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Pepi C, De Benedictis A, Rossi-Espagnet MC, Cappelletti S, Da Rold M, Falcicchio G, Vigevano F, Marras CE, Specchio N, De Palma L. Hemispherotomy in Infants with Hemimegalencephaly: Long-Term Seizure and Developmental Outcome in Early Treated Patients. Brain Sci 2022; 13:brainsci13010073. [PMID: 36672056 PMCID: PMC9856354 DOI: 10.3390/brainsci13010073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 12/21/2022] [Accepted: 12/26/2022] [Indexed: 01/01/2023] Open
Abstract
Hemimegalencephaly (HME) is a rare brain congenital malformation, consisting in altered neuronal migration and proliferation within one hemisphere, which is responsible for early onset drug-resistant epilepsy. Hemispherotomy is an effective treatment option for patients with HME and drug-resistant epilepsy. Surgical outcome may be variable among different surgical series, and the long-term neuropsychological trajectory has been rarely defined using a standardized neurocognitive test. We report the epileptological and neuropsychological long-term outcomes of four consecutive HME patients, operated on before the age of three years. All patients were seizure-free and drug-free, and the minimum follow-up duration was of five years. Despite the excellent post-surgical seizure outcome, the long-term developmental outcome is quite variable between patients, ranging from mild to severe intellectual disabilities. Patients showed improvement mainly in communication skills, while visuo-perceptive and coordination abilities were more impaired. Epileptological outcome seems to be improved in early treated patients; however, neuropsychological outcome in HME patients may be highly variable despite early surgery.
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Affiliation(s)
- Chiara Pepi
- Rare and Complex Epilepsies Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, IRCCS, Full Member of European Reference Network EpiCARE, 00165 Rome, Italy
| | | | | | - Simona Cappelletti
- Unit of Clinical Psychology, Department of Neuroscience, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Martina Da Rold
- Scientific Institute, IRCCS “E. Medea”, Association “La Nostra Famiglia”, 31015 Conegliano, Italy
| | - Giovanni Falcicchio
- Department of Basic Medical Sciences, Neurosciences and Sense Organs—University of Bari Aldo Moro, 70121 Bari, Italy
| | - Federico Vigevano
- Rare and Complex Epilepsies Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, IRCCS, Full Member of European Reference Network EpiCARE, 00165 Rome, Italy
| | - Carlo Efisio Marras
- Neurosurgery Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Nicola Specchio
- Rare and Complex Epilepsies Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, IRCCS, Full Member of European Reference Network EpiCARE, 00165 Rome, Italy
- Correspondence: ; Tel.: +39-06-68592645; Fax: +39-06-68592463
| | - Luca De Palma
- Rare and Complex Epilepsies Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, IRCCS, Full Member of European Reference Network EpiCARE, 00165 Rome, Italy
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Rasmussen's encephalitis: From immune pathogenesis towards targeted-therapy. Seizure 2020; 81:76-83. [DOI: 10.1016/j.seizure.2020.07.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/09/2020] [Accepted: 07/23/2020] [Indexed: 12/12/2022] Open
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Harris WB, Phillips HW, Chen JS, Weil AG, Ibrahim GM, Fallah A. Seizure outcomes in children with Rasmussen's encephalitis undergoing resective or hemispheric epilepsy surgery: an individual participant data meta-analysis. J Neurosurg Pediatr 2019; 25:274-283. [PMID: 31812145 DOI: 10.3171/2019.9.peds19380] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 09/23/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to perform an individual participant data meta-analysis to identify preoperative factors associated with a good seizure outcome in children with Rasmussen's encephalitis (RE) undergoing resective or hemispheric epilepsy surgery. METHODS Electronic databases (PubMed, Web of Science, CINAHL) were searched with no language or date restrictions to identify cohort studies of consecutive participants undergoing resective surgery that reported seizure outcomes. The authors recorded all preoperative factors that could plausibly be associated with seizure outcomes and used Cox regression analysis to identify which of these variables were associated with seizure freedom (i.e., Engel class I). RESULTS Of 720 citations, 19 articles reporting on 187 participants were eligible. Seizure freedom (Engel class I) was observed in 113 participants (60.4%). On univariate analyses, younger age at disease onset (hazard ratio [HR] 0.906, p = 0.001), younger age at surgery (HR 0.928, p < 0.001), shorter time to surgery (HR 0.921, p = 0.001), and hemispherectomy (HR 0.283, p < 0.001) were all associated with longer time to postoperative seizure recurrence. Additionally, multivariable analysis including the aforementioned variables showed that younger age at surgery (HR 0.946, p = 0.043) and hemispherectomy (HR 0.297, p < 0.001) were independently and significantly associated with a greater time to seizure recurrence and longer duration of seizure freedom. CONCLUSIONS The majority of pediatric patients undergoing resective or hemispheric surgery for RE achieve good seizure outcome. Although small retrospective cohort studies are inherently prone to bias, the best available evidence utilizing individual participant data suggests hemispheric surgery and younger age at surgery are associated with good seizure outcomes following epilepsy surgery. Large, multicenter observational studies with long-term follow-up are required to evaluate the risk factors identified in this review.
