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Cicutti SE, Cuello JF, Villamil F, Gromadzyn GP, Bartuluchi M. Surgical Anatomy and Technique of Peri-Insular Hemispherotomy in Pediatric Epilepsy. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01138. [PMID: 38651858 DOI: 10.1227/ons.0000000000001161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/28/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Hemispherotomy is a highly complex procedure that demands a steep learning curve. An incomplete brain disconnection often results in failure of seizure control. The purpose of this article was to present a step-by-step guide to the surgical anatomy of this procedure. It is composed of a 7-stage approach, enhancing access to and improving visualization of deep structures. METHODS A retrospective analysis of 39 pediatric patients with refractory epilepsy who underwent this technique was conducted. Engel scores were assessed 1 year postsurgery. Cadaveric dissections were performed to illustrate the procedure. RESULTS Between 2015 and 2022, 39 patients were surgically treated using the peri-insular technique. The technique involved 7 stages: patient positioning, operative approach, opercular resection, transventricular callosotomy, fronto-orbital disconnection, anterior temporal disconnection, and posterior temporal disconnection. Most of the patients (92.30%) were seizure-free (Engel class I) at 1 year postoperative, 5.13% were nearly seizure-free (Engel II), and 2.56% showed significant improvement (Engel III). Complications occurred in 8% of cases, including 1 infection, 2 cases of aseptic meningitis, and 1 non-shunt-requiring acute hydrocephalus. CONCLUSION The peri-insular hemispherotomy technique offers excellent seizure control with a low complication rate. Our visual documentation of surgical anatomy, complemented by detailed descriptions of surgical nuances, significantly contributes to a comprehensive understanding of this technique.
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Affiliation(s)
- Santiago E Cicutti
- Neurosurgery Department, Juan P. Garrahan Hospital, Buenos Aires, Argentina
| | - Javier F Cuello
- Neurosurgery Department, Hospital Provincial Petrona V. de Cordero, San Fernando, Buenos Aires, Argentina
| | | | - Guido P Gromadzyn
- Neurosurgery Department, Juan P. Garrahan Hospital, Buenos Aires, Argentina
| | - Marcelo Bartuluchi
- Neurosurgery Department, Juan P. Garrahan Hospital, Buenos Aires, Argentina
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Hoz SS, Ismail M, Palmisciano P, Al-Khazaali YM, Saleh SA, Muthana A, Forbes JA, Prestigiacomo CJ, Zuccarello M, Andaluz N. Cortical incisions and transcortical approaches for intra-axial and intraventricular lesions: A scoping review. Surg Neurol Int 2024; 15:82. [PMID: 38628541 PMCID: PMC11021096 DOI: 10.25259/sni_58_2024] [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] [Received: 01/23/2024] [Accepted: 02/11/2024] [Indexed: 04/19/2024] Open
Abstract
Background Transcortical approaches, encompassing various surgical corridors, have been employed to treat an array of intraparenchymal or intraventricular brain pathologies, including tumors, vascular malformations, infections, intracerebral hematomas, and epileptic surgery. Designing cortical incisions relies on the lesion location and characteristics, knowledge of eloquent functional anatomy, and advanced imaging such as tractography. Despite their widespread use in neurosurgery, there is a noticeable lack of systematic studies examining their common lobe access points, associated complications, and prevalent pathologies. This scoping review assesses current evidence to guide the selection of transcortical approaches for treating a variety of intracranial pathologies. Methods A scoping review was conducted using the PRISMA-ScR guidelines, searching PubMed, EMBASE, Scopus, and Web of Science. Studies were included if ≥5 patients operated on using transcortical approaches, with reported data on clinical features, treatments, and outcomes. Data analysis and synthesis were performed. Results A total of 50 articles encompassing 2604 patients were included in the study. The most common primary pathology was brain tumors (60.6%), particularly gliomas (87.4%). The transcortical-transtemporal approach was the most frequently identified cortical approach (70.48%), and the temporal lobe was the most accessed brain lobe (55.68%). The postoperative course outcomes were reported as good (55.52%), poor (28.38%), and death (14.62%). Conclusion Transcortical approaches are crucial techniques for managing a wide range of intracranial lesions, with the transcortical-transtemporal approach being the most common. According to the current literature, the selective choice of cortical incision and surgical corridor based on the lesion's pathology and anatomic-functional location correlates with acceptable functional outcomes.
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Affiliation(s)
- Samer S. Hoz
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, United States
| | - Mustafa Ismail
- Department of Neurosurgery, University of Baghdad, College of Medicine, Baghdad, Iraq
| | - Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati, Cincinnati, United States
| | | | - Saleh A. Saleh
- Department of Neurosurgery, University of Baghdad, Baghdad, Iraq
| | - Ahmed Muthana
- Department of Neurosurgery, University of Baghdad, College of Medicine, Baghdad, Iraq
| | - Jonathan A. Forbes
- Department of Neurosurgery, University of Cincinnati, Cincinnati, United States
| | | | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati, Cincinnati, United States
| | - Norberto Andaluz
- Department of Neurosurgery, University of Cincinnati, Cincinnati, United States
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Schijns OE. Functional hemispheric disconnection procedures for chronic epilepsy: history, indications, techniques, complications and current practice in Europe. A consensus statement on behalf of the EANS functional neurosurgery section. BRAIN & SPINE 2024; 4:102754. [PMID: 38510638 PMCID: PMC10951757 DOI: 10.1016/j.bas.2024.102754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/08/2024] [Accepted: 01/21/2024] [Indexed: 03/22/2024]
Abstract
Introduction The surgical procedure for severe, drug-resistant, unilateral hemispheric epilepsy is challenging. Over the last decades the surgical landscape for hemispheric disconnection procedures changed from anatomical hemispherectomy to functional hemispherotomy with a reduction of complications and stable good seizure outcome. Here, a task force of European epilepsy surgeons prepared, on behalf of the EANS Section for Functional Neurosurgery, a consensus statement on different aspects of the hemispheric disconnection procedure. Research question To determine history, indication, timing, techniques, complications and current practice in Europe for hemispheric disconnection procedures in drug-resistant epilepsy. Material and methods Relevant literature on the topic was collected by a literature search based on the PRISMA 2020 guidelines. Results A comprehensive overview on the historical development of hemispheric disconnection procedures for epilepsy is presented, while discussing indications, timing, surgical techniques and complications. Current practice for this procedure in European epilepsy surgery centers is provided. At present, our knowledge of long-term seizure outcomes primarily stems from open surgical disconnection procedures. Although minimal invasive surgical techniques in epilepsy are rapidly developing and reported in case reports or small case series, long-term seizure outcome remain uncertain and needs to be reported. Discussion and conclusion This is the first paper presenting a European consensus statement regarding history, indications, techniques and complications of hemispheric disconnection procedures for different causes of chronic, drug-resistant epilepsy. Furthermore, it serves as the pioneering document to report a comprehensive overview of the current surgical practices regarding this type of surgery employed in renowned epilepsy surgery centers across Europe.
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Affiliation(s)
- Olaf E.M.G. Schijns
- Corresponding author. Department of Neurosurgery, Maastricht University Medical Center, Maastricht, the Netherlands.
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Thomé U, Batista LA, Rocha RP, Terra VC, Hamad APA, Sakamoto AC, Santos AC, Santos MV, Machado HR. The Important Role of Hemispherotomy for Rasmussen Encephalitis: Clinical and Functional Outcomes. Pediatr Neurol 2024; 150:82-90. [PMID: 37992429 DOI: 10.1016/j.pediatrneurol.2023.10.016] [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: 03/22/2022] [Revised: 05/05/2023] [Accepted: 10/20/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Rasmussen encephalitis (RE) is characterized by pharmacoresistant epilepsy and progressive neurological deficits concurrent with unilateral hemispheric atrophy. Evidence of an inflammatory autoimmune process has been extensively described in the literature; however, the precise etiology of RE is still unknown. Despite data supporting a beneficial effect of early immunosuppressive and immunomodulatory interventions, surgical disconnection of the affected hemisphere is considered the treatment of choice for these patients. The aim of this study was to report a series of children and adolescents who underwent hemispheric surgery (HS) for the treatment of RE, analyzing their clinical, electrographic, and neuroimaging features pre-operatively, as well as their postoperative status, including seizure and functional outcomes. METHODS All patients with RE who underwent HS in the Epilepsy Surgery Center (CIREP) of the University Hospital of Ribeirão Preto Medical School, between 1995 and 2020 were retrospectively reviewed. Preoperative and postoperative analyses included gender; age at epilepsy onset; seizure semiology; seizure frequency; interictal and ictal electroencephalographic (EEG) findings; age at surgery; duration of epilepsy; surgical complications; duration of follow-up; histopathological findings; and postoperative seizure, cognitive, and functional outcomes. RESULTS Forty-four patients were evaluated. Mean age at seizure onset and epilepsy duration was 6 years and 2.5 years, respectively. Mean age at surgery was 9 years, with an average follow-up ranging from 3 months to 23 years. All patients presented with severe epilepsy and distinct neurological abnormalities on MRI. Before HS, different degrees of abnormal intellectual performance as well as hemiparesis were seen in 86% and 90%, respectively. Histopathology examination confirmed this diagnosis in 95% patients. At the last follow-up, 68% of patients were seizure free, and 70% were classified as Engel Class I or II. Postoperatively, the cognitive status remained unchanged in 64% of patients. Likewise, the gross motor function remained unchanged in 54% of patients and 74% had functional hand ability after HS. CONCLUSIONS Considering the progressive damage course of RE, hemispheric surgery should be offered to pediatric patients. It has manageable risks and results in good seizure outcome, and the preoperative functional status of these children is often preserved (even when the left hemisphere is involved), thus improving their quality of life.
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Affiliation(s)
- Ursula Thomé
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil.
| | - Larissa A Batista
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Renata P Rocha
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Vera C Terra
- Epilepsy Center, Nsa Sra das Graças Hospital, Curitiba, Brazil
| | - Ana Paula A Hamad
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Americo C Sakamoto
- Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Antônio C Santos
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Marcelo V Santos
- Pediatric Neurosurgery Division, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Hélio R Machado
- Pediatric Neurosurgery Division, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
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Nava BC, Costa UT, Hamad APA, Garcia CAB, Sakamoto AC, Aragon DC, Machado HR, Santos MV. Long-term seizure outcome and mobility after surgical treatment for Rasmussen encephalitis in children: A single-center experience. Epileptic Disord 2023; 25:749-757. [PMID: 37589547 DOI: 10.1002/epd2.20147] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVE Rasmussen Encephalitis (RE) is a rare inflammatory neurodegenerative disease associated with refractory seizures, hemiparesis, and cognitive deterioration, due to lateralized cortical atrophy. Hemispheric surgery (hemispherotomy) is the mainstay of treatment, but its unavoidable motor deficits and lack of long-term data regarding seizure outcomes can make patients and families apprehensive to undergo this procedure. The present study aimed at analyzing the results of surgical treatment for RE from a motor and epilepsy standpoint, and mitigate such concerns. METHODS Clinical and operative data were retrospectively collected from medical records of pharmacoresistant patients treated with functional hemispherectomy at a tertiary reference center for epilepsy surgery, during a 24-year period (1996-2020). Variables such as age of epilepsy onset, seizure semiology, seizure frequency, immunomodulatory therapy, age at surgery, duration of epilepsy, surgical procedures and complications, number of medications used preoperatively and postoperatively were described and statistically analyzed. RESULTS Forty-three (43) patients were included in this study. Mean age of epilepsy onset was 6.14 years, the average interval between epilepsy onset and hemispherotomy was 2.21 years. and the mean age at surgery was 8.28 years. Thirty patients (69.7%) were Engel I at their last follow-up, of whom 23 (56.4%) were Engel Ia, within a mean follow-up of 11.3 years. Duration of epilepsy, seizure frequency, and age at surgery, among others, did not correlate with seizure outcome, except the use of immunotherapy which led to worse outcomes (p < .05). Also, after surgery, motor functionality was significantly recovered (i.e., most patients returned to their previous status) with time. SIGNIFICANCE This study tackled some issues regarding the surgical treatment of this disease, particularly showing that hemispherotomy is safe and leads to potentially recoverable disability of motor functions while providing high rates of effective and long-lasting seizure control; therefore, early surgical indication should be warranted once medical refractoriness has been established.
