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Macdonald-Laurs E, Dzau W, Warren AEL, Coleman M, Mignone C, Stephenson SEM, Howell KB. Identification and treatment of surgically-remediable causes of infantile epileptic spasms syndrome. Expert Rev Neurother 2024; 24:661-680. [PMID: 38814860 DOI: 10.1080/14737175.2024.2360117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 05/22/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Infantile epileptic spasms syndrome (IESS) is a common developmental and epileptic encephalopathy with poor long-term outcomes. A substantial proportion of patients with IESS have a potentially surgically remediable etiology. Despite this, epilepsy surgery is underutilized in this patient group. Some surgically remediable etiologies, such as focal cortical dysplasia and malformation of cortical development with oligodendroglial hyperplasia in epilepsy (MOGHE), are under-diagnosed in infants and young children. Even when a surgically remediable etiology is recognised, for example, tuberous sclerosis or focal encephalomalacia, epilepsy surgery may be delayed or not considered due to diffuse EEG changes, unclear surgical boundaries, or concerns about operating in this age group. AREAS COVERED In this review, the authors discuss the common surgically remediable etiologies of IESS, their clinical and EEG features, and the imaging techniques that can aid in their diagnosis. They then describe the surgical approaches used in this patient group, and the beneficial impact that early epilepsy surgery can have on developing brain networks. EXPERT OPINION Epilepsy surgery remains underutilized even when a potentially surgically remediable cause is recognized. Overcoming the barriers that result in under-recognition of surgical candidates and underutilization of epilepsy surgery in IESS will improve long-term seizure and developmental outcomes.
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Affiliation(s)
- Emma Macdonald-Laurs
- Department of Neurology, The Royal Children's Hospital, Parkville, VIC, Australia
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Winston Dzau
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Aaron E L Warren
- Department of Medicine (Austin Health), The University of Melbourne, Melbourne, VIC, Australia
- Brigham and Women's Hospital, Harvard Medical School, Massachusetts, USA
| | - Matthew Coleman
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Cristina Mignone
- Department of Medical Imaging, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Sarah E M Stephenson
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Katherine B Howell
- Department of Neurology, The Royal Children's Hospital, Parkville, VIC, Australia
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
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Gauer L, Lagarde S, Valenti-Hirsch MP, Makhalova J, Milh M, Baer S, Lepine A, Ollivier I, Scavarda D, Hirsch E, Bartolomei F, De Saint-Martin A, Villeneuve N. Pathways to epilepsy surgery in children with tuberous sclerosis complex-associated epilepsy. Rev Neurol (Paris) 2024:S0035-3787(24)00533-2. [PMID: 38866657 DOI: 10.1016/j.neurol.2024.04.009] [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: 02/13/2024] [Revised: 04/22/2024] [Accepted: 04/25/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Previous studies showed the efficacy of epilepsy surgery in carefully selected children with epilepsy associated with tuberous sclerosis complex. However, how this selection is conducted, and the characteristics of the patients brought to surgery are still poorly described. By conducting a multicentric retrospective cohort study covering the practice of the last twenty years, we describe the paths leading to epilepsy surgery in children with epilepsy associated with tuberous sclerosis complex. METHODS We identified 84 children diagnosed with tuberous sclerosis complex and epilepsy by matching two exhaustive registries of genetic diseases and subsequent medical records reviews within two French neuropediatric and epilepsy centers. Demographic, clinical, longitudinal, and diagnostic and surgical procedures data were collected. RESULTS Forty-six percent of the children were initially drug-resistant and 19% underwent resective surgery, most often before the age of four. Stereotactic electroencephalography was performed prior to surgery in 44% of cases. Fifty-seven and 43% of patients remained seizure-free one and ten years after surgery, respectively. In addition, 52% of initially drug-resistant patients who did not undergo surgery were seizure-free at the last follow-up. The number of anti-seizure medications required decreased in 50% of cases after surgery. Infantile spasms, intellectual disability, autism spectrum disorder or severe behavioral disorders were not contraindications to surgery but were associated with a higher rate of complications and a lower rate of seizure freedom after surgery. CONCLUSION Despite the assumption of complex multifocal epilepsy and practical difficulties in young children with tuberous sclerosis complex, successful surgery results are comparable with other populations of patients with drug-resistant epilepsy, and a spontaneous evolution to drug-sensitive epilepsy may occur in non-operated patients.
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Affiliation(s)
- L Gauer
- Hôpitaux Universitaires de Strasbourg, Neurology Department, Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Reference Centre for Rare Epilepsies (member of the ERN network EPICARE), Strasbourg, France.
| | - S Lagarde
- Assistance publique-Hôpitaux de Marseille, Epileptology and Cerebral Rhythmology, Marseille, France; Assistance publique-Hôpitaux de Marseille, Reference Centre for Rare Epilepsies (member of the ERN network EPICARE), Marseille, France; Aix-Marseille University, INSERM, Institut de Neurosciences des Systèmes, Marseille, France
| | - M-P Valenti-Hirsch
- Hôpitaux Universitaires de Strasbourg, Neurology Department, Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Reference Centre for Rare Epilepsies (member of the ERN network EPICARE), Strasbourg, France
| | - J Makhalova
- Assistance publique-Hôpitaux de Marseille, Epileptology and Cerebral Rhythmology, Marseille, France; Assistance publique-Hôpitaux de Marseille, Reference Centre for Rare Epilepsies (member of the ERN network EPICARE), Marseille, France; Aix-Marseille University, INSERM, Institut de Neurosciences des Systèmes, Marseille, France
| | - M Milh
- Assistance publique-Hôpitaux de Marseille, Reference Centre for Rare Epilepsies (member of the ERN network EPICARE), Marseille, France; Assistance publique-Hôpitaux de Marseille, Pediatric Neurology Department, Marseille, France
| | - S Baer
- Hôpitaux Universitaires de Strasbourg, Pediatric Neurology Department, Strasbourg, France
| | - A Lepine
- Assistance publique-Hôpitaux de Marseille, Reference Centre for Rare Epilepsies (member of the ERN network EPICARE), Marseille, France; Assistance publique-Hôpitaux de Marseille, Pediatric Neurology Department, Marseille, France
| | - I Ollivier
- Hôpitaux Universitaires de Strasbourg, Neurosurgery Department, Strasbourg, France
| | - D Scavarda
- Aix-Marseille University, INSERM, Institut de Neurosciences des Systèmes, Marseille, France; Assistance publique-Hôpitaux de Marseille, Pediatric Neurosurgery Department, Marseille, France
| | - E Hirsch
- Hôpitaux Universitaires de Strasbourg, Neurology Department, Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Reference Centre for Rare Epilepsies (member of the ERN network EPICARE), Strasbourg, France
| | - F Bartolomei
- Assistance publique-Hôpitaux de Marseille, Epileptology and Cerebral Rhythmology, Marseille, France; Assistance publique-Hôpitaux de Marseille, Reference Centre for Rare Epilepsies (member of the ERN network EPICARE), Marseille, France; Aix-Marseille University, INSERM, Institut de Neurosciences des Systèmes, Marseille, France
| | - A De Saint-Martin
- Hôpitaux Universitaires de Strasbourg, Reference Centre for Rare Epilepsies (member of the ERN network EPICARE), Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Pediatric Neurology Department, Strasbourg, France
| | - N Villeneuve
- Assistance publique-Hôpitaux de Marseille, Reference Centre for Rare Epilepsies (member of the ERN network EPICARE), Marseille, France; Assistance publique-Hôpitaux de Marseille, Pediatric Neurology Department, Marseille, France
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Ghatan S. Pediatric Neurostimulation and Practice Evolution. Neurosurg Clin N Am 2024; 35:1-15. [PMID: 38000833 DOI: 10.1016/j.nec.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Since the late nineteenth century, the prevailing view of epilepsy surgery has been to identify a seizure focus in a medically refractory patient and eradicate it. Sadly, only a select number of the many who suffer from uncontrolled seizures benefit from this approach. With the development of safe, efficient stereotactic methods and targeted surgical therapies that can affect deep structures and modulate broad networks in diverse disorders, epilepsy surgery in children has undergone a paradigmatic evolutionary change. With modern diagnostic techniques such as stereo electroencephalography combined with closed loop neuromodulatory systems, pediatric epilepsy surgery can reach a much broader population of underserved patients.
