1
|
Macdonald-Laurs E, Dzau W, Warren AEL, Coleman M, Mignone C, Stephenson SEM, Howell KB. Identification and treatment of surgically-remediable causes of infantile epileptic spasms syndrome. Expert Rev Neurother 2024; 24:661-680. [PMID: 38814860 DOI: 10.1080/14737175.2024.2360117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 05/22/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Infantile epileptic spasms syndrome (IESS) is a common developmental and epileptic encephalopathy with poor long-term outcomes. A substantial proportion of patients with IESS have a potentially surgically remediable etiology. Despite this, epilepsy surgery is underutilized in this patient group. Some surgically remediable etiologies, such as focal cortical dysplasia and malformation of cortical development with oligodendroglial hyperplasia in epilepsy (MOGHE), are under-diagnosed in infants and young children. Even when a surgically remediable etiology is recognised, for example, tuberous sclerosis or focal encephalomalacia, epilepsy surgery may be delayed or not considered due to diffuse EEG changes, unclear surgical boundaries, or concerns about operating in this age group. AREAS COVERED In this review, the authors discuss the common surgically remediable etiologies of IESS, their clinical and EEG features, and the imaging techniques that can aid in their diagnosis. They then describe the surgical approaches used in this patient group, and the beneficial impact that early epilepsy surgery can have on developing brain networks. EXPERT OPINION Epilepsy surgery remains underutilized even when a potentially surgically remediable cause is recognized. Overcoming the barriers that result in under-recognition of surgical candidates and underutilization of epilepsy surgery in IESS will improve long-term seizure and developmental outcomes.
Collapse
Affiliation(s)
- Emma Macdonald-Laurs
- Department of Neurology, The Royal Children's Hospital, Parkville, VIC, Australia
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Winston Dzau
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Aaron E L Warren
- Department of Medicine (Austin Health), The University of Melbourne, Melbourne, VIC, Australia
- Brigham and Women's Hospital, Harvard Medical School, Massachusetts, USA
| | - Matthew Coleman
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Cristina Mignone
- Department of Medical Imaging, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Sarah E M Stephenson
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Katherine B Howell
- Department of Neurology, The Royal Children's Hospital, Parkville, VIC, Australia
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
| |
Collapse
|
2
|
Borne A, Perrone-Bertolotti M, Ferrand-Sorbets S, Bulteau C, Baciu M. Insights on cognitive reorganization after hemispherectomy in Rasmussen's encephalitis. A narrative review. Rev Neurosci 2024; 0:revneuro-2024-0009. [PMID: 38749928 DOI: 10.1515/revneuro-2024-0009] [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: 01/16/2024] [Accepted: 04/26/2024] [Indexed: 05/24/2024]
Abstract
Rasmussen's encephalitis is a rare neurological pathology affecting one cerebral hemisphere, therefore, posing unique challenges. Patients may undergo hemispherectomy, a surgical procedure after which cognitive development occurs in the isolated contralateral hemisphere. This rare situation provides an excellent opportunity to evaluate brain plasticity and cognitive recovery at a hemispheric level. This literature review synthesizes the existing body of research on cognitive recovery following hemispherectomy in Rasmussen patients, considering cognitive domains and modulatory factors that influence cognitive outcomes. While language function has traditionally been the focus of postoperative assessments, there is a growing acknowledgment of the need to broaden the scope of language investigation in interaction with other cognitive domains and to consider cognitive scaffolding in development and recovery. By synthesizing findings reported in the literature, we delineate how language functions may find support from the right hemisphere after left hemispherectomy, but also how, beyond language, global cognitive functioning is affected. We highlight the critical influence of several factors on postoperative cognitive outcomes, including the timing of hemispherectomy and the baseline preoperative cognitive status, pointing to early surgical intervention as predictive of better cognitive outcomes. However, further specific studies are needed to confirm this correlation. This review aims to emphasize a better understanding of mechanisms underlying hemispheric specialization and plasticity in humans, which are particularly important for both clinical and research advancements. This narrative review underscores the need for an integrative approach based on cognitive scaffolding to provide a comprehensive understanding of mechanisms underlying the reorganization in Rasmussen patients after hemispherectomy.
Collapse
Affiliation(s)
- Anna Borne
- Univ. Grenoble Alpes, CNRS, LPNC, 38000 Grenoble, France
| | | | - Sarah Ferrand-Sorbets
- Hôpital Fondation Adolphe de Rothschild, Service de Neurochirurgie Pédiatrique, 75019 Paris, France
| | - Christine Bulteau
- Hôpital Fondation Adolphe de Rothschild, Service de Neurochirurgie Pédiatrique, 75019 Paris, France
- Université de Paris-Cité, MC2Lab EA 7536, Institut de Psychologie, F-92100 Boulogne-Billancourt, France
| | - Monica Baciu
- Univ. Grenoble Alpes, CNRS, LPNC, 38000 Grenoble, France
- Neurology Department, CMRR, University Hospital, 38000 Grenoble, France
| |
Collapse
|
3
|
Gennari AG, Bicciato G, Lo Biundo SP, Kottke R, Stefanos-Yakoub I, Cserpan D, O'Gorman Tuura R, Ramantani G. Lesion volume and spike frequency on EEG impact perfusion values in focal cortical dysplasia: a pediatric arterial spin labeling study. Sci Rep 2024; 14:7601. [PMID: 38556543 PMCID: PMC10982306 DOI: 10.1038/s41598-024-58352-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/28/2024] [Indexed: 04/02/2024] Open
Abstract
Arterial spin labelling (ASL), an MRI sequence non-invasively imaging brain perfusion, has yielded promising results in the presurgical workup of children with focal cortical dysplasia (FCD)-related epilepsy. However, the interpretation of ASL-derived perfusion patterns remains unclear. Hence, we compared ASL qualitative and quantitative findings to their clinical, EEG, and MRI counterparts. We included children with focal structural epilepsy related to an MRI-detectable FCD who underwent single delay pseudo-continuous ASL. ASL perfusion changes were assessed qualitatively by visual inspection and quantitatively by estimating the asymmetry index (AI). We considered 18 scans from 15 children. 16 of 18 (89%) scans showed FCD-related perfusion changes: 10 were hypoperfused, whereas six were hyperperfused. Nine scans had perfusion changes larger than and seven equal to the FCD extent on anatomical images. Hyperperfusion was associated with frequent interictal spikes on EEG (p = 0.047). Perfusion changes in ASL larger than the FCD corresponded to larger lesions (p = 0.017). Higher AI values were determined by frequent interictal spikes on EEG (p = 0.004). ASL showed FCD-related perfusion changes in most cases. Further, higher spike frequency on EEG may increase ASL changes in affected children. These observations may facilitate the interpretation of ASL findings, improving treatment management, counselling, and prognostication in children with FCD-related epilepsy.
Collapse
Affiliation(s)
- Antonio Giulio Gennari
- Department of Neuropediatrics, University Children's Hospital Zurich, 75, 8032, Zurich, Switzerland
- MR-Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Giulio Bicciato
- Department of Neuropediatrics, University Children's Hospital Zurich, 75, 8032, Zurich, Switzerland
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Santo Pietro Lo Biundo
- Department of Neuropediatrics, University Children's Hospital Zurich, 75, 8032, Zurich, Switzerland
| | - Raimund Kottke
- Department of Radiology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ilona Stefanos-Yakoub
- Department of Neuropediatrics, University Children's Hospital Zurich, 75, 8032, Zurich, Switzerland
| | - Dorottya Cserpan
- Department of Neuropediatrics, University Children's Hospital Zurich, 75, 8032, Zurich, Switzerland
| | - Ruth O'Gorman Tuura
- MR-Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Georgia Ramantani
- Department of Neuropediatrics, University Children's Hospital Zurich, 75, 8032, Zurich, Switzerland.
- University of Zurich, Zurich, Switzerland.
- Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland.
| |
Collapse
|
4
|
Stefanos-Yakoub I, Wingeier K, Held U, Latal B, Wirrell E, Smith ML, Ramantani G. Long-term intellectual and developmental outcomes after pediatric epilepsy surgery: A systematic review and meta-analysis. Epilepsia 2024; 65:251-265. [PMID: 38031640 DOI: 10.1111/epi.17834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/20/2023] [Accepted: 11/27/2023] [Indexed: 12/01/2023]
Abstract
In addition to the primary aim of seizure freedom, a key secondary aim of pediatric epilepsy surgery is to stabilize and, potentially, optimize cognitive development. Although the efficacy of surgical treatment for seizure control has been established, the long-term intellectual and developmental trajectories are yet to be delineated. We conducted a systematic review and meta-analysis of studies reporting pre- and postsurgical intelligence or developmental quotients (IQ/DQ) of children with focal lesional epilepsy aged ≤18 years at epilepsy surgery and assessed at >2 years after surgery. We determined the IQ/DQ change and conducted a random-effects meta-analysis and meta-regression to assess its determinants. We included 15 studies reporting on 341 patients. The weighted mean age at surgery was 7.1 years (range = .3-13.8). The weighted mean postsurgical follow-up duration was 5.6 years (range = 2.7-12.8). The overall estimate of the mean presurgical IQ/DQ was 60 (95% confidence interval [CI] = 47-73), the postsurgical IQ/DQ was 61 (95% CI = 48-73), and the change was +.94 IQ/DQ (95% CI = -1.70 to 3.58, p = .486). Children with presurgical IQ/DQ ≥ 70 showed a tendency for higher gains than those with presurgical IQ/DQ < 70 (p = .059). Higher gains were determined by cessation of antiseizure medication (ASM; p = .041), not just seizure freedom. Our findings indicate, on average, stabilization of intellectual and developmental functioning at long-term follow-up after epilepsy surgery. Once seizure freedom has been achieved, ASM cessation enables the optimization of intellectual and developmental trajectories in affected children.
Collapse
Affiliation(s)
- Ilona Stefanos-Yakoub
- Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland
| | - Kevin Wingeier
- Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland
- Department of Psychosomatics and Psychiatry, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ulrike Held
- Department of Biostatistics at Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Beatrice Latal
- Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Elaine Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mary Lou Smith
- Department of Psychology, University of Toronto Mississauga; Neurosciences and Mental Health Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Georgia Ramantani
- Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| |
Collapse
|
5
|
Ramantani G, Cserpan D, Tisdall M, Otte WM, Dorfmüller G, Cross JH, van Schooneveld M, van Eijsden P, Nees F, Reuner G, Krayenbühl N, Zentner J, Bulteau C, Braun KPJ. Determinants of Functional Outcome after Pediatric Hemispherotomy. Ann Neurol 2024; 95:377-387. [PMID: 37962290 DOI: 10.1002/ana.26830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 10/04/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023]
Abstract
OBJECTIVE We aimed to evaluate determinants of functional outcome after pediatric hemispherotomy in a large and recent multicenter cohort. METHODS We retrospectively investigated the functional outcomes of 455 children who underwent hemispherotomy at 5 epilepsy centers in 2000-2016. We identified determinants of unaided walking, voluntary grasping with the hemiplegic hand, and speaking through Bayesian multivariable regression modeling using missing data imputation. RESULTS Seventy-five percent of children were seizure-free, and 44% stopped antiseizure medication at a 5.1-year mean follow-up (range = 1-17.1). Seventy-seven percent of children could walk unaided, 8% could grasp voluntarily, and 68% could speak at the last follow-up. Children were unlikely to walk when they had contralateral magnetic resonance imaging (MRI) abnormalities (40/73, p = 0.04), recurrent seizures following hemispherotomy (62/109, p = 0.04), and moderately (50/61, p = 0.03) or severely impaired (127/199, p = 0.001) postsurgical intellectual functioning, but were likely to walk when they were older at outcome determination (p = 0.01). Children were unlikely to grasp voluntarily with the hand contralateral to surgery when they had Rasmussen encephalitis (0/61, p = 0.001) or Sturge-Weber syndrome (0/32, p = 0.007). Children were unlikely to speak when they had contralateral MRI abnormalities (30/69, p = 0.002) and longer epilepsy duration (p = 0.01), but likely to speak when they had Sturge-Weber syndrome (29/35, p = 0.01), were older at surgery (p = 0.04), and were older at outcome determination (p < 0.001). INTERPRETATION Etiology and bilaterality of structural brain abnormalities were key determinants of functional outcome after hemispherotomy. Longer epilepsy duration affected language outcomes. Not surprisingly, walking and talking ability increased with older age at outcome evaluation. ANN NEUROL 2024;95:377-387.
Collapse
Affiliation(s)
- Georgia Ramantani
- Department of Neuropediatrics, University Children's Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Dorottya Cserpan
- Department of Neuropediatrics, University Children's Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Martin Tisdall
- Department of Neurosurgery, Great Ormond Street Hospital for Children National Health Service Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Willem M Otte
- Department of Child Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, Member of European Reference Network EpiCARE, Utrecht, the Netherlands
| | - Georg Dorfmüller
- Department of Pediatric Neurosurgery, Rothschild Foundation Hospital, Member of European Reference Network EpiCARE, Paris, France
| | - J Helen Cross
- Department of Neurology, Great Ormond Street Hospital for Children National Health Service Foundation Trust, Great Ormond Street and University College London National Institute for Health and Care Research Biomedical Research Centre Great Ormond Street Institute of Child Health, London, United Kingdom of Great Britain and Northern Ireland
| | - Monique van Schooneveld
- Department of Child Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, Member of European Reference Network EpiCARE, Utrecht, the Netherlands
| | - Pieter van Eijsden
- Department of Child Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, Member of European Reference Network EpiCARE, Utrecht, the Netherlands
| | - Frauke Nees
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Institute of Medical Psychology and Medical Sociology, University Medical Center Schleswig-Holstein, Kiel University, Kiel, Germany
| | - Gitta Reuner
- Institute of Education Studies, Faculty of Behavioral and Cultural Studies, University of Heidelberg, Heidelberg, Germany
| | - Niklaus Krayenbühl
- Department of Neurosurgery, University Children's Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Josef Zentner
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Christine Bulteau
- Department of Pediatric Neurosurgery, Rothschild Foundation Hospital, Member of European Reference Network EpiCARE, Paris, France
- University of Paris, MC2Lab, Institute of Psychology, Boulogne-Billancourt, France
| | - Kees P J Braun
- Department of Child Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, Member of European Reference Network EpiCARE, Utrecht, the Netherlands
| |
Collapse
|
6
|
Yu H, Liu Q, Wang R, Liu C, Sun Y, Wang Y, Ji T, Wang S, Liu X, Jiang Y, Cai L. Long-term seizure and developmental outcomes of epilepsy surgery in children under 3 years old: A single-center study of 113 patients. CNS Neurosci Ther 2024; 30:e14481. [PMID: 37786975 PMCID: PMC10805390 DOI: 10.1111/cns.14481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/30/2023] [Accepted: 09/15/2023] [Indexed: 10/04/2023] Open
Abstract
AIMS To investigate the clinical characteristics, surgical strategy, developmental and seizure outcomes, and predictors of surgical outcome in children with drug-resistant epilepsy (DRE) under 3 years old. METHODS One hundred thirteen consecutive children younger than 3 years of age with DRE underwent curative surgical treatment after multidisciplinary preoperative evaluation using the strategy developed in the pediatric epilepsy center of Peking University First Hospital (PKFHPEC) between 2014 and 2018. These patients were selected for retrospective study. The relevant clinical data were collected and analyzed. The surgical prognoses were classified using the Engel classification, and the developmental assessment results were collected. Statistical analysis of the clinical data was performed to analyze the predictors of seizure outcomes and their correlation with developmental outcomes. RESULTS All the patients were followed up for more than 3 years, and 98 (86.7%) patients had no seizure recurrence. One year after surgery, the seizure-free rate was 86.7%, which was as high as that at the last follow-up. Cortical dysplasia was the most frequent etiology of DRE in this cohort, accounting for 77.0%. According to the Engel classification, acute postoperative seizure (APOS; p < 0.001) was a predictor of seizure recurrence. No deaths occurred. No unpredicted long-term severe complications occurred except for one ventricular peritoneal shunt. The patients' neurodevelopmental statuses were improved after successful surgery, while the scores of the pre- and postoperative developmental assessments were closely correlated. CONCLUSIONS For children who are younger than 3 years old and have DRE and structural abnormalities, early curative treatment can lead to long-term good seizure outcomes and a low complication rate. The development of appropriate strategies for both presurgical evaluation and resection is crucial for the success of surgery.