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Affiliation(s)
- William B Harris
- 1John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawai'i
| | - H Westley Phillips
- 2Department of Neurosurgery, University of California, Los Angeles, California
| | | | - Alexander G Weil
- 4Division of Neurosurgery, Ste. Justine Hospital, University of Montreal, Quebec, Canada; and
| | - George M Ibrahim
- 5Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Aria Fallah
- 2Department of Neurosurgery, University of California, Los Angeles, California
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EEG lateralization and seizure outcome following peri-insular hemispherotomy for pediatric hemispheric epilepsy. Childs Nerv Syst 2019; 35:1189-1195. [PMID: 30701299 DOI: 10.1007/s00381-019-04067-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 01/16/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To determine whether preoperative non-lateralizing scalp electroencephalography (EEG) influences seizure outcome following peri-insular hemispherotomy (PIH) in pediatric hemispheric epilepsy. METHODS Retrospective data was collected on all 45 pediatric patients who underwent PIH between 2005 and 2016. All underwent a basic pre-surgical evaluation consisting of detailed history and examination, neuropsychological assessment, MRI, and EEG. SPECT/PET, fRMI, or Wada testing were done in only eight patients. Seizure outcome was assessed using the Engel classification. RESULTS Among those who underwent hemispherotomy, 20 (44%) were females. Mean age at surgery was 8 ± 4.3 years and mean duration of symptoms was 5.2 ± 3.7 years. The most common etiologies of hemispheric epilepsy were hemiconvulsion-hemiplegia epilepsy syndrome, Rasmussen encephalitis, and post-encephalitic sequelae, together comprising 27 (60%) patients. Among the 44 patients with follow-up data (mean duration 48 ± 33 months), seizure freedom (Engel class I) was attained by 41 (93.2%). Anti-epileptic medications were stopped or decreased in 36 (82%). Seventeen (38.6%) patients had non-lateralizing EEG. Seizure outcome was not related to lateralization of EEG activity. CONCLUSIONS PIH provides excellent long-term seizure control in patients despite the presence of non-lateralizing epileptiform activity, although occurrence of acute postoperative seizures may be higher. Routine SPECT/PET may not be required in patients with a non-lateralizing EEG if there is good clinico-radiological concordance.
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Li Y, Wang Y, Tan Z, Chen Q, Huang W. Longitudinal brain functional and structural connectivity changes after hemispherotomy in two pediatric patients with drug-resistant epilepsy. EPILEPSY & BEHAVIOR CASE REPORTS 2018; 11:58-66. [PMID: 30723671 PMCID: PMC6350230 DOI: 10.1016/j.ebcr.2018.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/24/2018] [Accepted: 11/20/2018] [Indexed: 11/30/2022]
Abstract
The main focus of the present study was to explore the longitudinal changes in the brain executive control system and default mode network after hemispherotomy. Resting-state functional magnetic resonance imaging and diffusion tensor imaging were collected in two children with drug-resistnt epilepsy underwent hemispherotomy. Two patients with different curative effects showed different trajectories of brain connectivity after surgery. The failed hemispherotomy might be due to the fact that the synchrony of epileptic neurons in both hemispheres is preserved by residual neural pathways. Loss of interhemispheric correlations with increased intrahemispheric correlations can be considered as neural marker for evaluating the success of hemispherotomy.