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Affiliation(s)
- Brenda Cristina Nava
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Ursula Thome Costa
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Ana Paula Andrade Hamad
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Camila Araujo Bernardino Garcia
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Americo Ceiki Sakamoto
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Davi Casale Aragon
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Helio Rubens Machado
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Marcelo Volpon Santos
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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Del Gaudio N, Ferrao Santos S, Raftopoulos C. Modified Vertical Parasagittal Sub-Insular Hemispherotomy-Case Series and Technical Note. Brain Sci 2023; 13:1395. [PMID: 37891764 PMCID: PMC10605112 DOI: 10.3390/brainsci13101395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
(1) Background: Hemispherotomy is the generally accepted treatment for hemispheric drug-resistant epilepsy (DRE). Lateral or vertical approaches are performed according to the surgeon's preference. Multiple technical variations have been proposed since Delalande first described his vertical technique. We propose a sub-insular variation of the vertical parasagittal hemispherotomy (VPH) and describe our case series of patients operated on using this procedure. (2) Methods: Data from a continuous series of patients with hemispheric DRE who were operated on by the senior author (CR) using the modified sub-insular VPH technique were analyzed retrospectively. Pre-operative demographic and epilepsy characteristics, functional outcome, and surgical complications were extracted from medical charts. (3) Results: Twenty-five patients were operated on between August 2008 and August 2023; 23 have at least 3 months of follow-up. Of this group, 20 (86.9%) patients are seizure-free. Only two patients developed postoperative hydrocephalus (8.7%). All patients who were able to walk autonomously preoperatively and 20 (86.9%) of those with follow-up were able to walk without assistance. A total of 17 (74%) patients were able to perform adapted social activities at the latest follow-up. (4) Conclusions: Modified sub-insular VPH is a successful surgical technique for hemispheric DRE with seizure freedom rates similar to the largest series reported in the literature. Compared to other series, patients who were operated on with our modified technique had a lower rate of postoperative hydrocephalus and excellent long-term motor and cognitive outcomes.
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Affiliation(s)
- Nicole Del Gaudio
- Neurosurgery Department, University Hospital Saint Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200 Brussels, Belgium;
| | - Susana Ferrao Santos
- Neurology Department, University Hospital Saint Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200 Brussels, Belgium;
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Baltus C, El M’Kaddem B, Ferrao Santos S, Ribeiro Vaz JG, Raftopoulos C. Second surgery after vertical paramedian hemispherotomy for epilepsy recurrence. Heliyon 2023; 9:e14326. [PMID: 36950565 PMCID: PMC10025104 DOI: 10.1016/j.heliyon.2023.e14326] [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: 05/18/2022] [Revised: 02/02/2023] [Accepted: 03/01/2023] [Indexed: 03/13/2023] Open
Abstract
Background Vertical Paramedian Hemispherotomy (VPH) is considered an effective surgical treatment for drug-resistant epilepsy with 80% of patients experiencing seizure freedom or worthwhile improvement. Identifying persistent connective tracts is challenging in failed VPH. Methods We reviewed our series of consecutive patients undergoing VPH for hemispheric drug-resistant epilepsy and included cases with recurrent epileptic seizures undergoing second surgery with at least 6 months of postoperative follow-up. The cases were extensively assessed to propose a targeted complementary resection. Results Two children suffering from seizure recurrence following hemispherotomy leading to second surgery were included. After complete assessment, persisting amygdala residue was suspected responsible for the epilepsy recurrence in both patients. Complementary resection of the amygdala residue led to seizure freedom for both patients (Engel IA/ILAE Class 1) without complication. Different diagnostic tools are used to assess patients after failed hemispherotomy including routine EEG, prolonged video EEG, MRI (particularly DTI sequences), SPECT or PET scans and clinical evaluation. These tools allow to rule out epileptic foci in the contralateral hemisphere and to localize a potentially persisting epileptogenic zone. Assessment of these patients should be as systematic and integrated as the initial workup. Although our two patients suffered from Rasmussen's encephalitis, seizure recurrence after VPH has been described in other pathologies. Conclusion Lying deep and medially in the surgical corridor of VPH, the amygdala can be incompletely resected and cause recurrent epilepsy. Complementary selective resection of the amygdala residue may safely lead to success in epilepsy control.
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Affiliation(s)
- Cedric Baltus
- Department of Neurosurgery, University Hospital St-Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200, Brussels, Belgium
| | - Bouchra El M’Kaddem
- Department of Pediatric Neurology, University Hospital St-Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200, Brussels, Belgium
| | - Susana Ferrao Santos
- Refractory Epilepsy Center, University Hospital St-Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200, Brussels, Belgium
| | - José Géraldo Ribeiro Vaz
- Department of Neurosurgery, University Hospital St-Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200, Brussels, Belgium
| | - Christian Raftopoulos
- Department of Neurosurgery, University Hospital St-Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200, Brussels, Belgium
- Corresponding author.
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Uda H, Uda T, Kunihiro N, Nakajo K, Umaba R, Kawashima T, Tanoue Y, Koh S, Goto T. How to disconnect the splenium and fornix in posterior quadrant disconnection, hemispherotomy, and subtotal hemispherotomy. Acta Neurochir (Wien) 2023; 165:743-745. [PMID: 36763131 DOI: 10.1007/s00701-023-05517-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 12/30/2022] [Indexed: 02/11/2023]
Affiliation(s)
- Hiroshi Uda
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
- Department of Pediatrics, Detroit Medical Center, Children's Hospital of Michigan, Wayne State University, Detroit, MI, 48201, USA
| | - Takehiro Uda
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan.
- Department of Pediatric Neurosurgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-Ku, Osaka, 534-0021, Japan.
| | - Noritsugu Kunihiro
- Department of Pediatric Neurosurgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-Ku, Osaka, 534-0021, Japan
| | - Kosuke Nakajo
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Ryoko Umaba
- Department of Pediatric Neurosurgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-Ku, Osaka, 534-0021, Japan
| | - Toshiyuki Kawashima
- Department of Pediatric Neurosurgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-Ku, Osaka, 534-0021, Japan
| | - Yuta Tanoue
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Saya Koh
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Takeo Goto
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
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Matsuo T, Fujimoto S. Surgical Strategy for Hemispherotomy. Neurol Med Chir (Tokyo) 2023; 63:131-136. [PMID: 36682794 PMCID: PMC10166605 DOI: 10.2176/jns-nmc.2022-0279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Hemispherotomy is a radical treatment for drug-resistant epilepsy that targets developmental, acquired, and progressive diseases with widespread epileptogenic regions in one cerebral hemisphere. Currently, two main approaches are utilized after repeated improvements: lateral and vertical approaches. With the lateral approach, the surgical field is wide, and the approach to the lateral ventricle is relatively easy. On the other hand, the vertical approach has the advantage of reducing intraoperative bleeding and operating time as the resection line of the radial fiber is short, and understanding the three-dimensional anatomy is relatively easy. The lateral approach is generally used for atrophic lesions, whereas the vertical approach is for hypertrophic lesions. Hemispherotomy is expected to not only suppress epileptic seizures but also improve psychomotor development by protecting the unaffected cerebral hemisphere. However, this method is one of the most invasive surgeries in epilepsy surgery, and it is important to fully consider its indications. Furthermore, understanding the neural fiber pathway is important for actual surgery.
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Affiliation(s)
- Takeshi Matsuo
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital
| | - So Fujimoto
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital
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Cossu M, Nichelatti M, De Benedictis A, Rizzi M. Lateral versus vertical hemispheric disconnection for epilepsy: a systematic review and meta-analysis. J Neurosurg 2021:1-11. [PMID: 34653979 DOI: 10.3171/2021.5.jns21949] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 05/18/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Lateral periinsular hemispherotomy (LPH) and vertical parasagittal hemispherotomy (VPH) are the most popular disconnective techniques for intractable epilepsies associated with unilateral hemispheric pathologies. The authors aimed to investigate possible differences in seizure outcome and complication rates between patients who underwent LPH and VPH. METHODS A comprehensive literature search of PubMed and Embase identified English-language articles published from database inception to December 2019 that reported series (minimum 12 patients with follow-up ≥ 12 months) on either LPH or VPH. Pooled rates of seizure freedom and complications (with a particular focus on hydrocephalus) were analyzed using meta-analysis to calculate both fixed and random effects. Heterogeneity (Cochran's Q test) and inconsistency (fraction of Q due to actual heterogeneity) were also calculated. RESULTS Twenty-five studies were included. Data from 825 patients were available for seizure outcome analysis (583 underwent LPH and 242 underwent VPH), and data from 692 patients were available for complication analysis (453 underwent LPH and 239 underwent VPH). No differences were found in the pooled rates of Engel class I seizure outcome between patients who underwent LPH (80.02% and 79.44% with fixed and random effects, respectively) and VPH (79.89% and 80.69% with fixed and random effects, respectively) (p = 0.953). No differences were observed in the pooled rates of shunted hydrocephalus between patients who underwent LPH (11.34% and 10.63% with fixed and random effects, respectively) and VPH (11.07% and 9.98% with fixed and random effects, respectively) (p = 0.898). Significant heterogeneity and moderate inconsistency were determined for hydrocephalus occurrence in patients who underwent both LPH and VPH. CONCLUSIONS LPH and VPH techniques present similar excellent seizure outcomes, with comparable and acceptable safety profiles.
