
- Department of Human Neurosciences, "Sapienza" University, Rome, Italy
| | - Giampaolo Vatti
- Department of Neurological and Sensorial Sciences, University of Siena, Siena, Italy
| | - Flavio Villani
- Division of Neurophysiology and Epilepsy Centre, IRCCS San Martino Policlinic Hospital, Genoa, Italy
| | - Nelia Zamponi
- Child Neuropsychiatric Unit, University of Ancona, Ancona, Italy
| | - Laura Tassi
- "C. Munari" Epilepsy Surgery Center, Niguarda Hospital, Milan, Italy
| | - Giancarlo Di Gennaro
- Epilepsy Surgery Centre, IRCCS Neuromed, Via Atinense, 18, 86170, Pozzilli, IS, Italy.
| | - Carlo Efisio Marras
- Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children Hospital, Rome, Italy
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Specchio N, Pepi C, De Palma L, Trivisano M, Vigevano F, Curatolo P. Neuroimaging and genetic characteristics of malformation of cortical development due to mTOR pathway dysregulation: clues for the epileptogenic lesions and indications for epilepsy surgery. Expert Rev Neurother 2021; 21:1333-1345. [PMID: 33754929 DOI: 10.1080/14737175.2021.1906651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Malformation of cortical development (MCD) is strongly associated with drug-resistant epilepsies for which surgery to remove epileptogenic lesions is common. Two notable technological advances in this field are identification of the underlying genetic cause and techniques in neuroimaging. These now question how presurgical evaluation ought to be approached for 'mTORpathies.'Area covered: From review of published primary and secondary articles, the authors summarize evidence to consider focal cortical dysplasia (FCD), tuber sclerosis complex (TSC), and hemimegalencephaly (HME) collectively as MCD mTORpathies. The authors also consider the unique features of these related conditions with particular focus on the practicalities of using neuroimaging techniques currently available to define surgical targets and predict post-surgical outcome. Ultimately, the authors consider the surgical dilemmas faced for each condition.Expert opinion: Considering FCD, TSC, and HME collectively as mTORpathies has some merit; however, a unified approach to presurgical evaluation would seem unachievable. Nevertheless, the authors believe combining genetic-centered classification and morphologic findings using advanced imaging techniques will eventually form the basis of a paradigm when considering candidacy for early surgery.
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Affiliation(s)
- Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Chiara Pepi
- Rare and Complex Epilepsy Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Luca De Palma
- Rare and Complex Epilepsy Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Marina Trivisano
- Rare and Complex Epilepsy Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Federico Vigevano
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Rome, Italy
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Melikyan AG, Kushel YV, Sorokin VS, Vlasov PA, Demin MO, Shults EI, Shevchenko AM, Strunina YV. [Lessons learnt from 101 hemispheric pediatric epilepsy surgeries part ii: pitfalls and complications]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2021; 85:44-52. [PMID: 34951759 DOI: 10.17116/neiro20218506144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To evaluate the spectrum of pitfalls and complications after hemisherotomy basing on a retrospective study of a large consecutive pediatric cohort of patients from a single institution. MATERIAL AND METHODS One hundred and one patients (med. age - 43 months) with refractory seizures underwent hemispherotomy. Developmental pathology was the anatomical substrate of disorder in 42 patients. The infantile post-stroke scarring and gliosis was the origin of epilepsy in the majority of 43 cases with acquired etiology. The progressive pathology (RE, S-W and TS) was the etiology in the rest of children (16 cases). The lateral periinsular technique was used to isolate the sick hemisphere in 55 patients; the vertical parasagittal approach was employed in 46 cases. Median perioperative blood loss constituted 10.5 ml/kg, but was markedly larger in kids with hemimegaly (52.8 ml/kg); 57 patients needed hemotransfusion during surgery. Median length of stay in ICU was 14.7 hours, and the length of stay in the hospital until discharge - 6.5 days. Eight patients underwent second-look surgery to complete sectioning of undercut commissural fibers. FU is known in 91 patients (med. length - 1.5 years). RESULTS Major surgical complications with serious hemorrhage and/or surgery induced life-threatening events developed in 7 patients (one of them has died on the 5th day post-surgery for the causes of brain edema and uncontrolled hyponatremia). Various early and late infectious complications were noted in 4 cases. Ten patients experienced new not anticipated but temporary neurological deficit. Nine patients needed shunting for the causes of hydrocephalus within several first months post-hemispherotomy. Early seizure onset was associated with probability of all complications in general (p=0.02), and developmental etiology - with intraoperative bleeding and hemorrhagic complications (p=0.03). CONCLUSION Children with developmental etiology, particularly those with hemimegalencephaly, are most challengeable in terms of perioperative hemorrhage and serious complications. Patients with relapse or persisting seizures should be evaluated for the possibility of incomplete hemispheric isolation and have good chances to become SF by re-doing hemispherotomy.
