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Cicutti SE, Cuello JF, Villamil F, Gromadzyn GP, Bartuluchi M. Surgical Anatomy and Technique of Peri-Insular Hemispherotomy in Pediatric Epilepsy. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01138. [PMID: 38651858 DOI: 10.1227/ons.0000000000001161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/28/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Hemispherotomy is a highly complex procedure that demands a steep learning curve. An incomplete brain disconnection often results in failure of seizure control. The purpose of this article was to present a step-by-step guide to the surgical anatomy of this procedure. It is composed of a 7-stage approach, enhancing access to and improving visualization of deep structures. METHODS A retrospective analysis of 39 pediatric patients with refractory epilepsy who underwent this technique was conducted. Engel scores were assessed 1 year postsurgery. Cadaveric dissections were performed to illustrate the procedure. RESULTS Between 2015 and 2022, 39 patients were surgically treated using the peri-insular technique. The technique involved 7 stages: patient positioning, operative approach, opercular resection, transventricular callosotomy, fronto-orbital disconnection, anterior temporal disconnection, and posterior temporal disconnection. Most of the patients (92.30%) were seizure-free (Engel class I) at 1 year postoperative, 5.13% were nearly seizure-free (Engel II), and 2.56% showed significant improvement (Engel III). Complications occurred in 8% of cases, including 1 infection, 2 cases of aseptic meningitis, and 1 non-shunt-requiring acute hydrocephalus. CONCLUSION The peri-insular hemispherotomy technique offers excellent seizure control with a low complication rate. Our visual documentation of surgical anatomy, complemented by detailed descriptions of surgical nuances, significantly contributes to a comprehensive understanding of this technique.
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Affiliation(s)
- Santiago E Cicutti
- Neurosurgery Department, Juan P. Garrahan Hospital, Buenos Aires, Argentina
| | - Javier F Cuello
- Neurosurgery Department, Hospital Provincial Petrona V. de Cordero, San Fernando, Buenos Aires, Argentina
| | | | - Guido P Gromadzyn
- Neurosurgery Department, Juan P. Garrahan Hospital, Buenos Aires, Argentina
| | - Marcelo Bartuluchi
- Neurosurgery Department, Juan P. Garrahan Hospital, Buenos Aires, Argentina
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2
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Schijns OE. Functional hemispheric disconnection procedures for chronic epilepsy: history, indications, techniques, complications and current practice in Europe. A consensus statement on behalf of the EANS functional neurosurgery section. BRAIN & SPINE 2024; 4:102754. [PMID: 38510638 PMCID: PMC10951757 DOI: 10.1016/j.bas.2024.102754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/08/2024] [Accepted: 01/21/2024] [Indexed: 03/22/2024]
Abstract
Introduction The surgical procedure for severe, drug-resistant, unilateral hemispheric epilepsy is challenging. Over the last decades the surgical landscape for hemispheric disconnection procedures changed from anatomical hemispherectomy to functional hemispherotomy with a reduction of complications and stable good seizure outcome. Here, a task force of European epilepsy surgeons prepared, on behalf of the EANS Section for Functional Neurosurgery, a consensus statement on different aspects of the hemispheric disconnection procedure. Research question To determine history, indication, timing, techniques, complications and current practice in Europe for hemispheric disconnection procedures in drug-resistant epilepsy. Material and methods Relevant literature on the topic was collected by a literature search based on the PRISMA 2020 guidelines. Results A comprehensive overview on the historical development of hemispheric disconnection procedures for epilepsy is presented, while discussing indications, timing, surgical techniques and complications. Current practice for this procedure in European epilepsy surgery centers is provided. At present, our knowledge of long-term seizure outcomes primarily stems from open surgical disconnection procedures. Although minimal invasive surgical techniques in epilepsy are rapidly developing and reported in case reports or small case series, long-term seizure outcome remain uncertain and needs to be reported. Discussion and conclusion This is the first paper presenting a European consensus statement regarding history, indications, techniques and complications of hemispheric disconnection procedures for different causes of chronic, drug-resistant epilepsy. Furthermore, it serves as the pioneering document to report a comprehensive overview of the current surgical practices regarding this type of surgery employed in renowned epilepsy surgery centers across Europe.
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Affiliation(s)
- Olaf E.M.G. Schijns
- Corresponding author. Department of Neurosurgery, Maastricht University Medical Center, Maastricht, the Netherlands.
