Postsurgical Health-related Quality of Life (HRQOL) in Children Following Hemispherectomy for Intractable Epilepsy

Quality of life of children with residual seizures after epileptic resection surgery

Objective

Epilepsy dramatically affects the quality of life (QoL) of children, and resection surgery can improve their QoL by reducing seizures or completely controlling them. Children who have postoperative seizures tend to show a poorer QoL. The aim of the present study was to investigate the QoL of children with seizures after resection surgery and its influencing factors.

Methods

In the present study, we retrospectively reviewed 151 consecutive children who underwent resection surgery. We then divided them into two groups, seizure and seizure-free groups, according to the seizure outcomes 1 year after surgery. Variables were categorized into a number of factor types such as preoperative factors, surgery-related factors, postoperative factors, and family factors. QoL and seizure outcomes more than 3 years after surgery were assessed according to the ILAE seizure outcome classification and the CHEQOL-25 scale.

Results

Forty-three (28.5%) of the 151 children had seizures 1 year after surgery, and two children died during the follow-up period. The mean CHEQOL-25 scale for children with seizures was 63.5 ± 18.2, and 20 (48.8%) patients had poor QoL. Surgery-related factors, such as surgical complications and surgical sequelae, were not statistically associated with QoL. Preoperative language development retardation or language dysfunction [odds ratio (OR) = 29.3, P = 0.012) and postoperative ILAE seizure outcome classification (OR = 1.9, P = 0.045)] were significantly associated with QoL.

Significance

Children with seizures after resection surgery had a relatively poor QoL. Surgery-related factors, such as surgical complications and surgical sequelae, cannot predict the QoL. Preoperative language development retardation or language dysfunction and postoperative ILAE seizure outcome classification were independent predictors of the quality of life (QoL). For children who could not achieve the expected freedom from seizure after surgery, a lower ILAE grade (ILAE 1-3) is also an acceptable outcome since it predicts a higher QoL.

The Dilemma of Hemispherectomy for Rasmussen's Encephalitis in a Neurologically Intact Child

Rasmussen's encephalitis is a rare drug-resistant focal epilepsy characterized by progressive hemiparesis, hemianopia, and cognitive decline. Hemispherectomy is currently the only known treatment that can be curative, though expected to cause postoperative motor and visual deficits in children and adolescents. To date, medical treatment with antiseizure medications and immunosuppressive agents can only offer partial, delayed, or temporary alleviation of symptoms. Hence, patients and families are often faced with the difficult decision to consider the possibility of seizure freedom at the cost of incurring permanent deficits. Here, we discussed the unique ethical issues when faced with a cure that can cause harm, and also discussed a shared decision-making approach guided by informed consent, principles of autonomy, and patient-centered values.

Seizure freedom improves health-related quality of life after epilepsy surgery in children

AIM

To determine whether epilepsy surgery improved health-related quality of life (HRQoL) and whether seizure freedom after surgery mediated the improvement in HRQoL.

METHOD

This multicenter cohort study compared HRQoL after epilepsy surgery to pharmacological management in children with drug-resistant epilepsy (DRE). HRQoL was measured using the Quality of Life in Childhood Epilepsy (QOLCE) questionnaire at baseline and 1-year follow-up. The mediator between treatment type and HRQoL was seizure freedom.

RESULTS

Two hundred and thirty-seven patients were recruited (surgery group: n=147 [92 males, 45 females]; pharmacological group: n=90 [53 males, 37 females]). Mean age at seizure onset was 6 years (SD 4y 4mo) in the surgical group and 6 years 1 month (SD 4y) in the pharmacological group. The odds ratio of seizure freedom was higher for the surgery versus pharmacological group (β=4.24 [95% confidence interval {CI}: 2.26-7.93], p<0.001). Surgery had no direct effect on total QOLCE score at 1-year (β=0.24 [95% CI -2.04 to 2.51], p=0.839) compared to pharmacological management, but had an indirect effect on total QOLCE that was mediated by seizure freedom (β=0.92 [95% CI 0.19-1.65], p=0.013), adjusting for baseline total QOLCE score. Surgery had a direct effect on improving social function (p=0.043), and an indirect effect on improving physical function (p=0.016), cognition (p=0.042), social function (p=0.012) and behavior (p=0.032), mediated by seizure freedom.