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Affiliation(s)
- Massimo Cossu
- 1"Claudio Munari" Epilepsy Surgery Centre, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Michele Nichelatti
- 2Service of Biostatistics, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano, Niguarda, Milan, Italy; and
| | - Alessandro De Benedictis
- 3Neurosurgery Unit, Department of Neurosciences, Bambino Gesù Children Hospital IRCCS, Rome, Italy
| | - Michele Rizzi
- 1"Claudio Munari" Epilepsy Surgery Centre, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Hemispherotomy for pediatric epilepsy: a systematic review and critical analysis. Childs Nerv Syst 2021; 37:2153-2161. [PMID: 33907902 DOI: 10.1007/s00381-021-05176-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/18/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Several variations of functional disconnection surgery have been described for the treatment of lateralized, hemispheric, drug-resistant epilepsy in children. The purpose of this study is to investigate the existing literature regarding patient selection, approach, and outcomes after hemispherotomy. METHODS A systematic review of the English literature through February 2019 was performed in accordance with the PRISMA statement. The articles were classified by level of evidence and summarized in an evidentiary table. Seizure outcomes, functional outcomes, surgical techniques, complications, and patient selection were critically analyzed. RESULTS A total of 173 papers were reviewed, of which 37 met criteria of inclusion and exclusion. Thirteen studies were classified as level III evidence, the remaining reached level IV. Vertical and lateral hemispherotomy achieve similar rates of seizure freedom and functional outcomes, though parasagittal and interhemispheric approaches may have shorter operative times and less blood loss. Etiology, bilateral MRI abnormalities, and nonlateralizing EEG did not predict worse seizure or functional outcomes. CONCLUSIONS Both vertical and lateral hemispherotomy approaches result in durable, reproducible benefits to epilepsy severity and functional status in appropriately selected pediatric patients.
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Harris WB, Phillips HW, Fallah A, Mathern GW. Pediatric Epilepsy Surgery in Focal and Generalized Epilepsy: Current Trends and Recent Advancements. JOURNAL OF PEDIATRIC EPILEPSY 2021. [DOI: 10.1055/s-0040-1722298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AbstractFor a subset of children with medically intractable epilepsy, surgery may provide the best chances of seizure freedom. Whereas the indications for epilepsy surgery are commonly thought to be limited to patients with focal epileptogenic foci, modern imaging and surgical interventions frequently permit successful surgical treatment of generalized epilepsy. Resection continues to be the only potentially curative intervention; however, the advent of various neuromodulation interventions provides an effective palliative strategy for generalized or persistent seizures. Although the risks and benefits vary greatly by type and extent of intervention, the seizure outcomes appear to be uniformly favorable. Advances in both resective and nonresective surgical interventions provide promise for improved seizure freedom, function, and quality of life. This review summarizes the current trends and recent advancements in pediatric epilepsy surgery from diagnostic workup and indications through surgical interventions and postoperative outcomes.
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Affiliation(s)
- William B. Harris
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawai'i
| | - H. Westley Phillips
- Department of Neurosurgery, University of California Los Angeles, California, United States
| | - Aria Fallah
- Department of Neurosurgery, University of California Los Angeles, California, United States
| | - Gary W. Mathern
- Department of Neurosurgery, University of California Los Angeles, California, United States
- Department of Psychiatry and Biobehavioral Medicine, David Geffen School of Medicine at UCLA, California, United States
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Nozaki T, Fujimoto A, Baba S, Enoki H, Okanishi T. Postoperative persistent fever may be a risk factor for hydrocephalus in hemispherical disconnection surgery. Epilepsy Behav 2020; 112:107466. [PMID: 33181888 DOI: 10.1016/j.yebeh.2020.107466] [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: 07/16/2020] [Revised: 08/24/2020] [Accepted: 08/30/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Hemispherical disconnection surgery such as hemispherotomy or posterior quadrant disconnection (PQD) surgery sometimes induces hydrocephalus. We postulated that some risk factors for postoperative hydrocephalus can be managed perioperatively. The purpose of this study was to clarify and statistically analyze perioperative risk factors for postoperative progressive hydrocephalus. METHODS We reviewed patients who underwent hemispherotomy or PQD. We compared patients with and without progressive hydrocephalus with multivariate and univariate logistic regression analysis to identify risk factors for hydrocephalus. RESULTS Twenty-four patients underwent hemispherectomy or PQD (age: 25 days-45 years old, mean: 13.3 years, median: 8 years, standard deviation: 13.9 years, 14 males). Among them, five patients (21%) required hydrocephalus treatment. Persistent fever was a risk factor for progressive hydrocephalus (multivariate analysis: p = 0.024, univariate analysis: p < 0.001). CONCLUSION Postoperative persistent fever may be a manageable risk factor for postoperative hydrocephalus in hemispherotomy and PQD surgery.
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Affiliation(s)
- Toshiki Nozaki
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Ayataka Fujimoto
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan.
| | - Shimpei Baba
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Hideo Enoki
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Tohru Okanishi
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
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Abstract
Hemispherectomy is a unique epilepsy surgery procedure that has undergone significant modification and evolution since Dandy's early description. This procedure is mainly indicated to treat early childhood and infancy medically intractable epilepsy. Various epileptic syndromes have been treated with this procedure, including hemimegalencephaly (HME), Rasmussen's encephalitis, Sturge-Weber syndrome (SWS), perinatal stroke, and hemispheric cortical dysplasia. In terms of seizure reduction, hemispherectomy remains one of the most successful epilepsy surgery procedures. The modification of this procedure over many years has resulted in lower mortality and morbidity rates. HME might increase morbidity and lower the success rate. Future studies should identify the predictors of outcomes based on the pathology and the type of hemispherectomy. Here, based on a literature review, we discuss the evolution of hemispherectomy techniques and their outcomes and complications.
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Silva JR, Sakamoto AC, Thomé Ú, Escorsi-Rosset S, Santos MV, Machado HR, Santos AC, Hamad AP. Left hemispherectomy in older children and adolescents: outcome of cognitive abilities. Childs Nerv Syst 2020; 36:1275-1282. [PMID: 31797069 DOI: 10.1007/s00381-019-04377-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/16/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Hemispherectomy is an effective treatment option for pharmacoresistant epilepsy. Nevertheless, when high cortical functions are at risk during the presurgical evaluation, especially for older children, and for the left hemisphere, despite good seizure outcome, the anticipated decrease of cognitive functions may prevent a decision to perform surgery. The objective of this study is to report the cognitive outcome, based on verbal and performance intelligence skills, in a series of older children and adolescents who underwent left hemispherectomy, analyzing the risks (residual cognitive deficit) and benefits (seizure reduction) of surgery. METHODS We retrospectively analyzed pre- and postoperative clinical and neuropsychological data from our patients who underwent left hemispherectomy, aged between 6 and 18 years. RESULTS We included 15 patients, with a mean follow-up of 3.1 years, 12 patients (80%) were Engel I, and the other three were classified as Engel II, III, and IV. Nine patients were tested by Wechsler Scales of Intelligence; postsurgically all but one kept the same intellectual levels; verbal intelligence quotient (VIQ) remained unchanged in 13 and improved in one, whereas performance intelligence quotient (PIQ) decreased in four patients. Both Total Vineland and communication scores of Vineland Adaptive Behavior Scales were obtained in six patients: in all, scores were classified as deficient adaptive functioning pre- and postoperatively, remaining unchanged. CONCLUSION The evaluation of the remaining intellectual abilities after left hemispherectomy in older children and adolescents is useful to discuss the risks and benefits of this surgery, enabling better and safer decisions regarding surgical indications and timing.
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Affiliation(s)
- Joceli Rodrigues Silva
- Department of Neurosciences and Behavioural Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Américo Ceiki Sakamoto
- Department of Neurosciences and Behavioural Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.,Center for Epilepsy Surgery (CIREP) Centro de Cirurgia de Epilepsia - HCFMRP-USP, Ribeirão Preto Medical School, University of São Paulo, Avenida Bandeirantes 3900 Monte Alegre, Ribeirão Preto, SP, CEP 14049-900, Brazil
| | - Úrsula Thomé
- Center for Epilepsy Surgery (CIREP) Centro de Cirurgia de Epilepsia - HCFMRP-USP, Ribeirão Preto Medical School, University of São Paulo, Avenida Bandeirantes 3900 Monte Alegre, Ribeirão Preto, SP, CEP 14049-900, Brazil
| | - Sara Escorsi-Rosset
- Center for Epilepsy Surgery (CIREP) Centro de Cirurgia de Epilepsia - HCFMRP-USP, Ribeirão Preto Medical School, University of São Paulo, Avenida Bandeirantes 3900 Monte Alegre, Ribeirão Preto, SP, CEP 14049-900, Brazil.,Radiology Division-Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Marcelo Volpon Santos
- Center for Epilepsy Surgery (CIREP) Centro de Cirurgia de Epilepsia - HCFMRP-USP, Ribeirão Preto Medical School, University of São Paulo, Avenida Bandeirantes 3900 Monte Alegre, Ribeirão Preto, SP, CEP 14049-900, Brazil.,Division of Pediatric Neurosurgery, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Hélio Rubens Machado
- Center for Epilepsy Surgery (CIREP) Centro de Cirurgia de Epilepsia - HCFMRP-USP, Ribeirão Preto Medical School, University of São Paulo, Avenida Bandeirantes 3900 Monte Alegre, Ribeirão Preto, SP, CEP 14049-900, Brazil.,Division of Pediatric Neurosurgery, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Antônio Carlos Santos
- Center for Epilepsy Surgery (CIREP) Centro de Cirurgia de Epilepsia - HCFMRP-USP, Ribeirão Preto Medical School, University of São Paulo, Avenida Bandeirantes 3900 Monte Alegre, Ribeirão Preto, SP, CEP 14049-900, Brazil.,Radiology Division-Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Ana Paula Hamad
- Department of Neurosciences and Behavioural Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil. .,Center for Epilepsy Surgery (CIREP) Centro de Cirurgia de Epilepsia - HCFMRP-USP, Ribeirão Preto Medical School, University of São Paulo, Avenida Bandeirantes 3900 Monte Alegre, Ribeirão Preto, SP, CEP 14049-900, Brazil.
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Dorfer C, Khalaveh F, Dorfmüller G, Czech T. Surgical Anatomy of Vertical Perithalamic Hemispherotomy. Oper Neurosurg (Hagerstown) 2020; 18:511-517. [PMID: 31407011 DOI: 10.1093/ons/opz214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 04/18/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Vertical perithalamic hemispherotomy was introduced by Olivier Delalande in 1992 as an alternative concept of functional hemispherectomy. OBJECTIVE To provide a step-by-step illustration of the surgical anatomy of this procedure. METHODS The descriptions in this manuscript are based on an experience of 52 hemispherotomies performed with the same technique by a single surgeon. RESULTS Our illustrations of the surgical anatomy and the descriptions of the surgical nuances facilitate a deep understanding for the surgical concept of Delalande's vertical hemispherotomy technique. They highlight the advantages (ie, reduced risk of inadvertent damage to the contralateral hemisphere and a clear orientation by defined anatomical landmarks) over the recently suggested modifications to this original technique. CONCLUSION Olivier Delalande's original technique remains the most appealing concept of vertical hemispherotomy to us.