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3
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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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4
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Abstract
Hemispherectomy is a unique epilepsy surgery procedure that has undergone significant modification and evolution since Dandy's early description. This procedure is mainly indicated to treat early childhood and infancy medically intractable epilepsy. Various epileptic syndromes have been treated with this procedure, including hemimegalencephaly (HME), Rasmussen's encephalitis, Sturge-Weber syndrome (SWS), perinatal stroke, and hemispheric cortical dysplasia. In terms of seizure reduction, hemispherectomy remains one of the most successful epilepsy surgery procedures. The modification of this procedure over many years has resulted in lower mortality and morbidity rates. HME might increase morbidity and lower the success rate. Future studies should identify the predictors of outcomes based on the pathology and the type of hemispherectomy. Here, based on a literature review, we discuss the evolution of hemispherectomy techniques and their outcomes and complications.
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Gaubatz J, Prillwitz CC, Ernst L, David B, Hoppe C, Hattingen E, Weber B, Vatter H, Surges R, Elger CE, Rüber T. Contralesional White Matter Alterations in Patients After Hemispherotomy. Front Hum Neurosci 2020; 14:262. [PMID: 32733222 PMCID: PMC7358777 DOI: 10.3389/fnhum.2020.00262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 06/12/2020] [Indexed: 12/17/2022] Open
Abstract
Cerebral lesions may cause degeneration and neuroplastic reorganization in both the ipsi- and the contralesional hemisphere, presumably creating an imbalance of primarily inhibitory interhemispheric influences produced via transcallosal pathways. The two hemispheres are thought to mutually hamper neuroplastic reorganization of the other hemisphere. The results of preceding degeneration and neuroplastic reorganization of white matter may be reflected by Diffusion Tensor Imaging-derived diffusivity parameters such as fractional anisotropy (FA). In this study, we applied Diffusion Tensor Imaging (DTI) to contrast the white matter status of the contralesional hemisphere of young lesioned brains with and without contralateral influences by comparing patients after hemispherotomy to those who had not undergone neurosurgery. DTI was applied to 43 healthy controls (26 females, mean age ± SD: 25.07 ± 11.33 years) and two groups of in total 51 epilepsy patients with comparable juvenile brain lesions (32 females, mean age ± SD: 25.69 ± 12.77 years) either after hemispherotomy (30 of 51 patients) or without neurosurgery (21 of 51 patients), respectively. FA values were compared between these groups using the unbiased tract-based spatial statistics approach. A voxel-wise ANCOVA controlling for age at scan yielded significant group differences in FA. A post hoc t-test between hemispherotomy patients and healthy controls revealed widespread supra-threshold voxels in the contralesional hemisphere of hemispherotomy patients indicating comparatively higher FA values (p < 0.05, FWE-corrected). The non-surgery group, in contrast, showed extensive supra-threshold voxels indicating lower FA values in the contralesional hemisphere as compared to healthy controls (p < 0.05, FWE-corrected). Whereas lower FA values are suggestive of pronounced contralesional degeneration in the non-surgery group, higher FA values in the hemispherotomy group may be interpreted as a result of preceding plastic remodeling. We conclude that, whether juvenile brain lesions are associated with contralesional degeneration or reorganization partly depends on the ipsilesional hemisphere. Contralesional reorganization as observed in hemispherotomy patients was most likely enabled by the complete neurosurgical deafferentation of the ipsilesional hemisphere and, thereby, the disinhibition of the neuroplastic potential of the contralesional hemisphere. The main argument of this study is that hemispherotomy may be seen as a major plastic stimulus and as a prerequisite for contralesional neuroplastic remodeling in patients with juvenile brain lesions.