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Affiliation(s)
- Yongxin Li
- Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Ya Wang
- Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Zhen Tan
- Department of Pediatric Neurosurgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Qian Chen
- Department of Pediatric Neurosurgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Wenhua Huang
- Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
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Cossu G, Lebon S, Seeck M, Pralong E, Messerer M, Roulet-Perez E, Daniel RT. Periinsular anterior quadrantotomy: technical note. J Neurosurg Pediatr 2018; 21:124-132. [PMID: 29219786 DOI: 10.3171/2017.8.peds17339] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Refractory frontal lobe epilepsy has been traditionally treated through a frontal lobectomy. A disconnective technique may allow similar seizure outcomes while avoiding the complications associated with large brain resections. The aim of this study was to describe a new technique of selective disconnection of the frontal lobe that can be performed in cases of refractory epilepsy due to epileptogenic foci involving 1 frontal lobe (anterior to the motor cortex), with preservation of motor function. In addition to the description of the technique, an illustrative case is also presented. This disconnective procedure is divided into 4 steps: the suprainsular window, the anterior callosotomy, the intrafrontal disconnection, and the frontobasal disconnection. The functional neuroanatomy is analyzed in detail for each step of the surgery. It is important to perform cortical and subcortical electrophysiological mapping to guide this disconnective procedure and identify eloquent cortices and intact neural pathways. The authors describe the case of a 9-year-old boy who presented with refractory epilepsy due to epileptogenic foci localized to the right frontal lobe. MRI confirmed the presence of a focal cortical dysplasia of the right frontal lobe. A periinsular anterior quadrant disconnection (quadrantotomy) was performed. The postoperative period was uneventful, and the patient was in Engel seizure outcome Class I at the 3-year follow-up. A significant cognitive gain was observed during follow-up. Periinsular anterior quadrantotomy may thus represent a safe technique to efficiently treat refractory epilepsy when epileptogenic foci are localized to 1 frontal lobe while preserving residual motor functions.
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Affiliation(s)
| | - Sebastien Lebon
- 2Unit of Pediatric Neurology and Neurorehabilitation, Department of Pediatrics, University Hospital of Lausanne; and
| | - Margitta Seeck
- 3Epilepsy Unit, Department of Neurology, University Hospital of Geneva, Switzerland
| | | | | | - Eliane Roulet-Perez
- 2Unit of Pediatric Neurology and Neurorehabilitation, Department of Pediatrics, University Hospital of Lausanne; and
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Hawasli AH, Chacko R, Szrama NP, Bundy DT, Pahwa M, Yarbrough CK, Dlouhy BJ, Limbrick DD, Barbour DL, Smyth MD, Leuthardt EC. Electrophysiological Sequelae of Hemispherotomy in Ipsilateral Human Cortex. Front Hum Neurosci 2017; 11:149. [PMID: 28424599 PMCID: PMC5371676 DOI: 10.3389/fnhum.2017.00149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 03/13/2017] [Indexed: 12/02/2022] Open
Abstract
Objectives: Hemispheric disconnection has been used as a treatment of medically refractory epilepsy and evolved from anatomic hemispherectomy to functional hemispherectomies to hemispherotomies. The hemispherotomy procedure involves disconnection of an entire hemisphere with limited tissue resection and is reserved for medically-refractory epilepsy due to diffuse hemispheric disease. Although it is thought to be effective by preventing seizures from spreading to the contralateral hemisphere, the electrophysiological effects of a hemispherotomy on the ipsilateral hemisphere remain poorly defined. The objective of this study was to evaluate the effects of hemispherotomy on the electrophysiologic dynamics in peri-stroke and dysplastic