INTERPRETATION

Greater seizure freedom achieved through epilepsy surgery mediated the improvement in HRQoL compared to pharmacological management in children with DRE.

WHAT THIS PAPER ADDS

Seizure freedom is higher after pediatric epilepsy surgery compared to pharmacologically managed epilepsy. Surgery indirectly improves health-related quality of life (HRQoL) mediated by seizure freedom compared to pharmacological management. Surgery has a direct effect on improving social function relative to pharmacological management. Baseline HRQoL was an important predictor of HRQoL after treatment.

Quality of Life After Epilepsy Surgery in Children: A Systematic Review and Meta-Analysis

BACKGROUND

Pediatric epilepsy surgery is a treatment modality appropriate for select patients with debilitating medication-resistant seizures. Previous publications have studied seizure freedom as the main outcome of epilepsy surgery. However, there has been no systematic assessment of the postoperative life quality for these children.

OBJECTIVE

To estimate the quality of life (QOL) long-term outcomes after surgery for intractable epilepsy in pediatric patients.

METHODS

A systematic search of the PubMed and Cochrane databases was performed. Studies reporting questionnaire-assessed QOL at least 12 months postoperatively were included. QOL means and standard deviations were compared between surgically and medically managed patients, between the preoperative and postoperative state of each patient, and were further stratified into patients achieving seizure freedom, and those who did not. Meta-analysis was performed using fixed effects models for weighted mean differences (WMD), 95% confidence intervals (CI) and sensitivity analyses. Funnel plots and Begg's tests were utilized to detect publication bias.

RESULTS

The search yielded 18 retrospective studies, reporting 890 surgical patients. Following epilepsy surgery, children had significant QOL improvement compared to their preoperative state (WMD: 16.71, 95% CI: 12.19-21.22, P < .001) and better QOL than matched medically treated controls (WMD: 12.42, 95% CI: 6.25-18.58, P < .001). Patients achieving total seizure freedom after surgery had significant postoperative QOL improvement (WMD: 16.12, 95% CI: 7.98-24.25, P < .001), but patients not achieving seizure freedom did not achieve statistical significance (P = .79).

CONCLUSION

Epilepsy surgery can effectively improve QOL in children with medication-resistant seizures, through seizure freedom, which was associated with the greatest improvement in life quality.

Surgery for Drug-Resistant Epilepsy in Children

BACKGROUND

Neurosurgical treatment may improve seizures in children and adolescents with drug-resistant epilepsy, but additional data are needed from randomized trials.

METHODS

In this single-center trial, we randomly assigned 116 patients who were 18 years of age or younger with drug-resistant epilepsy to undergo brain surgery appropriate to the underlying cause of epilepsy along with appropriate medical therapy (surgery group, 57 patients) or to receive medical therapy alone (medical-therapy group, 59 patients). The patients in the medical-therapy group were assigned to a waiting list for surgery. The primary outcome was freedom from seizures at 12 months. Secondary outcomes were the score on the Hague Seizure Severity scale, the Binet-Kamat intelligence quotient, the social quotient on the Vineland Social Maturity Scale, and scores on the Child Behavior Checklist and the Pediatric Quality of Life Inventory.

RESULTS

At 12 months, freedom from seizures occurred in 44 patients (77%) in the surgery group and in 4 (7%) in the medical-therapy group (P<0.001). Between-group differences in the change from baseline to 12 months significantly favored surgery with respect to the score on the Hague Seizure Severity scale (difference, 19.4; 95% confidence interval [CI], 15.8 to 23.1; P<0.001), on the Child Behavior Checklist (difference, 13.1; 95% CI, 10.7 to 15.6; P<0.001), on the Pediatric Quality of Life Inventory (difference, 21.9; 95% CI, 16.4 to 27.6; P<0.001), and on the Vineland Social Maturity Scale (difference, 4.7; 95% CI, 0.4 to 9.1; P=0.03), but not on the Binet-Kamat intelligence quotient (difference, 2.5; 95% CI, -0.1 to 5.1; P=0.06). Serious adverse events occurred in 19 patients (33%) in the surgery group, including hemiparesis in 15 (26%).