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Affiliation(s)
- Christian Dorfer
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Farjad Khalaveh
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Georg Dorfmüller
- Division of Pediatric Neurosurgery, Rothschild Foundation Hospital, Paris, France
| | - Thomas Czech
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
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Arifin MT, Muttaqin Z, Hanaya R, Bakhtiar Y, Bintoro AC, Iida K, Kurisu K, Arita K, Andar EBPS, B HK, Priambada D, Risdianto A, Kusnarto G, Bunyamin J. Hemispherotomy for drug-resistant epilepsy in an Indonesian population. Epilepsy Behav Rep 2019; 12:100337. [PMID: 31828236 PMCID: PMC6888712 DOI: 10.1016/j.ebr.2019.100337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/03/2019] [Accepted: 09/20/2019] [Indexed: 11/29/2022] Open
Abstract
Hemispherotomy is a surgical treatment indicated in patients with drug-resistant epilepsy due to unilateral hemispheric pathology. Hemispherotomy is less invasive compared with hemispherectomy. We reviewed our experience performing 24 hemispherotomy and report the results of 16 patients with prolonged follow-up of this relatively uncommon procedure in two centers in Indonesia. This is a retrospective observational study conducted from 1999 to July 2019 in two epilepsy neurosurgical centers in Semarang, Indonesia. Surgical techniques included vertical parasagittal hemispherotomy (VPH), peri-insular hemispherotomy (PIH), and modified PIH called the Shimizu approach (SA). The postoperative assessment was carried out using the Engel classification system of seizure outcome. Seizure freedom (Engel class I) outcome was achieved in 10 patients (62.5%), class II in 3 patients (18.7%), class III in 2 patients (12.5%), and class IV in 1 patient (6.3%) with follow-up duration spanning from 24 to 160 months. To the best of our knowledge, this series is the most extensive documentation of hemispherotomy in an Indonesian population. We report our experience performing hemispherotomy in selected cases in two centers in Indonesia To the best of our knowledge, this is the largest case series of hemispherotomy for drug-resistant epilepsy in Indonesia. Engel class I outcome was seen in 62.5% for 16 patients of which 81.3% of patients improved regarding reduction in pre-operative seizure frequency
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Affiliation(s)
| | - Zainal Muttaqin
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Indonesia
| | - Ryosuke Hanaya
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Japan
| | - Yuriz Bakhtiar
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Indonesia
| | - Aris Catur Bintoro
- Department of Neurology, Faculty of Medicine, Diponegoro University, Indonesia
| | - Koji Iida
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Kaoru Kurisu
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Kazunori Arita
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Japan
| | - Erie B P S Andar
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Indonesia
| | - Happy Kurnia B
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Indonesia
| | - Dody Priambada
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Indonesia
| | - Ajid Risdianto
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Indonesia
| | - Gunadi Kusnarto
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Indonesia
| | - Jacob Bunyamin
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Indonesia
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Outcome after hemispherotomy in patients with intractable epilepsy: Comparison of techniques in the Italian experience. Epilepsy Behav 2019; 93:22-28. [PMID: 30780077 DOI: 10.1016/j.yebeh.2019.01.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The objective of the study was to evaluate clinical characteristics and outcome of hemispherotomy in children and adolescents with hemispheric refractory epilepsy in an Italian cohort of patients. METHODS We retrospectively evaluated the clinical course and outcome of 92 patients with refractory epilepsy who underwent hemispherotomy in three Italian epilepsy centers between 2006 and 2016. Three different approaches for hemispherotomy were used: parasagittal, modified parasagittal, and lateral. RESULTS Mean age at epilepsy onset was 1.8 ± 2.51 years, and mean duration of epilepsy prior to surgery was 7.4 ± 5.6 years. Mean age at surgery was 9.2 ± 8.0 years. After a mean follow-up of 2.81 ± 2.4 years, 66 of 90 patients (two lost from follow-up, 73.3%) were seizure-free (Engel class I). The etiology of epilepsy was related to acquired lesions (encephalomalacia or gliosis) in 44 patients (47.8%), congenital malformations (cortical dysplasia, hemimegalencephaly, other cortical malformations) in 38 (41.3%), and progressive conditions (Rasmussen or Sturge-Weber syndrome) in 10 patients (10.9%). Regarding seizure outcome, we could not identify statistically significant differences between vertical and lateral approaches (p = 0.154). Seizure outcome was not statistically different in patients with congenital vs acquired or progressive etiologies (p = 0.43). Acute postoperative seizures (APOS) correlated with poor outcome (p < 0.05). On multivariate analysis, presurgical focal to bilateral tonic-clonic seizures (Odds Ratio (OR) = 3.63, 95% Confidence Interval (CI): 1.86-15.20, p = 0.048) independently predicted seizure recurrence. Twenty-one patients (22.8%) exhibited postoperative complications, with no unexpected and persistent neurological deficit. More than 50% of the patients completely tapered drugs. SIGNIFICANCE Our data confirm hemispherotomy to be a safe and effective procedure in patients with drug resistant epilepsies due to hemispheric lesions. Presurgical focal to bilateral tonic-clonic seizures are the strongest predictor of seizure recurrence after surgery, independently from the type of hemispherotomy.
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Chandra PS, Subianto H, Bajaj J, Girishan S, Doddamani R, Ramanujam B, Chouhan MS, Garg A, Tripathi M, Bal CS, Sarkar C, Dwivedi R, Sapra S, Tripathi M. Endoscope-assisted (with robotic guidance and using a hybrid technique) interhemispheric transcallosal hemispherotomy: a comparative study with open hemispherotomy to evaluate efficacy, complications, and outcome. J Neurosurg Pediatr 2018; 23:187-197. [PMID: 30497135 DOI: 10.3171/2018.8.peds18131] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 08/09/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEEndoscope-assisted hemispherotomy (EH) has emerged as a good alternative option for hemispheric pathologies with drug-resistant epilepsy.METHODSThis was a prospective observational study. Parameters measured included primary outcome measures (frequency, severity of seizures) and secondary outcomes (cognition, behavior, and quality of life). Blood loss, operating time, complications, and hospital stay were also taken into account. A comparison was made between the open hemispherotomy (OH) and endoscopic techniques performed by the senior author.RESULTSOf 59 cases (42 males), 27 underwent OH (8 periinsular, the rest vertical) and 32 received EH. The mean age was 8.65 ± 5.41 years (EH: 8.6 ± 5.3 years; OH: 8.6 ± 5.7 years). Seizure frequency per day was 7 ± 5.9 (EH: 7.3 ± 4.6; OH: 15.0 ± 6.2). Duration of disease (years since first episode) was 3.92 ± 1.24 years (EH: 5.2 ± 4.3; OH: 5.8 ± 4.5 years). Number of antiepileptic drugs per patient was 3.9 ± 1.2 (EH: 4.2 ± 1.2; OH: 3.8 ± 0.98). Values for the foregoing variables are expressed as the mean ± SD. Pathologies included the following: postinfarct encephalomalacia in 19 (EH: 11); Rasmussen's syndrome in 14 (EH: 7); hemimegalencephaly in 12 (EH: 7); hemispheric cortical dysplasia in 7 (EH: 4); postencephalitis sequelae in 6 (EH: 2); and Sturge-Weber syndrome in 1 (EH: 1). The mean follow-up was 40.16 ± 17.3 months. Thirty-nine of 49 (79.6%) had favorable outcomes (International League Against Epilepsy class I and II): in EH the total was 19/23 (82.6%) and in OH it was 20/26 (76.9%). There was no difference in the primary outcome between EH and OH (p = 0.15). Significant improvement was seen in the behavioral/quality of life performance, but not in IQ scores in both EH and OH (p < 0.01, no intergroup difference). Blood loss (p = 0.02) and hospital stay (p = 0.049) were less in EH.CONCLUSIONSEH was as effective as the open procedure in terms of primary and secondary outcomes. It also resulted in less blood loss and a shorter postoperative hospital stay.
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Affiliation(s)
- P Sarat Chandra
- Departments of1Neurosurgery.,3COE, Epilepsy, National Brain Research Centre and All India Institute of Medical Sciences, New Delhi; and
| | - Heri Subianto
- Departments of1Neurosurgery.,3COE, Epilepsy, National Brain Research Centre and All India Institute of Medical Sciences, New Delhi; and
| | - Jitin Bajaj
- Departments of1Neurosurgery.,3COE, Epilepsy, National Brain Research Centre and All India Institute of Medical Sciences, New Delhi; and
| | - Shabari Girishan
- Departments of1Neurosurgery.,3COE, Epilepsy, National Brain Research Centre and All India Institute of Medical Sciences, New Delhi; and
| | | | - Bhargavi Ramanujam
- 2Neurology.,3COE, Epilepsy, National Brain Research Centre and All India Institute of Medical Sciences, New Delhi; and
| | | | | | | | | | | | | | - Savita Sapra
- 8Pediatric Neuropsychology, All India Institute of Medical Sciences, New Delhi
| | - Manjari Tripathi
- 2Neurology.,3COE, Epilepsy, National Brain Research Centre and All India Institute of Medical Sciences, New Delhi; and
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Wagner K, Vaz-Guimaraes F, Camstra K, Lam S. Endoscope-assisted hemispherotomy: translation of technique from cadaveric anatomical feasibility study to clinical implementation. J Neurosurg Pediatr 2018; 23:178-186. [PMID: 30497226 DOI: 10.3171/2018.8.peds18349] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 08/22/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAppropriately chosen candidates with medically refractory epilepsy may benefit from hemispheric disconnection. Traditionally, this involves a large surgical exposure with significant associated morbidity. Minimally invasive approaches using endoscopic assistance have been described by only a few centers. Here, the authors report on the feasibility of endoscope-assisted functional hemispherotomy in a cadaver model and its first translation into clinical practice in appropriately selected patients.METHODSThree silicone-injected, formalin-fixed cadaver heads were used to establish the steps of the procedure in the laboratory. The steps of disconnection were performed using standard surgical instruments and a straight endoscope. The technique was then applied in two patients who had been referred for hemispherectomy and had favorable anatomy for an endoscope-assisted approach.RESULTSAll disconnections were performed in the cadaver model via a 4 × 2-cm paramedian keyhole craniotomy using endoscopic assistance. An additional temporal burr hole approach was marked in case the authors were unable to completely visualize the frontobasal and insular cuts from the paramedian vertical view. Their protocol was subsequently used successfully in two pediatric patients. Full disconnection was verified with postoperative tractography.CONCLUSIONSFull hemispheric disconnection can be accomplished with minimally invasive endoscope-assisted functional hemispherotomy. The procedure is technically feasible and can be safely applied in patients with favorable anatomy and pathology; it may lead to less surgical morbidity and faster recovery.
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Affiliation(s)
- Kathryn Wagner
- 1Department of Neurosurgery, Baylor College of Medicine; and.,2Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | | | - Kevin Camstra
- 1Department of Neurosurgery, Baylor College of Medicine; and
| | - Sandi Lam
- 1Department of Neurosurgery, Baylor College of Medicine; and.,2Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
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Iyer RS, Rao RM, Muthukalathi K, Kumar P. Trapped ipsilateral lateral ventricle: a delayed complication of hemispherotomy for Rasmussen's encephalitis. BMJ Case Rep 2017; 2017:bcr-2017-222040. [PMID: 29054955 DOI: 10.1136/bcr-2017-222040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Hemispherotomy is the currently preferred surgical treatment option for refractory unihemispheric epilepsies. The incidence of hydrocephalus is greatly reduced in this disconnective procedure when compared with the resective procedure of anatomical hemispherectomy. We describe the occurrence of ipsilateral trapped lateral ventricle months after hemispherotomy for Rasmussen's encephalitis. There is enough evidence to suggest that this rare and interesting complication is due to the local inflammatory changes associated with the surgical trauma.