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Affiliation(s)
- Jennifer Gaubatz
- Department of Epileptology, University of Bonn Medical Center, Bonn, Germany
| | - Conrad C Prillwitz
- Department of Epileptology, University of Bonn Medical Center, Bonn, Germany
| | - Leon Ernst
- Department of Epileptology, University of Bonn Medical Center, Bonn, Germany
| | - Bastian David
- Department of Epileptology, University of Bonn Medical Center, Bonn, Germany
| | - Christian Hoppe
- Department of Epileptology, University of Bonn Medical Center, Bonn, Germany
| | - Elke Hattingen
- Department of Neuroradiology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Bernd Weber
- Institute for Experimental Epileptology and Cognition Research, University of Bonn Medical Center, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University of Bonn Medical Center, Bonn, Germany
| | - Rainer Surges
- Department of Epileptology, University of Bonn Medical Center, Bonn, Germany
| | - Christian E Elger
- Department of Epileptology, University of Bonn Medical Center, Bonn, Germany
| | - Theodor Rüber
- Department of Epileptology, University of Bonn Medical Center, Bonn, Germany.,Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany.,Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
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6
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Young CC, Williams JR, Feroze AH, McGrath M, Ravanpay AC, Ellenbogen RG, Ojemann JG, Hauptman JS. Pediatric functional hemispherectomy: operative techniques and complication avoidance. Neurosurg Focus 2020; 48:E9. [DOI: 10.3171/2020.1.focus19889] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 01/28/2020] [Indexed: 11/06/2022]
Abstract
Functional hemispherectomy/hemispherotomy is a disconnection procedure for severe medically refractory epilepsy where the seizure foci diffusely localize to one hemisphere. It is an improvement on anatomical hemispherectomy and was first performed by Rasmussen in 1974. Less invasive surgical approaches and refinements have been made to improve seizure freedom and minimize surgical morbidity and complications. Key anatomical structures that are disconnected include the 1) internal capsule and corona radiata, 2) mesial temporal structures, 3) insula, 4) corpus callosum, 5) parietooccipital connection, and 6) frontobasal connection. A stepwise approach is indicated to ensure adequate disconnection and prevent seizure persistence or recurrence. In young pediatric patients, careful patient selection and modern surgical techniques have resulted in > 80% seizure freedom and very good functional outcome. In this report, the authors summarize the history of hemispherectomy and its development and present a graphical guide for this anatomically challenging procedure. The use of the osteoplastic flap to improve outcome and the management of hydrocephalus are discussed.
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Affiliation(s)
| | | | | | | | - Ali C. Ravanpay
- 1Department of Neurological Surgery, University of Washington
- 3Department of Neurological Surgery, VA Puget Sound Healthcare System, Seattle, Washington
| | - Richard G. Ellenbogen
- 1Department of Neurological Surgery, University of Washington
- 2Department of Neurological Surgery, Seattle Children’s Hospital; and
| | - Jeffrey G. Ojemann
- 1Department of Neurological Surgery, University of Washington
- 2Department of Neurological Surgery, Seattle Children’s Hospital; and
| | - Jason S. Hauptman
- 1Department of Neurological Surgery, University of Washington
- 2Department of Neurological Surgery, Seattle Children’s Hospital; and
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7
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Pyramidal tract and alternate motor fibers complementarily mediate motor compensation in patients after hemispherotomy. Sci Rep 2020; 10:1010. [PMID: 31974395 PMCID: PMC6978326 DOI: 10.1038/s41598-020-57504-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 12/30/2019] [Indexed: 11/23/2022] Open
Abstract
Motor function after hemispheric lesions has been associated with the structural integrity of either the pyramidal tract (PT) or alternate motor fibers (aMF). In this study, we aimed to differentially characterize the roles of PT and aMF in motor compensation by relating diffusion-tensor-imaging-derived parameters of white matter microstructure to measures of proximal and distal motor function in patients after hemispherotomy. Twenty-five patients (13 women; mean age: 21.1 years) after hemispherotomy (at mean age: 12.4 years) underwent Diffusion Tensor Imaging and evaluation of motor function using the Fugl-Meyer Assessment and the index finger tapping test. Regression analyses revealed that fractional anisotropy of the PT explained (p = 0.050) distal motor function including finger tapping rate (p = 0.027), whereas fractional anisotropy of aMF originating in the contralesional cortex and crossing to the ipsilesional hemisphere in the pons explained proximal motor function (p = 0.001). Age at surgery was found to be the only clinical variable to explain motor function (p < 0.001). Our results are indicative of complementary roles of the PT and of aMF in motor compensation of hemispherotomy mediating distal and proximal motor compensation of the upper limb, respectively.