CONCLUSIONS

In this single-center trial, children and adolescents with drug-resistant epilepsy who had undergone epilepsy surgery had a significantly higher rate of freedom from seizures and better scores with respect to behavior and quality of life than did those who continued medical therapy alone at 12 months. Surgery resulted in anticipated neurologic deficits related to the region of brain resection. (Funded by the Indian Council of Medical Research and others; Clinical Trial Registry-India number, CTRI/2010/091/000525 .).

Long-term outcomes of epilepsy surgery in 85 pediatric patients followed up for over 10 years: a retrospective survey

OBJECTIVE The aim of this study was to investigate the treatment outcomes and social engagement of patients who had undergone pediatric epilepsy surgery more than 10 years earlier. METHODS Between 1983 and 2005, 110 patients younger than 16 years underwent epilepsy surgery at the National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders. The authors sent a questionnaire to 103 patients who had undergone follow-up for more than 10 years after surgery; 85 patients (82.5%) responded. The survey contained 4 categories: seizure outcome, use of antiepileptic drugs, social participation, and general satisfaction with the surgical treatment (resection of the epileptic focus, including 4 hemispherectomies). The mean patient age at the time of surgery was 9.8 ± 4.2 (SD) years, and the mean duration of postoperative follow-up was 15.4 ± 5.0 years. Of the 85 patients, 79 (92.9%) presented with a lesional pathology, such as medial temporal sclerosis, developmental/neoplastic lesions, focal cortical dysplasia, and gliosis in a single lobe. RESULTS For 65 of the 85 responders (76.5%), the outcome was recorded as Engel Class I (including 15 [93.8%] of 16 patients with medial temporal sclerosis, 20 [80.0%] of 25 with developmental/neoplastic lesions, and 27 [73.0%] of 37 with focal cortical dysplasia). Of these, 29 (44.6%) were not taking antiepileptic drugs at the time of our survey, 29 (44.6%) held full-time jobs, and 33 of 59 patients (55.9%) eligible to drive had a driver's license. Among 73 patients who reported their degree of satisfaction, 58 (79.5%) were very satisfied with the treatment outcome. CONCLUSIONS The seizure outcome in patients who underwent resective surgery in childhood and underwent followup for more than 10 years was good. Of 85 respondents, 65 (76.5%) were classified in Engel Class I. The degree of social engagement was relatively high, and the satisfaction level with the treatment outcome was also high. From the perspective of seizure control and social adaptation, resective surgery yielded longitudinal benefits in children with intractable epilepsy, especially those with a lesional pathology in a single lobe.

The development of pragmatic skills in children after hemispherotomy: Contribution from left and right hemispheres

PURPOSE

Hemispherotomy (H) is the standard treatment used to cure hemispheric epileptic syndromes in childhood. The postoperative linguistic profile involves hemispheric specialization processes and developmental cognitive plasticity. This research concerns pragmatic aspects of language as a tool for communication which involves both linguistic and extralinguistic communication in context. Our aim was to analyze whether any correlation exists with age at surgery and side of surgery on pragmatic skills following H.

METHOD

Forty children who underwent H (23 females, 16 right H) were evaluated at a mean age of 12.8 years (±2.6) with two receptive tasks (oral comprehension and syntactic judgment), the Children's Communication Checklist (CCC) rating scale, and the Behavioral Rating Inventory of Executive Function (BRIEF) questionnaire in order to evaluate the role of executive functions on pragmatic skills. Children operated on before the age of 18 months were considered the "early" group (5 right H and 9 left H), while those operated on later were called the "late" group (11 right H and 15 left H).

KEY FINDINGS

The whole group had significant deficits in all three measures. We demonstrated a statistically significant crossed interaction between the side of H and the age at H with pragmatic language impairments (F(1,36)=17.48; p=.0002) and disorders in executive function (F(1,36)=5.80; p=.021) in left early H and in right late H patients. These findings are consistent with the previous studies of pragmatic language impairments concerning adolescents and adults with right hemisphere damage and emphasize the contribution of structural language in the early stage of verbal communication.

SIGNIFICANCE

These results emphasize for the first time that hemispherotomized children have pragmatic language impairments that are independent of receptive language. Our findings are congruent with the recent theory on pragmatic language development in childhood with evidence of a participation of the left hemisphere at the early age followed by right hemispheric specialization and involvement of executive functions, independently of receptive language.

