Hemispherotomy or lobectomy? The role of presurgical neuroimaging in a young case of a large porencephalic cyst with intractable epilepsy

The role of preoperative diffusion tensor imaging in predicting and improving functional outcome in pediatric patients undergoing epilepsy surgery: a systematic review

OBJECTIVE

Diffusion tensor imaging (DTI) is a useful neuroimaging technique for surgical planning in adult patients. However, no systematic review has been conducted to determine its utility for pre-operative analysis and planning of Pediatric Epilepsy surgery. We sought to determine the benefit of pre-operative DTI in predicting and improving neurological functional outcome after epilepsy surgery in children with intractable epilepsy.

METHODS

A systematic review of articles in English using PubMed, EMBASE and Scopus databases, from inception to January 10, 2020 was conducted. All studies that used DTI as either predictor or direct influencer of functional neurological outcome (motor, sensory, language and/or visual) in pediatric epilepsy surgical candidates were included. Data extraction was performed by two blinded reviewers. Risk of bias of each study was determined using the QUADAS 2 Scoring System.

RESULTS

13 studies were included (6 case reports/series, 5 retrospective cohorts, and 2 prospective cohorts) with a total of 229 patients. Seven studies reported motor outcome; three reported motor outcome prediction with a sensitivity and specificity ranging from 80 to 85.7 and 69.6 to 100%, respectively; four studies reported visual outcome. In general, the use of DTI was associated with a high degree of favorable neurological outcomes after epilepsy surgery.

CONCLUSION

Multiple studies show that DTI helps to create a tailored plan that results in improved functional outcome. However, more studies are required in order to fully assess its utility in pediatric patients. This is a desirable field of study because DTI offers a non-invasive technique more suitable for children.

ADVANCES IN KNOWLEDGE

This systematic review analyses, exclusively, studies of pediatric patients with drug-resistant epilepsy and provides an update of the evidence regarding the role of DTI, as part of the pre-operative armamentarium, in improving post-surgical neurological sequels and its potential for outcome prediction.

Intraparenchymal hemorrhage and cerebral venous thrombosis in an adult with congenital porencephalic cyst presenting for generalized tonic-clonic seizures

Prothrombotic conditions are known risk factors for porencephalic cyst formation and cerebral vein thrombosis. Intracerebral hemorrhage is a potential complication of a cerebral vein thrombosis. Porencephaly is a risk factor for intracerebral hemorrhage and cerebral vein thrombosis formation. We present the case of an adult patient with a past medical history of epilepsy and congenital porencephalic cyst with de novo mutation of the COL4A1 gene who presented for episodes of generalized tonic-clonic seizure after a substantial symptom-free period. A brain CT scan showed an intracerebral hemorrhage with porencephalic cyst and superior sagittal sinus thrombosis despite negative thrombophilia work-up. A CT perfusion study, CT angiography, and brain MRI confirmed the diagnosis. The cause-and-effect relationship between porencephalic cysts, cerebral venous thrombosis, and intracerebral hemorrhage is still not clear in the literature.

Unusual Presentation of Porencephalic Cyst in an Adult

Porencephalic cyst is quite a rare entity in adults with only a few cases reported so far. It is usually congenital and seen in neonates. Here, we report a 28-year-old female who presented with post-ictal confusion following a new onset of focal seizures with secondary generalisation. She was diagnosed to have porencephalic cyst in left posterior parietal lobe on brain imaging. She was started on anti-epileptic drugs and is on follow up.

The start and development of epilepsy surgery in Europe: a historical review

Epilepsy has not always been considered a brain disease, but was believed to be a demonic possession in the past. Therefore, trepanation was done not only for medical but also for religious or spiritual reasons, originating in the Neolithic period (3000 BC). The earliest documentation of trepanation for epilepsy is found in the writings of the Hippocratic Corpus and consisted mainly of just skull surgery. The transition from skull surgery to brain surgery took place in the middle of the nineteenth century when the insight of epilepsy as a cortical disorder of the brain emerged. This led to the start of modern epilepsy surgery. The pioneer countries in which epilepsy surgery was performed in Europe were the UK, Germany, and The Netherlands. Neurosurgical forerunners like Sir Victor Horsley, William Macewen, Fedor Krause, and Otfrid Foerster started with "modern" epilepsy surgery. Initially, epilepsy surgery was mainly done with the purpose to resect traumatic lesions or large surface tumours. In the course of the twentieth century, this changed to highly specialized microscopic navigation-guided surgery to resect lesional and non-lesional epileptogenic cortex. The development of epilepsy surgery in Southern Europe, which has not been described until now, will be elaborated in this manuscript. To summarize, in this paper, we provide (1) a detailed description of the evolution of European epilepsy surgery with special emphasis on the pioneer countries; (2) novel, never published information about the development of epilepsy surgery in Southern Europe; and (3) we review the historical dichotomy of invasive electrode implantation strategy (Anglo-Saxon surface electrodes versus French-Italian stereoencephalography (SEEG) model).

The patient had a normal magnetic resonance imaging and temporal lobe epilepsy secondary to a porencephalic cyst but showed structural lesions (hippocampal sclerosis)

Patients with a porencephalic cyst frequently develop intractable temporal lobe epilepsy (TLE). We report a surgically-treated male patient with intractable mesial TLE (mTLE) secondary to a porencephalic cyst. Although magnetic resonance imaging showed no hippocampal abnormalities, long-term video-electrocorticography revealed seizure onset discharges in the hippocampus. Temporal lobectomy brought an end to the patient's seizures. Hippocampal sclerosis was histopathologically confirmed (dual pathology). Careful evaluation of hippocampal epileptogenicity is required, and temporal lobectomy, which is less invasive than hemispherectomy, can be a treatment of choice for patients with mTLE secondary to a porencephalic cyst.