cortex. Methods: Intraoperative electrocorticography (ECoG) was recorded from ipsilateral cortex in 5 human subjects with refractory epilepsy before and after hemispherotomy. Power spectral density, mutual information, and phase-amplitude coupling were measured from the ECoG signals. Results: Epilepsy was a result of remote perinatal stroke in three of the subjects. In two of the subjects, seizures were a consequence of dysplastic tissue: one with hemimegalencephaly and the second with Rasmussen's encephalitis. Hemispherotomy reduced broad-band power spectral density in peri-stroke cortex. Meanwhile, hemispherotomy increased power in the low and high frequency bands for dysplastic cortex. Functional connectivity was increased in lower frequency bands in peri-stroke tissue but not affected in dysplastic tissue after hemispherotomy. Finally, hemispherotomy reduced band-specific phase-amplitude coupling in peristroke cortex but not dysplastic cortex. Significance: Disconnecting deep subcortical connections to peri-stroke cortex via a hemispherotomy attenuates power of oscillations and impairs the transfer of information from large-scale distributed brain networks to the local cortex. Hence, hemispherotomy reduces heterogeneity between neighboring cortex while impairing phase-amplitude coupling. In contrast, dysfunctional networks in dysplastic cortex lack the normal connectivity with distant networks. Therefore hemispherotomy does not produce the same effects.
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Affiliation(s)
- Ammar H Hawasli
- Department of Neurological Surgery, Washington University School of MedicineSaint Louis, MO, USA
| | - Ravi Chacko
- Department of Biomedical Engineering, Washington University School of MedicineSaint Louis, MO, USA
| | - Nicholas P Szrama
- Department of Biomedical Engineering, Washington University School of MedicineSaint Louis, MO, USA
| | - David T Bundy
- Department of Biomedical Engineering, Washington University School of MedicineSaint Louis, MO, USA
| | - Mrinal Pahwa
- Department of Biomedical Engineering, Washington University School of MedicineSaint Louis, MO, USA
| | - Chester K Yarbrough
- Department of Neurological Surgery, Washington University School of MedicineSaint Louis, MO, USA
| | - Brian J Dlouhy
- Department of Neurosurgery, University of Iowa Hospitals and ClinicsIowa City, IA, USA
| | - David D Limbrick
- Department of Neurological Surgery, Washington University School of MedicineSaint Louis, MO, USA
| | - Dennis L Barbour
- Department of Biomedical Engineering, Washington University School of MedicineSaint Louis, MO, USA
| | - Matthew D Smyth
- Department of Neurological Surgery, Washington University School of MedicineSaint Louis, MO, USA
| | - Eric C Leuthardt
- Department of Neurological Surgery, Washington University School of MedicineSaint Louis, MO, USA.,Department of Biomedical Engineering, Washington University School of MedicineSaint Louis, MO, USA
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Nagahama Y, Joshi C, Dlouhy B, Wu AY, Abel TJ, Baumbach G, Kawasaki H. Functional hemispherotomy in Rasmussen syndrome in the absence of classic MRI findings. EPILEPSY & BEHAVIOR CASE REPORTS 2017; 7:24-27. [PMID: 28239546 PMCID: PMC5315437 DOI: 10.1016/j.ebcr.2016.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/19/2016] [Accepted: 11/25/2016] [Indexed: 12/02/2022]
Abstract
A 7-year-old previously healthy girl presented with a left-sided focal seizure without impaired consciousness and subsequently developed epilepsia partialis continua. Initial MRI was normal, and the subsequent images only showed a focal T2/FLAIR hyperintense area without cortical atrophy. She was diagnosed with Rasmussen syndrome by pathology and promptly treated with functional hemispherotomy. Rasmussen syndrome is a rare progressive neurological disorder, the only definitive cure for which is hemispheric disconnection. The disease presents a management dilemma, especially early in disease course without characteristic neuroimaging features. A high index of suspicion, multidisciplinary approach, and clear timely communication with the family are critical.