Risk Factors on Health-Related Quality of Life in Children With Epilepsy

The goal of this study was to evaluate how epilepsy affected the health-related quality of life (HRQOL) in children with epilepsy, as well as the risk factors for poor HRQOL. Parents of epileptic children (n = 223) and parents of healthy children (n = 216) were enrolled. The Child Epilepsy Questionnaire-Parental form was given to all parents. Children with epilepsy had significantly lower HRQOL scores for overall QOL and all subscales. Seizure types were not associated with HRQOL, but the age of the child with epilepsy, disease courses and seizure frequency did influence the quality of life. Epilepsy has a severe impact on children's HRQOL, and age, increased seizure frequency and longer duration of epilepsy are associated with poor HRQOL.

Language recovery after left hemispherotomy for Rasmussen encephalitis

PURPOSE

Hemispherotomy (H) is the gold standard treatment to cure epilepsy in Rasmussen encephalitis (RE). Linguistic prognosis after surgery remains the main issue when the dominant hemisphere is involved. The topic of the present research is to specify the long-term linguistic profile of the right hemisphere after left dominant H for RE.

METHODS

We followed 6 children 8.4 to 14.6 years of age who underwent left H for RE. Preoperatively, four children experienced aphasia, but for two, worsening occurred after surgery. Age at H ranged from 4.1 to 8.4 years. The mean duration of epilepsy was 1.2 years and 5.6 years for follow-up. Neuropsychological evaluation included longitudinal follow-up of intellectual efficiency measurement and a long-term outcome of language using various components of receptive and expressive oral speech with computerized tasks.

KEY FINDINGS

Preoperatively, verbal comprehension index (VCI) was dramatically decreased in 4/6 patients, and performance reasoning index (PRI) was low in 5/6 participants, demonstrating a global impact of RE itself. Postoperatively, all children recovered sufficiently to attend a regular VCI (above 70) in a mean of 5 years after H, and 5/6 recovered normal or adapted school. There was a dissociation in favor of VCI, while PRI decreased in 5/6 patients. We found a specific linguistic profile for these children recovering language in the right hemisphere: normal verbal comprehension, and weakness of grammatical judgment, word repetition, statement production, semantic verbal fluency and metaphonological abilities. Language recovery scores were statistically correlated with those of Working Memory Index.

SIGNIFICANCE

This study emphasizes for the first time the ability of the right hemisphere to functionally reorganize language over a long period of time following left H for RE. Syntactic abilities and phonology remain low and support the hypothesis of an early left hemispheric specialization. Nevertheless, lexico-semantic processes recover in the right hemisphere that could reflect a pre-existing potential of both hemispheres. Our results support a decision to proceed to H in classical left RE disease until the late childhood even if there is no complete aphasia before surgery. These data should be taken in account in the overall postoperative follow-up and rehabilitation strategy.

A long-term patient perspective after hemispherotomy--a population based study

PURPOSE

Explore the long-term life situation for Swedish hemispherotomy patients reporting not only seizure outcome but also patients' perspectives on function, quality of life (QoL) and satisfaction with the surgery.

METHODS

This population based study uses prospectively collected data from the Swedish National Epilepsy Surgery Register. An independent researcher interviewed patients or parents, using two patient oriented questionnaires.

RESULTS

Twenty-nine patients underwent hemispherotomy in Sweden after 1995 and had a five- or ten-year follow-up. At the 2-year follow-up 55% (16/29) were seizure-free since surgery, and 11/29 (38%) were seizure-free at the long term follow up. Twenty-six (90%) participated in this study. Median time to interview was 13.5 years; 9/26 (35%) were seizure-free then; 23% were off antiepileptic medication. In those not seizure-free, seizures were considered mild or moderate; 11% attended mainstream school and 3/12 adults lived independently. Most parents both of seizure-free and non seizure-free patients reported QoL and general health to be very good/good; 73% were satisfied/very satisfied with the hemispherotomy.

