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Melikyan AG, Kozlova AB, Vlasov PA, Shishkina LV, Demin MO, Shults EI, Buklina SB, Nagorskaya IA, Strunina YV. [Lessons learnt from 101 hemispherotomies in children with symptomatic epilepsy. Part I: seizure outcome]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:15-21. [PMID: 34713999 DOI: 10.17116/neiro20218505115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate variables that may predict the outcome after hemispherotomy basing on a retrospective study of a large consecutive pediatric cohort of patients from a single institution. MATERIAL AND METHODS One hundred and one patients with refractory seizures and variable decline in development (n=78) underwent hemispherotomy (med. age - 43 months, med. epilepsy history - 30 months). Developmental pathology was the anatomical substrate of disorder in 42 patients, while the infantile post-stroke scarring and gliosis was its origin in the majority of 43 cases with acquired etiology. The progressive pathology (the Rasmussen encephalitis, Sturge-Weber angiomatosis and tuberous sclerosis) was the etiology in 16 children. Left-sided hemisphere was impaired in 54 cases; some contralateral anatomical and potentially epileptogenic MRI-abnormalities were noted also in «healthy» hemisphere in ¼ of all cases. Eight patients needed second surgery to complete sectioning of undercut commissural fibers. FU is known in 91 patients (med. - 1.5 years) and 73 of them were free of seizures (80.2%), but only 30 of 40 patients with FU > 2 years were still SF (75%). All but one of re-do hemispherotomies were successful. AED-treatment was discontinued in 46 cases and tapered in other 27 patients. Up to 90% of kids demonstrated some improvement in behavior and cognition. RESULTS AND CONCLUSION Developmental pathology, infantile spasms and younger age onset of seizures are negative predictors for achievement of SF-status (p<0.05). Neither bilateral epileptic EEG-signs, nor MRI-abnormalities in «healthy» hemisphere had any relation to outcome, but focal seizure onset was associated positively with further SF-status (p = 0.03). Kids with multiple lobe unilateral CD do somewhat worse than their counterparts with hemimegalencephaly and acquired etiology. Post-hemispherotomy hemiparesis (either new or worsening of already existed one) has no relation either to the age at surgery, or to the age onset (p = 0.41). Children with left-sided lesions were less successful in every neurodevelopmental domain except maintaining expressive language. Patients with relapse or persisting seizures have good chances to become SF by re-doing hemispherotomy and should be evaluated for the possibly incomplete hemispheric isolation.
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Affiliation(s)
| | - A B Kozlova
- Burdenko Neurosurgical Center, Moscow, Russia
| | - P A Vlasov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - M O Demin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - E I Shults
- Burdenko Neurosurgical Center, Moscow, Russia
| | - S B Buklina
- Pirogov Russian National Research Medical University, Moscow, Russia
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2
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Melikyan AG, Kushel YV, Sorokin VS, Vlasov PA, Demin MO, Shults EI, Shevchenko AM, Strunina YV. [Lessons learnt from 101 hemispheric pediatric epilepsy surgeries part ii: pitfalls and complications]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2021; 85:44-52. [PMID: 34951759 DOI: 10.17116/neiro20218506144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To evaluate the spectrum of pitfalls and complications after hemisherotomy basing on a retrospective study of a large consecutive pediatric cohort of patients from a single institution. MATERIAL AND METHODS One hundred and one patients (med. age - 43 months) with refractory seizures underwent hemispherotomy. Developmental pathology was the anatomical substrate of disorder in 42 patients. The infantile post-stroke scarring and gliosis was the origin of epilepsy in the majority of 43 cases with acquired etiology. The progressive pathology (RE, S-W and TS) was the etiology in the rest of children (16 cases). The lateral periinsular technique was used to isolate the sick hemisphere in 55 patients; the vertical parasagittal approach was employed in 46 cases. Median perioperative blood loss constituted 10.5 ml/kg, but was markedly larger in kids with hemimegaly (52.8 ml/kg); 57 patients needed hemotransfusion during surgery. Median length of stay in ICU was 14.7 hours, and the length of stay in the hospital until discharge - 6.5 days. Eight patients underwent second-look surgery to complete sectioning of undercut commissural fibers. FU is known in 91 patients (med. length - 1.5 years). RESULTS Major surgical complications with serious hemorrhage and/or surgery induced life-threatening events developed in 7 patients (one of them has died on the 5th day post-surgery for the causes of brain edema and uncontrolled hyponatremia). Various early and late infectious complications were noted in 4 cases. Ten patients experienced new not anticipated but temporary neurological deficit. Nine patients needed shunting for the causes of hydrocephalus within several first months post-hemispherotomy. Early seizure onset was associated with probability of all complications in general (p=0.02), and developmental etiology - with intraoperative bleeding and hemorrhagic complications (p=0.03). CONCLUSION Children with developmental etiology, particularly those with hemimegalencephaly, are most challengeable in terms of perioperative hemorrhage and serious complications. Patients with relapse or persisting seizures should be evaluated for the possibility of incomplete hemispheric isolation and have good chances to become SF by re-doing hemispherotomy.