Collapse
Affiliation(s)
- Hao Yu
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
| | - Qingzhu Liu
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
| | - Ruofan Wang
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
| | - Chang Liu
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
| | - Yu Sun
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
| | - Yao Wang
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
| | - Taoyun Ji
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
| | - Shuang Wang
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
| | - Xiaoyan Liu
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
| | - Yuwu Jiang
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
| | - Lixin Cai
- Pediatric Epilepsy CenterPeking University First HospitalBeijingChina
| |
Collapse
|
7
|
Hirsch M, Beck J, Brandt A, Papadopoulou G, Wagner K, Urbach H, Schulze-Bonhage A. Trends in referral patterns to presurgical evaluation at a European reference center. Seizure 2023; 111:78-86. [PMID: 37549617 DOI: 10.1016/j.seizure.2023.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 07/23/2023] [Accepted: 07/30/2023] [Indexed: 08/09/2023] Open
Abstract
PURPOSE To determine if growing evidence for epilepsy surgery as an early treatment option is reflected in the decrease of latencies between epilepsy onset and referral for presurgical evaluation METHODS: Retrospective analysis of latencies in 1646 patients (children and adults) from the time of epilepsy diagnosis to first presurgical workup in the period from 1999 to 2019 based on electronic patient charts at a tertiary epilepsy center. Time spans 1999-2009 and 2010-2019, prior to and following the ILAE definition of pharmacoresistance, and the role of etiological factors were assessed. RESULTS Over the whole period, the mean latency between diagnosis and a presurgical workup was 15.3 y. There was a significant reduction in the latencies between the periods 1999-2009 (16.9 y) and 2010-2019 (13.4 y), (p < 0.0001). In a linear regression analysis, the latency decreased by 2.6 months/year from 17.4 in 1999 to 13.1 y in 2019 (p < 0.001). Subgroup analyses showed significant decreases in latency to presurgical evaluation in patients with hippocampal sclerosis from 24.4 to 19.5 y, in malformations of cortical development from 16.4 to 13.2 y, and in nonlesional patients from 18.1 to 12.8 y, in contrast to patients with MR evidence for brain tumors with similar latencies across time (10.5 vs. 9.5 y, n.s.). CONCLUSION The reduction of the time span to a first presurgical evaluation was highly significant over time, yet moderate in its degree. Overall, the aim of early diagnostic evaluation for epilepsy surgery options after established pharmacoresistance was only achieved for a minority of patients.
Collapse
Affiliation(s)
- Martin Hirsch
- Epilepsy Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Armin Brandt
- Epilepsy Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Georgia Papadopoulou
- Epilepsy Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Kathrin Wagner
- Epilepsy Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Andreas Schulze-Bonhage
- Epilepsy Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| |
Collapse
|
8
|
Makridis KL, Klotz KA, Ramantani G, Becker L, San Antonio‐Arce V, Syrbe S, Wagner K, Shah MJ, Thomale U, Tietze A, Elger CE, Borggraefe I, Kaindl AM. Epilepsy surgery in early infancy: A retrospective, multicenter study. Epilepsia Open 2023; 8:1182-1189. [PMID: 37458529 PMCID: PMC10472416 DOI: 10.1002/epi4.12791] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 07/01/2023] [Indexed: 07/25/2023] Open
Abstract
Although epilepsy surgery is the only curative therapeutic approach for lesional drug-resistant epilepsy (DRE), there is reluctance to operate on infants due to a fear of complications. A recent meta-analysis showed that epilepsy surgery in the first 6 months of life can achieve seizure control in about two thirds of children. However, robust data on surgical complications and postoperative cognitive development are lacking. We performed a retrospective multicenter study of infants who underwent epilepsy surgery in the first 6 months of life. 15 infants underwent epilepsy surgery at a median age of 134 days (IQR: 58) at four centers. The most common cause was malformation of cortical development, and 13 patients underwent a hemispherotomy. Two thirds required intraoperative red blood transfusions. Severe intraoperative complications occurred in two patients including death in one infant due to cardiovascular insufficiency. At a median follow-up of 1.5 years (IQR: 1.8), 57% of patients were seizure-free. Three patients where reoperated at a later age, resulting in 79% seizure freedom. Anti-seizure medication could be reduced in two thirds, and all patients improved in their development. Our findings suggest that early epilepsy surgery can result in good seizure control and developmental improvement. However, given the perioperative risks, it should be performed only in specialized centers.
Collapse
Affiliation(s)
- Konstantin L. Makridis
- Department of Pediatric NeurologyCharité—Universitätsmedizin BerlinBerlinGermany
- Center for Chronically Sick ChildrenCharité—Universitätsmedizin BerlinBerlinGermany
- German Epilepsy Center for Children and AdolescentsCharité—Universitätsmedizin BerlinBerlinGermany
- Institute of Cell‐ and NeurobiologyCharité—Universitätsmedizin BerlinBerlinGermany
| | - Kerstin Alexandra Klotz
- Department of Neuropediatrics and Muscle Disorders, Center for Pediatrics, Medical Center—University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Georgia Ramantani
- Department of NeuropediatricsUniversity Children's Hospital ZurichZurichSwitzerland
- University of ZurichZurichSwitzerland
- Children's Research CentreUniversity Children's Hospital ZurichZurichSwitzerland
| | - Lena‐Luise Becker
- Department of Pediatric NeurologyCharité—Universitätsmedizin BerlinBerlinGermany
- Center for Chronically Sick ChildrenCharité—Universitätsmedizin BerlinBerlinGermany
- German Epilepsy Center for Children and AdolescentsCharité—Universitätsmedizin BerlinBerlinGermany
- Institute of Cell‐ and NeurobiologyCharité—Universitätsmedizin BerlinBerlinGermany
| | - Victoria San Antonio‐Arce
- Freiburg Epilepsy Center, Medical Center—University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Steffen Syrbe
- Division of Paediatric Epileptology, Centre for Paediatrics and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Kathrin Wagner
- Freiburg Epilepsy Center, Medical Center—University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Mukesch Johannes Shah
- Department of Neurosurgery, Medical Center—University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | | | - Anna Tietze
- Institute of Neuroradiology, Charité—Universitätsmedizin BerlinBerlinGermany
| | - Christian E. Elger
- Department of Pediatric NeurologyCharité—Universitätsmedizin BerlinBerlinGermany
- Center for Chronically Sick ChildrenCharité—Universitätsmedizin BerlinBerlinGermany
- German Epilepsy Center for Children and AdolescentsCharité—Universitätsmedizin BerlinBerlinGermany
- Beta Neurologie—Kompetenzzentrum für Epilepsie, Beta Klinik GmbHBonnGermany
| | - Ingo Borggraefe
- Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Department of Pediatrics, Dr. von Hauner Children's HospitalLMU University Hospital MunichMunichGermany
- Comprehensive Epilepsy CenterLMU University Hospital MunichMunichGermany
| | - Angela M. Kaindl
- Department of Pediatric NeurologyCharité—Universitätsmedizin BerlinBerlinGermany
- Center for Chronically Sick ChildrenCharité—Universitätsmedizin BerlinBerlinGermany
- German Epilepsy Center for Children and AdolescentsCharité—Universitätsmedizin BerlinBerlinGermany
- Institute of Cell‐ and NeurobiologyCharité—Universitätsmedizin BerlinBerlinGermany
| |
Collapse
|
9
|
Song T, Feng L, Xia Y, Pang M, Geng J, Zhang X, Wang Y. Safety and efficacy of brivaracetam in children epilepsy: a systematic review and meta-analysis. Front Neurol 2023; 14:1170780. [PMID: 37483441 PMCID: PMC10359931 DOI: 10.3389/fneur.2023.1170780] [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: 02/21/2023] [Accepted: 06/16/2023] [Indexed: 07/25/2023] Open
Abstract
Background Epilepsy is one of the most common neurological diseases, affecting people of any age. Although the treatments of epilepsy are more and more diverse, the uncertainty regarding efficacy and adverse events still exists, especially in the control of childhood epilepsy. Methods We performed a systematic review and meta- analysis following the Cochrane Handbook and preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Four databases including PubMed, Embase, Web of Science and Cochrane library were searched. Studies reporting the use of brivaracetam monotherapy or adjuvant therapy in children (aged ≤18 years) were eligible for inclusion. Each stage of the review was conducted by two authors independently. Random-effects models were used to combine effect sizes for the estimation of efficacy and safety. Results A total of 1884 articles were retrieved, and finally 9 articles were included, enrolling 503 children with epilepsy. The retention rate of BRV treatment was 78% (95% CI: 0.64-0.91), the responder rate (reduction of seizure frequency ≥ 50%) was 35% (95% CI: 0.24-0.47), the freedom seizure rate (no seizure) was 18% (95% CI: 0.10-0.25), and the incidence rate of any treatment-emergent adverse events (TEAE) was 39% (95% CI: 0.09-0.68). The most common TEAE was somnolence, which had an incidence rate of 9% (95% CI: 0.07-0.12). And the incidence rate of mental or behavioral disorders was 12% (95% CI: 0.06-0.17). Conclusion Our systematic review and meta-analysis showed that BRV seemed to be safe and effective in the treatment of childhood epilepsy.
Collapse
Affiliation(s)
- Ting Song
- Department of Neurology II, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Lingjun Feng
- Surgical Department, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Yulei Xia
- Department of Neurology II, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Meng Pang
- Department of Neurology II, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Jianhong Geng
- Department of Neurology II, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Xiaojun Zhang
- Department of Neurology II, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Yanqiang Wang
- Department of Neurology II, Affiliated Hospital of Weifang Medical University, Weifang, China
| |
Collapse
|
10
|
Stefanos-Yakoub I, Wingeier K, Cserpan D, Gennari AG, Latal B, Reuner G, Ramantani G. Lesion Extent Negatively Impacts Intellectual Skills in Pediatric Focal Epilepsy. Pediatr Neurol 2023; 145:67-73. [PMID: 37285765 DOI: 10.1016/j.pediatrneurol.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/08/2023] [Accepted: 05/10/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Cognitive development in children and adolescents with focal lesional epilepsy is determined by the underlying epileptogenic lesion, in addition to epilepsy itself. However, the impact of lesion-related variables on intelligence quotient (IQ) and developmental quotient (DQ) remains largely unexplored. Here, we aimed to determine the effect of lesion-related predictors and their relation with epilepsy-related predictors of intellectual functioning. METHODS We retrospectively analyzed data from children with focal lesional epilepsy who underwent standardized cognitive evaluation yielding IQ/DQ in our institution. RESULTS We included 50 consecutive patients aged 0.5 to 17.5 years (mean, 9.3; S.D., 4.9) at cognitive assessment. Epilepsy duration was 0 to 15.5 years (mean, 3.8; S.D., 4.1). Of the total cohort, 30 (60%) patients had unilobar lesions, seven (14%) multilobar, 10 (20%) hemispheric, and three (6%) bilateral. Etiology was congenital in 32 (64%) cases, acquired in 14 (28%), and progressive in four (8%). For patients with unilobar lesions, the mean IQ/DQ was 97.1 ± 15.7, for multilobar 98.9 ± 20.2, for hemispheric 76.1 ± 20.5, and for bilateral 76.3 ± 4.5. Larger lesion extent, earlier epilepsy onset, and longer epilepsy duration correlated with lower IQ/DQ in the univariate analysis, whereas only lesion extent and epilepsy duration contributed significantly to the explanatory model in the multivariable analysis. CONCLUSIONS The present study demonstrates that lesion extent and epilepsy duration are important risk factors for intellectual impairment in pediatric patients with focal lesional epilepsy. These findings are useful for family counseling and the early consideration of interventions that may limit the duration of epilepsy.
Collapse
Affiliation(s)
- Ilona Stefanos-Yakoub
- Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland
| | - Kevin Wingeier
- Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland
| | - Dorottya Cserpan
- Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland
| | - Antonio Giulio Gennari
- Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland; MR Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Beatrice Latal
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland; University of Zurich, Zurich, Switzerland; Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Gitta Reuner
- Faculty of Behavioral and Cultural Studies, Institute of Education Studies, University of Heidelberg, Heidelberg, Germany
| | - Georgia Ramantani
- Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland; University of Zurich, Zurich, Switzerland.
| |
Collapse
|
11
|
Makridis KL, Hoyer S, Elger CE, Kaindl AM. Is There a Cognitive Decline in Pediatric Patients Following Epilepsy Surgery? Pediatr Neurol 2023; 144:44-49. [PMID: 37146539 DOI: 10.1016/j.pediatrneurol.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 03/13/2023] [Accepted: 03/30/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Epilepsy surgery is currently the only way to cure drug-resistant epilepsy (DRE). The loss of epileptic activity or its propagation in the developing brain may not only result in seizure freedom but also be associated with further positive effects. Here, we analyzed the cognitive development of children and adolescents with DRE after epilepsy surgery. METHODS We evaluated retrospectively the cognitive development of children and adolescents before and after epilepsy surgery. RESULTS Fifty-three children and adolescents underwent epilepsy surgery at a median age of 7.62 years. Overall seizure freedom was 86.8% at a current median observation period of 20 months. Presurgically, 81.1% had the clinical diagnosis of cognitive impairment, which was confirmed by standardized tests in 43 of 53 patients (76.7%). Further 10 patients had severe cognitive impairment rendering a standardized test impossible. The median intelligence quotient (IQ)/development quotient value was 74. After surgery, caretakers reported developmental progress in all patients, whereas the median IQ decreased slightly (P = 0.404). In eight patients the IQ points decreased after surgery; however, their individual raw scores increased in line with their reported increase in cognitive abilities. CONCLUSIONS We did not detect any cognitive deterioration in children following epilepsy surgery. A loss of IQ points did not correspond to a real loss of cognitive abilities. These patients developed more slowly than age-matched peers with an average development speed but profited individually as seen in their raw scores. Therefore, an individual analysis of raw scores is relevant to assess the cognitive development after surgery.
Collapse
Affiliation(s)
- Konstantin L Makridis
- Department of Pediatric Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Center for Chronically Sick Children, Charité - Universitätsmedizin Berlin, Berlin, Germany; German Epilepsy Center for Children and Adolescents, Charité - Universitätsmedizin Berlin, Berlin, Germany; Institute of Cell- and Neurobiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian Hoyer
- Department of Pediatric Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Center for Chronically Sick Children, Charité - Universitätsmedizin Berlin, Berlin, Germany; German Epilepsy Center for Children and Adolescents, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian E Elger
- Department of Pediatric Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Center for Chronically Sick Children, Charité - Universitätsmedizin Berlin, Berlin, Germany; German Epilepsy Center for Children and Adolescents, Charité - Universitätsmedizin Berlin, Berlin, Germany; Beta Neurologie - Kompetenzzentrum für Epilepsie, Beta Klinik GmbH, Bonn, Germany
| | - Angela M Kaindl
- Department of Pediatric Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Center for Chronically Sick Children, Charité - Universitätsmedizin Berlin, Berlin, Germany; German Epilepsy Center for Children and Adolescents, Charité - Universitätsmedizin Berlin, Berlin, Germany; Institute of Cell- and Neurobiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| |
Collapse
|
12
|
Wei Z, Fallah A, Wang Y, Kuang S, Weil AG, Wang J, Liang S. Influence of resective extent of epileptogenic tuber on seizure outcome in patients with tuberous sclerosis complex-related epilepsy: A systematic review and meta-analysis. Seizure 2023; 108:81-88. [PMID: 37116294 DOI: 10.1016/j.seizure.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/28/2023] [Accepted: 04/03/2023] [Indexed: 04/05/2023] Open
Abstract
OBJECTIVE To perform a systematic review and meta-analysis to identify whether tuberectomy and tuberectomy plus are associated with different postoperative seizure outcomes in patients with tuberous sclerosis complex (TSC) -related epilepsy. METHODS Electronic databases (PubMed, Embase, Cochrane, Proquest, Web of Science, Scopus, Biosis Previews) were searched without date restriction. Retrospective cohort studies of participants with TSC-associated epilepsy undergoing resective surgery that reported demographics, presurgical evaluation, extent of resection and postoperative seizure outcomes were included. Title, abstract and the full text were checked independently and in duplicate by two reviewers. Disagreements were resolved through discussion. One author extracted data which was verified by a second author using identified common standard in advance, including using a risk of bias tool we agreed on to evaluate study quality. RESULTS Five studies, with a total of 327 participants, were included. One hundred and sixty patients received tuberectomy, and 93 of them (58.1%) achieved postoperative seizure freedom, while the other 167 patients underwent tuberectomy plus, and 128 of them (76.6%) achieved seizure freedom after adequate follow-ups (RR=0.72, 95% CI [0.60, 0.87], P<0.05). Subgroup analysis found that 40 of 63 (63.5%) patients after tuberectomy and 66 of 78 (84.6%) patients after tuberectomy plus of a single tuber achieved seizure freedom (RR = 0.71, 95% CI [0.56,0.91], P<0.05). In the multituber subrgroup, 16 of 42 (38.1%) and 21 of 31 (67.7%) patients achieved seizure freedom, after tuberectomy and tuberectomy plus, respectively (RR = 0.57, 95% CI [0.32,1.03], P = 0.06). CONCLUSIONS Tuberectomy plus is a more effective treatment than tuberectomy for patients with TSC-related intractable epilepsy.