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Affiliation(s)
- Yasunori Nagahama
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Charuta Joshi
- Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Brian Dlouhy
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Angela Y Wu
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Taylor J Abel
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Gary Baumbach
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Hiroto Kawasaki
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Abstract
First-line treatment for epilepsy is antiepileptic drug and requires an interdisciplinary approach and enduring commitment and adherence from the patient and family for successful outcome. Despite adherence to antiepileptic drugs, refractory epilepsy occurs in approximately 30% of children with epilepsy, and surgical treatment is an important intervention to consider. Surgical management of pediatric epilepsy is highly effective in selected patients with refractory epilepsy; however, an evidence-based protocol, including best methods of presurgical imaging assessments, and neurodevelopmental and/or behavioral health assessments, is not currently available for clinicians. Surgical treatment of epilepsy can be critical to avoid negative outcomes in functional, cognitive, and behavioral health status. Furthermore, it is often the only method to achieve seizure freedom in refractory epilepsy. Although a large literature base can be found for adults with refractory epilepsy undergoing surgical treatment, less is known about how surgical management affects outcomes in children with epilepsy. The purpose of the review was fourfold: (1) to evaluate the available literature regarding presurgical assessment and postsurgical outcomes in children with medically refractory epilepsy, (2) to identify gaps in our knowledge of surgical treatment and its outcomes in children with epilepsy, (3) to pose questions for further research, and (4) to advocate for a more unified presurgical evaluation protocol including earlier referral for surgical candidacy of pediatric patients with refractory epilepsy. Despite its effectiveness, epilepsy surgery remains an underutilized but evidence-based approach that could lead to positive short- and long-term outcomes for children with refractory epilepsy.
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Liu X, Otsuki T, Takahashi A, Kaido T. Vertical parasagittal hemispherotomy for Sturge-Weber syndrome in early infancy: case report and literature review. SPRINGERPLUS 2016; 5:1434. [PMID: 27652010 PMCID: PMC5005253 DOI: 10.1186/s40064-016-3096-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 08/17/2016] [Indexed: 11/10/2022]
Abstract
INTRODUCTION The authors here present a rare case of a 3-month-old infant with unilateral Sturge-Weber syndrome (SWS) who had excellent seizure control and no aggravation of previous existed neurological deficits after vertical parasagittal hemispherotomy (VPH). To our knowledge, this patient with SWS was the youngest one who received VPH. CASE DESCRIPTION The use of VPH results in a successful treatment of intractable epilepsy in a patient with seizure onset in early infancy. At follow-up, the patient's neurodevelopmental status has been improved since the surgery. DISCUSSION It is generally accepted that early-onset seizures in children with SWS are associated with worse neurological and developmental outcomes. However, when surgical treatment should be considered and how it should be performed remain a longstanding controversy. We promote early surgery in children with SWS and early-onset epilepsy. CONCLUSION We suggest that VPH may be a useful adjuvant in the management of SWS with refractory epilepsy in early infancy and this procedure carries low neurological risk.