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Affiliation(s)
| | - Yu V Kushel
- Burdenko Neurosurgical Center, Moscow, Russia
| | - V S Sorokin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - P A Vlasov
- Burdenko Neurosurgical Center, Moscow, Russia
| | - M O Demin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - E I Shults
- Burdenko Neurosurgical Center, Moscow, Russia
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3
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Tuite GF, Carey CM, Nelson WW, Raffa SJ, Winesett SP. Use of a contoured bioresorbable plate with a hemostatic plug to control life-threatening bleeding from the superior sagittal sinus during hemispherotomy: technical note. J Neurosurg Pediatr 2016; 18:487-492. [PMID: 27391919 DOI: 10.3171/2016.5.peds1633] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Profuse bleeding originating from an injured cerebral sinus can be a harrowing experience for any surgeon, particularly during an operation on a young child. Common surgical remedies include sinus ligation, primary repair, placement of a hemostatic plug, and patch or venous grafting that may require temporary stenting. In this paper the authors describe the use of a contoured bioresorbable plate to hold a hemostatic plug in place along a tear in the inferomedial portion of a relatively inaccessible part of the posterior segment of the superior sagittal sinus in an 11-kg infant undergoing hemispherotomy for epilepsy. This variation on previously described hemostatic techniques proved to be easy, effective, and ultimately lifesaving. Surgeons may find this technique useful in similar dire circumstances when previously described techniques are ineffective or impractical.
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Affiliation(s)
- Gerald F Tuite
- Divisions of 1 Pediatric Neurosurgery and.,Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa; and
| | - Carolyn M Carey
- Divisions of 1 Pediatric Neurosurgery and.,Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa; and
| | - William W Nelson
- Division of Anesthesiology, Department of Surgery, All Children's Hospital/Johns Hopkins Medicine, St. Petersburg, Florida
| | - Scott J Raffa
- Divisions of 1 Pediatric Neurosurgery and.,Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa; and
| | - S Parrish Winesett
- Neurology, Neuroscience Institute, All Children's Hospital/Johns Hopkins Medicine, St. Petersburg.,Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa; and
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Hu WH, Zhang C, Zhang K, Shao XQ, Zhang JG. Hemispheric surgery for refractory epilepsy: a systematic review and meta-analysis with emphasis on seizure predictors and outcomes. J Neurosurg 2016; 124:952-61. [DOI: 10.3171/2015.4.jns14438] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Conflicting conclusions have been reported regarding several factors that may predict seizure outcomes after hemispheric surgery for refractory epilepsy. The goal of this study was to identify the possible predictors of seizure outcome by pooling the rates of postoperative seizure freedom found in the published literature.
METHODS
A comprehensive literature search of PubMed, Embase, and the Cochrane Library identified English-language articles published since 1970 that describe seizure outcomes in patients who underwent hemispheric surgery for refractory epilepsy. Two reviewers independently assessed article eligibility and extracted the data. The authors pooled rates of seizure freedom from papers included in the study. Eight potential prognostic variables were identified and dichotomized for analyses. The authors also compared continuous variables within seizure-free and seizure-recurrent groups. Random- or fixed-effects models were used in the analyses depending on the presence or absence of heterogeneity.
RESULTS
The pooled seizure-free rate among the 1528 patients (from 56 studies) who underwent hemispheric surgery was 73%. Patients with an epilepsy etiology of developmental disorders, generalized seizures, nonlateralization on electroencephalography, and contralateral MRI abnormalities had reduced odds of being seizure-free after surgery.