Collapse
|
13
|
Mozaffari K, Krishnakumar A, Chen JS, Goel K, Wang A, Shlobin NA, Weil AG, Fallah A. Seizure outcomes in children with Sturge-Weber syndrome undergoing epilepsy surgery: An individual participant data meta-analysis. Seizure 2023; 107:43-51. [PMID: 36958063 DOI: 10.1016/j.seizure.2023.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/06/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
BACKGROUND A subpopulation of patients with Sturge-Weber syndrome (SWS) develop medically intractable epilepsy. There is a paucity of literature on preoperative factors that predict postoperative seizure outcomes in these patients. An individual participant data meta-analysis (IPDMA) was performed to discern preoperative variables associated with favorable seizure outcomes in pediatric SWS patients undergoing epilepsy surgery. METHODS PubMed, Cochrane, Web of Science, and Scopus were independently queried following PRISMA guidelines. Studies that reported seizure outcomes in individual pediatric SWS patients were selected. Preoperative demographic variables and disease characteristics were recorded and evaluated in a time-to-event fashion via Cox regression and Kaplan-Meier analysis with log-rank test. RESULTS A total of 18 studies with 108 patients were included for meta-analysis. Median age at seizure onset was 4.5 months, and 85 patients (78.7%) were seizure-free at last follow-up (median: 72 months). On multivariable Cox regression, no variables were independent predictors of post-operative seizure freedom duration, including the extent of hemispheric resection. There were also no differences in time-to-seizure recurrence on Kaplan-Meier analysis when comparing those treated with hemispheric surgery and those with less than hemispheric surgery (p = 0.52). CONCLUSION This IPDMA showed that both resective and hemispheric epilepsy surgery achieve favorable and comparable seizure outcomes in pediatric SWS patients. The best available evidence using IPD suggests that resective surgery may be an appropriate alternative to hemispheric epilepsy surgery in well-selected patients. Prospective multi-institutional studies with greater follow-up are warranted to further investigate predictors of seizure outcome in pediatric SWS patients.
Collapse
Affiliation(s)
- Khashayar Mozaffari
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, United States
| | - Asha Krishnakumar
- School of Medicine, Virginia Commonwealth University, Richmond, United States
| | - Jia-Shu Chen
- Warren Alpert Medical School of Brown University, Providence, United States
| | - Keshav Goel
- David Geffen School of Medicine at University of California, Los Angeles, United States
| | - Andrew Wang
- David Geffen School of Medicine at University of California, Los Angeles, United States
| | - Nathan A Shlobin
- Northwestern University Feinberg School of Medicine, Chicago, United States
| | - Alexander G Weil
- Department of Surgery, Division of Neurosurgery, Ste. Justine University Hospital, University of Montreal, Quebec, Canada; Department of Neuroscience, University of Montreal, Quebec, Canada; Division of Neurosurgery, Ste. Justine Hospital, University of Montreal, Quebec, Canada
| | - Aria Fallah
- Department of Neurosurgery and Pediatrics, Los Angeles (UCLA), University of California, 300 Stein Plaza Driveway, Suite 525, Los Angeles, CA 90095, United States.
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Frank NA, Greuter L, Guzman R, Soleman J. Early surgical approaches in pediatric epilepsy - a systematic review and meta-analysis. Childs Nerv Syst 2023; 39:677-688. [PMID: 36219224 DOI: 10.1007/s00381-022-05699-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/03/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Drug-resistant epilepsy occurs in up to 30% of children suffering from seizures and about 10% qualify for surgical treatment. The aim of this systematic review and meta-analysis is to analyze the potential benefit of early epilepsy surgery in children concerning primarily seizure and developmental outcome. METHODS PubMed and Embase databases were searched using a systematic search strategy to identify studies on pediatric epilepsy surgery under 3 years from their inception up to 2022. Outcome measures were seizure outcome, postoperative complications, seizure onset, and reduction rate of antiepileptic drugs. A meta-analysis was thereafter performed for all included cohort studies. A p-value of < 0.05 was considered as statistically significant. RESULTS A total of 532 patients were analyzed with 401 patients (75%) receiving resective or disconnective surgery under the age of 3 years and 80 patients (15%) receiving surgery older than 3 years. The remaining 51 patients (9%) underwent VNS implantation. Pooled outcome analysis for resective/disconnective surgery showed favorable outcome in 68% (95% CI [0.63; 0.73]), while comparative analysis between the age groups showed no significant difference (77% early group and 75% late group; RR 1.03, 95% CI [0.73; 1.46] p = 0.75). Favorable outcome for the VNS cohort was seen in 52%, 65% in the early and 45.1% in the late group (RR 1.4393, 95% CI [0.87; 2.4] z = 1.42, p = 0.16). Developmental outcome was improved in 26%. Morbidity rate was moderate and showed no significant difference comparing the age groups, and overall surgical mortality rate was very low (0.1%). CONCLUSION Epilepsy surgery in pediatric age, especially under the age of 3 years, is a feasible and safe way to treat intractable epilepsy. Further comparative studies of prospective nature, analyzing not only seizure but also developmental outcome, should be the focus of future studies.
Collapse
Affiliation(s)
| | - Ladina Greuter
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
- Department of Pediatric Neurosurgery, University Children's Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
- Department of Pediatric Neurosurgery, University Children's Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| |
Collapse
|
16
|
Gennari AG, Cserpan D, Stefanos-Yakoub I, Kottke R, O’Gorman Tuura R, Ramantani G. Diffusion tensor imaging discriminates focal cortical dysplasia from normal brain parenchyma and differentiates between focal cortical dysplasia types. Insights Imaging 2023; 14:36. [PMID: 36826756 PMCID: PMC9958211 DOI: 10.1186/s13244-023-01368-y] [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: 08/16/2022] [Accepted: 12/29/2022] [Indexed: 02/25/2023] Open
Abstract
OBJECTIVES Although diffusion tensor imaging (DTI) may facilitate the identification of cytoarchitectural changes associated with focal cortical dysplasia (FCD), the predominant aetiology of paediatric structural epilepsy, its potential has thus far remained unexplored in this population. Here, we investigated whether DTI indices can differentiate FCD from contralateral brain parenchyma (CBP) and whether clinical features affect these indices. METHODS In this single-centre, retrospective study, we considered children and adolescents with FCD-associated epilepsy who underwent brain magnetic resonance (MRI), including DTI. Fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity, and radial diffusivity, were calculated in both FCD and CBP. The DTI indices best discriminating between FCD and CBP were subsequently used to assess the link between DTI and selected clinical and lesion-related parameters. RESULTS We enrolled 32 patients (20 male; median age at MRI 4 years), including 15 with histologically confirmed FCD. FA values were lower (p = 0.03), whereas MD values were higher in FCD than in CBP (p = 0.04). The difference in FA values between FCD and CBP was more pronounced for a positive vs. negative history of status epilepticus (p = 0.004). Among histologically confirmed cases, the difference in FA values between FCD and CBP was more pronounced for type IIb versus type I FCD (p = 0.03). CONCLUSIONS FA and MD discriminate between FCD and CBP, while FA differentiates between FCD types. Status epilepticus increases differences in FA, potentially reflecting changes induced in the brain. Our findings support the potential of DTI to serve as a non-invasive biomarker to characterise FCD in the paediatric population.
Collapse
Affiliation(s)
- Antonio Giulio Gennari
- Department of Neuropediatrics, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland. .,MR-Research Centre, University Children's Hospital Zurich, Zurich, Switzerland.
| | - Dorottya Cserpan
- grid.412341.10000 0001 0726 4330Department of Neuropediatrics, University Children’s Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland
| | - Ilona Stefanos-Yakoub
- grid.412341.10000 0001 0726 4330Department of Neuropediatrics, University Children’s Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland
| | - Raimund Kottke
- grid.412341.10000 0001 0726 4330Department of Diagnostic Imaging, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Ruth O’Gorman Tuura
- grid.412341.10000 0001 0726 4330MR-Research Centre, University Children’s Hospital Zurich, Zurich, Switzerland ,grid.7400.30000 0004 1937 0650University of Zurich, Zurich, Switzerland ,grid.412341.10000 0001 0726 4330Children’s Research Centre, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Georgia Ramantani
- grid.412341.10000 0001 0726 4330Department of Neuropediatrics, University Children’s Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland ,grid.7400.30000 0004 1937 0650University of Zurich, Zurich, Switzerland ,grid.412341.10000 0001 0726 4330Children’s Research Centre, University Children’s Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
17
|
Hoppe C, Beeres K, Witt JA, Sassen R, Helmstaedter C. Clinical adult outcome 11-30 years after pediatric epilepsy surgery: Complications and other surgical adverse events, seizure control, and cure of epilepsy. Epilepsia 2023; 64:335-347. [PMID: 36468792 DOI: 10.1111/epi.17477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/25/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Pediatric epilepsy surgery promises seizure freedom or even cure of epilepsy. We evaluated the long-term (≥10 years) adult clinical outcome including surgery-related adverse events and complications, which are generally underreported. METHODS A monocentric, single-arm, questionnaire study in now adult patients who underwent epilepsy surgery during childhood. A novel ad hoc parental/patient questionnaire, which addressed diverse outcome domains was applied. RESULTS From a total of 353 eligible patients, 203 could be contacted (3 patients died of causes unknown) and 101 (50%) returned appropriately filled-in surveys. No evidence for a survey-response bias was found. The rate of surgical complications according to the patient records was 9%. As regards the survey, half of the parents/patients reported surgical adverse events (expected and unexpected issues) and one-third reported permanent aversive sequels. Two-thirds of the patients were seizure-free during the last year before follow-up; 63% were Engel class 1A; favorable seizure outcomes (including auras only) were obtained in 73%; and 54% were seizure-free and off antiseizure medicine (ASM), that is, cured of epilepsy. In non-seizure-free patients, seizure relapse occurred at any time during the follow-up interval but 87% of those with a seizure-free first postoperative year were seizure-free at follow-up. One patient experienced a seizure relapse during the ASM withdrawal trial but became seizure-free again with ASMs. Eleven patients reported an increased number of ASMs as compared to the time before surgery. Earlier focal surgery did not affect the long-term clinical outcome. SIGNIFICANCE Pediatric epilepsy surgery was capable of curing epilepsy in about one-half of the children and to significantly control seizures in about three-fourths. Long-term success of focal surgery did not depend on age at surgery or duration of epilepsy. Surgical adverse events including complications may be underreported and must be assessed more thoroughly.
Collapse
Affiliation(s)
- Christian Hoppe
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Kassandra Beeres
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | | | - Robert Sassen
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
- Department of Neuropediatrics, University Hospital Bonn, Bonn, Germany
| | | |
Collapse
|
18
|
Arfaie S, Amin P, Kwan ATH, Solgi A, Sarabi A, Hakak-Zargar B, Brunette-Clément T, Pushenko D, Mir-Moghtadaei K, Mashayekhi MS, Mofatteh M, Honarvar F, Ren LY, Noiseux-Lush C, Azizi Z, Pearl PL, Baldeweg T, Weil AG, Fallah A. Long-term full-scale intelligent quotient outcomes following pediatric and childhood epilepsy surgery: A systematic review and meta-analysis. Seizure 2023; 106:58-67. [PMID: 36774775 DOI: 10.1016/j.seizure.2023.01.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 12/28/2022] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Cognitive measures are an important primary outcome of pediatric, adolescents, and childhood epilepsy surgery. The purpose of this systematic review and meta-analysis is to assess whether there are long-term alterations (≥ 5 years) in the Full-Scale Intelligence Quotient (FSIQ) of pediatric patients undergoing epilepsy surgery. METHODS Electronic databases (EMBASE, MEDLINE, and Scopus) were searched for English articles from inception to October 2022 that examined intelligence outcomes in pediatric epilepsy surgery patients. Inclusion criteria were defined as the patient sample size of ≥ 5, average follow- up of ≥5 years, and surgeries performed on individuals ≤ 18 years old at the time of surgery. Exclusion criteria consisted of palliative surgery, animal studies, and studies not reporting surgical or FSIQ outcomes. Publication bias was assessed using a funnel plot and the Quality in Prognosis Studies (QUIPS) toolset was used for quality appraisal of the selected articles. A random-effects network meta-analysis was performed to compare FSIQ between surgical patients at baseline and follow-up and Mean Difference (MD) was used to calculate the effect size of each study. Point estimates for effects and 95% confidence intervals for moderation analysis were performed on variables putatively associated with the effect size. RESULTS 21,408 studies were screened for abstract and title. Of these, 797 fit our inclusion and exclusion criteria and proceeded to full-text screening. Overall, seven studies met our requirements and were selected. Quantitative analysis was performed on these studies (N = 330). The mean long-term difference between pre- and post- operative FSIQ scores across all studies was noted at 3.36 [95% CI: (0.14, 6.57), p = 0.04, I2 = 0%] and heterogeneity was low. CONCLUSION To our knowledge, this is the first meta-analysis to measure the long-term impacts of FSIQ in pediatric and adolescent epilepsy patients. Our overall results in this meta-analysis indicate that while most studies do not show long-term FSIQ deterioration in pediatric patients who underwent epilepsy surgery, there was an increase of 3.36 FSIQ points, however, the observed changes were not clinically significant. Moreover, at the individual patient level analysis, while most children did not show long-term FSIQ deterioration, few had significant decline. These findings indicate the importance of surgery as a viable option for pediatric patients with medically refractory epilepsy.