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Affiliation(s)
| | - Ravi Mohan Rao
- Department of Neurosurgery, Apollo Hospitals, Bangalore, Karnataka, India
| | | | - Praveen Kumar
- Department of Radiology, KG Hospital, Coimbatore, Tamil nadu, India
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Bartoli A, El Hassani Y, Jenny B, Momjian S, Korff CM, Seeck M, Vulliemoz S, Schaller K. What to do in failed hemispherotomy? Our clinical series and review of the literature. Neurosurg Rev 2017; 41:125-132. [DOI: 10.1007/s10143-017-0888-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 07/20/2017] [Accepted: 07/31/2017] [Indexed: 10/19/2022]
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Santos MV, Machado HR. Extratemporal disconnective procedures for the treatment of epilepsy in children. Epilepsia 2017; 58 Suppl 1:28-34. [DOI: 10.1111/epi.13683] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Marcelo Volpon Santos
- Center for Epilepsy Surgery (CIREP); Ribeirão Preto Medical School; University of São Paulo; Ribeirão Preto SP Brazil
- Division of Pediatric Neurosurgery; Ribeirão Preto Medical School; University of São Paulo; Ribeirão Preto SP Brazil
| | - Hélio Rubens Machado
- Center for Epilepsy Surgery (CIREP); Ribeirão Preto Medical School; University of São Paulo; Ribeirão Preto SP Brazil
- Division of Pediatric Neurosurgery; Ribeirão Preto Medical School; University of São Paulo; Ribeirão Preto SP Brazil
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Baumgartner JE, Blount JP, Blauwblomme T, Chandra PS. Technical descriptions of four hemispherectomy approaches: From the Pediatric Epilepsy Surgery Meeting at Gothenburg 2014. Epilepsia 2017; 58 Suppl 1:46-55. [DOI: 10.1111/epi.13679] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2016] [Indexed: 11/28/2022]
Affiliation(s)
| | - Jeffrey P. Blount
- Division of Neurosurgery; University of Alabama Birmingham Medical School; Birmingham Alabama U.S.A
| | - Thomas Blauwblomme
- Pediatric Neurosurgery; AP-HP Hopital Necker-Enfants Malades; Paris France
- PRES Sorbonne Paris Cité; University Paris Descartes; Paris France
| | - P. Sarat Chandra
- Department of Neurosurgery; All India Institute of Medical Sciences; New Delhi India
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25
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Verhaeghe A, Decramer T, Naets W, Van Paesschen W, van Loon J, Theys T. Posterior Quadrant Disconnection: A Fiber Dissection Study. Oper Neurosurg (Hagerstown) 2017; 14:45-50. [DOI: 10.1093/ons/opx060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 03/01/2017] [Indexed: 11/13/2022] Open
Abstract
AbstractBACKGROUNDPosterior quadrant disconnection can be highly effective in the surgical treatment of selected cases of refractory epilepsy. The technique aims to deafferent extensive areas of epileptogenic posterior cortex from the rest of the brain by isolating the temporoparietooccipital cortex.OBJECTIVETo describe this procedure and relevant white matter tracts with a specific emphasis on the extent of callosotomy in an anatomic study.METHODSTwenty hemispheres were dissected according to Klingler's fiber dissection technique illustrating the peri-insular (temporal stem, superior longitudinal fasciculus, corona radiata) and mesial disconnection (mesiotemporal cortex, cingulum, and corpus callosum).RESULTSExtensive white matter tract disconnection is obtained after posterior quadrant disconnection. Callosal fibers connecting the anterior most part of the parietal cortex invariably ran through the isthmus of the corpus callosum and need to be disconnected, while frontal lobe connections including the corticospinal tract and the anterior two-thirds of the corpus callosum are spared during the procedure.CONCLUSIONOur findings suggest the involvement of both the splenium and the isthmus in interhemispheric propagation in posterior cortex epilepsies. Sectioning the total extent of the posterior one-third of the corpus callosum might therefore be necessary to achieve optimal outcomes in posterior quadrant epilepsy surgery.
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Affiliation(s)
| | - Thomas Decramer
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Wim Naets
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Wim Van Paesschen
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Johannes van Loon
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Tom Theys
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
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Kim GH, Seo JH, Schroff S, Chen PC, Lee KH, Baumgartner J. Impact of intraoperative 3-T MRI with diffusion tensor imaging on hemispherectomy. J Neurosurg Pediatr 2017; 19:63-69. [PMID: 27791704 DOI: 10.3171/2016.4.peds15568] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hemispherectomy can produce remarkable seizure control of medically intractable hemispheric epilepsy in children, but some patients continue to have seizures after surgery. A frequent cause of treatment failure is incomplete surgical disconnection of the abnormal hemisphere. This study explores whether intraoperative 3-T MRI with diffusion tensor imaging (DTI) during hemispherectomy can identify areas of incomplete disconnection and allow complete disconnection during a single surgery. METHODS The charts of 32 patients with epilepsy who underwent hemispherectomy between January 2012 and July 2014 at the Florida Hospital for Children were reviewed. Patients were grouped as having had curative or palliative hemispherectomy. To assess the completeness of disconnection when the surgeon considered the operation completed, intraoperative 3-T MRI-DTI was performed. If incomplete disconnection was identified, additional surgery was performed until MRI-DTI sequences confirmed satisfactory disconnection. Seizure outcome data were collected via medical records at last follow-up. RESULTS Of 32 patients who underwent hemispherectomy, 23 had curative hemispherectomy and 9 had palliative hemispherectomy. In 11 of 32 surgeries, the first intraoperative MRI-DTI sequences suggested incomplete disconnection and additional surgery followed by repeat MRI-DTI was performed. Complete disconnection was accomplished in 30 of 32 patients (93.8%). Two of 32 disconnections (6.3%) were incomplete on postoperative imaging. Cross-sectional results showed that 21 of 23 patients (91.3%) who had curative hemispherectomy remained free of seizures (International League Against Epilepsy Class 1) at a median follow-up of 1.7 years (range 0.4-2.9 years). The longitudinal seizure freedom after curative hemispherectomy was 95.2% (SE 0.05) at 6 months, 90.5% (SE 0.06) at 1 year, and 90.5% (SE 0.05) at 2 years. CONCLUSIONS Intraoperative 3-T MRI-DTI sequences can identify incomplete disconnection during hemispherectomy and allow higher rates of complete disconnection in a single surgery. Higher rates of complete disconnection seem to achieve better seizure-free outcome following modified functional hemispherectomy.
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Affiliation(s)
- Gun-Ha Kim
- Department of Pediatrics, Korea University College of Medicine, Seoul, South Korea.,Comprehensive Epilepsy Center, Florida Hospital Orlando; and
| | - Joo Hee Seo
- Comprehensive Epilepsy Center, Florida Hospital Orlando; and
| | - Seema Schroff
- Comprehensive Epilepsy Center, Florida Hospital Orlando; and
| | - Po-Ching Chen
- Comprehensive Epilepsy Center, Florida Hospital Orlando; and.,Functional Brain Mapping and Brain Computer Interface Lab, Florida Hospital for Children, Orlando, Florida
| | - Ki Hyeong Lee
- Comprehensive Epilepsy Center, Florida Hospital Orlando; and
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Uda T, Tamrakar S, Tsuyuguchi N, Kawashima T, Goto H, Nakajo K, Umaba R, Sato H, Ohata K. Anatomic Understanding of Vertical Hemispherotomy With Cadaveric Brains and Intraoperative Photographs. Oper Neurosurg (Hagerstown) 2016; 12:374-382. [DOI: 10.1227/neu.0000000000001272] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 05/08/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND
Vertical hemispherotomy is performed in hemispheric epilepsy to disconnect commissural fibers, projecting fibers, and limbic system from the affected side of the brain with minimal parenchyma removal. However, anatomic understanding of this surgery is generally difficult.
OBJECTIVE
To present the vertical hemispherotomy procedures using cadaveric brains and intraoperative photographs.
METHODS
Two formalin-fixed adult cadaveric brains were used to demonstrate vertical hemispherotomy. Intraoperative photographs were taken of a 19-year-old man with intractable epilepsy due to head trauma in infancy.
RESULTS
After coronal skin incision along the coronal suture, bifrontal craniotomy and a C-shaped dural incision from lateral to medial to the midline are performed. The interhemispheric fissure is dissected from anterior to posterior. Interhemispheric total corpus callosotomy is performed to disconnect commissural fibers. Corticotomy on the cingulate gyrus is performed to approach the lateral ventricle. The lateral border of the thalamus is cut from posterior to anterior until exposing the inferior horn of the lateral ventricle and hippocampal head to disconnect projecting fibers. At the anteromedial side of the hippocampus, the inferior part of the amygdala and uncal gyrus is removed, exposing the basal cistern to disconnect the hippocampus and amygdala. The posterior column of the fornix at the trigone of the lateral ventricle is resected to disconnect the limbic system. Projecting fibers from the anterior frontal lobe are disconnected.
CONCLUSION
A step-by-step procedure using cadaveric brains and intraoperative photographs provide a better anatomic understanding of vertical hemispherotomy.
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Affiliation(s)
- Takehiro Uda
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Samantha Tamrakar
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Naohiro Tsuyuguchi
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toshiyuki Kawashima
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroyuki Goto
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kosuke Nakajo
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Ryoko Umaba
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hidetoshi Sato
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kenji Ohata
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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Abstract
The use of epilepsy surgery in various medically resistant epilepsies is well established. For patients with intractable pediatric epilepsy, the role of intracranial electrodes, resective surgery, hemispherectomy, corpus callosotomy, neurostimulation, and multiple subpial transections continues to be very effective in select cases. Newer treatment and diagnostic methods include laser thermal ablation, minimally invasive surgeries, stereo electroencephalography, electrocorticography, and other emerging techniques. This article will review the established and emerging surgical therapies for severe pediatric epilepsies, their respective indications and overall efficacy.