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Affiliation(s)
- Saadi Ghatan
- Neurological Surgery Icahn School of Medicine at Mt Sinai, New York, NY 10128, USA.
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Wang Z, Li Y, He Z, Li S, Huang K, Shi X, Sun X, Ruan R, Cui C, Wang R, Wang L, Lv S, Zhang C, Liu Z, Yang H, Yang X, Liu S. Predictive model for epileptogenic tubers from all tubers in patients with tuberous sclerosis complex based on 18F-FDG PET: an 8-year single-centre study. BMC Med 2023; 21:500. [PMID: 38110931 PMCID: PMC10729377 DOI: 10.1186/s12916-023-03121-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 10/19/2023] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND More than half of patients with tuberous sclerosis complex (TSC) suffer from drug-resistant epilepsy (DRE), and resection surgery is the most effective way to control intractable epilepsy. Precise preoperative localization of epileptogenic tubers among all cortical tubers determines the surgical outcomes and patient prognosis. Models for preoperatively predicting epileptogenic tubers using 18F-FDG PET images are still lacking, however. We developed noninvasive predictive models for clinicians to predict the epileptogenic tubers and the outcome (seizure freedom or no seizure freedom) of cortical tubers based on 18F-FDG PET images. METHODS Forty-three consecutive TSC patients with DRE were enrolled, and 235 cortical tubers were selected as the training set. Quantitative indices of cortical tubers on 18F-FDG PET were extracted, and logistic regression analysis was performed to select those with the most important predictive capacity. Machine learning models, including logistic regression (LR), linear discriminant analysis (LDA), and artificial neural network (ANN) models, were established based on the selected predictive indices to identify epileptogenic tubers from multiple cortical tubers. A discriminating nomogram was constructed and found to be clinically practical according to decision curve analysis (DCA) and clinical impact curve (CIC). Furthermore, testing sets were created based on new PET images of 32 tubers from 7 patients, and follow-up outcome data from the cortical tubers were collected 1, 3, and 5 years after the operation to verify the reliability of the predictive model. The predictive performance was determined by using receiver operating characteristic (ROC) analysis. RESULTS PET quantitative indices including SUVmean, SUVmax, volume, total lesion glycolysis (TLG), third quartile, upper adjacent and standard added metabolism activity (SAM) were associated with the epileptogenic tubers. The SUVmean, SUVmax, volume and TLG values were different between epileptogenic and non-epileptogenic tubers and were associated with the clinical characteristics of epileptogenic tubers. The LR model achieved the better performance in predicting epileptogenic tubers (AUC = 0.7706; 95% CI 0.70-0.83) than the LDA (AUC = 0.7506; 95% CI 0.68-0.82) and ANN models (AUC = 0.7425; 95% CI 0.67-0.82) and also demonstrated good calibration (Hosmer‒Lemeshow goodness-of-fit p value = 0.7). In addition, DCA and CIC confirmed the clinical utility of the nomogram constructed to predict epileptogenic tubers based on quantitative indices. Intriguingly, the LR model exhibited good performance in predicting epileptogenic tubers in the testing set (AUC = 0.8502; 95% CI 0.71-0.99) and the long-term outcomes of cortical tubers (1-year outcomes: AUC = 0.7805, 95% CI 0.71-0.85; 3-year outcomes: AUC = 0.8066, 95% CI 0.74-0.87; 5-year outcomes: AUC = 0.8172, 95% CI 0.75-0.87). CONCLUSIONS The 18F-FDG PET image-based LR model can be used to noninvasively identify epileptogenic tubers and predict the long-term outcomes of cortical tubers in TSC patients.
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Affiliation(s)
- Zhongke Wang
- Department of Neurosurgery, Armed Police Hospital of Chongqing, Chongqing, China
| | - Yang Li
- Department of Neurosurgery, Comprehensive Epilepsy Center, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Zeng He
- Department of Neurosurgery, Comprehensive Epilepsy Center, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Shujing Li
- Department of Neurosurgery, Comprehensive Epilepsy Center, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Kaixuan Huang
- Department of Neurosurgery, Comprehensive Epilepsy Center, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Xianjun Shi
- Department of Neurosurgery, Comprehensive Epilepsy Center, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Xiaoqin Sun
- Department of Neurosurgery, Comprehensive Epilepsy Center, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Ruotong Ruan
- Department of Virology, State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Chun Cui
- Department of Radiology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Ruodan Wang
- Department of Neurology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Li Wang
- Department of Neurology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Shengqing Lv
- Department of Neurosurgery, Comprehensive Epilepsy Center, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Chunqing Zhang
- Department of Neurosurgery, Comprehensive Epilepsy Center, Xinqiao Hospital, Army Medical University, Chongqing, China
- Chongqing Institute for Brain and Intelligence, Guangyang Bay Laboratory, Chongqing, China
| | - Zhonghong Liu
- Department of Neurosurgery, Armed Police Hospital of Chongqing, Chongqing, China
| | - Hui Yang
- Department of Neurosurgery, Comprehensive Epilepsy Center, Xinqiao Hospital, Army Medical University, Chongqing, China.