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Affiliation(s)
| | - Yu V Kushel
- Burdenko Neurosurgical Center, Moscow, Russia
| | - V S Sorokin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - P A Vlasov
- Burdenko Neurosurgical Center, Moscow, Russia
| | - M O Demin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - E I Shults
- Burdenko Neurosurgical Center, Moscow, Russia
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Guerrini R, Cavallin M, Pippucci T, Rosati A, Bisulli F, Dimartino P, Barba C, Garbelli R, Buccoliero AM, Tassi L, Conti V. Is Focal Cortical Dysplasia/Epilepsy Caused by Somatic MTOR Mutations Always a Unilateral Disorder? NEUROLOGY-GENETICS 2020; 7:e540. [PMID: 33542949 PMCID: PMC7735020 DOI: 10.1212/nxg.0000000000000540] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 10/21/2020] [Indexed: 11/15/2022]
Abstract
Objective To alert about the wide margin of unpredictability that distribution of somatic MTOR mosaicism may have in the brain and the risk for independent epileptogenesis arising from the seemingly healthy contralateral hemisphere after complete removal of epileptogenic focal cortical dysplasia (FCD). Methods Clinical, EEG, MRI, histopathology, and molecular genetics in 2 patients (1 and 2) treated with focal resections and subsequent complete hemispherectomy for epileptogenic FCD due to somatic MTOR mutations. Autoptic brain study of bilateral asymmetric hemispheric dysplasia and identification of alternative allele fraction (AAF) rates for AKT1 (patient 3). Results The strongly hyperactivating p.Ser2215Phe (patient 1) and p.Leu1460Pro (patient 2) MTOR mutations were at low-level AAF in the dysplastic tissue. After repeated resections and eventual complete hemispherectomy, both patients manifested intractable seizures arising from the contralateral, seemingly healthy hemisphere. In patient 3, the p.Glu17Lys AKT1 mutation exhibited random distribution and AAF rates in different tissues with double levels in the more severely dysplastic cerebral hemisphere. Conclusions Our understanding of the distribution of somatic mutations in the brain in relation to the type of malformation and its hypothesized time of origin may be faulty. Large studies may reveal that the risk of a first surgery being disappointing might be related more to the specific somatic mammalian target of rapamycin mutation identified than to completeness of resection and that the advantages of repeated resections after a first unsuccessful operation should be weighed against the risk of the contralateral hemisphere becoming in turn epileptogenic.