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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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Technical note on hemispherotomy. Childs Nerv Syst 2015; 31:2161-2. [PMID: 25939719 DOI: 10.1007/s00381-015-2737-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 04/22/2015] [Indexed: 10/23/2022]
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Giordano F, Spacca B, Barba C, Mari F, Pisano T, Guerrini R, Genitori L. Vertical extraventricular functional hemispherotomy: a new variant for hemispheric disconnection. Technical notes and results in three patients. Childs Nerv Syst 2015; 31:2151-60. [PMID: 26099230 DOI: 10.1007/s00381-015-2788-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 06/09/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE Hemispherectomy and disconnective hemispherotomy are the most effective epilepsy surgical procedures for the treatment of epilepsy due to hemispheric pathologies such as Sturge-Weber syndrome, diffuse hemispheric cortical dysplasia, and posttraumatic and postischemic focal lesions. Disconnective hemispherotomy is nowadays preferred to reduce surgical morbidity in term of early and late complications (i.e., cerebral superficial hemosiderosis). Despite the number of existing technical variants conceived to further reduce the amount of brain tissue to be removed, postoperative hydrocephalus still persists and may account for an average incidence of 15-41% according to different series and reviews. A new variant of disconnective vertical hemispherotomy we termed vertical extraventricular parasagittal hemispherotomy is described aiming to further reduce the amount of removed brain tissue and so the risk of postoperative hydrocephalus in favor of a pure hemispheric disconnection. METHODS Three patients affected by drug-resistant epilepsy due to different hemispheric pathologies (posttraumatic epilepsy, Sturge-Weber syndrome, diffuse hemispheric cortical dysplasia) were considered to be candidates for vertical extraventricular parasagittal hemispherotomy disconnective based on presurgical evaluation protocol. The oldest patient was 15 years old, the two youngest were both 2 years old. RESULTS None of the patients experienced early and late surgical complications. After a mean follow-up of 36 months (range 12-60 months), two patients were seizure free, one relapsed seizures 18 months later. Postoperative hydrocephalus never occurred. CONCLUSION Vertical extraventricular parasagittal hemispherotomy may be an efficacious and less invasive technique as it consists in a pure disconnection of the hemisphere with less amount of brain tissue removed and a theoretical reduced risk of postoperative hydrocephalus.
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Affiliation(s)
- Flavio Giordano
- Neurosurgery - Department of Neurosciences, Anna Meyer Pediatric Hospital, Viale Pieraccini 24, 50139, Florence, Italy.
| | - Barbara Spacca
- Neurosurgery - Department of Neurosciences, Anna Meyer Pediatric Hospital, Viale Pieraccini 24, 50139, Florence, Italy
| | - Carmen Barba
- Pediatric Neurology Clinic - Department of Neurosciences, Anna Meyer Pediatric Hospital, Florence, Italy
| | - Francesco Mari
- Pediatric Neurology Clinic - Department of Neurosciences, Anna Meyer Pediatric Hospital, Florence, Italy
| | - Tiziana Pisano
- Pediatric Neurology Clinic - Department of Neurosciences, Anna Meyer Pediatric Hospital, Florence, Italy
| | - Renzo Guerrini
- Pediatric Neurology Clinic - Department of Neurosciences, Anna Meyer Pediatric Hospital, Florence, Italy
| | - Lorenzo Genitori
- Neurosurgery - Department of Neurosciences, Anna Meyer Pediatric Hospital, Viale Pieraccini 24, 50139, Florence, Italy
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Sugano H, Arai H. Epilepsy surgery for pediatric epilepsy: optimal timing of surgical intervention. Neurol Med Chir (Tokyo) 2015; 55:399-406. [PMID: 25925754 PMCID: PMC4628167 DOI: 10.2176/nmc.ra.2014-0369] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Pediatric epilepsy has a wide variety of etiology and severity. A recent epidemiological study suggested that surgery might be indicated in as many as 5% of the pediatric epilepsy population. Now, we know that effective epilepsy surgery can result in seizure freedom and improvement of psychomotor development. Seizure control is the most effective way to improve patients neurologically and psychologically. In this review, we look over the recent evidence related to pediatric epilepsy surgery, and try to establish the optimal surgical timing for patients with intractable epilepsy. Appropriate surgical timing depends on the etiology and natural history of the epilepsy to be treated. The most common etiology of pediatric intractable epilepsy patients is malformation of cortical development (MCD) and early surgery is recommended for them. Patients operated on earlier than 12 months of age tended to improve their psychomotor development compared to those operated on later. Recent progress in neuroimaging and electrophysiological studies provide the possibility of very early diagnosis and comprehensive surgical management even at an age before 12 months. Epilepsy surgery is the only solution for patients with MCD or other congenital diseases associated with intractable epilepsy, therefore physicians should aim at an early and precise diagnosis and predicting the future damage, consider a surgical solution within an optimal timing.
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Chandra PS, Kurwale N, Garg A, Dwivedi R, Malviya SV, Tripathi M. Endoscopy-Assisted Interhemispheric Transcallosal Hemispherotomy. Neurosurgery 2015; 76:485-94; discussion 494-5. [DOI: 10.1227/neu.0000000000000675] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Various hemispherotomy techniques have been developed to reduce complication rates and achieve the best possible seizure control.
OBJECTIVE:
To present a novel and minimally invasive endoscopy-assisted approach to perform this procedure.
METHODS:
Endoscopy-assisted interhemispheric transcallosal hemispherotomy was performed in 5 children (April 2013-June 2014). The procedure consisted of performing a small craniotomy (4 × 3 cm) just lateral to midline using a transverse skin incision. After dural opening, the surgery was performed with the assistance of a rigid high-definition endoscope, and bayoneted self-irrigating bipolar forceps and other standard endoscopic instruments. Steps included a complete corpus callosotomy followed by the disconnection of the hemisphere at the level of the basal nuclei and thalamus. The surgeries were performed in a dedicated operating room with intraoperative magnetic resonance imaging and neuronavigation. Intraoperative magnetic resonance imaging confirmed a total disconnection.
RESULTS:
The pathologies for which surgeries were performed included sequelae of middle a cerebral artery infarct (n = 2), Rasmussen syndrome (n = 1), and hemimegalencephaly (2). Four patients had an Engel class I and 1 patient had a class II outcome at a mean follow-up of 10.2 months (range, 3-14 months). The mean blood loss was 80 mL, and mean operating time was 220 minutes. There were no complications in this study.
CONCLUSION:
This study describes a pilot novel technique and the feasibility of performing a minimally invasive, endoscopy-assisted hemispherotomy.
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Affiliation(s)
| | | | | | | | | | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Kamath AA, Limbrick DL, Smyth MD. Characterization of postoperative fevers after hemispherotomy. Childs Nerv Syst 2015; 31:291-6. [PMID: 25330864 DOI: 10.1007/s00381-014-2572-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 10/10/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Patients who have undergone hemispherotomy for intractable epilepsy tend to develop postoperative fevers, which can be severe and/or prolonged, for unclear reasons. The purpose of this paper is to characterize postoperative fever curves after hemispherotomy based on factors including seizure etiology, perioperative blood loss, and the presence or absence of ventricular drainage. METHODS We present 72 patients who underwent hemispherotomy at our institution between 1995 and 2013 by four surgeons. Data including daily maximum body temperature, seizure etiology, ventricular drain use, steroid and antipyretic use, and seizure control were gathered retrospectively based on electronic records including operative summaries, nursing notes, discharge summaries, and follow-up clinic notes. RESULTS Seventy-two patients from 11 weeks to 21 years old (mean 7.4 years old) underwent hemispherotomy between 1995 and 2013. Sixty (83%) had fevers postoperatively, while the remainder were afebrile. Patients without external ventricular drains had higher and more prolonged fevers compared to those with drains (p = 0.003). Patients with Rasmussen's encephalitis tended to have higher postoperative fevers than patients with other seizure etiologies (p = 0.005), while patients with cortical dysplasia and polymicrogyria tended to have less severe fevers (p = 0.027 and 0.017, respectively). Fifty-five patients (76%) had freedom from disabling seizures (Engel class I), and 96% showed worthwhile improvement or better (Engel classes I-III). CONCLUSION Postoperative fever can be anticipated in hemispherotomy patients, may vary based on certain seizure etiologies, and may be mitigated by routinely utilizing external ventricular drainage. Hemispherotomy is an effective surgical procedure for intractable epilepsy in selected patients.
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Affiliation(s)
- Ashwin A Kamath
- Department of Neurological Surgery, St. Louis Children's Hospital, Washington University School of Medicine, One Children's Place, Suite 4S20, St. Louis, MO, 63110, USA,
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Iwasaki M, Uematsu M, Osawa SI, Shimoda Y, Jin K, Nakasato N, Tominaga T. Interhemispheric Vertical Hemispherotomy: A Single Center Experience. Pediatr Neurosurg 2015; 50:295-300. [PMID: 26277842 DOI: 10.1159/000437145] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 06/23/2015] [Indexed: 11/19/2022]
Abstract
PURPOSE Hemispheric epileptogenic lesions such as hemimegalencephaly often manifest as intractable epilepsy in early infancy. Hemispherotomy is the treatment of choice for controlling intractable hemispheric epilepsy. Less invasive procedures are desirable for surgery on infants with low body weight. This study compared our experience with interhemispheric vertical hemispherotomy (IVH) and peri-insular lateral hemispherotomy (PIH). METHODS Thirteen consecutive patients underwent hemispherotomy for treatment of intractable epilepsy in our institution between 2001 and 2012. The etiology of epilepsy included hemimegalencephaly in 7 patients and cortical dysplasia in 3. PIH was performed on the first 5 patients and IVH on the last 8 patients. In the latter procedure, complete section of the corpus callosum was first performed via the interhemispheric approach. After removing part of the cingulate gyrus, section of the descending fibers was performed anterolaterally to the thalamus. Clinical characteristics, duration of operation and amount of blood transfusion were compared between the PIH and IVH groups. RESULTS There was no difference in age at surgery, body weight and age of epilepsy onset between the two groups. No surgery-related death was observed. No patients required shunt operation. One patient who underwent IVH required reoperation for incomplete disconnection. The amount of intraoperative blood transfusion was smaller and the total duration of operation was shorter in the IVH group than in the PIH group. CONCLUSION The interhemispheric approach minimizes cortical resection and may be less invasive than PIH. IVH is advantageous for treating infants with low body weight.
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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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Hemispheric malformations of cortical development: surgical indications and approach. Childs Nerv Syst 2014; 30:1831-7. [PMID: 25296544 DOI: 10.1007/s00381-014-2483-7] [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] [Received: 06/26/2014] [Accepted: 06/27/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The term "hemispheric malformation of cortical development" (MCD) has come into the medical lexicon in the past 20 years as improvements and availability of advanced imaging techniques have permitted more precise diagnosis of a variety of brain developmental disorders that affect large regions of brain. These conditions are united by their propensity to elicit seizures that are difficult to control with medication in the children who suffer them. PURPOSE The goal of surgical intervention is always to achieve seizure freedom and thereby give the affected child the best possible hope for neurological development. Even when seizure freedom cannot be achieved, a reduction in seizure burden is necessary to permit the survival of the child in many cases of MCD. EVALUATION A presurgical evaluation of a patient presenting with severe epilepsy and a possible hemispheric malformation can be divided into three stages. The first includes an evaluation of available imaging, clinical, and genetic data to accurately diagnose the child and help determine if surgical intervention is an option. The next includes an evaluation of EEG and neurological data, although this has limited utility in many clinical circumstances. Finally, a clinical team must decide upon an appropriate surgical strategy among a variety of options. CONCLUSIONS In this review, we will examine the set of diagnoses and associated imaging characteristics that describe the set of conditions for which surgical intervention is a possibility. We include a discussion of available surgical options, describing our own experience with surgery for MCD and the associated postoperative considerations including rates of seizure freedom, considerations for reoperation, and hydrocephalus.