- Chongqing Institute for Brain and Intelligence, Guangyang Bay Laboratory, Chongqing, China.
| | - Xiaolin Yang
- Department of Neurosurgery, Comprehensive Epilepsy Center, Xinqiao Hospital, Army Medical University, Chongqing, China.
| | - Shiyong Liu
- Department of Neurosurgery, Comprehensive Epilepsy Center, Xinqiao Hospital, Army Medical University, Chongqing, China.
- Chongqing Institute for Brain and Intelligence, Guangyang Bay Laboratory, Chongqing, China.
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Guo J, Guo M, Liu R, Kong Y, Hu X, Yao L, Lv S, Lv J, Wang X, Kong QX. Seizure Outcome After Surgery for Refractory Epilepsy Diagnosed by 18F-fluorodeoxyglucose positron emission tomography ( 18F-FDG PET/MRI): A Systematic Review and Meta-Analysis. World Neurosurg 2023; 173:34-43. [PMID: 36746239 DOI: 10.1016/j.wneu.2023.01.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 01/30/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE When magnetic resonance imaging (MRI) fails to detect an underlying epileptogenic lesion, the odds of a good outcome after epilepsy surgery are significantly lower (20%-65% compared with 60%-90% if a lesion is detected). We investigated the possible effects of introducing hybrid 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET)/MRI into the decision algorithm for patients with lesioned and nonlesioned drug-resistant epilepsy. METHODS Three databases were searched from January 1990 to October 2022. We registered the protocol with International Platform of Registered Systematic Review and Meta-analysis Protocols. Studies in which 18F-FDG PET/MRI was conducted with ≥12 months of postsurgical follow-up in patients with refractory epilepsy. Random-effects meta-analysis was used to calculate the proportion of patients with good outcomes. Metaregression was used to investigate sources of heterogeneity. RESULTS We identified 8105 studies, of which 23 (1292 patients in total) were included. The overall good postoperative outcome rate was 71% (95% confidence interval 63.6-74.9). Good outcome was associated with the location of the refractory epileptic lesion (temporal lobe or extratemporal; risk ratio 1.27 [95% confidence interval 1.01-1.52], P = 0.009); Length of postoperative follow-up ≥40 months included in the same study accounted for 0.6% of the observed heterogeneity. CONCLUSIONS Seventy-one percent of patients with refractory epilepsy and 18F-FDG PET/MRI epileptogenic lesion features had a good outcome of epilepsy after surgery. Our findings can be incorporated into routine preoperative consultations and emphasize the importance of the complete resection of the temporal lobe epileptogenic zone for 18F-FDG PET/MRI detection when safe and feasible.
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Affiliation(s)
- Jia Guo
- Clinical Medical College, Jining Medical University, Jining, China
| | - Mujie Guo
- Department of Imaging, Affiliated Hospital of Jining Medical University, Jining, China
| | - Ruihan Liu
- Department of Pediatrics, Affiliated Hospital of Jining Medical University, Jining, China; Postdoctoral Mobile Station of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yu Kong
- Department of Imaging, Affiliated Hospital of Jining Medical University, Jining, China
| | - Xibin Hu
- Department of Imaging, Affiliated Hospital of Jining Medical University, Jining, China
| | - Lei Yao
- Clinical Medical College, Jining Medical University, Jining, China
| | - Shaomin Lv
- Clinical Medical College, Jining Medical University, Jining, China
| | - Jiahua Lv
- Clinical Medical College, Jining Medical University, Jining, China
| | - Xinyu Wang
- Clinical Medical College, Jining Medical University, Jining, China
| | - Qing-Xia Kong
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, China.
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Singh A, Hadjinicolaou A, Peters JM, Salussolia CL. Treatment-Resistant Epilepsy and Tuberous Sclerosis Complex: Treatment, Maintenance, and Future Directions. Neuropsychiatr Dis Treat 2023; 19:733-748. [PMID: 37041855 PMCID: PMC10083014 DOI: 10.2147/ndt.s347327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/22/2023] [Indexed: 04/13/2023] Open
Abstract
Tuberous sclerosis complex (TSC) is a neurogenetic disorder that affects multiple organ systems, including the heart, kidneys, eyes, skin, and central nervous system. The neurologic manifestations have the highest morbidity and mortality, in particular in children. Clinically, patients with TSC often present with new-onset seizures within the first year of life. TSC-associated epilepsy is often difficult to treat and refractory to multiple antiseizure medications. Refractory TSC-associated epilepsy is associated with increased risk of neurodevelopmental comorbidities, including developmental delay, intellectual disability, autism spectrum disorder, and attention hyperactivity disorder. An increasing body of research suggests that early, effective treatment of TSC-associated epilepsy during critical neurodevelopmental periods can potentially improve cognitive outcomes. Therefore, it is important to treat TSC-associated epilepsy aggressively, whether it be with pharmacological therapy, surgical intervention, and/or neuromodulation. This review discusses current and future pharmacological treatments for TSC-associated epilepsy, as well as the importance of early surgical evaluation for refractory epilepsy in children with TSC and consideration of neuromodulatory interventions in young adults.