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8
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Ravindra VM, Mazur MD, Mohila CA, Sweney MT, Hersh A, Bollo RJ. Rasmussen encephalitis with dual pathology in a patient without seizures: case report and literature review. Childs Nerv Syst 2015; 31:2165-71. [PMID: 26033376 DOI: 10.1007/s00381-015-2757-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 05/21/2015] [Indexed: 12/01/2022]
Abstract
PURPOSE Rasmussen encephalitis without seizures is rare. We report a case of Rasmussen encephalitis and cortical dysplasia without epilepsy as well as describe the imaging, pathology, and clinical course and review the literature to investigate whether this may represent a rare subset of Rasmussen encephalitis. CASE REPORT We report the case of a 12-year-old girl with a history of cognitive decline and right arm weakness. Magnetic resonance imaging demonstrated diffuse left hemispheric cortical and subcortical atrophy suggestive of Rasmussen encephalitis. The patient had no clinical history of seizures, and electroencephalography did not demonstrate epileptiform abnormalities. Craniotomy for open brain biopsy was performed, and histopathologic evaluation identified Rasmussen encephalitis with cortical dysplasia (dual pathology). CONCLUSIONS To the best of our knowledge, this is the third case of Rasmussen encephalitis diagnosed by both imaging and histopathology that had no clinical or electroencephalographic evidence of seizures and is the only case of Rasmussen encephalitis with cortical dysplasia without epilepsy.
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Affiliation(s)
- Vijay M Ravindra
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA.,Division of Pediatric Neurosurgery, Primary Children's Hospital, 100 North Mario Capecchi Drive, Suite 1475, Salt Lake City, UT, 84113, USA
| | - Marcus D Mazur
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA.,Division of Pediatric Neurosurgery, Primary Children's Hospital, 100 North Mario Capecchi Drive, Suite 1475, Salt Lake City, UT, 84113, USA
| | - Carrie A Mohila
- Department of Pathology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Matthew T Sweney
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA.,Division of Pediatric Neurology, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Aimee Hersh
- Department of Rheumatology/Immunology, University of Utah School of Medicine, Salt Lake City, UT, USA.,Division of Pediatric Rheumatology/Immunology, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Robert J Bollo
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA. .,Division of Pediatric Neurosurgery, Primary Children's Hospital, 100 North Mario Capecchi Drive, Suite 1475, Salt Lake City, UT, 84113, USA.
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9
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Nelles M, Urbach H, Sassen R, Schöne-Bake JC, Tschampa H, Träber F, Delev D, Elger CE, Jurcoane A, Hattingen E. Functional hemispherectomy: postoperative motor state and correlation to preoperative DTI. Neuroradiology 2015; 57:1093-102. [PMID: 26263839 DOI: 10.1007/s00234-015-1564-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 07/12/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Functional hemispherectomy (FH) is an infrequent method to reduce seizure frequency in patients with intractable epilepsy. The risk that hemispherotomy injures brain structures involved in residual motor function is challenging to predict. Our purpose was to evaluate MR diffusion tensor imaging (DTI) to preoperatively assess residual ipsilateral motor function prior to FH. METHODS We applied DTI in 34 patients scheduled for FH to perform fiber tracking in healthy and damaged hemispheres of the corticospinal tracts (CSTs) and of the corpus callosum. We assessed the CSTs and the commissural fibers for streamline count, for fractional anisotropy (FA), and for respective ratios (affected/unaffected side). We correlated these DTI values to post-to-prior changes of muscle strength and evaluated their diagnostic accuracy. RESULTS FA of the affected CSTs and of commissural fibers was significantly higher in patients with postoperative loss of muscle strength compared to patients without (p = 0.014 and p = 0.008). In contrast, CST FA from healthy hemispheres was not different between both groups. Ratios of streamline counts and FA from CSTs were higher in patients with postoperative reduced muscle strength compared to those without (1.14 ± 0.22 vs. 0.58 ± 0.14, p = 0.040; 0.93 ± 0.05 vs. 0.74 ± 0.03, p = 0.003). CSTs' normalized FA ratio greater than -0.085 predicted loss of muscle strength with 80 % sensitivity and 69.6 % specificity. CONCLUSION Preoperative tracking of the CST and of commissural fibers contributes to the prediction of postoperative motor outcome after functional hemispherectomy.
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Affiliation(s)
- M Nelles
- Department of Radiology, University of Bonn Medical Center, Sigmund Freud Str. 25, D - 53105, Bonn, Germany.