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Toda K, Baba H, Ono T, Ono K. The utility of diffusion tensor imaging tractography for post-operative evaluation of a patient with hemispherotomy performed for intractable epilepsy. Brain Dev 2014; 36:641-4. [PMID: 23981348 DOI: 10.1016/j.braindev.2013.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 08/03/2013] [Accepted: 08/04/2013] [Indexed: 11/27/2022]
Abstract
Hemispherotomy is an effective treatment for patients with severe epilepsy caused by hemispheric abnormalities such as hemimegalencephaly or other dysplastic malformations. Here, we report a 5-year-old boy who experienced right-side hemiconvulsion due to left hemispheric cortical dysplasia. He presented with mild right hemiparesis that had been present since seizure onset. Ictal electroencephalogram obtained during the hemiconvulsion showed localized epileptic discharges in the left hemisphere. He underwent a left peri-insular hemispherotomy. Three months after surgery, clonic convulsions returned in the left leg and EEG-video monitoring showed localized epileptic discharges in the frontal region. Magnetic resonance images showed that the genu of corpus callosum was unsectioned and diffusion tensor imaging tractography confirmed the presence of callosal fibers in the genu of the corpus callosum. Clonic convulsion disappeared after additional section of the corpus callosum. Further studies are warranted to determine the utility of diffusion tensor imaging tractography on the assessment of subcortical fibers following disconnective epilepsy surgery.
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Affiliation(s)
- Keisuke Toda
- Department of Neurosurgery, Nagasaki Medical Center, National Hospital Organization, Japan.
| | - Hiroshi Baba
- Department of Neurosurgery, Nagasaki Medical Center, National Hospital Organization, Japan
| | - Tomonori Ono
- Department of Neurosurgery, Nagasaki Medical Center, National Hospital Organization, Japan
| | - Kenji Ono
- Department of Neurosurgery, Nagasaki Medical Center, National Hospital Organization, Japan
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Leach JL, Miles L, Henkel DM, Greiner HM, Kukreja MK, Holland KD, Rose DF, Zhang B, Mangano FT. Magnetic resonance imaging abnormalities in the resection region correlate with histopathological type, gliosis extent, and postoperative outcome in pediatric cortical dysplasia. J Neurosurg Pediatr 2014; 14:68-80. [PMID: 24866708 DOI: 10.3171/2014.3.peds13560] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED OBJECT.: The authors conducted a study to correlate histopathological features, MRI findings, and postsurgical outcomes in children with cortical dysplasia (CD) by performing a novel resection site-specific evaluation. METHODS The study cohort comprised 43 children with intractable epilepsy and CD. The MR image review was blinded to pathology but with knowledge of the resection location. An MRI score (range 0-7) was calculated for each resection region based on the number of imaging features of CD and was classified as "lesional" or "nonlesional" according to all imaging features. Outcome was determined using the International League Against Epilepsy (ILAE) scale. The determination of pathological CD type was based on the ILAE 2011 consensus classification system, and the cortical gliosis pattern was assessed on GFAP staining. RESULTS There were 89 resection regions (50 ILAE Type I, 29 Type IIa, and 10 Type IIb). Eleven (25.6%) of 43 children had more than one type of CD. The authors observed MRI abnormalities in 63% of patients, characteristic enough to direct resection (lesional) in 42%. Most MRI features, MRI score ≥ 3, and lesional abnormalities were more common in patients with Type II CD. Increased cortical signal was more common in those with Type IIb (70%) rather than Type IIa (17.2%) CD (p = 0.004). A good outcome was demonstrated in 39% of children with Type I CD and 72% of those with Type II CD (61% in Type IIa and 100% in Type IIb) (p = 0.03). A lesional MRI abnormality and an MRI score greater than 3 correlated with good outcome in 78% and 90% of patients, respectively (p < 0.03). Diffuse cortical gliosis was more prevalent in Type II CD and in resection regions exhibiting MRI abnormalities. Complete surgical exclusion of the MRI abnormality was associated with a better postoperative outcome. CONCLUSIONS This study provides a detailed correlation of MRI findings, neuropathological features, and outcomes in children with intractable epilepsy by using a novel resection site-specific evaluation. Because 25% of the patients had multiple CD subtypes, a regional analysis approach was mandated. Those children with lesional MRI abnormalities, Type II CD, and surgical exclusion of the MRI abnormality had better outcomes. Type II CD is more detectable by MRI than other types, partly because of the greater extent of associated gliosis in Type II. Although MRI findings were correlated with the pathological CD type and outcome in this study, the majority of patients (58%) did not have MRI findings that could direct surgical therapy, underscoring the need for improved MRI techniques for detection and for the continued use of multimodal evaluation methods in patient selection.
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Lee YJ, Kim EH, Yum MS, Lee JK, Hong S, Ko TS. Long-term outcomes of hemispheric disconnection in pediatric patients with intractable epilepsy. J Clin Neurol 2014; 10:101-7. [PMID: 24829595 PMCID: PMC4017012 DOI: 10.3988/jcn.2014.10.2.101] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 10/18/2013] [Accepted: 10/22/2013] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose Hemispherectomy reportedly produces remarkable results in terms of seizure outcome and quality of life for medically intractable hemispheric epilepsy in children. We reviewed the neuroradiologic findings, pathologic findings, epilepsy characteristics, and clinical long-term outcomes in pediatric patients following a hemispheric disconnection. Methods We retrospectively studied 12 children (8 males) who underwent a hemispherectomy at Asan Medical Center between 1997 and 2005. Clinical, EEG, neuroradiological, and surgical data were collected. Long-term outcomes for seizure, motor functions, and cognitive functions were evaluated at a mean follow-up of 12.7 years (range, 7.6-16.2 years) after surgery. Results The mean age at epilepsy onset was 3.0 years (range, 0-7.6 years). The following epilepsy syndromes were identified in our cohort: focal symptomatic epilepsy (n=8), West syndrome (n=3), and Rasmussen's syndrome (n=1). Postoperative histopathology of our study patients revealed malformation of cortical development (n=7), encephalomalacia as a sequela of infarction or trauma (n=3), Sturge-Weber syndrome (n=1), and Rasmussen's encephalitis (n=1). The mean age at surgery was 6.5 years (range, 0.8-12.3 years). Anatomical or functional hemispherectomy was performed in 8 patients, and hemispherotomy was performed in 4 patients. Eight of our 12 children (66.7%) were seizure-free, but 3 patients with perioperative complications showed persistent seizure. Although all patients had preoperative hemiparesis and developmental delay, none had additional motor or cognitive deficits after surgery, and most achieved independent walking and improvement in daily activities. Conclusions The long-term clinical outcomes of hemispherectomy in children with intractable hemispheric epilepsy are good when careful patient selection and skilled surgical approaches are applied.
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Affiliation(s)
- Yun-Jeong Lee
- Division of Pediatric Neurology, Department of Pediatrics, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Eun-Hee Kim
- Division of Pediatric Neurology, Department of Pediatrics, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Mi-Sun Yum
- Division of Pediatric Neurology, Department of Pediatrics, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Jung Kyo Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seokho Hong
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Sung Ko
- Division of Pediatric Neurology, Department of Pediatrics, Asan Medical Center Children's Hospital, Seoul, Korea
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Granata T, Matricardi S, Ragona F, Freri E, Casazza M, Villani F, Deleo F, Tringali G, Gobbi G, Tassi L, Lo Russo G, Marras CE, Specchio N, Vigevano F, Fusco L. Hemispherotomy in Rasmussen encephalitis: long-term outcome in an Italian series of 16 patients. Epilepsy Res 2014; 108:1106-19. [PMID: 24815913 DOI: 10.1016/j.eplepsyres.2014.03.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Revised: 03/13/2014] [Accepted: 03/24/2014] [Indexed: 10/25/2022]
Abstract
Surgical disconnection of the affected hemisphere is considered the treatment of choice for Rasmussen encephalitis (RE), however few data on long-term outcomes after disconnective surgery are available. We report on long-term seizure, cognitive and motor outcomes after disconnective surgery in 16 (8 M, 8 F) RE patients. Pre- and post-operative evaluations included long-term video-EEG monitoring, MRI, assessment of motor function, and cognitive evaluation. Hemispherotomy, by various techniques was used to obtain functional disconnection of the affected hemisphere. The patients, of median current age 23.5 years, range 12-33, were operated on between 1993 and 2009. Median age at disease onset was 5.8 years (range 3-11.4). Median time from seizure onset to surgery was 3.8 years, range 8 months to 21 years. Post-surgical follow-up was a median of 9.5 years, range 3-20. At surgery all patients were receiving two or more antiepileptic drugs (AEDs). All but three patients were seizure-free at latest follow-up. AEDs had been stopped in ten patients; in the remaining six AEDs were markedly reduced. Postural control improved in all patients. Gain in cognitive functioning was significantly (p=0.002) related to disease duration. The long-term outcomes, in terms of seizure control, motor improvement, and cognitive improvement provide important support for disconnective surgery as first choice treatment for RE.
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Affiliation(s)
- Tiziana Granata
- Department of Pediatric Neuroscience, Carlo Besta Neurological Institute, Milan, Italy.