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Affiliation(s)
- Avantika Singh
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Aristides Hadjinicolaou
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Jurriaan M Peters
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Catherine L Salussolia
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
- F.M. Kirby Neurobiology Center, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
- Correspondence: Catherine L Salussolia, 3 Blackfan Circle, Center for Life Sciences 14060, Boston, MA, 02115, USA, Tel +617-355-7970, Email
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Melikyan AG, Kozlova AB, Vlasov PA, Dorofeeva MY, Shishkina LV, Agrba SB. [Epilepsy surgery in children with tuberous sclerosis]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:5-16. [PMID: 37011323 DOI: 10.17116/neiro2023870215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Most children with tuberous sclerosis (TS) present with intractable seizures. Various factors including demography, clinical data and surgery option are mentioned to affect the outcome after epilepsy surgery in these cases. OBJECTIVE To evaluate some demographic and clinical variables probably related to seizure outcome. MATERIAL AND METHODS Thirty-three children, median age 4.2 ys (7.5 mths-16 ys), with TS and DR-epilepsy underwent surgery. Within overall 38 procedures (redo surgery was needed in 5 cases), tuberectomy (with or without perituberal cortectomy) was performed in 21 cases, lobectomy - 8, callosotomy - 3, various disconnections (anterior frontal, TPO and hemispherotomy) - 6 patients. Standard preoperative evaluation included MRI and video-EEG. Invasive recordings were used in 8 cases, coupled by MEG and SISCOM SPECT in some cases. ECOG and neuronavigation were used routinely during tuberectomies, and stimulation and mapping were employed in cases with lesions overlapping or near to eloquent cortex. Surgical complications: wound CSF leak (n=1) and hydrocephalus (n=2) were noted in 7.5% of cases. Postoperative neurological deficit (most frequently hemiparesis) developed in 12 patients, being temporary in majority of them. At the last FU (med 5.4 ys) favorable outcome (Engel I) has been achieved in 18 cases (54%), while 7 patients (15%) with persisting seizures reported less common attacks and their milder form (Engel Ib-III). Six patients were able to discontinue AED-treatment and 15 children resumed development and markedly improved in cognition and behavior. RESULTS AND CONCLUSION Among different variables potentially influencing the outcome after epilepsy surgery in cases with TS, the most important one is seizure type. If prevalent, focal type may be a biomarker of favorable outcomes and probability to become free of seizures.
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Affiliation(s)
| | - A B Kozlova
- Burdenko Neurosurgical Center, Moscow, Russia
| | - P A Vlasov
- Burdenko Neurosurgical Center, Moscow, Russia
| | - M Yu Dorofeeva
- Veltishchev Research and Clinical Institute for Pediatrics and Pediatric Surgery, Moscow, Russia
| | | | - S B Agrba
- Burdenko Neurosurgical Center, Moscow, Russia
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Whitney R, Zak M, Haile D, Nabavi Nouri M. The state of pediatric tuberous sclerosis complex epilepsy care: Results from a national survey. Epilepsia Open 2022; 7:718-728. [PMID: 36161285 PMCID: PMC9712483 DOI: 10.1002/epi4.12652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/21/2022] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Epilepsy associated with tuberous sclerosis complex (TSC) can be challenging to treat and is associated with significant disease burden. Our objective was to better understand the state of epilepsy care of TSC amongst pediatric neurologists in Canada, identify gaps in care and determine whether access to a dedicated TSC clinic has an impact on epilepsy management. METHODS A survey was developed after a literature review and discussion amongst two pediatric epileptologists and one nurse practitioner with expertise in TSC about the state of epilepsy care of TSC patients in Canada. Canadian pediatric neurologists were asked to participate in sharing their experiences via an anonymous web-based survey through the Canadian League Against Epilepsy (CLAE) and the Canadian Neurological Sciences Federation (CNSF). RESULTS Fifty-seven responses were received. Access to a dedicated TSC clinic was reported by 25% (n = 14). Sixty percent (n = 34) reported performing serial EEG monitoring in infants with TSC and 57% (n = 33) started prophylactic antiseizure therapy when EEG abnormalities were detected, regardless of whether there was access to a TSC clinic (P = .06 and P = .29, respectively). While 52% (n = 29) did not feel comfortable prescribing mTORi for epilepsy, 65% (n = 36) indicated they would consider it with additional training. Epilepsy surgery was offered in 93% (n = 13) of centers with a dedicated TSC clinic but only 45% of centers without a TSC clinic (n = 19) (P = .002). SIGNIFICANCE Our findings demonstrate the variability in neurological care of pediatric patients with TSC as it pertains to epilepsy management. There is a need for the establishment of epilepsy practice guidelines and a national network to support clinical practice, research, and education.
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Affiliation(s)
- Robyn Whitney
- Division of Neurology, Department of PaediatricsMcMaster UniversityHamiltonOntarioCanada
| | - Maria Zak
- Division of Neurology, Department of PaediatricsThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Denait Haile
- Department of Paediatrics, Schulich School of Dentistry and MedicineWestern UniversityLondonOntarioCanada
| | - Maryam Nabavi Nouri
- Department of Paediatrics, Schulich School of Dentistry and MedicineWestern UniversityLondonOntarioCanada
- Children's Health Research InstituteLawson Health Research InstituteLondonOntarioCanada
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Nijman M, Yang E, Jaimes C, Prohl AK, Sahin M, Krueger DA, Wu JY, Northrup H, Stone SS, Madsen JR, Fallah A, Blount JP, Weiner HL, Grayson L, Bebin EM, Porter BE, Warfield SK, Prabhu SP, Peters JM. Limited utility of structural MRI to identify the epileptogenic zone in young children with tuberous sclerosis. J Neuroimaging 2022; 32:991-1000. [PMID: 35729081 PMCID: PMC11267633 DOI: 10.1111/jon.13016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND PURPOSE The success of epilepsy surgery in children with tuberous sclerosis complex (TSC) hinges on identification of the epileptogenic zone (EZ). We studied structural MRI markers of epileptogenic lesions in young children with TSC. METHODS We included 26 children with TSC who underwent epilepsy surgery before the age of 3 years at five sites, with 12 months or more follow-up. Two neuroradiologists, blinded to surgical outcome data, reviewed 10 candidate lesions on preoperative MRI for characteristics of the tuber (large affected area, calcification, cyst-like properties) and of focal cortical dysplasia (FCD) features (cortical malformation, gray-white matter junction blurring, transmantle sign). They selected lesions suspect for the EZ based on structural MRI, and reselected after unblinding to seizure onset location on electroencephalography (EEG). RESULTS None of the tuber characteristics and FCD features were distinctive for the EZ, indicated by resected lesions in seizure-free children. With structural MRI alone, the EZ was identified out of 10 lesions in 31%, and with addition of EEG data, this increased to 48%. However, rates of identification of resected lesions in non-seizure-free children were similar. Across 251 lesions, interrater agreement was moderate for large size (κ = .60), and fair (κ = .24) for all other features. CONCLUSIONS In young children with TSC, the utility of structural MRI features is limited in the identification of the epileptogenic tuber, but improves when combined with EEG data.