| | - H Urbach
- Department of Radiology, University of Bonn Medical Center, Sigmund Freud Str. 25, D - 53105, Bonn, Germany
| | - R Sassen
- Department of Epileptology, University of Bonn Medical Center, Bonn, Germany
| | - J C Schöne-Bake
- Department of Epileptology, University of Bonn Medical Center, Bonn, Germany
| | - H Tschampa
- Department of Radiology, University of Bonn Medical Center, Sigmund Freud Str. 25, D - 53105, Bonn, Germany
| | - F Träber
- Department of Radiology, University of Bonn Medical Center, Sigmund Freud Str. 25, D - 53105, Bonn, Germany
| | - D Delev
- Department of Neurosurgery, University of Bonn Medical Center, Bonn, Germany
| | - C E Elger
- Department of Epileptology, University of Bonn Medical Center, Bonn, Germany
| | - A Jurcoane
- Department of Radiology, University of Bonn Medical Center, Sigmund Freud Str. 25, D - 53105, Bonn, Germany
| | - E Hattingen
- Department of Radiology, University of Bonn Medical Center, Sigmund Freud Str. 25, D - 53105, Bonn, Germany
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10
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Schramm J. Epilepsy Surgery and the Evolution of Clinical and Translational Science. Neurosurgery 2014; 61 Suppl 1:54-65. [DOI: 10.1227/neu.0000000000000399] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Johannes Schramm
- Professor emeritus, Medical Faculty, Bonn University, Bonn, Germany
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11
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Schramm J. Disconnecting epileptogenic zone is as effective as resection. J Neurol Neurosurg Psychiatry 2013; 84:1300-1. [PMID: 23704312 DOI: 10.1136/jnnp-2013-304963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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12
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Bien CG, Tiemeier H, Sassen R, Kuczaty S, Urbach H, von Lehe M, Becker AJ, Bast T, Herkenrath P, Karenfort M, Kruse B, Kurlemann G, Rona S, Schubert-Bast S, Vieker S, Vlaho S, Wilken B, Elger CE. Rasmussen encephalitis: Incidence and course under randomized therapy with tacrolimus or intravenous immunoglobulins. Epilepsia 2012; 54:543-50. [DOI: 10.1111/epi.12042] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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13
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Pediatric functional hemispherectomy: outcome in 92 patients. Acta Neurochir (Wien) 2012; 154:2017-28. [PMID: 22941395 DOI: 10.1007/s00701-012-1481-3] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 08/10/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The revival of epilepsy surgery after the introduction of modern presurgical evaluation procedures has led to an increase in hemispherectomy or hemispherotomy procedures. Since a large part of our pediatric series was done using a newer hemispherotomy technique, we focus mainly on the outcomes after a recently developed hemispherotomy technique (transsylvian keyhole). METHODS Ninety-six pediatric patients (aged 4 months to 18 years, mean 7.3) were operated on between 1990 and 2009; 92 were available with follow-up. RESULTS The most frequent diagnosis was porencephaly in 46 % of all patients. Progressive etiologies were present in 20 % and developmental etiologies in 22 %. At last available outcome (LAO), 85 % of the patients were seizure free (ILAE class 1). Year-to-year outcome was rather stable; usually over 80 % were class 1 for up to 13 years (n = 24). Of 92 assessable patients, 71 were treated with the transsylvian keyhole technique, with 89 % being seizure free. The overall shunt rate was 5.3 % for the whole series and 3 % for the keyhole technique subgroup. Mortality was 1 of 96 patients. Excluding patients with hemimegalencephaly (HME), patients with the shortest duration of epilepsy and the lowest age at seizure onset had the highest rates of seizure freedom. The etiology does influence outcome, with HME patients having the poorest seizure outcome and patients with Sturge-Weber syndrome and porencephaly having excellent seizure control. CONCLUSION Hemispherotomies/functional hemispherectomies are very effective and safe procedures for treating drug-resistant epilepsy with extensive unihemispheric pathology. Etiology and surgery type clearly influence seizure outcome.
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14
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Liégeois F, Morgan AT, Stewart LH, Helen Cross J, Vogel AP, Vargha-Khadem F. Speech and oral motor profile after childhood hemispherectomy. BRAIN AND LANGUAGE 2010; 114:126-134. [PMID: 20096448 DOI: 10.1016/j.bandl.2009.12.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Revised: 12/08/2009] [Accepted: 12/08/2009] [Indexed: 05/28/2023]
Abstract
Hemispherectomy (disconnection or removal of an entire cerebral hemisphere) is a rare surgical procedure used for the relief of drug-resistant epilepsy in children. After hemispherectomy, contralateral hemiplegia persists whereas gross expressive and receptive language functions can be remarkably spared. Motor speech deficits have rarely been examined systematically, thus limiting the accuracy of postoperative prognosis. We describe the speech profiles of hemispherectomized participants characterizing their intelligibility, articulation, phonological speech errors, dysarthric features, and execution and sequencing of orofacial speech and non-speech movements. Thirteen participants who had undergone hemispherectomy (six left, seven right; nine with congenital, four with acquired hemiplegia; operated between four months and 13 years) were investigated. Results showed that all participants were intelligible but showed a mild dysarthric profile characterized by neuromuscular asymmetry and reduced quality and coordination of movements, features that are characteristic of adult-onset unilateral upper motor neuron dysarthria, flaccid-ataxic variant. In addition, one left and four right hemispherectomy cases presented with impaired production of speech and non-speech sequences. No participant showed evidence of verbal or oral dyspraxia. It is concluded that mild dysarthria is persistent after left or right hemispherectomy, irrespective of age at onset of hemiplegia. These results indicate incomplete functional re-organization for the control of fine speech motor movements throughout childhood, and provide no evidence of hemispheric differences.