Collapse
Affiliation(s)
- Saman Arfaie
- Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada; Faculty of Medicine, McGill University, Montreal, QC, Canada; Department of Molecular and Cell Biology, University of California Berkeley, Berkeley, CA, United States of America
| | - Pouya Amin
- Department of Molecular and Cell Biology, University of California Berkeley, Berkeley, CA, United States of America
| | - Angela T H Kwan
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Chemical and Physical Sciences, University of Toronto, Toronto, ON, Canada
| | - Arad Solgi
- School of Kinesiology & Health Science, York University, Toronto, ON, Canada
| | - Ali Sarabi
- School of Computing and Augmented Intelligence, Arizona State University, Tempe, AZ, United States of America
| | | | | | - Denys Pushenko
- Department of Chemical and Physical Sciences, University of Toronto, Toronto, ON, Canada; Department of Biology, University of Toronto, Toronto, ON, Canada
| | | | | | - Mohammad Mofatteh
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, United Kingdom.
| | - Faraz Honarvar
- Faculty of Medicine, Queen's University, Kingston, ON, Canada
| | - Lily Yuxi Ren
- Lane Medical Library and Knowledge Management Center, Stanford Medicine, Stanford University, Palo Alto, CA, United States of America
| | | | - Zahra Azizi
- Stanford Medicine, Stanford University, Palo Alto, CA, United States of America; School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, United Kingdom
| | - Phillip Lawrence Pearl
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Torsten Baldeweg
- Department of Developmental Neuroscience, UCL Great Ormond Street Institute for Child Health, London WC1N 1EH, United Kingdom; Great Ormond Street Hospital NHS Foundation Trust, London WC1N 3JH, United Kingdom
| | - Alexander G Weil
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Montreal, QC, Canada
| | - Aria Fallah
- Department of Neurosurgery and Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, CA, United States of America
| |
Collapse
|
19
|
Tsou AY, Kessler SK, Wu M, Abend NS, Massey SL, Treadwell JR. Surgical Treatments for Epilepsies in Children Aged 1-36 Months: A Systematic Review. Neurology 2023; 100:e1-e15. [PMID: 36270898 PMCID: PMC9827129 DOI: 10.1212/wnl.0000000000201012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 06/09/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Early life epilepsies (epilepsies in children 1-36 months old) are common and may be refractory to antiseizure medications. We summarize findings of a systematic review commissioned by the American Epilepsy Society to assess evidence and identify evidence gaps for surgical treatments for epilepsy in children aged 1-36 months without infantile spasms. METHODS EMBASE, MEDLINE, PubMed, and the Cochrane Library were searched for studies published from 1/1/1999 to 8/19/21. We included studies reporting data on children aged 1 month to ≤36 months undergoing surgical interventions or neurostimulation for epilepsy and enrolling ≥10 patients per procedure. We excluded studies of infants with infantile spasms or status epilepticus. For effectiveness outcomes (seizure freedom, seizure frequency), studies were required to report follow-up at ≥ 12 weeks. For harm outcomes, no minimum follow-up was required. Outcomes for all epilepsy types, regardless of etiology, were reported together. RESULTS Eighteen studies (in 19 articles) met the inclusion criteria. Sixteen prestudies/poststudies reported on efficacy, and 12 studies addressed harms. Surgeries were performed from 1979 to 2020. Seizure freedom for infants undergoing hemispherectomy/hemispherotomy ranged from 7% to 76% at 1 year after surgery. For nonhemispheric surgeries, seizure freedom ranged from 40% to 70%. For efficacy, we concluded low strength of evidence (SOE) suggests some infants achieve seizure freedom after epilepsy surgery. Over half of infants undergoing hemispherectomy/hemispherotomy achieved a favorable outcome (Engel I or II, International League Against Epilepsy I to IV, or >50% seizure reduction) at follow-up of >1 year, although studies had key limitations. Surgical mortality was rare for functional hemispherectomy/hemispherotomy and nonhemispheric resections. Low SOE suggests postoperative hydrocephalus is uncommon for infants undergoing nonhemispheric procedures for epilepsy. DISCUSSION Although existing evidence remains sparse and low quality, some infants achieve seizure freedom after surgery and ≥50% achieve favorable outcomes. Future prospective studies in this age group are needed. In addition to seizure outcomes, studies should evaluate other important outcomes (developmental outcomes, quality of life [QOL], sleep, functional performance, and caregiver QOL). TRIAL REGISTRATION INFORMATION This systematic review was registered in PROSPERO (CRD42021220352) on March 5, 2021.
Collapse
Affiliation(s)
- Amy Y Tsou
- From the ECRI Evidence Based Practice Center (A.Y.T., M.W., J.R.T.), Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Biostatistics (N.S.A.), Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine.
| | - Sudha Kilaru Kessler
- From the ECRI Evidence Based Practice Center (A.Y.T., M.W., J.R.T.), Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Biostatistics (N.S.A.), Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | - Mingche Wu
- From the ECRI Evidence Based Practice Center (A.Y.T., M.W., J.R.T.), Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Biostatistics (N.S.A.), Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | - Nicholas S Abend
- From the ECRI Evidence Based Practice Center (A.Y.T., M.W., J.R.T.), Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Biostatistics (N.S.A.), Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | - Shavonne L Massey
- From the ECRI Evidence Based Practice Center (A.Y.T., M.W., J.R.T.), Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Biostatistics (N.S.A.), Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | - Jonathan R Treadwell
- From the ECRI Evidence Based Practice Center (A.Y.T., M.W., J.R.T.), Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Biostatistics (N.S.A.), Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| |
Collapse
|
20
|
Moorhouse FJ, Cornell S, Gerstl L, Wagner J, Tacke M, Roser T, Heinen F, von Stülpnagel C, Vollmar C, Kunz M, Ramantani G, Borggraefe I. Cognitive profiles in pediatric unilobar vs. multilobar epilepsy. Eur J Paediatr Neurol 2022; 41:48-54. [PMID: 36265333 DOI: 10.1016/j.ejpn.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 09/12/2022] [Accepted: 09/24/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We aimed to determine how cognitive impairment relates to the extent of the presumed epileptogenic zone in pediatric focal epilepsies. We analyzed the cognitive functions in unilobar compared to multilobar focal epilepsy patients that underwent neuropsychological testing at a tertiary epilepsy center. METHODS We assessed cognitive functions of pediatric focal epilepsy patients with the German version of the Wechsler Intelligence Scales that measures full-scale IQ and subcategories. We assessed differences in IQ and epilepsy-related variables between unilobar and multilobar epilepsy patients. RESULTS We included 62 patients (37 unilobar, 25 multilobar), aged 10.6 ± 3.7 years. Full-scale IQ values were significantly higher in unilobar (93.6 ± 17.7, 95% CI 87.7-99.6) than in multilobar epilepsy patients (77.3 ± 17.2, 95% CI 69.3-85.0; p = 0.001). In all but one IQ subcategory (working memory), significantly higher values were measured in unilobar than in multilobar epilepsy patients. The proportion of unilobar epilepsy patients with severe cognitive impairment (8.3%) and below-average intelligence (30.5%) was lower compared to multilobar epilepsy patients (47.6% and 61.9%; p = 0.002 and p = 0.021, respectively). Epilepsy onset occurred earlier in multilobar (4.0 years, 95% CI 2.6-5.5, SD ± 3.4 years) than in unilobar epilepsy patients (7.0 years, 95% CI 5.5-8.5, SD ± 4.4 years, p = 0.008). CONCLUSIONS Pediatric multilobar epilepsy patients face more cognitive issues than unilobar epilepsy patients on average. Our findings should help to identify children and adolescents who are most at risk for impaired cognitive development. A limitation of our study is the simple division into unilobar and multilobar epilepsies, with no specific account being taken of etiology/epilepsy syndrome, which can have a profound effect on cognition.
Collapse
Affiliation(s)
- Frederik Jan Moorhouse
- Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Department of Pediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Sonia Cornell
- Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Department of Pediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Lucia Gerstl
- Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Department of Pediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Johanna Wagner
- Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Department of Pediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Moritz Tacke
- Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Department of Pediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Timo Roser
- Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Department of Pediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Florian Heinen
- Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Department of Pediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Celina von Stülpnagel
- Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Department of Pediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany; Paracelsus Medical University, Salzburg, Austria
| | - Christian Vollmar
- Department of Neurology, Ludwig-Maximilians-University, Munich, Germany; Comprehensive Epilepsy Center, Ludwig-Maximilians-University, Munich, Germany
| | - Mathias Kunz
- Comprehensive Epilepsy Center, Ludwig-Maximilians-University, Munich, Germany; Department of Neurosurgery, Ludwig-Maximilians-University, Munich, Germany
| | - Georgia Ramantani
- Department of Neuropediatrics, University Children's Hospital, Zurich, Switzerland; University of Zurich, Zurich, Switzerland
| | - Ingo Borggraefe
- Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Department of Pediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany; Comprehensive Epilepsy Center, Ludwig-Maximilians-University, Munich, Germany.
| |
Collapse
|
21
|
Pepper J, Lo WB, Agrawal S, Mohamed R, Horton J, Balloo S, Philip S, Basnet A, Wimalachandra WSB, Lawley A, Seri S, Walsh AR. Functional hemispherotomy for epilepsy in the very young. J Neurosurg Pediatr 2022; 30:400-409. [PMID: 35932273 DOI: 10.3171/2022.6.peds21521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 06/02/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Epilepsy is one of the most common neurological disorders in children. Among very young children, one-third are resistant to medical treatment, and lack of effective treatment may result in adverse outcomes. Although functional hemispherotomy is an established treatment for epilepsy, its outcome in the very young child has not been widely reported. In this study the authors investigated seizure and developmental results after hemispherotomy in children younger than 3 years. METHODS The authors reviewed a prospective database of all children younger than 3 years with medically intractable epilepsy who underwent functional hemispherotomy at the authors' institution during the period between 2012 and 2020. Demographic data, epilepsy history, underlying etiology, operative and transfusion details, and seizure and developmental outcomes were analyzed. RESULTS Twelve patients were included in this study. The mean age (± SD) at seizure onset was 3 ± 2.6 months and at surgery was 1.3 ± 0.77 years, with a mean follow-up of 4 years. Diagnoses included hemimegalencephaly (n = 5), hemidysplasia (n = 2), hypoxic/hemorrhagic (n = 2), traumatic (n = 1), Sturge-Weber syndrome (n = 1), and mild hemispheric structural abnormality with EEG/PET correlates (n = 1). Eleven patients achieved an Engel class I outcome, and 1 patient achieved Engel class IV at last follow-up. No deaths, infections, cerebrovascular events, or unexpected long-term neurological deficits were recorded. All children progressed neurodevelopmentally following surgery, but their developmental levels remained behind their chronological age, with an overall mean composite Vineland Adaptive Behavior Scale score of 58 (normal: 86-114, low: < 70). One patient required insertion of a subdural peritoneal shunt, 1 patient required dural repair for a CSF fluid leak, and 1 patient required aspiration of a pseudomeningocele. In 2 patients, both of whom weighed less than 5.7 kg, the first operation was incomplete due to blood loss. CONCLUSIONS Hemispherotomy in children younger than 3 years offers excellent seizure control and an acceptable risk-to-benefit ratio in well-selected patients. Families of children weighing less than 6 kg should be counseled regarding the possibility of staged surgery. Postoperatively, children continue to make appropriate, despite delayed, developmental progress.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Stefano Seri
- 4Department of Neurophysiology, Birmingham Children's Hospital, Birmingham, United Kingdom
| | | |
Collapse
|
22
|
Jehi L, Jette N, Kwon CS, Josephson CB, Burneo JG, Cendes F, Sperling MR, Baxendale S, Busch RM, Triki CC, Cross JH, Ekstein D, Englot DJ, Luan G, Palmini A, Rios L, Wang X, Roessler K, Rydenhag B, Ramantani G, Schuele S, Wilmshurst JM, Wilson S, Wiebe S. Timing of referral to evaluate for epilepsy surgery: Expert Consensus Recommendations from the Surgical Therapies Commission of the International League Against Epilepsy. Epilepsia 2022; 63:2491-2506. [PMID: 35842919 PMCID: PMC9562030 DOI: 10.1111/epi.17350] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/25/2022] [Accepted: 06/27/2022] [Indexed: 11/26/2022]
Abstract
Epilepsy surgery is the treatment of choice for patients with drug-resistant seizures. A timely evaluation for surgical candidacy can be life-saving for patients who are identified as appropriate surgical candidates, and may also enhance the care of nonsurgical candidates through improvement in diagnosis, optimization of therapy, and treatment of comorbidities. Yet, referral for surgical evaluations is often delayed while palliative options are pursued, with significant adverse consequences due to increased morbidity and mortality associated with intractable epilepsy. The Surgical Therapies Commission of the International League Against Epilepsy (ILAE) sought to address these clinical gaps and clarify when to initiate a surgical evaluation. We conducted a Delphi consensus process with 61 epileptologists, epilepsy neurosurgeons, neurologists, neuropsychiatrists, and neuropsychologists with a median of 22 years in practice, from 28 countries in all six ILAE world regions. After three rounds of Delphi surveys, evaluating 51 unique scenarios, we reached the following Expert Consensus Recommendations: (1) Referral for a surgical evaluation should be offered to every patient with drug-resistant epilepsy (up to 70 years of age), as soon as drug resistance is ascertained, regardless of epilepsy duration, sex, socioeconomic status, seizure type, epilepsy type (including epileptic encephalopathies), localization, and comorbidities (including severe psychiatric comorbidity like psychogenic nonepileptic seizures [PNES] or substance abuse) if patients are cooperative with management; (2) A surgical referral should be considered for older patients with drug-resistant epilepsy who have no surgical contraindication, and for patients (adults and children) who are seizure-free on 1-2 antiseizure medications (ASMs) but have a brain lesion in noneloquent cortex; and (3) referral for surgery should not be offered to patients with active substance abuse who are noncooperative with management. We present the Delphi consensus results leading up to these Expert Consensus Recommendations and discuss the data supporting our conclusions. High level evidence will be required to permit creation of clinical practice guidelines.
Collapse
Affiliation(s)
- Lara Jehi
- Epilepsy Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Nathalie Jette
- Department of Neurology and Department of Population Health, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Churl-Su Kwon
- Department of Neurology, Epidemiology, Neurosurgery and the Gertrude H. Sergievsky Center, Columbia University, New York, USA
| | - Colin B Josephson
- Department of Clinical Neurosciences and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jorge G. Burneo
- Department of Clinical Neurological Sciences and NeuroEpidemiology Unit, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Fernando Cendes
- Department of Neurology, University of Campinas, Campinas, Brazil
| | | | - Sallie Baxendale
- Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK
| | - Robyn M. Busch
- Epilepsy Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Chahnez Charfi Triki
- Department of Child Neurology, Hedi Chaker Hospital, LR19ES15 Sfax University, Sfax, Tunisia
| | - J Helen Cross
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Dana Ekstein
- Department of Neurology, Agnes Ginges Center for Human Neurogenetics, Hadassah Medical Organization, Jerusalem, Israel
| | - Dario J Englot
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Guoming Luan
- Department of Neurosurgery, Comprehensive Epilepsy Center, Sanbo Brain Hospital, Capital Medical University; Beijing Key Laboratory of Epilepsy; Epilepsy Institution, Beijing Institute for Brain Disorders, Beijing, China
| | - Andre Palmini
- Neurosciences and Surgical Departments, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Loreto Rios
- Clínica Integral de Epilepsia, Campus Clínico Facultad de Medicina Universidad Finis Terrae, Santiago, Chile
| | - Xiongfei Wang
- Department of Neurosurgery, Comprehensive Epilepsy Center, Sanbo Brain Hospital, Capital Medical University; Beijing Key Laboratory of Epilepsy; Epilepsy Institution, Beijing Institute for Brain Disorders, Beijing, China
| | - Karl Roessler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Bertil Rydenhag
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Georgia Ramantani
- Department of Neuropediatrics, and University Children’s Hospital Zurich, Switzerland, University of Zurich, Switzerland
| | - Stephan Schuele
- Department of Neurology, Northwestern University, Chicago, Illinois, USA
| | - Jo M Wilmshurst
- Department of Pediatric Neurology, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa; Institute of Neurosciences, University of Cape Town, South Africa
| | - Sarah Wilson
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Vic., Australia
| | - Samuel Wiebe
- Department of Clinical Neurosciences and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
23
|
Ramantani G, Bölsterli BK, Alber M, Klepper J, Korinthenberg R, Kurlemann G, Tibussek D, Wolff M, Schmitt B. Treatment of Infantile Spasm Syndrome: Update from the Interdisciplinary Guideline Committee Coordinated by the German-Speaking Society of Neuropediatrics. Neuropediatrics 2022; 53:389-401. [PMID: 35882373 PMCID: PMC9643068 DOI: 10.1055/a-1909-2977] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECTIVES The manuscript serves as an update on the current management practices for infantile spasm syndrome (ISS). It includes a detailed summary of the level of current evidence of different treatment options for ISS and gives recommendations for the treatment and care of patients with ISS. METHODS A literature search was performed using the Cochrane and Medline Databases (2014 to July 2020). All studies were objectively rated using the Scottish Intercollegiate Guidelines Network. For recommendations, the evidence from these studies was combined with the evidence from studies used in the 2014 guideline. RECOMMENDATIONS If ISS is suspected, electroencephalography (EEG) should be performed within a few days and, if confirmed, treatment should be initiated immediately. Response to first-line treatment should be evaluated clinically and electroencephalographically after 14 days. The preferred first-line treatment for ISS consists of either hormone-based monotherapy (AdrenoCorticoTropic Hormone [ACTH] or prednisolone) or a combination of hormone and vigabatrin. Children with tuberous sclerosis complex and those with contraindications against hormone treatment should be treated with vigabatrin. If first-line drugs are ineffective, second-line treatment options such as ketogenic dietary therapies, sulthiame, topiramate, valproate, zonisamide, or benzodiazepines should be considered. Children refractory to drug therapy should be evaluated early for epilepsy surgery, especially if focal brain lesions are present. Parents should be informed about the disease, the efficacy and adverse effects of the medication, and support options for the family. Regular follow-up controls are recommended.