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Affiliation(s)
- Maaike Nijman
- Localization Laboratory, Division of Epilepsy and Clinical Neurophysiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward Yang
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Camilo Jaimes
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna K. Prohl
- Computational Radiology Laboratory, Department of Radiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mustafa Sahin
- Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Darcy A. Krueger
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Joyce Y. Wu
- Division of Neurology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
- Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Hope Northrup
- Department of Pediatrics, McGovern Medical School, at University of Texas Health Science Center at Houston (UTHealth) and Children’s Memorial Hermann Hospital, Houston, Texas, USA
| | - Scellig S.D. Stone
- Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph R. Madsen
- Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aria Fallah
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of California Los Angeles Mattel Children’s Hospital, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Jeffrey P. Blount
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Children’s of Alabama, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Howard L. Weiner
- Department of Surgery, Division of Pediatric Neurosurgery, Texas Children’s Hospital, Houston, Texas, USA
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Leslie Grayson
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - E. Martina Bebin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brenda E. Porter
- Department of Neurology, Stanford University Medical Center, Stanford, California, USA
| | - Simon K. Warfield
- Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sanjay P. Prabhu
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jurriaan M. Peters
- Localization Laboratory, Division of Epilepsy and Clinical Neurophysiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Computational Radiology Laboratory, Department of Radiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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10
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Specchio N, Pavia GC, Palma L, De Benedictis A, Pepi C, Conti M, Marras CE, Vigevano F, Curatolo P. Current role of surgery for tuberous sclerosis complex‐associated epilepsy. Pediatr Investig 2022; 6:16-22. [PMID: 35382422 PMCID: PMC8960933 DOI: 10.1002/ped4.12312] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 12/30/2021] [Indexed: 11/18/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is a rare multisystem, autosomal dominant neurocutaneous syndrome in which epilepsy is the most common of several neurological and psychiatric manifestations. Around two thirds of patients develop drug‐resistant epilepsy for whom surgical resection of epileptogenic foci is indicated when seizures remain inadequately controlled following trial of two antiseizure medications. The challenge with presurgical and surgical approaches with patients with TSC is overcoming the complexity from the number of tubers and the multiplex epileptogenic network forming the epileptogenic zone. Data suggest that seizure freedom is achieved by 55%–60% of patients, but predictive factors for success have remained elusive, which makes for unconfident selection of surgical candidates. This article presents three different cases as illustrations of the potential challenges faced when assessing the suitability of TSC patients for epilepsy surgery.
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Affiliation(s)
- Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neurosciences Bambino Gesù Children's Hospital, IRCCS Rome Italy
| | - Giusy Carfi Pavia
- Rare and Complex Epilepsy Unit, Department of Neurosciences Bambino Gesù Children's Hospital, IRCCS Rome Italy
| | - Luca Palma
- Rare and Complex Epilepsy Unit, Department of Neurosciences Bambino Gesù Children's Hospital, IRCCS Rome Italy
| | - Alessandro De Benedictis
- Neurosurgery Unit, Department of Neurosciences Bambino Gesù Children's Hospital, IRCCS Rome Italy
| | - Chiara Pepi
- Rare and Complex Epilepsy Unit, Department of Neurosciences Bambino Gesù Children's Hospital, IRCCS Rome Italy
| | - Marta Conti
- Rare and Complex Epilepsy Unit, Department of Neurosciences Bambino Gesù Children's Hospital, IRCCS Rome Italy
| | - Carlo Efisio Marras
- Neurosurgery Unit, Department of Neurosciences Bambino Gesù Children's Hospital, IRCCS Rome Italy
| | - Federico Vigevano
- Department of Neurosciences Bambino Gesù Children's Hospital, IRCCS Rome Italy
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department Tor Vergata University Rome Italy
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11
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Nabavi Nouri M, Zak M, Jain P, Whitney R. Epilepsy Management in Tuberous Sclerosis Complex: Existing and Evolving Therapies and Future Considerations. Pediatr Neurol 2022; 126:11-19. [PMID: 34740132 DOI: 10.1016/j.pediatrneurol.2021.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/22/2021] [Accepted: 09/25/2021] [Indexed: 10/20/2022]
Abstract
Tuberous sclerosis complex (TSC) is a rare autosomal dominant condition that affects multiple body systems. Disruption of the mammalian target of rapamycin (mTOR) pathway results in abnormal cell growth, proliferation, protein synthesis, and cell differentiation and migration in TSC. In the central nervous system, mTOR disruption is also believed to influence neuronal excitability and promote epileptogenesis. Epilepsy is the most common neurological manifestation of TSC and affects 80% to 90% of individuals with high rates of treatment resistance (up to 75%). The onset of epilepsy in the majority of individuals with TSC occurs before the age of two years, which is a critical time in neurodevelopment. Both medically refractory epilepsy and early-onset epilepsy are associated with intellectual disability in TSC, while seizure control and remission are associated with lower rates of cognitive impairment. Our current knowledge of the treatment of epilepsy in TSC has expanded immensely over the last decade. Several new therapies such as preemptive vigabatrin therapy in infants, cannabidiol, and mTOR inhibitors have emerged in recent years for the treatment of epilepsy in TSC. This review will provide clinicians with a comprehensive overview of the pharmacological and nonpharmacological therapies available for the treatment of epilepsy related to TSC.
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Affiliation(s)
- Maryam Nabavi Nouri
- Division of Neurology, Department of Pediatrics, Western University, London, Ontario, Canada
| | - Maria Zak
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Puneet Jain
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robyn Whitney
- Division of Neurology, Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada.
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12
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Romanowski EF, McNamara N. Surgery for Intractable Epilepsy in Pediatrics, a Systematic Review of Outcomes other than Seizure Freedom. Semin Pediatr Neurol 2021; 39:100928. [PMID: 34620460 DOI: 10.1016/j.spen.2021.100928] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/23/2021] [Accepted: 08/27/2021] [Indexed: 11/25/2022]
Abstract
To perform a systematic review evaluating reported outcomes for epilepsy surgery in pediatric patients with pharmacoresistant epilepsy beyond seizure control, including impact on quality of life, behavioral, neurocognitive outcomes as well as complications, and death. We reviewed articles from both EMBASE and MEDLINE/PubMed articles that met formal criteria (patients ≤18 years, those with intractable epilepsy, at least 5 patients in the case series, published in peer-reviewed journal). Each reviewer independently reviewed the articles and those with discrepancies were discussed and consensus was reached. Out of a total of 536 abstracts obtained from EMBASE and MEDLINE/PubMed searches combined with additional cross-referencing, a total of 98 manuscripts ultimately met all inclusion criteria. The manuscripts were divided into 3 outcomes categories: Quality of Life (16), Cognitive Outcomes (60), and Deficits and Complications (50). Several papers fell into more than 1 category. These were separated by surgical types and evaluated. We found that overall reporting in all domains was variable and inconsistent amongst the different studies. This systematic review highlights the lack of completeness in reporting outcomes and complications involving pediatric epilepsy surgery and discordant results. This underscores the importance of multicenter systematic prospective data collection in pediatric patients who undergo pediatric epilepsy surgery.