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15
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Bien CG, Schramm J. Treatment of Rasmussen encephalitis half a century after its initial description: promising prospects and a dilemma. Epilepsy Res 2009; 86:101-12. [PMID: 19615863 DOI: 10.1016/j.eplepsyres.2009.06.001] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2009] [Revised: 06/03/2009] [Accepted: 06/07/2009] [Indexed: 11/26/2022]
Abstract
Rasmussen encephalitis (RE), initially described half a century ago, is an inflammatory unihemispheric brain disorder. Its two clinical key facets are the progressive tissue and function loss and the epilepsy, often in form of epilepsia partialis continua. For both, treatment options are available. Anti-seizure effect of anti-epilepsy drugs is usually limited to secondarily generalized seizures and complex partial seizures whereas epilepsia partialis continua usually is totally refractory. Hemispherectomy in one of its modern variants offers a very high chance of seizure freedom, however at the price of irreversible loss of functions located in the affected hemisphere. In a proportion of patients, long-term immunotherapy is able to prevent or slow down hemispheric tissue loss and the associated functional decline. It does, however, mostly not improve the epilepsy. Whereas for many patients unequivocal treatment proposals can be readily made, a dilemma may emerge in those with severe epilepsy but still preserved hemispheric function.
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Affiliation(s)
- Christian G Bien
- University of Bonn, Department of Epileptology, Sigmund-Freud-Str. 25, 53105 Bonn, Germany.
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Bordonné C, Delalande O, Dorfmuller G, Dorfumuller G, Héran F. [CT and MR brain imaging following hemispherotomy]. J Neuroradiol 2009; 36:255-64. [PMID: 19395029 DOI: 10.1016/j.neurad.2009.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2008] [Revised: 01/30/2009] [Accepted: 02/03/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE The aim of the study was to define the usual and pathological modifications arising in the brain following hemispherotomy for intractable epilepsy in children. METHODS Preoperative MRI and postoperative imaging scans (CT in the first week, MRI at 3 months and 1 year after surgery) were reviewed in a series of 52 patients, average age 8 years and 7 months, with intractable epilepsy due to dysplasia, Rasmussen's encephalitis, ischemic lesions and/or Sturge-Weber disease. The posterior fossa, brain parenchyma, ventricles and subdural space were also analyzed. RESULTS Hemispheric scarring was a typical finding on CT and MRI as a consequence of the surgical procedure. Also frequently seen were small subdural effusions, bleeding along the surgical scar on early CT, and chronic subdural effusions with no mass effect on mid-term and late MRI scans. Other features - such as large subdural effusions that required external shunts and hydrocephalus - were rare, but severe, and considered to be postoperative complications. In contrast to the complications associated with other surgical techniques such as hemispherectomy, infection, extensive edema or hemosiderosis were never found in our series. CONCLUSION Hemispherotomy is a surgical technique performed to treat intractable epilepsy. Our findings will help to identify the typical morphology of postsurgical scars, and to differentiate the usual features and complications seen in the postoperative period on CT and MRI brain scans.
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Affiliation(s)
- C Bordonné
- Service d'imagerie, fondation ophtalmologique Rothschild, 75019 Paris, France.