CONCLUSION

In this series there were more long-term recurrences than previously reported. This might be related to the lower level of function of this cohort and higher percentage of developmental aetiologies compared to other series. However, most hemispherotomy patients have a good QoL in the long run and feel that the operation was worthwhile, even when it did not stop seizures. The majority had persisting impairments. Proxies were not very concerned about seizures, indicating that reduction in seizure frequency and/or severity may be an important gain with hemispherotomy.

Surgery for intractable epilepsy due to unilateral brain disease: a retrospective study comparing hemispherectomy techniques

BACKGROUND

Hemispherectomy is a surgical procedure used to treat medically intractable epilepsy in children with severe unilateral cortical disease secondary to acquired brain or congenital lesions. The major surgical approaches for hemispherectomy are anatomic hemispherectomy, traditional functional hemispherectomy, and peri-insular hemispherotomy. We describe the epilepsy outcome, including the need for reoperation, after hemispherectomy in patients with brain malformations or acquired brain lesions who underwent hemispherectomy for refractory epilepsy.

METHODS

We conducted a retrospective observational study at Children's Hospital Boston. Cases were ascertained from a research database of patients who underwent epilepsy surgery from 1997 to 2011. Data were obtained from electronic medical records and office charts. Outcome after surgery was defined as improvement in seizures (quantity and severity) represented by the Engel classification score measured at last follow-up, with a minimum of 12 months of follow-up. The need for reoperation for completion of hemispheric disconnection. We also examined whether placement of ventriculoperitoneal shunt was required after hemispherectomy was a secondary outcome.

RESULTS

We identified 36 patients who underwent hemispherectomy for severe, medically intractable epilepsy. Group 1 (n = 14) had static acquired lesions, and group 2 (n = 22) had malformations of cortical development. Mean age at surgery for group 1 was 9 years (S.D. 5.5) and 2.77 years for group 2 (S.D. 4.01; P < 0.001). The seizure outcome was good in both groups (Engel score I for 25, II for three, III for six, and IV for two patients) and did not differ between the two groups. In group 1, five patients underwent anatomic hemispherectomy (one had prior focal resection), four underwent functional hemispherectomy, and five underwent peri-insular hemispherotomy; none required a second procedure. In group 2, a total of 14 patients had anatomic hemispherectomy (of these, three had had limited prior focal resection), five had functional hemispherectomy, and three had peri-insular hemispherotomy. Among the patients in group 2 who had had functional hemispherectomy, one required reoperation to complete the disconnection and one required peri-insular hemispherotomy because of persistent seizures. In group 1, three patients underwent a ventriculoperitoneal shunt, and from these patients two underwent anatomic hemispherectomy and one had functional hemispherectomy. In group 2, 12 patients had ventriculoperitoneal shunt, and all of them had anatomic hemispherectomy as a first or second procedure.

CONCLUSION

Seizure outcome after hemispherectomy is good in patients with acquired lesions and with developmental malformations. Although the seizure outcome was similar in the three procedures, the complication rate was higher with anatomic hemispherectomy than with the more recent functional hemispherectomy and peri-insular hemispherotomy. The group with cortical malformations generally had surgery at a younger age; two patients with malformations of cortical development who underwent functional hemispherectomy required second surgeries. The need for reoperation in these cases may reflect the anatomic complexity of developmental hemispheric malformations, which may lead to incomplete disconnection.

Health-related quality of life before and after pediatric epilepsy surgery: the influence of seizure outcome on changes in physical functioning and social functioning

Health-related quality of life (HRQOL) is an important outcome in pediatric epilepsy surgery, but there are few studies that utilize presurgical ratings to assess the effect of surgery on HRQOL. We collected parental ratings on the Quality of Life in Childhood Epilepsy (QOLCE) questionnaire for 28 children who participated in neuropsychological assessment before and after epilepsy surgery. Our results revealed significant improvements in overall HRQOL after surgery, especially in physical and social activities. These changes were apparent despite generally unchanged intellectual and psychological functioning. Children with better seizure outcome had more improvement in HRQOL; however, improvements were not statistically different among children with Engel class I, II, and III outcomes. Our results suggest that children can experience significant improvements in HRQOL following epilepsy surgery even when neuropsychological functioning remains unchanged. Moreover, improvements in HRQOL appear evident in children who experience any worthwhile improvement in seizure control (Engel class III or better).