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Affiliation(s)
- Xiangyu Liu
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, 305 East Zhongshan Road, Nanjing, 210002 Jiangsu Province People's Republic of China
| | - Taisuke Otsuki
- Department of Neurosurgery, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551 Japan
| | - Akio Takahashi
- Department of Neurosurgery, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551 Japan
| | - Takanobu Kaido
- Department of Neurosurgery, National Hospital Organization Nara Medical Center, Shichijo 2-789, Nara, 630-8053 Japan
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Küpper H, Kudernatsch M, Pieper T, Groeschel S, Tournier JD, Raffelt D, Winkler P, Holthausen H, Staudt M. Predicting hand function after hemidisconnection. Brain 2016; 139:2456-68. [PMID: 27383529 DOI: 10.1093/brain/aww170] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 05/31/2016] [Indexed: 12/13/2022] Open
Abstract
Hemidisconnections (i.e. hemispherectomies or hemispherotomies) invariably lead to contralateral hemiparesis. Many patients with a pre-existing hemiparesis, however, experience no deterioration in motor functions, and some can still grasp with their paretic hand after hemidisconnection. The scope of our study was to predict this phenomenon. Hypothesizing that preserved contralateral grasping ability after hemidisconnection can only occur in patients controlling their paretic hands via ipsilateral corticospinal projections already in the preoperative situation, we analysed the asymmetries of the brainstem (by manual magnetic resonance imaging volumetry) and of the structural connectivity of the corticospinal tracts within the brainstem (by magnetic resonance imaging diffusion tractography), assuming that marked hypoplasia or Wallerian degeneration on the lesioned side in patients who can grasp with their paretic hands indicate ipsilateral control. One hundred and two patients who underwent hemidisconnections between 0.8 and 36 years of age were included. Before the operation, contralateral hand function was normal in 3/102 patients, 47/102 patients showed hemiparetic grasping ability and 52/102 patients could not grasp with their paretic hands. After hemidisconnection, 20/102 patients showed a preserved grasping ability, and 5/102 patients began to grasp with their paretic hands only after the operation. All these 25 patients suffered from pre- or perinatal brain lesions. Thirty of 102 patients lost their grasping ability. This group included all seven patients with a post-neonatally acquired or progressive brain lesion who could grasp before the operation, and also all three patients with a preoperatively normal hand function. The remaining 52/102 patients were unable to grasp pre- and postoperatively. On magnetic resonance imaging, the patients with preserved grasping showed significantly more asymmetric brainstem volumes than the patients who lost their grasping ability. Similarly, these patients showed striking asymmetries in the structural connectivity of the corticospinal tracts. In summary, normal preoperative hand function and a post-neonatally acquired or progressive lesion predict a loss of grasping ability after hemidisconnection. A postoperatively preserved grasping ability is possible in hemiparetic patients with pre- or perinatal lesions, and this is highly likely when the brainstem is asymmetric and especially when the structural connectivity of the corticospinal tracts within the brainstem is asymmetric.
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Affiliation(s)
- Hanna Küpper
- 1 Department of Paediatric Neurology and Developmental Medicine, Children's Hospital, University of Tübingen, Germany
| | - Manfred Kudernatsch
- 2 Neurosurgery Clinic and Clinic for Epilepsy Surgery, Schön Klinik Vogtareuth, Germany
| | - Tom Pieper
- 3 Clinic for Neuropaediatrics and Neurorehabilitation, Epilepsy Centre for Children and Adolescents, Schön Klinik, Vogtareuth, Germany
| | - Samuel Groeschel
- 1 Department of Paediatric Neurology and Developmental Medicine, Children's Hospital, University of Tübingen, Germany
| | | | - David Raffelt
- 5 Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - Peter Winkler
- 3 Clinic for Neuropaediatrics and Neurorehabilitation, Epilepsy Centre for Children and Adolescents, Schön Klinik, Vogtareuth, Germany
| | - Hans Holthausen
- 3 Clinic for Neuropaediatrics and Neurorehabilitation, Epilepsy Centre for Children and Adolescents, Schön Klinik, Vogtareuth, Germany
| | - Martin Staudt
- 1 Department of Paediatric Neurology and Developmental Medicine, Children's Hospital, University of Tübingen, Germany 3 Clinic for Neuropaediatrics and Neurorehabilitation, Epilepsy Centre for Children and Adolescents, Schön Klinik, Vogtareuth, Germany
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A connectomics approach combining structural and effective connectivity assessed by intracranial electrical stimulation. Neuroimage 2016; 132:344-358. [DOI: 10.1016/j.neuroimage.2016.02.054] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/31/2016] [Accepted: 02/17/2016] [Indexed: 10/22/2022] Open