Collapse
Affiliation(s)
- Georgia Ramantani
- Division of Clinical Neurophysiology and Epilepsy, University Children's Hospital, Zurich, Switzerland,Address for correspondence Georgia Ramantani, MD, PhD Department of Neuropediatrics, Steinwiesstrasse 758032 ZurichSwitzerland
| | - Bigna K. Bölsterli
- Division of Clinical Neurophysiology and Epilepsy, University Children's Hospital, Zurich, Switzerland
| | - Michael Alber
- Department of Pediatric Neurology and Developmental Medicine, University Children's Hospital, Tubingen, Germany
| | - Joerg Klepper
- Department of Pediatrics, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Germany
| | - Rudolf Korinthenberg
- Department of Neuropediatrics and Muscular Diseases, Centre of Pediatrics and Adolescent Medicine, University Medical Centre, Freiburg, Germany
| | - Gerhard Kurlemann
- St. Bonifatius Hospital Lingen, Children's Hospital, Lingen, Germany
| | - Daniel Tibussek
- Center for Pediatric and Teenage Health Care, Child Neurology, Sankt Augustin, Germany
| | - Markus Wolff
- Department of Pediatric Neurology, Vivantes Hospital Neukölln, Berlin, Germany
| | - Bernhard Schmitt
- Division of Clinical Neurophysiology and Epilepsy, University Children's Hospital, Zurich, Switzerland
| |
Collapse
|
24
|
Xie MG, Qiao J, Wang X, Zhou J, Guan Y, Liu C, Zhao M, Li T, Luan G. The cognitive functions and seizure outcomes of patients with low-grade epilepsy-associated neuroepithelial tumors. J Neurooncol 2022; 160:1-12. [PMID: 36053451 DOI: 10.1007/s11060-022-04076-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 06/22/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of the study was to evaluate the cognitive functions and seizure outcomes of patients with low-grade epilepsy-associated neuroepithelial tumors (LEATs). METHODS We retrospectively reviewed the clinical data of patients who underwent preoperative neuropsychological evaluations and subsequent epilepsy surgery for LEATs. The neuropsychological results of full-scaled intelligence quotient (FSIQ) and full-scaled memory quotient (FSMQ) were analyzed, as well as the postoperative seizure outcomes. RESULTS Of the 138 patients included in the study, 59 patients (40.4%) were female and 47 (36.6%) patients were children. Preoperatively, 138 patients received FSIQ assessments and 30 patients (21.7%) had an intellectual deficit (FSIQ < 80 scores); 124 patients received FSMQ assessments and 32 patients (25.8%) had a memory deficit (FSMQ < 80 scores). Younger age at seizure onset (OR 0.93; P = 0.035) and discordant ictal electroencephalography (EEG) findings (OR 5.26; P = 0.001) were found to predict intellectual deficits, while abnormal hippocampus (OR 2.36; P = 0.051) as well as discordant ictal EEG findings (OR 4.03; P = 0.007) tended to cause memory deficits. During postoperative follow-up, 123 patients (90.7%) were followed up at least 12 months, and among them, 105 patients (85.4%) got seizure-free (Engel class I), while 18 patients (14.6%) were not (Engel class II-IV); longer duration of epilepsy (OR 1.01; P < 0.001) and discordant interictal EEG findings (OR 5.91; P = 0.005) were found to be related to poor seizure outcomes in patients with LEATs. CONCLUSION Cognitive deficits commonly occur in patients with LEATs, especially in patients with early or childhood seizures. Early surgical intervention, however, could prevent most of patients from repeated seizure onsets and thus cognitive impairments.
Collapse
Affiliation(s)
- Ming-Guo Xie
- Department of Neurosurgery, Epilepsy Center, Sanbo Brain Hospital, Capital Medical University, Xiangshan Yikesong Road 50, Haidian District, Beijing, 100093, China.,Beijing Key Laboratory of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jiao Qiao
- Department of Neurosurgery, Epilepsy Center, Sanbo Brain Hospital, Capital Medical University, Xiangshan Yikesong Road 50, Haidian District, Beijing, 100093, China.,Beijing Key Laboratory of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Xiongfei Wang
- Department of Neurosurgery, Epilepsy Center, Sanbo Brain Hospital, Capital Medical University, Xiangshan Yikesong Road 50, Haidian District, Beijing, 100093, China.,Beijing Key Laboratory of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jian Zhou
- Department of Neurosurgery, Epilepsy Center, Sanbo Brain Hospital, Capital Medical University, Xiangshan Yikesong Road 50, Haidian District, Beijing, 100093, China.,Beijing Key Laboratory of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Yuguang Guan
- Department of Neurosurgery, Epilepsy Center, Sanbo Brain Hospital, Capital Medical University, Xiangshan Yikesong Road 50, Haidian District, Beijing, 100093, China.,Beijing Key Laboratory of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Changqing Liu
- Department of Neurosurgery, Epilepsy Center, Sanbo Brain Hospital, Capital Medical University, Xiangshan Yikesong Road 50, Haidian District, Beijing, 100093, China.,Beijing Key Laboratory of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Meng Zhao
- Department of Neurosurgery, Epilepsy Center, Sanbo Brain Hospital, Capital Medical University, Xiangshan Yikesong Road 50, Haidian District, Beijing, 100093, China.,Beijing Key Laboratory of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Tianfu Li
- Beijing Key Laboratory of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Beijing, China.,Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China.,Department of Neurology, Epilepsy Center, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Guoming Luan
- Department of Neurosurgery, Epilepsy Center, Sanbo Brain Hospital, Capital Medical University, Xiangshan Yikesong Road 50, Haidian District, Beijing, 100093, China. .,Beijing Key Laboratory of Epilepsy, Sanbo Brain Hospital, Capital Medical University, Beijing, China. .,Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China.
| |
Collapse
|
25
|
Novais F, Andrea M, Andrade G, Loureiro S, Pimentel J, Câmara Pestana L. Intelligence quotient (IQ) as a predictor of epilepsy surgery outcome. Epilepsy Behav 2022; 132:108708. [PMID: 35640399 DOI: 10.1016/j.yebeh.2022.108708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/20/2022] [Accepted: 04/15/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION About one-third of patients with epilepsy have a refractory form which is associated with important economic and psychosocial burden. Most of these patients also suffer from comorbidities. One of the most frequent is cognitive impairment. Resective surgery or neuromodulation techniques may improve seizure control. Several factors have been proposed as potential predictors of the success of surgery regarding seizure frequency. We aimed to study preoperative cognitive performance as a predictor of the epilepsy surgery outcome. METHODS In this ambispective study we studied total intelligence quotients (IQ) measured before surgery with the Wechsler Adult Intelligence Scale (WAIS) as a potential predictor of Engel Class at 1 year after surgery. Then we included IQ in a multivariate model and tested its performance. RESULTS Preoperative IQ was a significant and independent predictor of the Engel Class at 1 year after surgery (OR 0.94; CI 0.90-0.98; p = 0.007). The multivariate model including the age at epilepsy onset, education level, sex, and the type of surgery (resective versus palliative surgery) showed an area under the ROC curve of 0.85. CONCLUSIONS A low intelligence level may constitute a marker of worse prognosis after epilepsy surgery. However, other predictors should also be considered when evaluating surgical candidates.
Collapse
Affiliation(s)
- Filipa Novais
- Department of Neurosciences and Mental Health, Psychiatry Department, Hospital de Santa Maria (CHULN), Lisbon, Portugal; Faculdade de Medicina, Universidade de Lisboa, Portugal; Centro de Referência de Epilepsia Refratária, Hospital de Santa Maria, (CHULN), Lisboa, Portugal; EpiCARE Network, European Reference Network for Rare and Complex Epilepsies, Portugal.
| | - Mafalda Andrea
- Department of Neurosciences and Mental Health, Psychiatry Department, Hospital de Santa Maria (CHULN), Lisbon, Portugal; Centro de Referência de Epilepsia Refratária, Hospital de Santa Maria, (CHULN), Lisboa, Portugal; EpiCARE Network, European Reference Network for Rare and Complex Epilepsies, Portugal
| | - Gabriela Andrade
- Department of Neurosciences and Mental Health, Psychiatry Department, Hospital de Santa Maria (CHULN), Lisbon, Portugal; Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - Susana Loureiro
- Department of Neurosciences and Mental Health, Psychiatry Department, Hospital de Santa Maria (CHULN), Lisbon, Portugal; Faculdade de Medicina, Universidade de Lisboa, Portugal; Centro de Referência de Epilepsia Refratária, Hospital de Santa Maria, (CHULN), Lisboa, Portugal; EpiCARE Network, European Reference Network for Rare and Complex Epilepsies, Portugal
| | - José Pimentel
- Faculdade de Medicina, Universidade de Lisboa, Portugal; Department of Neurosciences and Mental Health, Neurology Department, Hospital de Santa Maria (CHULN), Lisbon, Portugal; Centro de Referência de Epilepsia Refratária, Hospital de Santa Maria, (CHULN), Lisboa, Portugal; EpiCARE Network, European Reference Network for Rare and Complex Epilepsies, Portugal
| | - Luís Câmara Pestana
- Department of Neurosciences and Mental Health, Psychiatry Department, Hospital de Santa Maria (CHULN), Lisbon, Portugal; Faculdade de Medicina, Universidade de Lisboa, Portugal; Centro de Referência de Epilepsia Refratária, Hospital de Santa Maria, (CHULN), Lisboa, Portugal; EpiCARE Network, European Reference Network for Rare and Complex Epilepsies, Portugal
| | | |
Collapse
|
26
|
Cross JH, Reilly C, Gutierrez Delicado E, Smith ML, Malmgren K. Epilepsy surgery for children and adolescents: evidence-based but underused. THE LANCET CHILD & ADOLESCENT HEALTH 2022; 6:484-494. [DOI: 10.1016/s2352-4642(22)00098-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 03/12/2022] [Accepted: 03/23/2022] [Indexed: 11/30/2022]
|
27
|
Hirano T, Suzuki H, Komatsu K, Kanno A, Kimura Y, Enatsu R, Ochi S, Ohnishi H, Mikuni N. Effect of Early Surgical Intervention for Brain Tumors Associated with Epilepsy on the Improvement in Memory Performance. Neurol Med Chir (Tokyo) 2022; 62:286-293. [PMID: 35418529 PMCID: PMC9259083 DOI: 10.2176/jns-nmc.2021-0175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
We evaluated the effect of early surgical intervention on the change in memory performance of patients with low-grade brain tumors associated with epilepsy. Twenty-three adult patients with low-grade brain tumors and epilepsy who underwent surgery at our institution between 2010 and 2019 were included. The Wechsler Memory Scale-Revised (WMS-R) was used to assess cognitive memory performance. Memory performance before and after surgery was retrospectively evaluated. In addition, the relationships among preoperative memory function, postoperative seizure outcome, preoperative seizure control, temporal lobe lesion, and change in memory function were examined. There were statistically significant improvements from median preoperative to postoperative WMS-R subscale scores for verbal memory, general memory, and delayed recall (p<0.001, p<0.001, and p=0.0055, respectively) regardless of preoperative sores and tumor location. Good postsurgical seizure control was associated with significant improvements in postoperative WMS-R performance. Our results indicated that early surgical intervention might improve postoperative memory function in patients with low-grade brain tumors and epilepsy.
Collapse
Affiliation(s)
| | - Hime Suzuki
- Department of Neurosurgery, Sapporo Medical University
| | | | - Aya Kanno
- Department of Neurosurgery, Sapporo Medical University
| | | | - Rei Enatsu
- Department of Neurosurgery, Sapporo Medical University
| | - Satoko Ochi
- Department of Neurosurgery, Sapporo Medical University
| | | | | |
Collapse
|
28
|
O'Hara NB, Lee MH, Juhász C, Asano E, Jeong JW. Diffusion tractography predicts propagated high-frequency activity during epileptic spasms. Epilepsia 2022; 63:1787-1798. [PMID: 35388455 DOI: 10.1111/epi.17251] [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: 01/09/2022] [Revised: 03/28/2022] [Accepted: 04/05/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Determine the structural networks that constrain propagation of ictal oscillations during epileptic spasm events, and compare observed propagation patterns across patients with successful or unsuccessful surgical outcomes. METHODS Subdural electrode recordings of 18 young patients (age 1-11 years) were analyzed during epileptic spasm events to determine ictal networks and quantify the amplitude and onset time of ictal oscillations across the cortical surface. Corresponding structural networks were generated with diffusion MRI tractography by seeding the cortical region associated with the earliest average oscillation onset time, and white matter pathways connecting active electrode regions within the ictal network were isolated. Properties of this structural network were used to predict oscillation onset times and amplitudes, and this relationship was compared across patients who did and did not achieve seizure freedom following resective surgery. RESULTS Onset propagation patterns were relatively consistent across each patients' spasm events. An electrode's average ictal oscillation onset latency was most significantly associated with the length of direct corticocortical tracts connecting to the area with the earliest average oscillation onset (p < .001, model R2 = 0.54). Moreover, patients demonstrating a faster propagation of ictal oscillation signals within the corticocortical network were more likely to have seizure recurrence following resective surgery (p = .039). Ictal oscillation amplitude was also associated with connecting tractography length and weighted fractional anisotropy (FA) measures along these pathways (p = .002/.030, model R2 = 0.31/0.25). Characteristics of analogous corticothalamic pathways did not show significant associations with ictal oscillation onset latency or amplitude. SIGNIFICANCE Spatiotemporal propagation patterns of high-frequency activity in epileptic spasms align with length and FA measures from onset-originating corticocortical pathways. Considering data in this individualized framework may help inform surgical decision making and expectations of surgical outcomes.
Collapse
Affiliation(s)
- Nolan B O'Hara
- Wayne State University (WSU) Translational Neuroscience Program.,Children's Hospital of Michigan Translational Imaging Laboratory
| | - Min-Hee Lee
- Children's Hospital of Michigan Translational Imaging Laboratory
| | - Csaba Juhász
- Wayne State University (WSU) Translational Neuroscience Program.,Children's Hospital of Michigan Translational Imaging Laboratory.,WSU Department of Pediatrics.,WSU Department of Neurology
| | - Eishi Asano
- Wayne State University (WSU) Translational Neuroscience Program.,Children's Hospital of Michigan Translational Imaging Laboratory.,WSU Department of Pediatrics.,WSU Department of Neurology
| | - Jeong-Won Jeong
- Wayne State University (WSU) Translational Neuroscience Program.,Children's Hospital of Michigan Translational Imaging Laboratory.,WSU Department of Pediatrics.,WSU Department of Neurology
| |
Collapse
|
29
|
Cserpan D, Gennari A, Gaito L, Lo Biundo SP, Tuura R, Sarnthein J, Ramantani G. Scalp HFO rates are higher for larger lesions. Epilepsia Open 2022; 7:496-503. [PMID: 35357778 PMCID: PMC9436296 DOI: 10.1002/epi4.12596] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/23/2022] [Accepted: 03/28/2022] [Indexed: 11/30/2022] Open
Abstract
High‐frequency oscillations (HFO) in scalp EEG are a new and promising noninvasive epilepsy biomarker, providing added prognostic value, particularly in pediatric lesional epilepsy. However, it is unclear if lesion characteristics, such as lesion volume, depth, type, and localization, impact scalp HFO rates. We analyzed scalp EEG from 13 children and adolescents with focal epilepsy associated with focal cortical dysplasia (FCD), low‐grade tumors, or hippocampal sclerosis. We applied a validated automated detector to determine HFO rates in bipolar channels. We identified the lesion characteristics in MRI. Larger lesions defined by MRI volumetric analysis corresponded to higher cumulative scalp HFO rates (P = .01) that were detectable in a higher number of channels (P = .05). Both superficial and deep lesions generated HFO detectable in the scalp EEG. Lesion type (FCD vs tumor) and lobar localization (temporal vs extratemporal) did not affect scalp HFO rates in our study. Our observations support that all lesions may generate HFO detectable in scalp EEG, irrespective of their characteristics, whereas larger epileptogenic lesions generate higher scalp HFO rates over larger areas that are thus more accessible to detection. Our study provides crucial insight into scalp HFO detectability in pediatric lesional epilepsy, facilitating their implementation as an epilepsy biomarker in a clinical setting.