Doing resilience with "half a brain:" navigating moral sensibilities 35 years after hemispherectomy

This paper investigates experiences of resilience in the context of individuals suffering from disability as a result of severe intractable seizure disorder and consequent hemispherectomy, a surgical procedure in which part or all of either the left or right cerebral hemisphere is removed. Two adults who underwent childhood hemispherectomies-one left and one right-are the focus of this study. Previous research has extensively detailed the clinical outcomes of this neurological procedure, yet the actual day-to-day experiences of individuals living post-hemispherectomy remains unexplored. Utilizing open-ended, qualitative, and narrative techniques from a phenomenology of performativity perspective, the authors question how each individual's experiences of daily living are invariably acts of resilience, involving several different strategies that are somewhat unique to each. Rather than working as an adjective or noun signifying certain environmental or individual attributes, this paper proposes that "resilience" is best conceptualized as the individualized intentional actions which disabled, distraught, or at risk individuals perform in contextually relevant and idiosyncratic ways as they navigate health and well-being within their local social and moral worlds.

Quality of life in children with new-onset epilepsy: a 2-year prospective cohort study

OBJECTIVES

To assess health-related quality of life (HRQL) over 2 years in children 4-12 years old with new-onset epilepsy and risk factors.

METHODS

Data are from a multicenter prospective cohort study, the Health-Related Quality of Life Study in Children with Epilepsy Study (HERQULES). Parents reported on children's HRQL and family factors and neurologists on clinical characteristics 4 times. Mean subscale and summary scores were computed for HRQL. Individual growth curve models identified trajectories of change in HRQL scores. Multiple regression identified baseline risk factors for HRQL 2 years later.

RESULTS

A total of 374 (82) questionnaires were returned postdiagnosis and 283 (62%) of eligible parents completed all 4. Growth rates for HRQL summary scores were most rapid during the first 6 months and then stabilized. About one-half experienced clinically meaningful improvements in HRQL, one-third maintained their same level, and one-fifth declined. Compared with the general population, at 2 years our sample scored significantly lower on one-third of CHQ subscales and the psychosocial summary. After controlling for baseline HRQL, cognitive problems, poor family functioning, and high family demands were risk factors for poor HRQL 2 years later.

CONCLUSIONS

On average, HRQL was relatively good but with highly variable individual trajectories. At least one-half did not experience clinically meaningful improvements or declined over 2 years. Cognitive problems were the strongest risk factor for compromised HRQL 2 years after diagnosis and may be largely responsible for declines in the HRQL of children newly diagnosed with epilepsy.

Quality of life in young adults who underwent resective surgery for epilepsy in childhood

PURPOSE

This study investigated quality of life (QOL) in young adults who had undergone epilepsy surgery before the age of 16 years. The contribution to QOL of seizure status in the prior year, sex, number of antiepileptic drugs, and mood were evaluated.

METHODS

Sixty-nine young adults who had undergone surgery were subdivided into those who were seizure-free in the past year (n = 38) and those who had seizures (n = 31) in that time. A nonsurgical comparison group of young adults (n = 29) with childhood-onset medically intractable epilepsy was also studied. All groups completed measures of QOL and mood.

KEY FINDINGS

After accounting for mood, sex, and number of antiepileptic drugs, the seizure-free group reported better cognitive and physical function and overall QOL, experienced less seizure worry, and had better self-perception. Mood was the most consistently predictive covariate, and was independently predictive of many aspects of QOL.

SIGNIFICANCE

Seizure freedom associated with surgery in childhood is associated with improved QOL in certain domains. Findings highlight the importance of mood in determining self-perception of QOL.

Hemispherectomy in pediatric patients with epilepsy: a study of 45 cases with special emphasis on epileptic syndromes

OBJECTIVE

In this study we report the clinical outcomes of hemispherectomy for epilepsy in pediatric patients with special emphasis on the epileptic syndromes and their etiologies.

MATERIAL AND METHODS

We retrospectively studied 45 patients with medically refractory epilepsy with hemispheric lesions who underwent hemispherectomy at the "Hospital de Pediatría Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina between February 1990 and February 2010. Patients had been assessed using a standard protocol involving clinical, neuroradiological, neurophysiological, and neuropsychological teams.