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Affiliation(s)
- Renzo Guerrini
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories (R. Guerrini, M.C., A.R, C.B., V.C.), Children's Hospital A. Meyer, University of Florence; Medical Genetics Unit (T.P.), Sant'Orsola-Malpighi University Hospital, Bologna; IRCCS Bologna Institute for Neurological Sciences (F.B.), Bologna. Member of ERN EpiCARE; Department of Medical and Surgical Sciences (P.D.), University of Bologna; Clinical Epileptology and Experimental Neurophysiology Unit (R. Garbelli), IRCCS Istituto Neurologico C. Besta, Milan; Pathology Unit (A.M.B.), Children's Hospital A. Meyer-University of Florence; and "C. Munari" Epilepsy Surgery Center (L.T.), Niguarda Hospital, Milan, Italy
| | - Mara Cavallin
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories (R. Guerrini, M.C., A.R, C.B., V.C.), Children's Hospital A. Meyer, University of Florence; Medical Genetics Unit (T.P.), Sant'Orsola-Malpighi University Hospital, Bologna; IRCCS Bologna Institute for Neurological Sciences (F.B.), Bologna. Member of ERN EpiCARE; Department of Medical and Surgical Sciences (P.D.), University of Bologna; Clinical Epileptology and Experimental Neurophysiology Unit (R. Garbelli), IRCCS Istituto Neurologico C. Besta, Milan; Pathology Unit (A.M.B.), Children's Hospital A. Meyer-University of Florence; and "C. Munari" Epilepsy Surgery Center (L.T.), Niguarda Hospital, Milan, Italy
| | - Tommaso Pippucci
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories (R. Guerrini, M.C., A.R, C.B., V.C.), Children's Hospital A. Meyer, University of Florence; Medical Genetics Unit (T.P.), Sant'Orsola-Malpighi University Hospital, Bologna; IRCCS Bologna Institute for Neurological Sciences (F.B.), Bologna. Member of ERN EpiCARE; Department of Medical and Surgical Sciences (P.D.), University of Bologna; Clinical Epileptology and Experimental Neurophysiology Unit (R. Garbelli), IRCCS Istituto Neurologico C. Besta, Milan; Pathology Unit (A.M.B.), Children's Hospital A. Meyer-University of Florence; and "C. Munari" Epilepsy Surgery Center (L.T.), Niguarda Hospital, Milan, Italy
| | - Anna Rosati
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories (R. Guerrini, M.C., A.R, C.B., V.C.), Children's Hospital A. Meyer, University of Florence; Medical Genetics Unit (T.P.), Sant'Orsola-Malpighi University Hospital, Bologna; IRCCS Bologna Institute for Neurological Sciences (F.B.), Bologna. Member of ERN EpiCARE; Department of Medical and Surgical Sciences (P.D.), University of Bologna; Clinical Epileptology and Experimental Neurophysiology Unit (R. Garbelli), IRCCS Istituto Neurologico C. Besta, Milan; Pathology Unit (A.M.B.), Children's Hospital A. Meyer-University of Florence; and "C. Munari" Epilepsy Surgery Center (L.T.), Niguarda Hospital, Milan, Italy
| | - Francesca Bisulli
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories (R. Guerrini, M.C., A.R, C.B., V.C.), Children's Hospital A. Meyer, University of Florence; Medical Genetics Unit (T.P.), Sant'Orsola-Malpighi University Hospital, Bologna; IRCCS Bologna Institute for Neurological Sciences (F.B.), Bologna. Member of ERN EpiCARE; Department of Medical and Surgical Sciences (P.D.), University of Bologna; Clinical Epileptology and Experimental Neurophysiology Unit (R. Garbelli), IRCCS Istituto Neurologico C. Besta, Milan; Pathology Unit (A.M.B.), Children's Hospital A. Meyer-University of Florence; and "C. Munari" Epilepsy Surgery Center (L.T.), Niguarda Hospital, Milan, Italy
| | - Paola Dimartino
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories (R. Guerrini, M.C., A.R, C.B., V.C.), Children's Hospital A. Meyer, University of Florence; Medical Genetics Unit (T.P.), Sant'Orsola-Malpighi University Hospital, Bologna; IRCCS Bologna Institute for Neurological Sciences (F.B.), Bologna. Member of ERN EpiCARE; Department of Medical and Surgical Sciences (P.D.), University of Bologna; Clinical Epileptology and Experimental Neurophysiology Unit (R. Garbelli), IRCCS Istituto Neurologico C. Besta, Milan; Pathology Unit (A.M.B.), Children's Hospital A. Meyer-University of Florence; and "C. Munari" Epilepsy Surgery Center (L.T.), Niguarda Hospital, Milan, Italy
| | - Carmen Barba