CONCLUSIONS
Hemispheric surgery is an effective therapeutic modality for medically intractable epilepsy. This meta-analysis provides useful evidence-based information for the selection of candidates for hemispheric surgery, presurgical counseling, and explanation of seizure outcomes.
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Affiliation(s)
| | | | | | - Xiao-Qiu Shao
- 3Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian-Guo Zhang
- 1Beijing Neurosurgical Institute and
- Departments of 2Neurosurgery and
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5
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Griessenauer CJ, Salam S, Hendrix P, Patel DM, Tubbs RS, Blount JP, Winkler PA. Hemispherectomy for treatment of refractory epilepsy in the pediatric age group: a systematic review. J Neurosurg Pediatr 2015; 15:34-44. [PMID: 25380174 DOI: 10.3171/2014.10.peds14155] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Evidence in support of hemispherectomy stems from a multitude of retrospective studies illustrating individual institutions' experience. A systematic review of this topic, however, is lacking in the literature. METHODS A systematic review of hemispherectomy for the treatment of refractory epilepsy available up to October 2013 was performed using the following inclusion criteria: reports of a total of 10 or more patients in the pediatric age group (≤ 20 years) undergoing hemispherectomy, seizure outcome reported after a minimum follow-up of 1 year after the initial procedure, and description of the type of hemispherectomy. Only the most recent paper from institutions that published multiple papers with overlapping study periods was included. Two reviewers independently applied the inclusion criteria and extracted all the data. RESULTS Twenty-nine studies with a total of 1161 patients met the inclusion criteria. Seizure outcome was available for 1102 patients, and the overall rate of seizure freedom at the last follow-up was 73.4%. Sixteen studies (55.2%) exclusively reported seizure outcomes of a single type of hemispherectomy. There was no statistically significant difference in seizure outcome and type of hemispherectomy (p = 0.737). Underlying etiology was reported for 85.4% of patients with documented seizure outcome, and the overall distribution of acquired, developmental, and progressive etiologies was 30.5%, 40.7%, and 28.8%, respectively. Acquired and progressive etiologies were associated with significantly higher seizure-free rates than developmental etiologies (p < 0.001). Twenty of the 29 studies (69%) reported complications. The overall rate of hydrocephalus requiring CSF diversion was 14%. Mortality within 30 days was 2.2% and was not statistically different between types of hemispherectomy (p = 0.787). CONCLUSIONS Hemispherectomy is highly effective for treating refractory epilepsy in the pediatric age group, particularly for acquired and progressive etiologies. While the type of hemispherectomy does not have any influence on seizure outcome, hemispherotomy procedures are associated with a more favorable complication profile.
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Affiliation(s)
- Christoph J Griessenauer
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Alabama
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6
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Kovanda TJ, Rey-Dios R, Travnicek J, Cohen-Gadol AA. Modified periinsular hemispherotomy: operative anatomy and technical nuances. J Neurosurg Pediatr 2014; 13:332-8. [PMID: 24410122 DOI: 10.3171/2013.12.peds13277] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Surgical options for pediatric patients with marked dysfunction of a single epileptogenic hemisphere have evolved over time. Complications resulting from highly resective operations such as anatomical hemispherectomy, including superficial siderosis and secondary hydrocephalus, have led to the development of less resective and more disconnective functional hemispherectomy. Functional hemispherectomy has recently given rise to hemispherotomy, the least resective operation primarily aimed at disconnecting the abnormal hemisphere. Hemispherotomy is effective in decreasing seizure frequency and most likely decreases the risk of postoperative complications when compared with its predecessors. Hemispherotomy is a technically challenging operation that requires a thorough understanding of 3D cerebral anatomy to ensure adequate hemispheric disconnection without placing important structures at risk. The details of germane operative anatomy are not currently available because of the difficulty in exposing this operative anatomy adequately in cadavers to prepare detailed instructive illustrations. Using 3D graphic models, the authors have prepared 2D overlay illustrations to discuss the relevant operative nuances for a modified form of this procedure. Through hemispherotomy, experienced surgeons can effectively treat patients with unilateral epileptogenic hemisphere dysfunction while limiting potential complications.