Collapse
Affiliation(s)
- Dorottya Cserpan
- Department of Neuropediatrics University Children's Hospital Zurich Switzerland
| | - Antonio Gennari
- Department of Neuropediatrics University Children's Hospital Zurich Switzerland
- MR‐Research Centre University Children's Hospital Zurich Switzerland
| | - Luca Gaito
- Department of Neuropediatrics University Children's Hospital Zurich Switzerland
- Department of Neurosurgery University Hospital Zurich Switzerland
| | | | - Ruth Tuura
- MR‐Research Centre University Children's Hospital Zurich Switzerland
- University of Zurich Switzerland
- Children’s Research Centre University Children's Hospital Zurich Switzerland
| | - Johannes Sarnthein
- Department of Neurosurgery University Hospital Zurich Switzerland
- University of Zurich Switzerland
| | - Georgia Ramantani
- Department of Neuropediatrics University Children's Hospital Zurich Switzerland
- University of Zurich Switzerland
- Children’s Research Centre University Children's Hospital Zurich Switzerland
| |
Collapse
|
30
|
Makridis KL, Atalay DA, Thomale UW, Tietze A, Elger CE, Kaindl AM. Epilepsy surgery in the first six months of life: A systematic review and meta-analysis. Seizure 2022; 96:109-117. [DOI: 10.1016/j.seizure.2022.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/11/2022] [Accepted: 02/13/2022] [Indexed: 11/16/2022] Open
|
31
|
Burelo K, Ramantani G, Indiveri G, Sarnthein J. A neuromorphic spiking neural network detects epileptic high frequency oscillations in the scalp EEG. Sci Rep 2022; 12:1798. [PMID: 35110665 PMCID: PMC8810784 DOI: 10.1038/s41598-022-05883-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/17/2022] [Indexed: 12/04/2022] Open
Abstract
Interictal High Frequency Oscillations (HFO) are measurable in scalp EEG. This development has aroused interest in investigating their potential as biomarkers of epileptogenesis, seizure propensity, disease severity, and treatment response. The demand for therapy monitoring in epilepsy has kindled interest in compact wearable electronic devices for long-term EEG recording. Spiking neural networks (SNN) have emerged as optimal architectures for embedding in compact low-power signal processing hardware. We analyzed 20 scalp EEG recordings from 11 pediatric focal lesional epilepsy patients. We designed a custom SNN to detect events of interest (EoI) in the 80–250 Hz ripple band and reject artifacts in the 500–900 Hz band. We identified the optimal SNN parameters to detect EoI and reject artifacts automatically. The occurrence of HFO thus detected was associated with active epilepsy with 80% accuracy. The HFO rate mirrored the decrease in seizure frequency in 8 patients (p = 0.0047). Overall, the HFO rate correlated with seizure frequency (rho = 0.90 CI [0.75 0.96], p < 0.0001, Spearman’s correlation). The fully automated SNN detected clinically relevant HFO in the scalp EEG. This study is a further step towards non-invasive epilepsy monitoring with a low-power wearable device.
Collapse
Affiliation(s)
- Karla Burelo
- Klinik für Neurochirurgie, Universitätsspital und Universität Zürich, 8091, Zurich, Switzerland.,Institute of Neuroinformatics, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Georgia Ramantani
- Neuropädiatrie, Universitäts-Kinderspital und Universität Zürich, Zurich, Switzerland.,Forschungszentrum für das Kind, Universitäts-Kinderspital Zürich, Zurich, Switzerland.,Zentrum für Neurowissenschaften Zürich, ETH und Universität Zürich, Zurich, Switzerland
| | - Giacomo Indiveri
- Institute of Neuroinformatics, University of Zurich and ETH Zurich, Zurich, Switzerland.,Zentrum für Neurowissenschaften Zürich, ETH und Universität Zürich, Zurich, Switzerland
| | - Johannes Sarnthein
- Klinik für Neurochirurgie, Universitätsspital und Universität Zürich, 8091, Zurich, Switzerland. .,Zentrum für Neurowissenschaften Zürich, ETH und Universität Zürich, Zurich, Switzerland.
| |
Collapse
|
32
|
Scalp HFO rates decrease after successful epilepsy surgery and are not impacted by the skull defect resulting from craniotomy. Sci Rep 2022; 12:1301. [PMID: 35079091 PMCID: PMC8789862 DOI: 10.1038/s41598-022-05373-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/05/2022] [Indexed: 02/06/2023] Open
Abstract
Epilepsy surgery can achieve seizure freedom in selected pediatric candidates, but reliable postsurgical predictors of seizure freedom are missing. High frequency oscillations (HFO) in scalp EEG are a new and promising biomarker of treatment response. However, it is unclear if the skull defect resulting from craniotomy interferes with HFO detection in postsurgical recordings. We considered 14 children with focal lesional epilepsy who underwent presurgical evaluation, epilepsy surgery, and postsurgical follow-up of ≥ 1 year. We identified the nearest EEG electrodes to the skull defect in the postsurgical MRI. We applied a previously validated automated HFO detector to determine HFO rates in presurgical and postsurgical EEG. Overall, HFO rates showed a positive correlation with seizure frequency (p < 0.001). HFO rates in channels over the HFO area decreased following successful epilepsy surgery, irrespective of their proximity to the skull defect (p = 0.005). HFO rates in channels outside the HFO area but near the skull defect showed no increase following surgery (p = 0.091) and did not differ from their contralateral channels (p = 0.726). Our observations show that the skull defect does not interfere with postsurgical HFO detection. This supports the notion that scalp HFO can predict postsurgical seizure freedom and thus guide therapy management in focal lesional epilepsy.
Collapse
|
33
|
Li H, Ji S, Dong B, Chen L. Seizure control after epilepsy surgery in early childhood: A systematic review and meta-analysis. Epilepsy Behav 2021; 125:108369. [PMID: 34731717 DOI: 10.1016/j.yebeh.2021.108369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/15/2021] [Accepted: 09/25/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This meta-analysis aimed to determine the main factors influencing surgical outcomes in children <3 years old with refractory epilepsy. METHODS The PubMed and Cochrane database were systematically searched for epilepsy surgery outcomes from December 1, 1991, to March 30, 2021, using the following search terms: "Epilepsy surgery OR Seizure operation" AND "under three years" OR "first three years" OR "early childhood" OR "infancy OR infants." Seizure onset, duration of epilepsy, magnetic resonance imaging findings, age at the time of surgery, surgical methods, resection extent, and pathological findings were considered potential moderators of differences in seizure outcomes. The fixed-effects models, combined effect sizes, and 95% confidence intervals (CI) were used to calculate the influence of potential factors on seizure outcomes. RESULTS Thirty two studies (559 cases) were included in the meta-analysis. The significant factors that correlated with a lower seizure control rate were frontal lobectomy (odds ratio [OR]: 0.33, 95% CI: 0.12-0.91; p = 0.03) and malformation of cortical development (MCD) (OR, 0.38; 95% CI: 0.24-0.62; p < 0.01). A higher seizure control rate was observed in children with tumors (92.86%) and Sturge-Weber syndrome (SWS, 91.43%). Frontal lobe epilepsy induced by MCD was related to the worst postoperative efficacy (OR, 0.26; 95% CI: 0.13-0.53; p < 0.01). SIGNIFICANCE The results of our meta-analyses revealed that pathology and surgical location play critical roles in the outcome of epilepsy surgery in children <3 years old. Clarification of the etiology of epilepsy before surgery is critical for better postoperative outcomes.
Collapse
Affiliation(s)
- Hua Li
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan 610041, China
| | - Shuming Ji
- Department of Clinical Research Management, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan 610041, China
| | - Bosi Dong
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan 610041, China
| | - Lei Chen
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan 610041, China; Department of Clinical Research Management, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan 610041, China.
| |
Collapse
|
34
|
Cloppenborg T, van Schooneveld M, Hagemann A, Hopf JL, Kalbhenn T, Otte WM, Polster T, Bien CG, Braun KPJ. Development and Validation of Prediction Models for Developmental and Intellectual Outcome Following Pediatric Epilepsy Surgery. Neurology 2021; 98:e225-e235. [PMID: 34795046 DOI: 10.1212/wnl.0000000000013065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 11/12/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To (1) identify predictors of postoperative intelligence and developmental quotients (IQ/DQ) and (2) develop and validate clinically applicable IQ/DQ prediction models. METHODS We retrospectively analyzed neuropsychological outcomes and their possible determinants for children treated in Bethel and Utrecht since 1990. We performed separate analyses for patients with IQ and those with only DQ available. We developed prediction models based on presurgical determinants to predict dichotomized levels of performance (IQ≥85, IQ≥70, DQ≥50). RESULTS IQ/DQ data before and two years after surgery were available for 492 patients (IQ n=365, DQ n=127). At a cutoff-level ±10 points, the chance of improvement was considerably higher than the chance of deterioration (IQ 37.3% vs. 6.6% and DQ 31.5% vs. 15.0%, respectively). Presurgical IQ/DQ was the strongest predictor of postoperative cognition (IQ r=0.85, p<.001, DQ: r=0.57, p<.001).Two IQ models were developed in the Bethel cohort (n=258) and externally validated in the Utrecht cohort (n=102). For DQ, we developed the model in the Bethel cohort and used 10-fold cross-validation. Models allowed good prediction at all three cutoff-levels (correct classification for IQ≥85=86%, IQ≥70=91%, DQ≥50=76%). External validation of the IQ models showed high accuracy (IQ≥85: 0.82, CI 0.75-0.91, IQ≥70: 0.84, CI 0.77-0.92) and excellent discrimination (ROC curves IQ≥85: AUC 0.90, CI 0.84-0.96; IQ≥70: AUC 0.92, CI 0.87-0.97). DISCUSSION After epilepsy surgery in children, the risk of cognitive deterioration is very low. Presurgical development has a strong impact on the postoperative trajectory. The presented models can improve presurgical counseling of patients and parents by reliably predicting cognitive outcomes. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that for children undergoing epilepsy surgery presurgical IQ/DQ was the strongest predictor of postoperative cognition.
Collapse
Affiliation(s)
- Thomas Cloppenborg
- Bielefeld University, Medical School, Department of Epileptology (Krankenhaus Mara), Bielefeld, Germany
| | - Monique van Schooneveld
- University Medical Center Utrecht, Department of Pediatric Neurology, The Netherlands, member of the ERN EpiCARE
| | | | - Johanna Lena Hopf
- Bielefeld University, Medical School, Department of Epileptology (Krankenhaus Mara), Bielefeld, Germany
| | - Thilo Kalbhenn
- Bielefeld University, Medical School, Department of Neurosurgery (Evangelisches Klinikum Bethel), Bielefeld, Germany
| | - Willem M Otte
- University Medical Center Utrecht, Department of Pediatric Neurology, The Netherlands, member of the ERN EpiCARE
| | - Tilman Polster
- Bielefeld University, Medical School, Department of Epileptology (Krankenhaus Mara), Bielefeld, Germany
| | - Christian G Bien
- Bielefeld University, Medical School, Department of Epileptology (Krankenhaus Mara), Bielefeld, Germany
| | - Kees P J Braun
- University Medical Center Utrecht, Department of Pediatric Neurology, The Netherlands, member of the ERN EpiCARE
| |
Collapse
|
35
|
Romanowski EF, McNamara N. Surgery for Intractable Epilepsy in Pediatrics, a Systematic Review of Outcomes other than Seizure Freedom. Semin Pediatr Neurol 2021; 39:100928. [PMID: 34620460 DOI: 10.1016/j.spen.2021.100928] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/23/2021] [Accepted: 08/27/2021] [Indexed: 11/25/2022]
Abstract
To perform a systematic review evaluating reported outcomes for epilepsy surgery in pediatric patients with pharmacoresistant epilepsy beyond seizure control, including impact on quality of life, behavioral, neurocognitive outcomes as well as complications, and death. We reviewed articles from both EMBASE and MEDLINE/PubMed articles that met formal criteria (patients ≤18 years, those with intractable epilepsy, at least 5 patients in the case series, published in peer-reviewed journal). Each reviewer independently reviewed the articles and those with discrepancies were discussed and consensus was reached. Out of a total of 536 abstracts obtained from EMBASE and MEDLINE/PubMed searches combined with additional cross-referencing, a total of 98 manuscripts ultimately met all inclusion criteria. The manuscripts were divided into 3 outcomes categories: Quality of Life (16), Cognitive Outcomes (60), and Deficits and Complications (50). Several papers fell into more than 1 category. These were separated by surgical types and evaluated. We found that overall reporting in all domains was variable and inconsistent amongst the different studies. This systematic review highlights the lack of completeness in reporting outcomes and complications involving pediatric epilepsy surgery and discordant results. This underscores the importance of multicenter systematic prospective data collection in pediatric patients who undergo pediatric epilepsy surgery.
Collapse
Affiliation(s)
| | - Nancy McNamara
- Division of Pediatric Neurology, University of Michigan, Ann Arbor, MI.
| |
Collapse
|
36
|
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.
Collapse
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.
| |
Collapse
|
37
|
Marashly A, Karia S, Zonjy B. Epilepsy Surgery: Special Circumstances. Semin Pediatr Neurol 2021; 39:100921. [PMID: 34620459 DOI: 10.1016/j.spen.2021.100921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 08/16/2021] [Accepted: 08/24/2021] [Indexed: 11/25/2022]
Abstract
Epilepsy surgery has proven to be very effective in treating refractory focal epilepsies in children, producing seizure freedom or partial seizure control well beyond any other medical or dietary therapies. While surgery is mostly utilized in certain clinical phenotypes, either based on the location such as temporal lobe epilepsy, or based on the presence of known epileptogenic lesions such as focal cortical dysplasia, tumors or hemimegalencephaly, there is a growing body of evidence to support the role of surgery in other patients' cohorts that were classically not thought of as surgical candidates. These include patients with rare genetic disorders, electrical status epilepticus in sleep, status epilepticus and the very young patients. Furthermore, epilepsy surgery is not considered as a "last resort" as seizure and cognitive outcomes of surgery are considerably better when done earlier rather than later in relation to the time of onset of epilepsy and age of surgery especially in the context of known focal cortical dysplasia. This article examines the accumulating evidence of the utility of epilepsy surgery in these special circumstances.
Collapse
Affiliation(s)
- Ahmad Marashly
- Assistant Professor, University of Washington/Seattle Children's Hospital, Seattle, WA.
| | - Samir Karia
- Associate Professor, Univeristy of Louisville, Luisiville, KY
| | - Bilal Zonjy
- Assistant Professor, University of Washington/Seattle Children's Hospital, Seattle, WA
| |
Collapse
|
38
|
Lewis AK, Taylor NF, Carney PW, Harding KE. What is the effect of delays in access to specialist epilepsy care on patient outcomes? A systematic review and meta-analysis. Epilepsy Behav 2021; 122:108192. [PMID: 34265620 DOI: 10.1016/j.yebeh.2021.108192] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/16/2021] [Accepted: 06/24/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To determine the association between delays in access to specialist epilepsy care and patient outcomes. METHODS Three databases were searched using eligibility criteria related to the concepts of timely access, epilepsy, and clinical outcome. Comparative data on patient outcomes by time to treatment was required for inclusion. Studies were selected independently by two researchers who reviewed title/abstract, then full text articles. Data were extracted and risk of bias was evaluated. Results were synthesized in random effects model meta-analyses, and strength of the body of evidence was evaluated. Descriptive analysis was conducted for studies not included in meta-analyses. RESULTS Thirty-five studies, reported in 40 papers, were included. The studies investigated impact of delays in diagnosis, commencement of medication, or surgery for children and adults. Early diagnosis and access to specialist neurology care was associated with improvements in seizure status, development, and/or intelligence quotients. Meta-analyses provided low to high certainty evidence of increased odds of improved seizure outcome with early commencement of medication depending on follow-up period and individual risk factors. There was moderate certainty evidence that people with favorable seizure outcomes wait less time (MD 2.8 years, 95% CI 1.7-3.9) for surgery compared to those with unfavorable outcomes. SIGNIFICANCE This review provides evidence that earlier access to specialist epilepsy care for diagnosis, commencement of medication, and surgery is associated with better patient outcomes.