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Affiliation(s)
| | - Nancy McNamara
- Division of Pediatric Neurology, University of Michigan, Ann Arbor, MI.
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13
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Seizure outcome after epilepsy surgery in tuberous sclerosis complex: Results and analysis of predictors from a multicenter study. J Neurol Sci 2021; 427:117506. [PMID: 34087568 DOI: 10.1016/j.jns.2021.117506] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 04/22/2021] [Accepted: 05/18/2021] [Indexed: 12/30/2022]
Abstract
Epilepsy surgery is recommended in selected patients with Tuberous Sclerosis Complex (TSC). However, reports on predictive factors of seizure outcome are variable. Here we report on seizure and cognitive outcome of 35 TSC patients who received surgery for refractory epilepsy in 7 Italian centers over a period of 22 years (1997-2019). The rate of seizure-free individuals at last follow-up (mean 7.5 years, range 1-21 years) was 51%. Patients with longer follow-up (≥10 years) had a lower rate of Engel I outcome (11.1%) than those who received surgery in the last 10 years (65.4%, p = 0.003). Factors associated with Engel II, III, IV outcome in our cohort included: high number of cortical tubers (≥5); presence of subependymal nodules (SENs); seizure onset before age 1 year; and multifocal interictal epileptic discharges (IEDs) on electroencephalogram (EEG). A subset of patients evaluated with Vineland Adaptive Behaviour Scales (VABS) showed developmental gains, in line with their developmental trajectories, but no improvement in standard scores after surgery was noted. Our study demonstrates that the rates of successful seizure outcome of epilepsy surgery in TSC have improved in the last 10 years. More than half of the patients achieved seizure freedom, and a high proportion of affected individuals experienced a reduction in seizure burden and in antiseizure medications. A comprehensive assessment after surgery should be performed in TSC patients to evaluate the overall neurodevelopmental outcome, as measures that are based only on seizure control do not adequately identify the benefits of surgery on global functioning in these patients.
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14
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Specchio N, Pepi C, De Palma L, Trivisano M, Vigevano F, Curatolo P. Neuroimaging and genetic characteristics of malformation of cortical development due to mTOR pathway dysregulation: clues for the epileptogenic lesions and indications for epilepsy surgery. Expert Rev Neurother 2021; 21:1333-1345. [PMID: 33754929 DOI: 10.1080/14737175.2021.1906651] [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: 10/21/2022]
Abstract
Introduction: Malformation of cortical development (MCD) is strongly associated with drug-resistant epilepsies for which surgery to remove epileptogenic lesions is common. Two notable technological advances in this field are identification of the underlying genetic cause and techniques in neuroimaging. These now question how presurgical evaluation ought to be approached for 'mTORpathies.'Area covered: From review of published primary and secondary articles, the authors summarize evidence to consider focal cortical dysplasia (FCD), tuber sclerosis complex (TSC), and hemimegalencephaly (HME) collectively as MCD mTORpathies. The authors also consider the unique features of these related conditions with particular focus on the practicalities of using neuroimaging techniques currently available to define surgical targets and predict post-surgical outcome. Ultimately, the authors consider the surgical dilemmas faced for each condition.Expert opinion: Considering FCD, TSC, and HME collectively as mTORpathies has some merit; however, a unified approach to presurgical evaluation would seem unachievable. Nevertheless, the authors believe combining genetic-centered classification and morphologic findings using advanced imaging techniques will eventually form the basis of a paradigm when considering candidacy for early surgery.
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Affiliation(s)
- Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Chiara Pepi
- Rare and Complex Epilepsy Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Luca De Palma
- Rare and Complex Epilepsy Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Marina Trivisano
- Rare and Complex Epilepsy Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Federico Vigevano
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Rome, Italy
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15
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Huang Q, Zhou J, Wang X, Li T, Wang M, Wang J, Teng P, Qi X, Zhu M, Luan G, Zhai F. Predictors and Long-term Outcome of Resective Epilepsy Surgery in Patients with Tuberous Sclerosis Complex: A Single-centre Retrospective Cohort Study. Seizure 2021; 88:45-52. [PMID: 33812307 DOI: 10.1016/j.seizure.2021.03.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/24/2021] [Accepted: 03/22/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To identify prognostic factors and long-term seizure outcomes for patients with tuberous sclerosis complex (TSC) who underwent resective treatment for epilepsy. METHODS We enrolled 81 patients with TSC who had undergone resective epilepsy surgery at Sanbo Brain Hospital, Capital Medical University, between April 2004 and June 2019. We estimated cumulative probability of remaining seizure-free and plotted survival curves. Variables were compared using Mann-Whitney U, Pearson's correlation, continuity correction, and Fisher's exact chi-square tests. Prognostic predictors were analysed using log-rank (Mantel-Cox) tests and Cox regression models. RESULTS At the last follow-up, 48 (59.3%) patients were classified as International League Against Epilepsy Class 1 (including 14 patients who had seizures <3 times postoperatively on the same or different day and were seizure-free at all other times). The estimated cumulative probability of remaining seizure-free postoperatively was 69.0% (95% confidence interval [CI] 58.8-79.2%), 61.9% (95% CI 51.1-72.7%), and 55.0% (95% CI 42.8-67.2%) at 2, 5, and 10 years, respectively. The mean time of remaining seizure-free was 7.24 ± 0.634 years (95% CI 6.00-8.49); en bloc resection was an essential positive predictor of postoperative seizure freedom, as was age at seizure onset, regional interictal video-electroencephalography pattern, and temporal lobe surgery. The longer the seizure-free time, the less likely a relapse. Patients who postoperatively experienced seizures remained likely to recover. CONCLUSIONS We demonstrated the efficacy of surgical treatment for patients with TSC and intractable epilepsy. Detailed perioperative tests are a reliable predictor of postoperative seizure freedom.