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Affiliation(s)
- Timothy J Kovanda
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana; and
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7
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Buckley RT, Morgan T, Saneto RP, Barber J, Ellenbogen RG, Ojemann JG. Dysphagia after pediatric functional hemispherectomy. J Neurosurg Pediatr 2014; 13:95-100. [PMID: 24206342 DOI: 10.3171/2013.10.peds13182] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Functional hemispherectomy is a well-recognized surgical option for the treatment of unihemispheric medically intractable epilepsy. While the resultant motor deficits are a well-known and expected consequence of the procedure, the impact on other cortical functions has been less well defined. As the cortical control of swallowing would appear to be threatened after hemispherectomy, the authors retrospectively studied a pediatric population that underwent functional hemispherectomy for medically intractable epilepsy to characterize the incidence and severity of dysphagia after surgery. METHODS A retrospective cohort (n = 39) of pediatric patients who underwent hemispherectomy at a single institution was identified, and available clinical records were reviewed. Additionally, the authors examined available MR images for integrity of the thalamus and basal ganglia before and after hemispherectomy. Clinical and video fluoroscopic assessments of speech pathology were reviewed, and the presence, type, and duration of pre- and postoperative dysphagia were recorded. RESULTS New-onset, transient dysphagia occurred in 26% of patients after hemispherectomy along with worsening of preexisting dysphagia noted in an additional 15%. Clinical symptoms lasted a median of 19 days. Increased duration of symptoms was seen with late (> 14 days postoperative) pharyngeal swallow dysfunction when compared with oral dysphagia alone. Neonatal stroke as a cause for seizures decreased the likelihood of postoperative dysphagia. There was no association with seizure freedom or postoperative hydrocephalus. CONCLUSIONS New-onset dysphagia is a frequent and clinically significant consequence of hemispherectomy for intractable epilepsy in pediatric patients. This dysphagia was always self-limited except in those patients in whom preexisting dysphagia was noted.
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Abstract
The surgical options available for intractable hemispheric epilepsy have evolved since their initial description in the early 20th century. Surgical techniques have advanced, as has the ability to predict good surgical outcomes with noninvasive diagnostics. The authors review the history of hemispherectomy and detail the novel imaging and surgical strategies used to confer seizure freedom.
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Affiliation(s)
- Alexandra D. Beier
- 1Division of Pediatric Neurological Surgery, University of Florida Health Science Center Jacksonville, Florida; and
| | - James T. Rutka
- 2Division of Neurosurgery, The Hospital for Sick Children and Department of Surgery, University of Toronto, Ontario, Canada
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9
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Gonçalves-Ferreira A, Campos AR, Herculano-Carvalho M, Pimentel J, Bentes C, Peralta AR, Morgado C. Amygdalohippocampotomy: surgical technique and clinical results. J Neurosurg 2013; 118:1107-13. [PMID: 23432145 DOI: 10.3171/2013.1.jns12727] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The removal of mesial temporal structures, namely amygdalohippocampectomy, is the most efficient surgical procedure for the treatment of epilepsy. However, disconnection of the epileptogenic zones, as in temporal lobotomy or, for different purposes, hemispherotomy, have shown equivalent results with less morbidity. Thus, authors of the present study began performing selective amygdalohippocampotomy in cases of refractory mesial temporal lobe epilepsy (TLE) to treat mesial temporal lobe sclerosis (MTLS). METHOD The authors conducted a retrospective analysis of all cases of amygdalohippocampotomy collected in a database between November 2007 and March 2011. RESULTS Since 2007, 21 patients (14 males and 7 females), ages 20-58 years (mean 41 years), all with TLE due to MTLS, were treated with selective ablation of the lateral amygdala plus perihippocampal disconnection (anterior one-half to two-thirds in dominant hemisphere), the left side in 11 cases and the right in 10. In 20 patients the follow-up was 2 or more years (range 24-44 months, average 32 months). Clinical outcome for epilepsy 2 years after surgery (20 patients) was good/very good in 19 patients (95%) with an Engel Class I (15 patients [75%]) or II outcome (4 patients [20%]) and bad in 1 patient (5%) with an Engel Class IV outcome (extratemporal focus and later reoperation). Surgical morbidity included hemiparesis (capsular hypertensive hemorrhage 24 hours after surgery, 1 patient), verbal memory worsening (2 patients), and quadrantanopia (permanent in 2 patients, transient in 1). Late psychiatric depression developed in 3 cases. Operative time was reduced by about 30 minutes (15%) on average with this technique. CONCLUSIONS Amygdalohippocampotomy is as effective as amygdalohippocampectomy to treat MTLS and is a potentially safer, time-saving procedure.