Collapse
Affiliation(s)
- Annie K Lewis
- Eastern Health, Melbourne, Australia; La Trobe University, Melbourne, Australia.
| | - Nicholas F Taylor
- Eastern Health, Melbourne, Australia; La Trobe University, Melbourne, Australia
| | - Patrick W Carney
- Eastern Health, Melbourne, Australia; Monash University Melbourne, Australia; The Florey Institute for Neuroscience and Mental Health, Melbourne, Australia
| | - Katherine E Harding
- Eastern Health, Melbourne, Australia; La Trobe University, Melbourne, Australia
| |
Collapse
|
39
|
Iwasaki M, Iijima K, Kawashima T, Tachimori H, Takayama Y, Kimura Y, Kaneko Y, Ikegaya N, Sumitomo N, Saito T, Nakagawa E, Takahashi A, Sugai K, Otsuki T. Epilepsy surgery in children under 3 years of age: surgical and developmental outcomes. J Neurosurg Pediatr 2021; 28:395-403. [PMID: 34388720 DOI: 10.3171/2021.4.peds21123] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/13/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pediatric epilepsy surgery is known to be effective, but early surgery in infancy is not well characterized. Extensive cortical dysplasia, such as hemimegalencephaly, can cause refractory epilepsy shortly after birth, and early surgical intervention is indicated. However, the complication rate of early pediatric surgery is significant. In this study, the authors assessed the risk-benefit balance of early pediatric epilepsy surgery as relates to developmental outcomes. METHODS This is a retrospective descriptive study of 75 patients who underwent their first curative epilepsy surgery at an age under 3 years at the authors' institution between 2006 and 2019 and had a minimum 1-year follow-up of seizure and developmental outcomes. Clinical information including surgical complications, seizure outcomes, and developmental quotient (DQ) was collected from medical records. The effects of clinical factors on DQ at 1 year after surgery were evaluated. RESULTS The median age at surgery was 6 months, peaking at between 3 and 4 months. Operative procedures included 27 cases of hemispherotomy, 19 cases of multilobar surgery, and 29 cases of unilobar surgery. Seizure freedom was achieved in 82.7% of patients at 1 year and in 71.0% of patients at a mean follow-up of 62.8 months. The number of antiseizure medications (ASMs) decreased significantly after surgery, and 19 patients (30.6%) had discontinued their ASMs by the last follow-up. Postoperative complications requiring cerebrospinal fluid (CSF) diversion surgery, such as hydrocephalus and cyst formation, were observed in 13 patients (17.3%). The mean DQ values were 74.2 ± 34.3 preoperatively, 60.3 ± 23.3 at 1 year after surgery, and 53.4 ± 25.1 at the last follow-up. Multiple regression analysis revealed that the 1-year postoperative DQ was significantly influenced by preoperative DQ and postoperative seizure freedom but not by the occurrence of any surgical complication requiring CSF diversion surgery. CONCLUSIONS Early pediatric epilepsy surgery has an acceptable risk-benefit balance. Seizure control after surgery is important for postoperative development.
Collapse
Affiliation(s)
- Masaki Iwasaki
- 1Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo
| | - Keiya Iijima
- 1Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo
| | - Takahiro Kawashima
- 2Department of Clinical Epidemiology, Translational Medical Center, NCNP, Kodaira, Tokyo
| | - Hisateru Tachimori
- 2Department of Clinical Epidemiology, Translational Medical Center, NCNP, Kodaira, Tokyo
| | - Yutaro Takayama
- 1Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo
| | - Yuiko Kimura
- 1Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo
| | - Yuu Kaneko
- 1Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo
| | - Naoki Ikegaya
- 3Department of Neurosurgery, Yokohama City University Hospital, Yokohama, Kanagawa
| | - Noriko Sumitomo
- 4Department of Child Neurology, National Center Hospital, NCNP, Kodaira, Tokyo
| | - Takashi Saito
- 4Department of Child Neurology, National Center Hospital, NCNP, Kodaira, Tokyo
| | - Eiji Nakagawa
- 4Department of Child Neurology, National Center Hospital, NCNP, Kodaira, Tokyo
| | - Akio Takahashi
- 5Department of Neurosurgery, Shibukawa Medical Center, Shibukawa, Gunma; and
| | - Kenji Sugai
- 4Department of Child Neurology, National Center Hospital, NCNP, Kodaira, Tokyo
| | | |
Collapse
|
40
|
Jehi L, Braun K. Does etiology really matter for epilepsy surgery outcome? Brain Pathol 2021; 31:e12965. [PMID: 34196987 PMCID: PMC8412085 DOI: 10.1111/bpa.12965] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 04/01/2021] [Indexed: 12/17/2022] Open
Abstract
Multiple factors influence the outcomes of epilepsy surgery. Prognostic indicators varying from clinical characteristics, imaging findings, ictal, and interictal electrophysiological activity have been linked to surgical outcomes. In this review, we focus on the relatively under‐studied role of the underlying epilepsy histopathology in driving post‐surgical outcomes, specifically focusing on the broad categories of seizure outcomes and cognitive outcomes. For each of these two outcomes of interest, we answer two questions: 1)‐ does etiology matter? and 2)‐ how could it matter? The goal is to review the existing literature on the relationship between etiology and surgical outcomes to provide the best possible judgment as to whether a causal relationship exists between histopathology and the ultimate surgical outcome as an initial step. Then, we delve into the possible mechanisms via which such relationships can be explained. We conclude with a call to action to the epilepsy surgery and histopathology research community to push the mechanistic understanding of the pathology‐outcome interaction and identify actionable knowledge and biomarkers that could inform patient care in a timely fashion. In this review, we focus on the relatively under‐studied role of the underlying epilepsy histopathology in driving post‐surgical outcomes, specifically focusing on the broad categories of seizure outcomes and cognitive outcomes. For each of these two outcomes of interest, we answer two questions: (1) does etiology matter? and (2) how could it matter? We then delve into the mechanisms of these answers.
Collapse
Affiliation(s)
- Lara Jehi
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | - Kees Braun
- Dept. of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht University, the Netherlands
| |
Collapse
|
41
|
Roth J, Constantini S, Ekstein M, Weiner HL, Tripathi M, Chandra PS, Cossu M, Rizzi M, Bollo RJ, Machado HR, Santos MV, Keating RF, Oluigbo CO, Rutka JT, Drake JM, Jallo GI, Shimony N, Treiber JM, Consales A, Mangano FT, Wisoff JH, Teresa Hidalgo E, Bingaman WE, Gupta A, Erdemir G, Sundar SJ, Benifla M, Shapira V, Lam SK, Fallah A, Maniquis CAB, Tisdall M, Chari A, Cinalli G, Blount JP, Dorfmüller G, Christine Bulteau, Uliel-Sibony S. Epilepsy surgery in infants up to 3 months of age: Safety, feasibility, and outcomes: A multicenter, multinational study. Epilepsia 2021; 62:1897-1906. [PMID: 34128544 DOI: 10.1111/epi.16959] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/18/2021] [Accepted: 05/23/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Drug-resistant epilepsy (DRE) during the first few months of life is challenging and necessitates aggressive treatment, including surgery. Because the most common causes of DRE in infancy are related to extensive developmental anomalies, surgery often entails extensive tissue resections or disconnection. The literature on "ultra-early" epilepsy surgery is sparse, with limited data concerning efficacy controlling the seizures, and safety. The current study's goal is to review the safety and efficacy of ultra-early epilepsy surgery performed before the age of 3 months. METHODS To achieve a large sample size and external validity, a multinational, multicenter retrospective study was performed, focusing on epilepsy surgery for infants younger than 3 months of age. Collected data included epilepsy characteristics, surgical details, epilepsy outcome, and complications. RESULTS Sixty-four patients underwent 69 surgeries before the age of 3 months. The most common pathologies were cortical dysplasia (28), hemimegalencephaly (17), and tubers (5). The most common procedures were hemispheric surgeries (48 procedures). Two cases were intentionally staged, and one was unexpectedly aborted. Nearly all patients received blood products. There were no perioperative deaths and no major unexpected permanent morbidities. Twenty-five percent of patients undergoing hemispheric surgeries developed hydrocephalus. Excellent epilepsy outcome (International League Against Epilepsy [ILAE] grade I) was achieved in 66% of cases over a median follow-up of 41 months (19-104 interquartile range [IQR]). The number of antiseizure medications was significantly reduced (median 2 drugs, 1-3 IQR, p < .0001). Outcome was not significantly associated with the type of surgery (hemispheric or more limited resections). SIGNIFICANCE Epilepsy surgery during the first few months of life is associated with excellent seizure control, and when performed by highly experienced teams, is not associated with more permanent morbidity than surgery in older infants. Thus surgical treatment should not be postponed to treat DRE in very young infants based on their age.
Collapse
Affiliation(s)
- Jonathan Roth
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Constantini
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Margaret Ekstein
- Pediatric Anesthesia Unit, Department of Anesthesia, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Howard L Weiner
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Manjari Tripathi
- Center of Excellence for Epilepsy and MEG, AIIMS, New Delhi, India
| | | | - Massimo Cossu
- "C. Munari" Centre for Epilepsy Surgery, Niguarda Hospital, Milan, Italy
| | - Michele Rizzi
- "C. Munari" Centre for Epilepsy Surgery, Niguarda Hospital, Milan, Italy
| | - Robert J Bollo
- Division of Pediatric Neurosurgery, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Hélio Rubens Machado
- Pediatric Neurosurgery, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirão Preto, Sao Paulo, Brazil
| | - Marcelo Volpon Santos
- Pediatric Neurosurgery, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirão Preto, Sao Paulo, Brazil
| | - Robert F Keating
- Department of Neurosurgery, Children's National Medical Center, Washington, DC, USA
| | - Chima O Oluigbo
- Department of Neurosurgery, Children's National Medical Center, Washington, DC, USA
| | - James T Rutka
- Department of Surgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - James M Drake
- Department of Surgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - George I Jallo
- Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nir Shimony
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Neurosurgery, Geisinger Commonwealth School of Medicine, Danville, Pennsylvania, USA
| | - Jeffrey M Treiber
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Alessandro Consales
- Department of Pediatric Neurosurgery, IRRCS Istituto Giannina Gaslini, Genoa, Italy
| | - Francesco T Mangano
- Department of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jeffrey H Wisoff
- Division of Pediatric Neurosurgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, NY, USA
| | - Eveline Teresa Hidalgo
- Division of Pediatric Neurosurgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, NY, USA
| | - William E Bingaman
- Department of Neurological Surgery, Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | - Ajay Gupta
- Department of Neurology, Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | - Gozde Erdemir
- Department of Neurology, Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | - Swetha J Sundar
- Department of Neurological Surgery, Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | - Mony Benifla
- Pediatric Neurosurgery Department, Rambam Health Care Campus, Haifa, Israel
| | - Vladimir Shapira
- Pediatric Neurosurgery Department, Rambam Health Care Campus, Haifa, Israel
| | - Sandi K Lam
- Department of Pediatric Neurosurgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Cassia A B Maniquis
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Martin Tisdall
- Department of Neurosurgery, Great Ormond Street Hospital & Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Aswin Chari
- Department of Neurosurgery, Great Ormond Street Hospital & Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Giuseppe Cinalli
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Jeffrey P Blount
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Al, USA
| | - Georg Dorfmüller
- Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France
| | - Christine Bulteau
- Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France.,MC2Lab, University of Paris, Boulogne-Billancourt, France
| | - Shimrit Uliel-Sibony
- Pediatric Neurology Unit, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
42
|
Cserpan D, Boran E, Lo Biundo SP, Rosch R, Sarnthein J, Ramantani G. Scalp high-frequency oscillation rates are higher in younger children. Brain Commun 2021; 3:fcab052. [PMID: 33870193 PMCID: PMC8042248 DOI: 10.1093/braincomms/fcab052] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/30/2021] [Accepted: 02/15/2021] [Indexed: 12/15/2022] Open
Abstract
High-frequency oscillations in scalp EEG are promising non-invasive biomarkers of epileptogenicity. However, it is unclear how high-frequency oscillations are impacted by age in the paediatric population. We prospectively recorded whole-night scalp EEG in 30 children and adolescents with focal or generalized epilepsy. We used an automated and clinically validated high-frequency oscillation detector to determine ripple rates (80-250 Hz) in bipolar channels. Children < 7 years had higher high-frequency oscillation rates (P = 0.021) when compared with older children. The median test-retest reliability of high-frequency oscillation rates reached 100% (iqr 50) for a data interval duration of 10 min. Scalp high-frequency oscillation frequency decreased with age (r = -0.558, P = 0.002), whereas scalp high-frequency oscillation duration and amplitude were unaffected. The signal-to-noise ratio improved with age (r = 0.37, P = 0.048), and the background ripple band activity decreased with age (r = -0.463, P = 0.011). We characterize the relationship of scalp high-frequency oscillation features and age in paediatric patients. EEG intervals of ≥ 10 min duration are required for reliable measurements of high-frequency oscillation rates. This study is a further step towards establishing scalp high-frequency oscillations as a valid epileptogenicity biomarker in this vulnerable age group.
Collapse
Affiliation(s)
- Dorottya Cserpan
- Department of Neuropediatrics, University Children's Hospital Zurich, 8032 Zurich, Switzerland,Department of Neurosurgery, University Hospital Zurich, 8006 Zurich, Switzerland
| | - Ece Boran
- Department of Neurosurgery, University Hospital Zurich, 8006 Zurich, Switzerland
| | - Santo Pietro Lo Biundo
- Department of Neuropediatrics, University Children's Hospital Zurich, 8032 Zurich, Switzerland
| | - Richard Rosch
- Department of Neuropediatrics, University Children's Hospital Zurich, 8032 Zurich, Switzerland
| | - Johannes Sarnthein
- Department of Neurosurgery, University Hospital Zurich, 8006 Zurich, Switzerland,University of Zurich, 8006 Zurich, Switzerland,Klinisches Neurozentrum Zurich, University Hospital Zurich, 8006 Zurich, Switzerland
| | - Georgia Ramantani
- Department of Neuropediatrics, University Children's Hospital Zurich, 8032 Zurich, Switzerland,University of Zurich, 8006 Zurich, Switzerland,Children’s Research Centre, University Children's Hospital Zurich, 8032 Zurich, Switzerland,Correspondence to: Georgia Ramantani, MD, PhD Department of Neuropediatrics, University Children's Hospital Zurich Steinwiesstrasse 75, 8032 Zurich, Switzerland. E-mail:
| |
Collapse
|
43
|
Kim HJ, Jang HN, Ahn H, Yum MS, Ko TS. Over 10-Year Outcomes of Infantile-Onset Epilepsies. J Clin Med 2021; 10:jcm10030430. [PMID: 33499362 PMCID: PMC7865548 DOI: 10.3390/jcm10030430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 11/24/2022] Open
Abstract
Seizures in infancy have highly variable courses and underlying etiologies. However, there are only a few long-term follow-up studies regarding infantile-onset epilepsy. Therefore, we aimed to describe the clinical courses, seizure outcomes, and risk factors of infantile-onset epilepsy followed up for more than 10 years in a tertiary center. Methods: Data of the patients with epilepsy, diagnosed under the age of 12 months and followed up for more than 10 years, were retrieved from the electronic medical records of Asan Medical Center Children’s Hospital. The patients’ medical records were retrospectively reviewed, and clinical outcomes were assessed based on the duration of seizure freedom at the last follow-up. Results: Of the 146 patients, 103 (70.5%) entered at least one remission, of whom epilepsy was resolved in 46 (31.5%). Forty-nine (33.6%) were found to be intractable at last contact. Delayed development, neurological deficits, and later onset (>3 months) were significantly associated with intractable epilepsies (p < 0.01). Conclusions: This study demonstrated that many patients with infantile-onset epilepsy can experience seizure remission. However, in some cases, early onset epilepsy was highly associated with various comorbidities and intractable seizures. Therefore, appropriate diagnosis and treatment are necessary to prevent further neuropsychiatric complications.
Collapse
Affiliation(s)
- Hyun-Jin Kim
- Department of Pediatrics, Myongji Hospital, Goyang 10475, Korea;
| | - Han Na Jang
- Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.N.J.); (H.A.)
| | - Hyunji Ahn
- Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.N.J.); (H.A.)
| | - Mi-Sun Yum
- Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.N.J.); (H.A.)
- Correspondence: (M.-S.Y.); (T.-S.K.); Tel.: +82-2-3010-3386 (M.-S.Y. & T.-S.K.); Fax: +82-2-473-3725 (M.-S.Y. & T.-S.K.)
| | - Tae-Sung Ko
- Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.N.J.); (H.A.)