RESULTS

Twenty-seven males and 18 females with a mean age of 8.5 years (range, 2 months to 18 years) who underwent epilepsy surgery for refractory epilepsy were assessed. The mean time of follow-up was 9.5 years (range, 1 to 16 years). The following epileptic syndromes were recognized: West syndrome in 15 patients (33.5%), Rasmussen syndrome in 13 (29%), focal symptomatic epilepsy in 8 (17.5%), startle epilepsy in 6 (13.5%), Lennox-Gastaut syndrome in 2 (5%), and continuous spikes and waves during slow sleep in 1 (2%). The surgical specimens revealed malformations of cortical development in 18 patients (40%), Rasmussen encephalitis in 13 (29%), porencephalic lesions in 10 (22%), gliosis in 2 (4.4%), tumor in 1 (2.2%), and Sturge-Weber syndrome in 1 (2.2%).

CONCLUSION

The outcome of hemispherectomy in pediatric patients is good for those with refractory epilepsies, such as West syndrome, Lennox-Gastaut syndrome, epileptic encephalopathy with continuous spikes and waves during slow sleep, and startle epilepsy arising from a hemispheric lesion associated with hemiplegia.

Quality of life and epilepsy surgery in childhood and adolescence

Epilepsy can affect the quality of life (QOL) of patients. The temporal lobe epilepsy (TLE) is often refractory to medication, which has an adverse impact on QOL. The surgery can be a form to control the seizures and to improve the QOL of the patients. OBJECTIVE: The aim of this study was to verify the QOL of children and adolescents with TLE who underwent surgery for epilepsy, comparing QOL before and after surgery and investigating which parameters showed improvement. METHOD: We used semi-structured questionnaire in the pre-and post-surgery in 13 patients. The data were analyzed using the Wilcoxon test. RESULTS: The analysis showed that there was general improvement in the QOL postoperatively. There was improvement in general health issues, adverse effects of antiepileptic drugs and the relationship with parents. CONCLUSION: When properly indicated, epilepsy surgery improves quality of life of patients with TLE.

Health-related quality of life is reduced in pediatric multiple sclerosis

The health-related quality of life of children with multiple sclerosis was compared with that of healthy children and of those with other neurologic diseases. The Pediatric Quality of Life Inventory Version 4.0 was administered to children with multiple sclerosis and clinically isolated syndrome and their parents (proxy reporters) at the University of California, San Francisco (UCSF), Regional Pediatric Multiple Sclerosis Center. Scores were compared with those of siblings and to those of children seen at the UCSF Pediatric Muscular Dystrophy Association Center. After adjustment for age and sex, children with multiple sclerosis or clinically isolated syndrome (P = 0.003) and their parents (P = 0.001) reported worse overall health-related quality of life than their siblings. Although overall scores for those with early multiple sclerosis or clinically isolated syndrome were better than for children with neuromuscular disease, their self-reported psychosocial scores were similar. The main predictor of reduced self-reported health-related quality of life among children with multiple sclerosis or clinically isolated syndrome was greater neurologic disability, whereas parents reported worse scores for girls, older children, and those with longer disease duration. Although it is better than for children with chronic neuromuscular diseases, children with multiple sclerosis or clinically isolated syndrome have substantial reductions in health-related quality of life.

Current and future indications for deep brain stimulation in pediatric populations

Deep brain stimulation (DBS) has proven to be an effective and safe treatment option in patients with various advanced and treatment-refractory conditions. Thus far, most of the experience with DBS has been in the movement disorder literature, and more specifically in the adult population, where its use in conditions such as Parkinson disease has revolutionized management strategies. The pediatric population, however, can also be afflicted by functionally incapacitating neurological conditions that remain refractory despite the clinicians' best efforts. In such cases, DBS offers an additional treatment alternative. In this paper, the authors review their institution's experience with DBS in the pediatric population, and provide an overview of the literature on DBS in children. The authors conclude that DBS in children can and should be considered a valid and effective treatment option, albeit in highly specific and carefully selected cases.

Contralateral MRI abnormalities in candidates for hemispherectomy for refractory epilepsy

PURPOSE

To assess the impact of contralateral magnetic resonance imaging (MRI) findings on seizure outcome after hemispherectomy for refractory epilepsy.