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Abstract
The idea of surgical treatment for epilepsy is not new. However, widespread use and general acceptance of this treatment has only been achieved during the past three decades. A crucial step in this direction was the development of video electroencephalographic monitoring. Improvements in imaging resulted in an increased ability for preoperative identification of intracerebral and potentially epileptogenic lesions. High resolution magnetic resonance imaging plays a major role in structural and functional imaging; other functional imaging techniques (e.g., positron emission tomography and single-photon emission computed tomography) provide complementary data and, together with corresponding electroencephalographic findings, result in a hypothesis of the epileptogenic lesion, epileptogenic zone, and the functional deficit zone. The development of microneurosurgical techniques was a prerequisite for the general acceptance of elective intracranial surgery. New less invasive and safer resection techniques have been developed, and new palliative and augmentative techniques have been introduced. Today, epilepsy surgery is more effective and conveys a better seizure control rate. It has become safer and less invasive, with lower morbidity and mortality rates. This article summarizes the various developments of the past three decades and describes the present tools for presurgical evaluation and surgical strategy, as well as ideas and future perspectives for epilepsy surgery.
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Affiliation(s)
- Johannes Schramm
- Department of Neurosurgery, University of Bonn Medical Center, Bonn, Germany
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Cats EA, Kho KH, Van Nieuwenhuizen O, Van Veelen CWM, Gosselaar PH, Van Rijen PC. Seizure freedom after functional hemispherectomy and a possible role for the insular cortex: the Dutch experience. J Neurosurg 2007; 107:275-80. [PMID: 17941490 DOI: 10.3171/ped-07/10/275] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors undertook this study to identify predictors of persistent postoperative seizures in their group of 28 Dutch pediatric and adolescent patients with medically intractable epilepsy who underwent functional hemispherectomy. METHODS The records of 28 pediatric and adolescent patients who underwent a functional hemispherectomy in the University Medical Center Utrecht were retrospectively analyzed. The authors performed a Cox regression analysis, using the first postoperative seizure as the event. Pathology, age at surgery, age at seizure onset, duration of epilepsy, type of surgery, surgeon, possible incomplete disconnection on MR images, and presence of residual insular cortex were analyzed as potential associated variables during the follow-up period. RESULTS The patients' mean age at surgery was 69.9 months (range 3.0-294.2 months) and mean duration of follow-up was 39.0 months (range 6.0-132.0 months). Six patients had postoperative seizures (21%). One patient had persistent bilateral status epilepticus and died 4 months after surgery. The Cox regression analysis showed presence of insular cortex to be the only variable statistically associated with postoperative seizures (p = 0.021) in this group of 28 patients. CONCLUSIONS In this group of Dutch pediatric and adolescent patients, residual insular cortex was positively correlated with persistent postoperative seizures. Given the small sample size in this study, however, caution should be used in drawing conclusions about the role of the insular cortex.
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Affiliation(s)
- Elisabeth A Cats
- Department of Neurology, Rudolf Magnus Center of Neuroscience, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
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Cats EA, Kho KH, van Nieuwenhuizen O, van Veelen CWM, Gosselaar PH, van Rijen PC. Seizure freedom after functional hemispherectomy and a possible role for the insular cortex: the Dutch experience. J Neurosurg 2007. [DOI: 10.3171/ped.2007.107.4.275] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
OBJECTIVE To describe the technique of transsylvian-transventricular functional hemispherectomy developed at our institution. METHODS We review appropriate patient selection and evaluation, timing of surgery, selection of surgical approach, preoperative preparation, details of operative procedure, and postoperative management. CONCLUSIONS The transsylvian "keyhole" functional hemispherectomy technique involves a smaller craniotomy than other functional hemispherectomy techniques and consists of transsylvian exposure, resection of mesial temporal structures, transventricular frontobasal disconnection, callosotomy, and occipitoparietal disconnection. The key advantages of this approach compared to the Rasmussen's "classic" functional hemispherectomy are smaller exposure, shorter operative time, and lower blood loss. The efficacy of functional hemispherectomy procedures in achieving seizure freedom appears to be at least as good compared to resective procedures. The long-term complication rate will require longer follow-up times.
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Affiliation(s)
- Devin K Binder
- Department of Neurosurgery, University of Bonn Medical Center, Sigmund-Freud-Str. 25, 53105, Bonn, Germany
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Fountas KN, Smith JR, Robinson JS, Tamburrini G, Pietrini D, Di Rocco C. Anatomical hemispherectomy. Childs Nerv Syst 2006; 22:982-91. [PMID: 16810492 DOI: 10.1007/s00381-006-0135-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2006] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Anatomical hemispherectomy is frequently employed in the surgical management of pediatric patients with medically refractory epilepsy. MATERIALS AND METHODS In this chapter, we review the historical evolution of this surgical procedure, outline the indications and the criteria for selecting surgical candidates and describe the important pre-operative evaluation of the surgical candidates. DISCUSSION We provide a detailed description of our surgical technique, anesthesiological considerations, and post-operative care plan. Ultimately we analyze the most common complications associated with this procedure. CONCLUSION Anatomical hemispherectomy performed in carefully selected pediatric patients with medically intractable epilepsy can be a safe and efficacious surgical procedure.