- Correspondence: (M.-S.Y.); (T.-S.K.); Tel.: +82-2-3010-3386 (M.-S.Y. & T.-S.K.); Fax: +82-2-473-3725 (M.-S.Y. & T.-S.K.)
| |
Collapse
|
44
|
Lenck-Santini PP, Sakkaki S. Alterations of Neuronal Dynamics as a Mechanism for Cognitive Impairment in Epilepsy. Curr Top Behav Neurosci 2021; 55:65-106. [PMID: 33454922 DOI: 10.1007/7854_2020_193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Epilepsy is commonly associated with cognitive and behavioral deficits that dramatically affect the quality of life of patients. In order to identify novel therapeutic strategies aimed at reducing these deficits, it is critical first to understand the mechanisms leading to cognitive impairments in epilepsy. Traditionally, seizures and epileptiform activity in addition to neuronal injury have been considered to be the most significant contributors to cognitive dysfunction. In this review we however highlight the role of a new mechanism: alterations of neuronal dynamics, i.e. the timing at which neurons and networks receive and process neural information. These alterations, caused by the underlying etiologies of epilepsy syndromes, are observed in both animal models and patients in the form of abnormal oscillation patterns in unit firing, local field potentials, and electroencephalogram (EEG). Evidence suggests that such mechanisms significantly contribute to cognitive impairment in epilepsy, independently of seizures and interictal epileptiform activity. Therefore, therapeutic strategies directly targeting neuronal dynamics rather than seizure reduction may significantly benefit the quality of life of patients.
Collapse
Affiliation(s)
- Pierre-Pascal Lenck-Santini
- Aix-Marseille Université, INSERM, INMED, Marseille, France. .,Department of Neurological sciences, University of Vermont, Burlington, VT, USA.
| | - Sophie Sakkaki
- Department of Neurological sciences, University of Vermont, Burlington, VT, USA.,Université de. Montpellier, CNRS, INSERM, IGF, Montpellier, France
| |
Collapse
|
45
|
Pisani F, Spagnoli C, Falsaperla R, Nagarajan L, Ramantani G. Seizures in the neonate: A review of etiologies and outcomes. Seizure 2021; 85:48-56. [PMID: 33418166 DOI: 10.1016/j.seizure.2020.12.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 12/21/2022] Open
Abstract
Neonatal seizures occur in their majority in close temporal relation to an acute brain injury or systemic insult, and are accordingly defined as acute symptomatic or provoked seizures. However less frequently, unprovoked seizures may also present in the neonatal period as secondary to structural brain abnormalities, thus corresponding to structural epilepsies, or to genetic conditions, thus corresponding to genetic epilepsies. Unprovoked neonatal seizures should be thus considered as the clinical manifestation of early onset structural or genetic epilepsies that often have the characteristics of early onset epileptic encephalopathies. In this review, we address the conundrum of neonatal seizures including acute symptomatic, remote symptomatic, provoked, and unprovoked seizures, evolving to post-neonatal epilepsies, and neonatal onset epilepsies. The different clinical scenarios involving neonatal seizures, each with their distinct post-neonatal evolution are presented. The structural and functional impact of neonatal seizures on brain development and the concept of secondary epileptogenesis, with or without a following latent period after the acute seizures, are addressed. Finally, we underline the need for an early differential diagnosis between an acute symptomatic seizure and an unprovoked seizure, since it is associated with fundamental differences in clinical evolution. These are crucial aspects for neonatal management, counselling and prognostication. In view of the above aspects, we provide an outlook on future strategies and potential lines of research in this field.
Collapse
Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatry Unit, Medicine and Surgery Department, University of Parma, Italy
| | - Carlotta Spagnoli
- Child Neurology Unit, Department of Pediatrics, Azienda USL-IRCCS, Reggio Emilia, Italy
| | - Raffaele Falsaperla
- Neonatal Intensive Care Unit, University-Hospital Policlinico Vittorio Emanuele, Catania, Italy
| | - Lakshmi Nagarajan
- Children's Neuroscience Service, Department of Neurology, Perth Children's Hospital, Australia
| | - Georgia Ramantani
- Department of Neuropediatrics, University Children's Hospital Zurich, Switzerland.
| |
Collapse
|
46
|
Kogias E, Bast T, Schubert-Bast S, Wiegand G, Brandt A, Strobl K, Korinthenberg R, Schulze-Bonhage A, Zentner J, Ramantani G. Multilobar Epilepsy Surgery in Childhood and Adolescence: Predictors of Long-Term Seizure Freedom. Neurosurgery 2020; 88:174-182. [PMID: 32814942 DOI: 10.1093/neuros/nyaa368] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 06/18/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although multilobar resections correspond to one-fifth of pediatric epilepsy surgery, there are little data on long-term seizure control. OBJECTIVE To investigate the long-term seizure outcomes of children and adolescents undergoing multilobar epilepsy surgery and identify their predictors. METHODS In this retrospective study, we considered 69 consecutive patients that underwent multilobar epilepsy surgery at the age of 10.0 ± 5.0 yr (mean ± SD). The magnetic resonance imaging revealed a lesion in all but 2 cases. Resections were temporo-parieto(-occipital) in 30%, temporo-occipital in 41%, parieto-occipital in 16%, and fronto-(temporo)-parietal in 13% cases. Etiologies were determined as focal cortical dysplasia in 67%, perinatal or postnatal ischemic lesions in 23%, and benign tumors in 10% of cases. RESULTS At last follow-up of median 9 yr (range 2.8-14.8), 48% patients were seizure free; 33% were off antiepileptic drugs. 10% of patients, all with dysplastic etiology, required reoperations: 4 of 7 achieved seizure freedom. Seizure recurrence occurred mostly (80%) within the first 6 mo. Among presurgical variables, only an epileptogenic zone far from eloquent cortex independently correlated with significantly higher rates of seizure arrest in multivariate analysis. Among postsurgical variables, the absence of residual lesion and of acute postsurgical seizures was independently associated with significantly higher rates of seizure freedom. CONCLUSION Our study demonstrates that multilobar epilepsy surgery is effective regarding long-term seizure freedom and antiepileptic drug withdrawal in selected pediatric candidates. Epileptogenic zones-and lesions-localized distant from eloquent cortex and, thus, fully resectable predispose for seizure control. Acute postsurgical seizures are critical markers of seizure recurrence that should lead to prompt reevaluation.
Collapse
Affiliation(s)
- Evangelos Kogias
- Department of Neurosurgery, University Hospital Freiburg, Freiburg im Breisgau, Germany.,Medical Faculty, University of Freiburg, Freiburg im Breisgau, Germany
| | - Thomas Bast
- Medical Faculty, University of Freiburg, Freiburg im Breisgau, Germany.,Epilepsy Center Kork, Kehl-Kork, Germany
| | - Susanne Schubert-Bast
- Department of General Pediatrics, University Children's Hospital Heidelberg, Heidelberg, Germany.,Department of Neuropediatrics, University Children's Hospital Frankfurt, Frankfurt, Germany.,Epilepsy Center Frankfurt Rhine-Main, Frankfurt am Main, Germany
| | - Gert Wiegand
- Department of Neuropediatrics, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Armin Brandt
- Epilepsy Center, University Hospital Freiburg, Freiburg im Breisgau, Germany
| | - Karl Strobl
- Medical Faculty, University of Freiburg, Freiburg im Breisgau, Germany
| | - Rudolf Korinthenberg
- Department of Neuropediatrics and Muscular Disorders, University Children's Hospital Freiburg, Freiburg im Breisgau, Germany
| | | | - Josef Zentner
- Department of Neurosurgery, University Hospital Freiburg, Freiburg im Breisgau, Germany
| | - Georgia Ramantani
- Medical Faculty, University of Freiburg, Freiburg im Breisgau, Germany.,Epilepsy Center, University Hospital Freiburg, Freiburg im Breisgau, Germany.,Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
47
|
Uliel-Sibony S, Chernuha V, Meirson H, Fattal-Valevski A. Medical treatment of tuberous sclerosis-related epilepsy. Childs Nerv Syst 2020; 36:2511-2517. [PMID: 32829444 DOI: 10.1007/s00381-020-04772-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 06/23/2020] [Indexed: 01/13/2023]
Abstract
Epilepsy is one of the most frequent CNS manifestations of tuberous sclerosis, and for most patients, it is the major debilitating factor. In up to 70% of the cases, the epilepsy is refractory and usually associated with significant behavioral as well as developmental consequences. Therefore, controlling seizures is one of the biggest medical and surgical challenges. Understanding the cellular mechanism involved in the disease empowered targeted research aimed toward early intervention in the epileptogenicity process. In this review, we present an update on the pharmacological treatments in tuberous sclerosis-related epilepsy.
Collapse
Affiliation(s)
- Shimrit Uliel-Sibony
- Pediatric Neurology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv, Israel. .,Pediatric Neurology institute, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, 64239, Tel Aviv, Israel.
| | - Veronika Chernuha
- Pediatric Neurology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Hadas Meirson
- Pediatric Neurology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Aviva Fattal-Valevski
- Pediatric Neurology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv, Israel
| |
Collapse
|
48
|
Lidzba K, Bürki SE, Staudt M. Predicting Language Outcome After Left Hemispherotomy: A Systematic Literature Review. Neurol Clin Pract 2020; 11:158-166. [PMID: 33842069 DOI: 10.1212/cpj.0000000000000852] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 02/28/2020] [Indexed: 01/11/2023]
Abstract
Objective Hemidecortication is a therapeutic option in patients with drug-resistant structural epilepsy. If surgery is performed early enough in left-hemispheric pathology, the plasticity of the developing brain may enable the right hemisphere to take over language-if this has not occurred before surgery. A systematic overview of potential predictors of language outcome after left hemidecortication in children is warranted. Methods In a systematic literature review, we analyzed 58 studies on language lateralization after congenital or postneonatally acquired left-hemispheric pathology, and on language outcome after left-sided hemidisconnection, such as hemispherotomy. Single-subject data were pooled to determine the distribution of lateralization across etiologies in congenital lesions and across age groups in acute postneonatal lesions. A hierarchical linear regression assessed the influence of age at surgery, lesion type, age at seizure onset, and presurgery language function on language outcome after left hemidecortication. Results In acute postneonatal lesions, younger age at injury was significantly associated with right-sided language lateralization (Cramér V = 0.458; p = 0.039). In patients with hemidecortication, age at surgery was not significantly associated with language outcome (Cramér V = -0.056; p = 0.584). Presurgical language function was the most powerful predictor for postsurgical language outcome (F 4,47 = 7.35, p < 0.0001), with good presurgical language bearing the risk of postsurgical deterioration. In congenital pathology, right-sided language lateralization was most frequent in pre-/perinatal stroke (Cramér V = 0.357; p < 0.0001). Conclusions We propose a presurgical decision algorithm with age, presurgical language function, language lateralization, and left-hemispheric structural pathology as decision points regarding surgery.
Collapse
Affiliation(s)
- Karen Lidzba
- Department of Pediatric Neurology and Developmental Medicine (KL, MS), University Children's Hospital Tübingen, Germany; Clinic for Neuropediatrics and Neurorehabilitation (MS), Epilepsy Center for Children and Adolescents, Schön Klinik Vogtareuth, Germany; Pediatric Neurology (KL), Inselspital University Children's Hospital, University of Bern, Switzerland; and Department of Neuropediatrics (SEB), University Children's Hospital Zurich, Switzerland
| | - Sarah E Bürki
- Department of Pediatric Neurology and Developmental Medicine (KL, MS), University Children's Hospital Tübingen, Germany; Clinic for Neuropediatrics and Neurorehabilitation (MS), Epilepsy Center for Children and Adolescents, Schön Klinik Vogtareuth, Germany; Pediatric Neurology (KL), Inselspital University Children's Hospital, University of Bern, Switzerland; and Department of Neuropediatrics (SEB), University Children's Hospital Zurich, Switzerland
| | - Martin Staudt
- Department of Pediatric Neurology and Developmental Medicine (KL, MS), University Children's Hospital Tübingen, Germany; Clinic for Neuropediatrics and Neurorehabilitation (MS), Epilepsy Center for Children and Adolescents, Schön Klinik Vogtareuth, Germany; Pediatric Neurology (KL), Inselspital University Children's Hospital, University of Bern, Switzerland; and Department of Neuropediatrics (SEB), University Children's Hospital Zurich, Switzerland
| |
Collapse
|
49
|
Xiang J, Maue E, Fan Y, Qi L, Mangano FT, Greiner H, Tenney J. Kurtosis and skewness of high-frequency brain signals are altered in paediatric epilepsy. Brain Commun 2020; 2:fcaa036. [PMID: 32954294 PMCID: PMC7425348 DOI: 10.1093/braincomms/fcaa036] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 02/19/2020] [Accepted: 03/02/2020] [Indexed: 01/15/2023] Open
Abstract
Intracranial studies provide solid evidence that high-frequency brain signals are a new biomarker for epilepsy. Unfortunately, epileptic (pathological) high-frequency signals can be intermingled with physiological high-frequency signals making these signals difficult to differentiate. Recent success in non-invasive detection of high-frequency brain signals opens a new avenue for distinguishing pathological from physiological high-frequency signals. The objective of the present study is to characterize pathological and physiological high-frequency signals at source levels by using kurtosis and skewness analyses. Twenty-three children with medically intractable epilepsy and age-/gender-matched healthy controls were studied using magnetoencephalography. Magnetoencephalographic data in three frequency bands, which included 2–80 Hz (the conventional low-frequency signals), 80–250 Hz (ripples) and 250–600 Hz (fast ripples), were analysed. The kurtosis and skewness of virtual electrode signals in eight brain regions, which included left/right frontal, temporal, parietal and occipital cortices, were calculated and analysed. Differences between epilepsy and controls were quantitatively compared for each cerebral lobe in each frequency band in terms of kurtosis and skewness measurements. Virtual electrode signals from clinical epileptogenic zones and brain areas outside of the epileptogenic zones were also compared with kurtosis and skewness analyses. Compared to controls, patients with epilepsy showed significant elevation in kurtosis and skewness of virtual electrode signals. The spatial and frequency patterns of the kurtosis and skewness of virtual electrode signals among the eight cerebral lobes in three frequency bands were also significantly different from that of the controls (2–80 Hz, P < 0.001; 80–250 Hz, P < 0.00001; 250–600 Hz, P < 0.0001). Compared to signals from non-epileptogenic zones, virtual electrode signals from epileptogenic zones showed significantly altered kurtosis and skewness (P < 0.001). Compared to normative data from the control group, aberrant virtual electrode signals were, for each patient, more pronounced in the epileptogenic lobes than in other lobes(kurtosis analysis of virtual electrode signals in 250–600 Hz; odds ratio = 27.9; P < 0.0001). The kurtosis values of virtual electrode signals in 80–250 and 250–600 Hz showed the highest sensitivity (88.23%) and specificity (89.09%) for revealing epileptogenic lobe, respectively. The combination of virtual electrode and kurtosis/skewness measurements provides a new quantitative approach to distinguishing pathological from physiological high-frequency signals for paediatric epilepsy. Non-invasive identification of pathological high-frequency signals may provide novel important information to guide clinical invasive recordings and direct surgical treatment of epilepsy.
Collapse
Affiliation(s)
- Jing Xiang
- MEG Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Ellen Maue
- MEG Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Yuyin Fan
- MEG Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Department of Pediatric Neurology, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Lei Qi
- MEG Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Department of Neurosurgery, Beijing Fengtai Hospital, Beijing 100071, China
| | - Francesco T Mangano
- Division of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Hansel Greiner
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Jeffrey Tenney
- MEG Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| |
Collapse
|
50
|
Braun KPJ. Influence of epilepsy surgery on developmental outcomes in children. Eur J Paediatr Neurol 2020; 24:40-42. [PMID: 31917082 DOI: 10.1016/j.ejpn.2019.12.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 12/06/2019] [Indexed: 11/26/2022]
Abstract
Epilepsy surgery is the most effective treatment option for children with refractory focal lesional epilepsy, with seizure-freedom rates exceeding 70% two years after surgery. Although numbers of procedures in children are increasing over time, epilepsy surgery remains underutilized. Particularly in young children with developmental delay, arrest, or even regression, surgery can improve cognitive outcome. Many factors determine eventual developmental abilities, of which epilepsy duration is the most important modifiable predictor. Earlier surgery is not only associated with higher seizure-freedom rates, it also improves postoperative developmental outcomes. Every child with focal lesional epilepsy should therefore be referred early, to evaluate the possibilities of epilepsy surgery.
Collapse
Affiliation(s)
- Kees P J Braun
- University Medical Center Utrecht Brain Center (the UMC Utrecht is part of the ERN EpiCARE), Utrecht University, the Netherlands.
| |
Collapse
|