METHODS

We retrospectively reviewed 110 children, 0.4-18 (median 5.9) years of age, who underwent hemispherectomy for severe refractory epilepsy at Cleveland Clinic Children's Hospital. In children with contralateral (as well as ipsilateral) MRI findings appreciated preoperatively, the decision to proceed to surgery was based on other features concordant with the side with the most severe MRI abnormality, including ipsilateral epileptiform discharges, lateralizing seizure semiology, and side of hemiparesis.

RESULTS

We retrospectively observed contralateral MRI abnormalities (predominantly small hemisphere, white matter loss or abnormal signal, or sulcation abnormalities) in 81 patients (74%), including 31 of 43 (72%) with malformations of cortical development (MCD), 31 of 42 (73%) with perinatal injury from infarction or hypoxia, and 15 of 25 (60%) with Rasmussen's encephalitis, Sturge-Weber syndrome, or posttraumatic encephalomalacia. Among 84 children (76%) with lesions that were congenital or acquired pre- or perinatally, 67 (83%) had contralateral MRI abnormalities (p = 0.02). Contralateral findings were subjectively judged to be mild or moderate in 70 (86%). At follow-up 12-84 (median 24) months after surgery, 79% of patients with contralateral MRI abnormalities were seizure-free compared to 83% of patients without contralateral MRI findings, with no differences based on etiology group or type or severity of contralateral MRI abnormality.

DISCUSSION

MRI abnormalities, usually mild to moderate in severity, were seen in the contralateral hemisphere in the majority of children who underwent hemispherectomy for refractory epilepsy due to various etiologies, especially those that were congenital or early acquired. The contralateral MRI findings, always much less prominent than those in the ipsilateral hemisphere, did not correlate with seizure outcome and may not contraindicate hemispherectomy in otherwise favorable candidates.

Outcomes of epilepsy surgery in adults and children

Surgery is widely accepted as an effective therapy for selected individuals with medically refractory epilepsy. Numerous studies in the past 20 years have reported seizure freedom for at least 1 year in 53-84% of patients after anteromesial temporal lobe resections for mesial temporal lobe sclerosis, in 66-100% of patients with dual pathology, in 36-76% of patients with localised neocortical epilepsy, and in 43-79% of patients after hemispherectomies. Reported rates for non-resective surgery have been less impressive in terms of seizure freedom; however, the benefit is more apparent when reported in terms of significant seizure reductions. In this Review, we consider the outcomes of surgery in adults and children with epilepsy and review studies of neurological and cognitive sequelae, psychiatric and behavioural outcomes, and overall health-related quality of life.

Sociodemographic correlates of health-related quality of life in pediatric epilepsy

In most chronic conditions, better health-related quality of life (HRQOL) is associated with higher socioeconomic status (SES) and ethnic majority status, with disadvantaged groups typically reporting lower HRQOL. In 163 children with intractable epilepsy, we evaluated the relationship between HRQOL and a broad spectrum of demographic variables (SES, parental education, gender, age, marital status, family size, and ethnic and linguistic status), in relation to known neurological and behavioral correlates of HRQOL. No demographic variable was found to be related to child HRQOL, except for marital status, where children from divorced/separated parents had lower HRQOL. However, marital status was not uniquely predictive of HRQOL when neurological and behavioral variables were taken into account. Exploratory analyses indicated that children of separated/divorced parents were more likely to have early epilepsy onset, lower adaptive/developmental levels, and worse seizure frequency, suggesting that severe epilepsy may be a risk factor for marital stress. In sum, contrary to research in other chronic conditions, sociodemographic variables in pediatric epilepsy were weak predictors of HRQOL in comparison to neurological and behavioral variables. The results are discussed with respect to epilepsy-specific determinants of HRQOL.

Marked benefits in physical activity and well-being, but not in functioning domains, 2 years after successful epilepsy surgery in children

In this first study comparing epilepsy-specific quality-of-life measures of children after epilepsy surgery (2.4 years after focal resection) with those of a matched comparison group of nonoperated patients, seizure severity, medication side effects, overall quality of life, general health, physical activity, and well-being were better in surgical patients (70.6% seizure free vs 8.3%). Cognitive, social, and behavioral functioning did not differ, suggesting that these may require additional interventions during postsurgical follow-up.