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Affiliation(s)
- K N Fountas
- Department of Neurosurgery, Medical College of Georgia, Augusta, GA, USA.
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O'Brien DF, Basu S, Williams DH, May PL. Anatomical hemispherectomy for intractable seizures: excellent seizure control, low morbidity and no superficial cerebral haemosiderosis. Childs Nerv Syst 2006; 22:489-98; discussion 499. [PMID: 16470390 DOI: 10.1007/s00381-005-0023-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2005] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This current study was performed to evaluate whether superficial cerebral haemosiderosis (SCH) is still a complication of modern day anatomical hemispherectomy. METHODS We report a 13-year institutional experience with anatomical hemispherectomy for intractable epilepsy. Seizure control at a mean follow-up interval of 7 years was 83%. Though one patient died post-operatively from a non-neurosurgical complication, mortality was otherwise zero and morbidity minimal. The much-described complication of SCH following anatomical hemispherectomy was non-existent. We explain the history of SCH as a complication of anatomical hemispherectomy, and the measures that are presently taken to prevent it. CONCLUSIONS We suggest that the importance of SCH in modern epilepsy surgery is probably over-emphasised.
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Affiliation(s)
- Donncha F O'Brien
- Department of Neurosurgery, Royal Liverpool Children's Hospital NHS Trust, Alder Hey and the Walton Centre for Neurology and Neurosurgery NHS Trust, Eaton Road, Liverpool, L12 2AP, UK.
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De Almeida AN, Marino R, Aguiar PH, Jacobsen Teixeira M. Hemispherectomy: a schematic review of the current techniques. Neurosurg Rev 2006; 29:97-102; discussion 102. [PMID: 16463191 DOI: 10.1007/s10143-005-0011-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2005] [Revised: 09/01/2005] [Accepted: 10/17/2005] [Indexed: 10/25/2022]
Abstract
Anatomical hemispherectomy has been used for the treatment of seizures since 1938. However, it was almost abandoned in the 1960s after reports of postoperative fatalities caused by hydrocephalus, hemosiderosis, and trivial head traumas. Despite serious complications, the remarkable improvement of patients encouraged authors to carry out modifications on anatomical hemispherectomy in order to lessen its morbidity while preserving its efficacy. The effort to improve the technique generated several original procedures. This paper reviews current techniques of hemispherectomy and proposes a classification scheme based on their surgical characteristics. Techniques of hemispherectomy were sorted into two major groups: (1) those that remove completely the cortex from the hemisphere and (2) those that associate partial cortical removal and disconnection. Group 1 was subdivided into two subgroups based on the integrity of the ventricular cavity and group 2 was subdivided into three subgroups depending on the amount and location of the corticectomy. Grouping similar techniques may allow a better understanding of the distinctive features of each one and creates the possibility of comparing data from different authors.
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Affiliation(s)
- Antonio Nogueira De Almeida
- Departamento de Neurologia do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Brazil.
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Abstract
INTRODUCTION Hemispherectomy constitutes an established surgical method in the management of patients with medically intractable epilepsy, secondary to severe unilateral hemisphere damage. The well-established association of the anatomical hemispherectomy initially described with severe complications such as late hydrocephalus has led to the development of less resective and more disconnecting procedures. All these technical variations of hemispherotomy carry less favorable outcomes compared with anatomic hemispherectomy, but significantly fewer complications. METHODS In our current communication, we outline the indications and the surgical technique of hemispherotomy and report our experience of the clinical application of this surgical procedure. RESULTS In our clinical series, the 5-year follow-up shows that 66.6% of our patients (6 out of 9) had class I outcome according to Engel's classification system, 22.2% (2 out of 9) class II outcome, while 11.1% (1 out of 9) had class III outcome. No mortality occurred in the current series and operative blood loss was significantly lowered. CONCLUSION Hemispherotomy represents a less efficacious technique compared with anatomic hemispherectomy, but is a safe and technically simple surgical alternative for the management of patients with medically intractable seizures.
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Affiliation(s)
- Joseph R Smith
- Department of Neurosurgery, Medical College of Georgia, Augusta, GA, USA
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