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Affiliation(s)
- Qi Huang
- Department of Neurosurgery, Center of Epilepsy, Sanbo Brain Hospital, Capital Medical University, XiangshanYikesong 50, Haidian District, Beijing 100093, China.
| | - Jian Zhou
- Department of Neurosurgery, Center of Epilepsy, Sanbo Brain Hospital, Capital Medical University, XiangshanYikesong 50, Haidian District, Beijing 100093, China
| | - Xiongfei Wang
- Department of Neurosurgery, Center of Epilepsy, Sanbo Brain Hospital, Capital Medical University, XiangshanYikesong 50, Haidian District, Beijing 100093, China
| | - Tianfu Li
- Department of Brian Institute, Center of Epilepsy, Sanbo Brain Hospital, Capital Medical University, XiangshanYikesong 50, Haidian District, Beijing 100093, China; Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, XiangshanYikesong 50, Haidian District, Beijing 100093, China
| | - Mengyang Wang
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, XiangshanYikesong 50, Haidian District, Beijing 100093, China
| | - Jing Wang
- Department of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, XiangshanYikesong 50, Haidian District, Beijing 100093, China
| | - Pengfei Teng
- Department of Magnetoencephalography, Sanbo Brain Hospital, Capital Medical University, XiangshanYikesong 50, Haidian District, Beijing 100093, China
| | - Xueling Qi
- Department of Pathology, Sanbo Brain Hospital, Capital Medical University, XiangshanYikesong 50, Haidian District, Beijing 100093, China
| | - Mingwang Zhu
- Department of Radiology, Sanbo Brain Hospital, Capital Medical University, XiangshanYikesong 50, Haidian District, Beijing 100093, China
| | - Guoming Luan
- Department of Neurosurgery, Center of Epilepsy, Sanbo Brain Hospital, Capital Medical University, XiangshanYikesong 50, Haidian District, Beijing 100093, China
| | - Feng Zhai
- Department of Neurosurgery, Center of Epilepsy, Sanbo Brain Hospital, Capital Medical University, XiangshanYikesong 50, Haidian District, Beijing 100093, China.
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16
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Liu AJ, Staffaroni AM, Rojas-Martinez JC, Olney NT, Alquezar-Burillo C, Ljubenkov PA, La Joie R, Fong JC, Taylor J, Karydas A, Ramos EM, Coppola G, Boxer AL, Rabinovici GD, Miller BL, Kao AW. Association of Cognitive and Behavioral Features Between Adults With Tuberous Sclerosis and Frontotemporal Dementia. JAMA Neurol 2021; 77:358-366. [PMID: 31860018 DOI: 10.1001/jamaneurol.2019.4284] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Individuals with tuberous sclerosis complex can develop a progressive neuropsychiatric syndrome known as tuberous sclerosis-associated neuropsychiatric disorders. Tuberous sclerosis-associated neuropsychiatric disorders symptoms overlap with clinical criteria for frontotemporal dementia, yet the association between the 2 has not been explored. Objective To investigate the potential association between tuberous sclerosis-associated neuropsychiatric disorders and frontotemporal dementia. Design, Setting, and Participants Case-control study that enrolled patients with tuberous sclerosis complex with normal IQs in an observational clinical study at the University of California, San Francisco, from 2017 to 2019 where they underwent a comprehensive clinical evaluation including neuropsychologic testing, cerebral spinal fluid biomarker profiling, and structural neuroimaging. The study included adults who fulfilled the clinical criteria for tuberous sclerosis complex and had normal IQs, had frontotemporal dementia, or were healthy control individuals. Main Outcomes and Measures Tuberous sclerosis-associated neuropsychiatric disorders checklist severity score, neuropsychologic test scores, cerebral spinal fluid concentrations of phosphorylated tau181, total tau, amyloid-β 42, and neurofilament light chain. Amyloid and tau positron emission tomography scans were obtained in a subset of patients. Results Eighteen patients with tuberous sclerosis complex (mean [SD] age, 48 years [9.54]; 13 women [72%]), 16 with frontotemporal dementia (60 [6.93] years; 7 women [44%]) and 18 healthy control individuals (63 [3.85] years; 9 women [50%]) were included. The tuberous sclerosis-associated neuropsychiatric disorders checklist and neuropsychological test results were not significantly different when the tuberous sclerosis complex and frontotemporal dementia cohorts were compared. The tuberous sclerosis complex cohort exhibited elevated cerebral spinal fluid phosphorylated tau181 and neurofilament light chain with a mean of 32 pg/mL and 2300 pg/mL, respectively, when compared to healthy control individuals. All 3 patients with tuberous sclerosis complex who underwent fluorine 1B-labeled flortaucipir tau positron emission tomographic neuroimaging showed punctate foci of elevated [18F]flortaucipir binding in the frontal and temporal regions. Conclusions and Relevance Adults with tuberous sclerosis complex showed phenotypic overlap with frontotemporal dementia. The results support a possible clinical continuum between tuberous sclerosis-associated neuropsychiatric disorders and frontotemporal dementia and highlights a potential pathophysiological link between neurodevelopmental and neurodegenerative processes. Quantitative neuropsychological testing and the tuberous sclerosis-associated neuropsychiatric disorders checklist, potentially supplemented by cerebral spinal fluid and imaging biomarkers, could be used to screen and prognosticate for risk of a neurodegenerative process in adult patients with tuberous sclerosis complex.
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Affiliation(s)
- Andy J Liu
- Memory and Aging Center, University of California, San Francisco
| | | | | | | | | | | | - Renaud La Joie
- Memory and Aging Center, University of California, San Francisco
| | - Jamie C Fong
- Memory and Aging Center, University of California, San Francisco
| | - Joanne Taylor
- Memory and Aging Center, University of California, San Francisco
| | - Anna Karydas
- Memory and Aging Center, University of California, San Francisco
| | - Eliana Marisa Ramos
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - Giovanni Coppola
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - Adam L Boxer
- Memory and Aging Center, University of California, San Francisco
| | - Gil D Rabinovici
- Memory and Aging Center, University of California, San Francisco.,Associate Editor
| | - Bruce L Miller
- Memory and Aging Center, University of California, San Francisco
| | - Aimee W Kao
- Memory and Aging Center, University of California, San Francisco
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17
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Assadsangabi R, Ozturk A, Kantamneni T, Azizi N, Asaikar SM, Hacein-Bey L. Neuroimaging of Childhood Epilepsy: Focal versus Generalized Epilepsy. JOURNAL OF PEDIATRIC EPILEPSY 2021. [DOI: 10.1055/s-0040-1722301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractNeuroimaging plays an increasingly crucial role in delineating the pathophysiology, and guiding the evaluation, management and monitoring of epilepsy. Imaging contributes to adequately categorizing seizure/epilepsy types in complex clinical situations by demonstrating anatomical and functional changes associated with seizure activity. This article reviews the current status of multimodality neuroimaging in the pediatric population, including focal lesions which may result in focal epileptic findings, focal structural abnormalities that may manifest as generalized epileptiform discharges, and generalized epilepsy without evidence of detectable focal abnormalities.