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories (R. Guerrini, M.C., A.R, C.B., V.C.), Children's Hospital A. Meyer, University of Florence; Medical Genetics Unit (T.P.), Sant'Orsola-Malpighi University Hospital, Bologna; IRCCS Bologna Institute for Neurological Sciences (F.B.), Bologna. Member of ERN EpiCARE; Department of Medical and Surgical Sciences (P.D.), University of Bologna; Clinical Epileptology and Experimental Neurophysiology Unit (R. Garbelli), IRCCS Istituto Neurologico C. Besta, Milan; Pathology Unit (A.M.B.), Children's Hospital A. Meyer-University of Florence; and "C. Munari" Epilepsy Surgery Center (L.T.), Niguarda Hospital, Milan, Italy
| | - Rita Garbelli
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories (R. Guerrini, M.C., A.R, C.B., V.C.), Children's Hospital A. Meyer, University of Florence; Medical Genetics Unit (T.P.), Sant'Orsola-Malpighi University Hospital, Bologna; IRCCS Bologna Institute for Neurological Sciences (F.B.), Bologna. Member of ERN EpiCARE; Department of Medical and Surgical Sciences (P.D.), University of Bologna; Clinical Epileptology and Experimental Neurophysiology Unit (R. Garbelli), IRCCS Istituto Neurologico C. Besta, Milan; Pathology Unit (A.M.B.), Children's Hospital A. Meyer-University of Florence; and "C. Munari" Epilepsy Surgery Center (L.T.), Niguarda Hospital, Milan, Italy
| | - Anna Maria Buccoliero
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories (R. Guerrini, M.C., A.R, C.B., V.C.), Children's Hospital A. Meyer, University of Florence; Medical Genetics Unit (T.P.), Sant'Orsola-Malpighi University Hospital, Bologna; IRCCS Bologna Institute for Neurological Sciences (F.B.), Bologna. Member of ERN EpiCARE; Department of Medical and Surgical Sciences (P.D.), University of Bologna; Clinical Epileptology and Experimental Neurophysiology Unit (R. Garbelli), IRCCS Istituto Neurologico C. Besta, Milan; Pathology Unit (A.M.B.), Children's Hospital A. Meyer-University of Florence; and "C. Munari" Epilepsy Surgery Center (L.T.), Niguarda Hospital, Milan, Italy
| | - Laura Tassi
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories (R. Guerrini, M.C., A.R, C.B., V.C.), Children's Hospital A. Meyer, University of Florence; Medical Genetics Unit (T.P.), Sant'Orsola-Malpighi University Hospital, Bologna; IRCCS Bologna Institute for Neurological Sciences (F.B.), Bologna. Member of ERN EpiCARE; Department of Medical and Surgical Sciences (P.D.), University of Bologna; Clinical Epileptology and Experimental Neurophysiology Unit (R. Garbelli), IRCCS Istituto Neurologico C. Besta, Milan; Pathology Unit (A.M.B.), Children's Hospital A. Meyer-University of Florence; and "C. Munari" Epilepsy Surgery Center (L.T.), Niguarda Hospital, Milan, Italy
| | - Valerio Conti
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories (R. Guerrini, M.C., A.R, C.B., V.C.), Children's Hospital A. Meyer, University of Florence; Medical Genetics Unit (T.P.), Sant'Orsola-Malpighi University Hospital, Bologna; IRCCS Bologna Institute for Neurological Sciences (F.B.), Bologna. Member of ERN EpiCARE; Department of Medical and Surgical Sciences (P.D.), University of Bologna; Clinical Epileptology and Experimental Neurophysiology Unit (R. Garbelli), IRCCS Istituto Neurologico C. Besta, Milan; Pathology Unit (A.M.B.), Children's Hospital A. Meyer-University of Florence; and "C. Munari" Epilepsy Surgery Center (L.T.), Niguarda Hospital, Milan, Italy
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Sturge-Weber syndrome: an update on the relevant issues for neurosurgeons. Childs Nerv Syst 2020; 36:2553-2570. [PMID: 32564157 DOI: 10.1007/s00381-020-04695-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/21/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Sturge-Weber syndrome (SWS) is a neurocutaneous facomatosis characterized by facial and leptomeningeal angioma, glaucoma, seizures, and neurological disability. Therefore, a challenging multidisciplinary interaction is required for its management. The goal of this paper is to review the main aspects of SWS and to present an illustrative pediatric series. METHODS The pertinent literature has been analyzed, focused mainly on etiopathogenesis, pathology, clinical features, diagnostic tools, management, and outcome of the disease. Moreover, a series of 11 children operated on for refractory epilepsy between 2005 and 2015 (minimum follow-up 5 years, mean follow-up 9.6 years) is reported. The series consists of six boys and five girls with 6.5-month and 16.2-month mean age at