| | - Sara Matricardi
- Department of Pediatric Neuroscience, Carlo Besta Neurological Institute, Milan, Italy; Department of Pediatrics, University of Chieti, Chieti, Italy
| | - Francesca Ragona
- Department of Pediatric Neuroscience, Carlo Besta Neurological Institute, Milan, Italy
| | - Elena Freri
- Department of Pediatric Neuroscience, Carlo Besta Neurological Institute, Milan, Italy
| | - Marina Casazza
- Department of Neurophysiology, Carlo Besta Neurological Institute, Milan, Italy
| | - Flavio Villani
- Clinical Epileptology and Experimental Neurophysiology Unit, Carlo Besta Neurological Institute, Milan, Italy
| | - Francesco Deleo
- Clinical Epileptology and Experimental Neurophysiology Unit, Carlo Besta Neurological Institute, Milan, Italy
| | - Giovanni Tringali
- Department of Neurosurgery, Carlo Besta Neurological Institute, Milan, Italy
| | - Giuseppe Gobbi
- Child Neurology Unit, IRCCS Istituto delle Scienze Neurologiche, Bellaria Hospital, Bologna, Italy
| | - Laura Tassi
- Epilepsy Surgery Centre C. Munari, Milan, Italy
| | | | | | - Nicola Specchio
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
| | - Federico Vigevano
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
| | - Lucia Fusco
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
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42
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Sugano H, Nakanishi H, Nakajima M, Higo T, Iimura Y, Tanaka K, Hosozawa M, Niijima S, Arai H. Posterior quadrant disconnection surgery for Sturge-Weber syndrome. Epilepsia 2014; 55:683-689. [DOI: 10.1111/epi.12547] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Hidenori Sugano
- Department of Neurosurgery; Juntendo University; Tokyo Japan
| | | | - Madoka Nakajima
- Department of Neurosurgery; Juntendo University; Tokyo Japan
| | - Takuma Higo
- Department of Neurosurgery; Juntendo University; Tokyo Japan
| | - Yasushi Iimura
- Department of Neurosurgery; Juntendo University; Tokyo Japan
| | - Kyoko Tanaka
- Department of Pediatrics; Juntendo University; Tokyo Japan
| | | | | | - Hajime Arai
- Department of Neurosurgery; Juntendo University; Tokyo Japan
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43
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Modification of vertical hemispherotomy for refractory epilepsy. Brain Dev 2014; 36:124-9. [PMID: 23422258 DOI: 10.1016/j.braindev.2012.12.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 12/28/2012] [Accepted: 12/30/2012] [Indexed: 11/24/2022]
Abstract
Delalande's vertical hemispherotomy is an innovative evolution of hemispherectomy in minimizing brain resection. We report our modification for this surgical procedure. We modified the original procedure in two aspects for the purpose of less brain resection and confirmation of the complete disconnection. Firstly, all procedures were done via an interhemispheric route instead of a transcortical route. Secondly, we set the anterior disconnection plane as the one that connects the anterior end of the choroidal fissure to the anterior end of the foramen of Monro, instead of the former to the subcallosal area. We applied this modified vertical hemispherotomy to 7 cases. Four cases were children with hemimegalencephaly and other 3 were adults with ulegyric hemisphere. Surgical procedure was completed without complication in all cases. There was no case that required CSF shunting. Seizure outcome was Engel's class I in 6 and class IV in 1. Postoperative MRI revealed complete disconnection of the affected hemisphere in all patients. We reported our modification of vertical hemispherotomy. Although these are minor modifications, they further minimized brain resection and may serve for less invasiveness of procedure and improvement in completeness of disconnection and its confirmation during surgery.
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Kucukyuruk B, Yagmurlu K, Tanriover N, Uzan M, Rhoton AL. Microsurgical Anatomy of the White Matter Tracts in Hemispherotomy. Oper Neurosurg (Hagerstown) 2014; 10 Suppl 2:305-24; discussion 324. [DOI: 10.1227/neu.0000000000000288] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Abstract
BACKGROUND:
Hemispherotomy is a surgical procedure performed for refractory epileptic seizures due to wide hemispheric damage.
OBJECTIVE:
To describe the microanatomy of the white matter tracts transected in a hemispherotomy and the relationship of the surgical landmarks used during the intraventricular callosotomy.
METHODS:
The cortical and subcortical structures were examined in 32 hemispheres.
RESULTS:
Incision of the temporal stem along the inferior limiting sulcus crosses the insulo-opercular fibers, uncinate, inferior occipitofrontal and middle longitudinal fasciculi, anterior commissure, and optic and auditory radiations. The incision along the superior limiting sulcus transects insulo-opercular fibers and the genu and posterior limb of internal capsule. The incision along the anterior limiting sulcus crosses the insulo-opercular fibers, anterior limb of the internal capsule, anterior commissure, and the anterior thalamic bundle. The disconnection of the posterior part of the corpus callosum may be incomplete if the point at which the last cortical branch of the anterior cerebral artery (ACA) turns upward and disappears from the view through the intraventricular exposure is used as the landmark for estimating the posterior extent of the callosotomy. This ACA branch turns upward before reaching the posterior edge of the splenium in 85% of hemispheres. The falx, followed to the posterior edge of the splenium, is a more reliable landmark for completing the posterior part of an intraventricular callosotomy.
CONCLUSION:
The fiber tracts disconnected in hemispherotomy were reviewed. The falx is a more reliable guide than the ACA in completing the posterior part of the intraventricular callosotomy.
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Affiliation(s)
- Baris Kucukyuruk
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Kaan Yagmurlu
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Necmettin Tanriover
- Department of Neurosurgery, Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Mustafa Uzan
- Department of Neurosurgery, Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Albert L. Rhoton
- Department of Neurosurgery, University of Florida, Gainesville, Florida
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Dorfer C, Czech T, Dressler A, Gröppel G, Mühlebner-Fahrngruber A, Novak K, Reinprecht A, Reiter-Fink E, Traub-Weidinger T, Feucht M. Vertical perithalamic hemispherotomy: A single-center experience in 40 pediatric patients with epilepsy. Epilepsia 2013; 54:1905-12. [DOI: 10.1111/epi.12394] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Christian Dorfer
- Department of Neurosurgery; Medical University of Vienna; Vienna Austria
| | - Thomas Czech
- Department of Neurosurgery; Medical University of Vienna; Vienna Austria
| | - Anastasia Dressler
- Epilepsy Monitoring Unit; Department of Pediatrics and Adolescence Medicine; Medical University of Vienna; Vienna Austria
| | - Gudrun Gröppel
- Epilepsy Monitoring Unit; Department of Pediatrics and Adolescence Medicine; Medical University of Vienna; Vienna Austria
| | - Angelika Mühlebner-Fahrngruber
- Epilepsy Monitoring Unit; Department of Pediatrics and Adolescence Medicine; Medical University of Vienna; Vienna Austria
| | - Klaus Novak
- Department of Neurosurgery; Medical University of Vienna; Vienna Austria
| | - Andrea Reinprecht
- Department of Neurosurgery; Medical University of Vienna; Vienna Austria
| | - Edith Reiter-Fink
- Epilepsy Monitoring Unit; Department of Pediatrics and Adolescence Medicine; Medical University of Vienna; Vienna Austria
| | | | - Martha Feucht
- Epilepsy Monitoring Unit; Department of Pediatrics and Adolescence Medicine; Medical University of Vienna; Vienna Austria
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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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47
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Abstract
Whereas there is no specific neurosurgical technique in pediatric epilepsy, the frequency of each type of surgery is very different from epilepsy surgery applied in adults, and reflects the underlying etiologies, which are much more diverse in children, with malformations of cortical development and tumors as the prevailing etiologies. Extensive resective or disconnective procedures for extratemporal epilepsy are more frequently performed in infants and younger children, whereas temporo-mesial resection is by far the most common surgical treatment for adults with epilepsy. More recently, less invasive techniques in children with an extensive epileptogenic zone, such as multilobar disconnection, hemispherotomy and other functional hemispherectomy variants, have been introduced in order to reduce duration of surgery, perioperative morbidity and length of hospital stay. Likewise, minimally invasive techniques are utilized, such as the endoscopic disconnection of hypothalamic hamartomas for gelastic epilepsy. This development has been encouraged with the introduction of image-guided navigation systems for the preoperative planning and during surgery. Historically, epilepsy surgery for children has been established much later than for adults. Apart from the particular aspects in perioperative management of younger infants, surgery-related morbidity as well as seizure outcome is in general similar to those in adults, depending rather on each type of surgery.
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Affiliation(s)
- Georg Dorfmüller
- Division of Pediatric Neurosurgery, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; INSERM, U663, Paris, France.
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48
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Pediatric functional hemispherectomy: outcome in 92 patients. Acta Neurochir (Wien) 2012; 154:2017-28. [PMID: 22941395 DOI: 10.1007/s00701-012-1481-3] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 08/10/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The revival of epilepsy surgery after the introduction of modern presurgical evaluation procedures has led to an increase in hemispherectomy or hemispherotomy procedures. Since a large part of our pediatric series was done using a newer hemispherotomy technique, we focus mainly on the outcomes after a recently developed hemispherotomy technique (transsylvian keyhole). METHODS Ninety-six pediatric patients (aged 4 months to 18 years, mean 7.3) were operated on between 1990 and 2009; 92 were available with follow-up. RESULTS The most frequent diagnosis was porencephaly in 46 % of all patients. Progressive etiologies were present in 20 % and developmental etiologies in 22 %. At last available outcome (LAO), 85 % of the patients were seizure free (ILAE class 1). Year-to-year outcome was rather stable; usually over 80 % were class 1 for up to 13 years (n = 24). Of 92 assessable patients, 71 were treated with the transsylvian keyhole technique, with 89 % being seizure free. The overall shunt rate was 5.3 % for the whole series and 3 % for the keyhole technique subgroup. Mortality was 1 of 96 patients. Excluding patients with hemimegalencephaly (HME), patients with the shortest duration of epilepsy and the lowest age at seizure onset had the highest rates of seizure freedom. The etiology does influence outcome, with HME patients having the poorest seizure outcome and patients with Sturge-Weber syndrome and porencephaly having excellent seizure control. CONCLUSION Hemispherotomies/functional hemispherectomies are very effective and safe procedures for treating drug-resistant epilepsy with extensive unihemispheric pathology. Etiology and surgery type clearly influence seizure outcome.
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Ciliberto MA, Limbrick D, Powers A, Titus JB, Munro R, Smyth MD. Palliative hemispherotomy in children with bilateral seizure onset. J Neurosurg Pediatr 2012; 9:381-8. [PMID: 22462702 DOI: 10.3171/2011.12.peds11334] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intractable epilepsy is a significant burden on families and on the cognitive development and quality of life (QOL) of patients. Periinsular hemispherotomy (PIH) for medically intractable epilepsy can benefit patients who qualify for this procedure. The ideal hemispherotomy candidate has ipsilateral ictal and interictal epileptiform activity, unilateral MR imaging abnormalities, contralateral hemiplegia, and a normal contralateral hemisphere. However, certain patients present with a mixed picture of bilateral electroencephalography (EEG) findings and severe intractable epilepsy, prompting consideration of a more aggressive treatment approach. This report introduces the possibility of surgery for patients who normally would not meet criteria for this treatment modality. METHODS In this retrospective chart review, the authors report on 7 patients with bilateral seizure onset noted on routine or video-EEG monitoring. A QOL phone questionnaire, based on the Quality of Life in Childhood Epilepsy tool, was administered to a parent. The authors reviewed each patient's chart for surgical complications, changes in examination, QOL, limited neuropsychological outcomes, and seizure outcomes. They also investigated each chart for MR imaging and EEG findings as well as the patient's epilepsy clinic notes for seizure semiology and frequency. RESULTS All patients enjoyed a decrease in seizure frequency and a subjective increase in QOL after PIH. Five patients (71%) achieved Engel Class I or II seizure control. The mean follow-up was 3.64 years (2-5.3 years). One patient is now off all antiseizure medication. No patient had a decrement in Full Scale IQ on postsurgical testing, and 2 (28.5%) of 7 individuals had increased adaptive and social functioning. Postsurgical examination changes included hemiplegia and homonymous hemianopia. CONCLUSIONS Hemispherotomy in patients with intractable epilepsy is generally reserved for individuals with unilateral epileptiform abnormalities or lesions on MR imaging. Seven patients in this study benefited from surgery despite bilateral seizure onset with improvement in seizure control and overall QOL. Thus, bilateral ictal onset does not necessarily preclude consideration for hemispherotomy in selected patients with severe medically refractory epilepsy.
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Affiliation(s)
- Michael Anthony Ciliberto
- Departments of Developmental and Pediatric Neurology, Washington University, St. Louis, MO 63110, USA.
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50
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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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