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Rangel-Castilla L, Hwang SW, Al-Shamy G, Jea A, Curry DJ. The periinsular functional hemispherotomy. Neurosurg Focus 2012; 32:E7. [DOI: 10.3171/2012.1.focus11331] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The surgical treatment of refractory epilepsy has evolved as new innovations have been created. Disconnective procedures such as hemispherectomy have evolved. Presently, hemispherotomy has replaced hemispherectomy to reduce complication rates while maintaining good seizure control. Several disconnective techniques have been described including the Rasmussen, vertical, and lateral approaches. The lateral approach, or periinsular hemispherectomy, was derived from modifications on the functional hemispherectomy and involves removal of the temporal lobe mesial structures, exposure of the atrium via the circular sulcus, internal capsule transection under the central sulcus, intraventricular callosotomy, and frontobasal disconnection. The purpose of this article is to describe and illustrate in detail the anatomy and operative technique for periinsular hemispherotomy, as well as to discuss the nuances and issues involved with this procedure.
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Affiliation(s)
| | - Steven W. Hwang
- 2Division of Pediatric Neurosurgery, Department of Neurosurgery, Floating Hospital for Children, Tufts Medical Center, Boston, Massachusetts; and
| | - George Al-Shamy
- 3Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Andrew Jea
- 3Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Daniel J. Curry
- 3Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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11
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Jazayeri MA, Jensen JN, Lew SM. Craniosynostosis following hemispherectomy in a 2.5-month-old boy with intractable epilepsy. J Neurosurg Pediatr 2011; 8:450-4. [PMID: 22044367 DOI: 10.3171/2011.8.peds11176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report on the case of a 6-week-old boy who presented with infantile spasms. At 2.5 months of age, the patient underwent a right hemispherectomy. Approximately 3 months postoperatively, the patient presented with left coronal craniosynostosis. Subsequent cranial vault remodeling resulted in satisfactory cosmesis. Four years after surgery, the patient remains seizure free without the need for anticonvulsant medications. The authors believe this to be the first reported case of iatrogenic craniosynostosis due to hemispherectomy, and they describe 2 potential mechanisms for its development. This case suggests that, in the surgical treatment of infants with intractable epilepsy, minimization of brain volume loss through disconnection techniques should be considered, among other factors, when determining the best course of action.
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Affiliation(s)
- Mohammad-Ali Jazayeri
- Department of Neurosurgery, Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
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Limbrick DD, Narayan P, Powers AK, Ojemann JG, Park TS, Bertrand M, Smyth MD. Hemispherotomy: efficacy and analysis of seizure recurrence. J Neurosurg Pediatr 2009; 4:323-32. [PMID: 19795963 DOI: 10.3171/2009.5.peds0942] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Hemispherotomy generally is performed in hemiparetic patients with severe, intractable epilepsy arising from one cerebral hemisphere. In this study, the authors evaluate the efficacy of hemispherotomy and present an analysis of the factors influencing seizure recurrence following the operation. METHODS The authors performed a retrospective review of 49 patients (ages 0.2-20.5 years) who underwent functional hemispherotomy at their institution. The first 14 cases were traditional functional hemispherotomies, and included temporal lobectomy, while the latter 35 were performed using a modified periinsular technique that the authors adopted in 2003. RESULTS Thirty-eight of the 49 patients (77.6%) were seizure free at the termination of the study (mean follow-up 28.6 months). Of the 11 patients who were not seizure free, all had significant improvement in seizure frequency, with 6 patients (12.2%) achieving Engel Class II outcome and 5 patients (10.2%) achieving Engel Class III. There were no cases of Engel Class IV outcome. The effect of hemispherotomy was durable over time with no significant change in Engel class over the postoperative follow-up period. There was no statistical difference in outcome between surgery types. Analysis of factors contributing to seizure recurrence after hemispherotomy revealed no statistically significant predictors of treatment failure, although bilateral electrographic abnormalities on the preoperative electroencephalogram demonstrated a trend toward a worse outcome. CONCLUSIONS In the present study, hemispherotomy resulted in freedom from seizures in nearly 78% of patients; worthwhile improvement was demonstrated in all patients. The seizure reduction observed after hemispherotomy was durable over time, with only rare late failure. Bilateral electrographic abnormalities may be predictive of posthemispherotomy recurrent seizures.
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Affiliation(s)
- David D Limbrick
- Department of Neurosurgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri 63110-1077, USA.