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Tamburrini G, Battaglia D, Albamonte E, Contaldo I, Massimi L, Caldarelli M, Di Rocco C. Surgery for posterior quadrantic cortical dysplasia. A review. Childs Nerv Syst 2014; 30:1859-68. [PMID: 25296547 DOI: 10.1007/s00381-014-2449-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 05/19/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Posterior quadrant dysplastic lesions represent 3-15 % of multilobar cortical developmental pathologies, 3-5 % of all the indications to surgery for epilepsy resistant to medical treatment. OBJECTIVE AND METHODS The objective of this study is to review the pertinent literature related to the presurgical clinical, neurophysiological, and neuroradiological evaluation of children affected by posterior quadrant dysplasia in order to discuss the intraoperative management and the different surgical techniques that have been proposed to treat this condition as well as factors related with postsurgical seizure outcome. RESULTS AND CONCLUSIONS Seizures appear most commonly in infants and rapidly progress to a catastrophic course. They are mostly represented by focal seizures and spasms. Surface interictal video-EEG is characterized by background flattening and paroxysmal discharges prevalent on the affected side but not unusually extending to the controlateral hemisphere. The last occasionally shows an independent irritative activity in spite of the absence of further visible structural abnormalities. Most of the patients have visual field or visual attention deficits at diagnosis. Resective as well as disconnective surgical procedures have been proposed for the management of this condition, none of them having shown clear advantages in terms of seizure outcome and complications. Intraoperative electrocorticography (EcoG) and sensorimotor monitoring have been successfully used to improve the localization of the epileptic focus and reduce surgical complication rates. Undistincted lesion borders, independent controlateral ictal or/and interictal EEG activity, and incomplete resections/disconnections are among the main factors that have resulted to be associated with a worse seizure outcome.
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Affiliation(s)
- G Tamburrini
- Pediatric Neurosurgery Unit, Institute of Neurosurgery, Catholic University Medical School, Largo "A. Gemelli", 8, 00168, Rome, Italy,
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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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15
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Varadkar S, Bien CG, Kruse CA, Jensen FE, Bauer J, Pardo CA, Vincent A, Mathern GW, Cross JH. Rasmussen's encephalitis: clinical features, pathobiology, and treatment advances. Lancet Neurol 2014; 13:195-205. [PMID: 24457189 DOI: 10.1016/s1474-4422(13)70260-6] [Citation(s) in RCA: 256] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Rasmussen's encephalitis is a rare chronic neurological disorder, characterised by unilateral inflammation of the cerebral cortex, drug-resistant epilepsy, and progressive neurological and cognitive deterioration. Neuropathological and immunological studies support the notion that Rasmussen's encephalitis is probably driven by a T-cell response to one or more antigenic epitopes, with potential additional contribution by autoantibodies. Careful analysis of the association between histopathology and clinical presentation suggests that initial damage to the brain is mediated by T cells and microglia, suggesting a window for treatment if Rasmussen's encephalitis can be diagnosed early. Advances in neuroimaging suggest that progression of the inflammatory process seen with MRI might be a good biomarker in Rasmussen's encephalitis. For many patients, families, and doctors, choosing the right time to move from medical management to surgery is a real therapeutic dilemma. Cerebral hemispherectomy remains the only cure for seizures, but there are inevitable functional compromises. Decisions of whether or when surgery should be undertaken are challenging in the absence of a dense neurological deficit, and vary by institutional experience. Further, the optimum time for surgery, to give the best language and cognitive outcome, is not yet well understood. Immunomodulatory treatments seem to slow rather than halt disease progression in Rasmussen's encephalitis, without changing the eventual outcome.
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Affiliation(s)
- Sophia Varadkar
- Epilepsy Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and UCL Institute of Child Health, London, UK.
| | | | - Carol A Kruse
- Department of Neurosurgery, Brain Research Institute, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Frances E Jensen
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, PA, USA
| | - Jan Bauer
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Carlos A Pardo
- Department of Neurology and Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Gary W Mathern
- Departments of Neurosurgery and Psychiatry and Biobehavioral Medicine, David Geffen School of Medicine, Mattel Children's Hospital, University of California, Los Angeles, CA, USA
| | - J Helen Cross
- Neurosciences Unit, UCL Institute of Child Health, Great Ormond Street Hospital for Children NHS Foundation Trust, London, and Young Epilepsy, Lingfield, UK
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