seizure onset and at surgery, respectively. Seizures affected all children, followed by hemiparesis and psychomotor delay (81%), glaucoma (54%), and other neurological deficits (45%). RESULTS All children underwent hemispherectomy (anatomical in three cases, functional in two cases, hemispherotomy in six cases); one patient needed a redo hemispherotomy. Mortality was nil; disseminated intravascular coagulation and interstitial pneumonia occurred in one patient each; three children had subdural fluid collection. Eight patients (72%) are in the ILAE Class 1 (completely seizure and aura free), two in Class 2 (only auras, no seizure), and one in Class 3 (1-3 seizure days per year). AEDs discontinuation was possible in 73% of cases. The most important news from the literature concerned the pathogenesis (role of the mutation of the GNAQ gene in the abnormal SWS vasculogenesis), the clinical findings (the features and pathogenesis of the stroke-like episodes are being understood), the diagnostic tools (quantitative MRI and EEG), and both the medical (migraine, seizures) and surgical management (epilepsy). The epileptic outcome of SWS patients is very good (80% are seizure-free), if compared with other hemispheric syndromes. The quality of life is affected by the neurological and cognitive deficits. CONCLUSIONS SWS still is an etiological and clinical challenge. However, the improvements over the time are consistent. In particular, the neurosurgical treatment of refractory epilepsy provides very good results as long as the indication to treatment is correct.
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Specchio N, Pietrafusa N, Ferretti A, De Palma L, Santarone ME, Pepi C, Trivisano M, Vigevano F, Curatolo P. Treatment of infantile spasms: why do we know so little? Expert Rev Neurother 2020; 20:551-566. [PMID: 32316776 DOI: 10.1080/14737175.2020.1759423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Infantile spasm (IS) is an epileptic syndrome with typical onset within the first 2 years of life. This condition might be caused by several etiologies. IS is associated with pathological neuronal networks; however, definite hypotheses on neurobiological processes are awaited. AREAS COVERED Changes in NMDA and GABAB receptors and increase of Ca2+ conductance are some of the possible pathophysiological mechanisms. Animal models can help, but most have only some features of IS. Outcome is strongly affected by etiology and the timing of treatment, which relies still on ACTH, oral steroids, and vigabatrin. No significant differences in terms of efficacy have been documented, though a combination of ACTH and vigabatrin seems to be associated with better long-term outcomes. Despite the increasing knowledge about the etiology and pathophysiology of IS, in the last years, no new treatment approaches have been recognized to be able to modify the neurobiological process underlying IS. Precision medicine has far to come in IS. EXPERT OPINION Recently, no new therapeutic options for IS have emerged, probably due to the lack of reliable animal models and to the extreme variability in etiologies. Consequently, the outlook for patients and families is poor and early recognition and intervention remain research priorities.
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Affiliation(s)
- Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , Rome, 00165, Italy.,Member of European Reference Network EpiCARE
| | - Nicola Pietrafusa
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , Rome, 00165, Italy
| | - Alessandro Ferretti
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , Rome, 00165, Italy
| | - Luca De Palma
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , Rome, 00165, Italy
| | - Marta Elena Santarone
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , 00165, Rome, Italy
| | - Chiara Pepi
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , Rome, 00165, Italy.,Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University , 00133, Rome, Italy
| | - Marina Trivisano
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , Rome, 00165, Italy
| | - Federico Vigevano
- Member of European Reference Network EpiCARE.,Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS , 00165, Rome, Italy
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University , 00133, Rome, Italy
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