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13
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Abstract
The surgical treatment of intractable epilepsy has evolved as new technical innovations have been made. Hemispherotomy techniques have been developed to replace hemispherectomy in order to reduce the complication rates while maintaining good seizure control. Disconnective procedures are based on the interruption of the epileptic network rather than the removal of the epileptogenic zone. They can be applied to hemispheric pathologies, leading to hemispherotomy, but they can also be applied to posterior quadrant epilepsies, or hypothalamic hamartomas. In this paper, the authors review the literature, present an overview of the historical background, and discuss the different techniques along with their outcomes and complications.
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Affiliation(s)
- Sandrine De Ribaupierre
- Department of Clinical Neurological Sciences, University of Western Ontario, London Health Sciences Centre, London, Ontario, Canada.
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14
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Cats EA, Kho KH, Van Nieuwenhuizen O, Van Veelen CWM, Gosselaar PH, Van Rijen PC. Seizure freedom after functional hemispherectomy and a possible role for the insular cortex: the Dutch experience. J Neurosurg 2007; 107:275-80. [PMID: 17941490 DOI: 10.3171/ped-07/10/275] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors undertook this study to identify predictors of persistent postoperative seizures in their group of 28 Dutch pediatric and adolescent patients with medically intractable epilepsy who underwent functional hemispherectomy. METHODS The records of 28 pediatric and adolescent patients who underwent a functional hemispherectomy in the University Medical Center Utrecht were retrospectively analyzed. The authors performed a Cox regression analysis, using the first postoperative seizure as the event. Pathology, age at surgery, age at seizure onset, duration of epilepsy, type of surgery, surgeon, possible incomplete disconnection on MR images, and presence of residual insular cortex were analyzed as potential associated variables during the follow-up period. RESULTS The patients' mean age at surgery was 69.9 months (range 3.0-294.2 months) and mean duration of follow-up was 39.0 months (range 6.0-132.0 months). Six patients had postoperative seizures (21%). One patient had persistent bilateral status epilepticus and died 4 months after surgery. The Cox regression analysis showed presence of insular cortex to be the only variable statistically associated with postoperative seizures (p = 0.021) in this group of 28 patients. CONCLUSIONS In this group of Dutch pediatric and adolescent patients, residual insular cortex was positively correlated with persistent postoperative seizures. Given the small sample size in this study, however, caution should be used in drawing conclusions about the role of the insular cortex.
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Affiliation(s)
- Elisabeth A Cats
- Department of Neurology, Rudolf Magnus Center of Neuroscience, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
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Cats EA, Kho KH, van Nieuwenhuizen O, van Veelen CWM, Gosselaar PH, van Rijen PC. Seizure freedom after functional hemispherectomy and a possible role for the insular cortex: the Dutch experience. J Neurosurg 2007. [DOI: 10.3171/ped.2007.107.4.275] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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16
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De Almeida AN, Marino R, Aguiar PH, Jacobsen Teixeira M. Hemispherectomy: a schematic review of the current techniques. Neurosurg Rev 2006; 29:97-102; discussion 102. [PMID: 16463191 DOI: 10.1007/s10143-005-0011-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2005] [Revised: 09/01/2005] [Accepted: 10/17/2005] [Indexed: 10/25/2022]
Abstract
Anatomical hemispherectomy has been used for the treatment of seizures since 1938. However, it was almost abandoned in the 1960s after reports of postoperative fatalities caused by hydrocephalus, hemosiderosis, and trivial head traumas. Despite serious complications, the remarkable improvement of patients encouraged authors to carry out modifications on anatomical hemispherectomy in order to lessen its morbidity while preserving its efficacy. The effort to improve the technique generated several original procedures. This paper reviews current techniques of hemispherectomy and proposes a classification scheme based on their surgical characteristics. Techniques of hemispherectomy were sorted into two major groups: (1) those that remove completely the cortex from the hemisphere and (2) those that associate partial cortical removal and disconnection. Group 1 was subdivided into two subgroups based on the integrity of the ventricular cavity and group 2 was subdivided into three subgroups depending on the amount and location of the corticectomy. Grouping similar techniques may allow a better understanding of the distinctive features of each one and creates the possibility of comparing data from different authors.
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Affiliation(s)
- Antonio Nogueira De Almeida
- Departamento de Neurologia do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Brazil.
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