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Affiliation(s)
- Reza Assadsangabi
- Department of Neuroradiology, Radiology, University of California Davis School of Medicine, Sacramento, California, United States
| | - Arzu Ozturk
- Department of Neuroradiology, Radiology, University of California Davis School of Medicine, Sacramento, California, United States
| | - Trishna Kantamneni
- Department of Neurology, University of California Davis School of Medicine, Sacramento, California, United States
| | - Nazarin Azizi
- Department of Neuroradiology, Radiology, University of California Davis School of Medicine, Sacramento, California, United States
| | - Shailesh M. Asaikar
- Child & Adolescent Neurology Consultants, Sacramento, California, United States
| | - Lotfi Hacein-Bey
- Department of Neuroradiology, Radiology, University of California Davis School of Medicine, Sacramento, California, United States
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18
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Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a rare genetic disorder that commonly leads to drug-resistant epilepsy in affected patients. This study aimed to determine whether the underlying genetic mutation (TSC1 vs. TSC2) predicts seizure outcomes following surgical treatments for epilepsy. METHODS We retrospectively assessed TSC patients using the TSC Natural History Database core registry. Data review focused on outcomes in patients treated with surgical resection or vagus nerve stimulation. RESULTS A total of 42 patients with a TSC1 mutation, and 145 patients with a TSC2 mutation, were identified. We observed a distinct clinical phenotype: children with TSC2 mutations tended to be diagnosed with TSC at a younger age than those with a TSC1 mutation (p < 0.001), were more likely to have infantile spasms (p < 0.001), and to get to surgery at a later age (p = 0.003). Among this TSC2 cohort, seizure control following resective epilepsy surgery was achieved in less than half (47%) the study sample. In contrast, patients with TSC1 mutations tended to have more favorable postsurgical outcomes; seizure control was achieved in 66% of this group. CONCLUSION TSC2 mutations result in a more severe epilepsy phenotype that is also less responsive to resective surgery. It is important to consider this distinct clinical disposition when counseling families preoperatively with respect to seizure freedom. Larger samples are required to better characterize the independent effects of genetic mutation, infantile spasms, and duration of epilepsy as they relate to seizure control following resective or neuromodulatory epilepsy surgery.
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19
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Grayson LE, Peters JM, McPherson T, Krueger DA, Sahin M, Wu JY, Northrup HA, Porter B, Cutter GR, O’Kelley SE, Krefting J, Stone SS, Madsen JR, Fallah A, Blount JP, Weiner HL, Bebin EM. Pilot Study of Neurodevelopmental Impact of Early Epilepsy Surgery in Tuberous Sclerosis Complex. Pediatr Neurol 2020; 109:39-46. [PMID: 32418847 PMCID: PMC7387194 DOI: 10.1016/j.pediatrneurol.2020.04.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/01/2020] [Accepted: 04/03/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND To determine if early epilepsy surgery mitigates detrimental effects of refractory epilepsy on development, we investigated surgical and neurodevelopmental outcomes in children with tuberous sclerosis complex who underwent surgery before age two years. METHODS Prospective multicenter observational study of 160 children with tuberous sclerosis complex. Surgical outcome was determined for the seizure type targeted by surgery. We obtained Vineland Adaptive Behavior Scales, Second Edition (Vineland-II); Mullen Scales of Early Learning; and Preschool Language Scales, Fifth Edition, at age three, six, nine, 12, 18, 24, and 36 months. Surgical cases were compared with children without seizures, with controlled seizures, and with medically refractory seizures. RESULTS Nineteen children underwent surgery (median age 17 months, range 3.7 to 21.3), and mean follow-up was 22.8 months (range 12 to 48). Surgical outcomes were favorable in 12 (63%, Engel I-II) and poor in seven (37%, Engel III-IV). Nine (47%) had new or ongoing seizures distinct from those surgically targeted. All children with seizures demonstrated longitudinal decline or attenuated gains in neurodevelopment, the surgical group scoring the lowest. Favorable surgical outcome was associated with increased Mullen Scales of Early Learning receptive and expressive language subscores compared with the medically refractory seizure group. A nonsignificant but consistent pattern of improvement with surgery was seen in all tested domains. CONCLUSIONS These pilot data show neurodevelopmental gains in some domains following epilepsy surgery. A properly powered, prospective multicenter observational study of early epilepsy surgery is needed, using both surgical and developmental outcome metrics.
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Affiliation(s)
- Leslie E Grayson
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Jurriaan M Peters
- Localization Laboratory, Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Tarrant McPherson
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL
| | - Darcy A Krueger
- Department of Neurology, Cincinnati Children’s Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Mustafa Sahin
- Department of Neurology and the F.M. Kirby Neurobiology Center, Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Joyce Y Wu
- Division of Pediatric Neurology, UCLA Mattel Children’s Hospital, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Hope A Northrup
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Brenda Porter
- Department of Neurology, The Stanford University Medical Center, Stanford, CA
| | - Gary R Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL
| | - Sarah E O’Kelley
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL
| | - Jessica Krefting
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Scellig S Stone
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Joseph R Madsen
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Aria Fallah
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of California Los Angeles Mattel Children’s Hospital, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Jeffrey P. Blount
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Children’s Hospital of Alabama and University of Alabama at Birmingham, Birmingham, AL
| | - Howard L. Weiner
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children’s Hospital and Department of Neurosurgery, Baylor College of Medicine, Houston, TX
| | - E. Martina Bebin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL.,Corresponding author. Department of Neurology; CIRC 312; 1530 3rd Ave S; Birmingham, AL 35294-3280. Tel (256) 533-0833 Fax (256) 533-0855
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Kuzan-Fischer CM, Parker WE, Schwartz TH, Hoffman CE. Challenges of Epilepsy Surgery. World Neurosurg 2020; 139:762-774. [PMID: 32689697 DOI: 10.1016/j.wneu.2020.03.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 03/02/2020] [Indexed: 12/22/2022]
Abstract
Though frequently effective in the management of medically refractory seizures, epilepsy surgery presents numerous challenges. Selection of the appropriate candidate patients who are likely to benefit from surgery is critical to achieving seizure freedom and avoiding neurocognitive morbidity. Identifying the seizure focus and mapping epileptogenic networks involves an interdisciplinary team dedicated to formulating a safe and effective surgical plan. Various strategies can be employed either to eliminate the epileptic focus or to modulate network activity, including resection of the focus with open surgery or laser interstitial thermal therapy; modulation of epileptogenic firing patterns with responsive neurostimulation, deep brain stimulation, or vagus nerve stimulation; or non-invasive disconnection of epileptic circuits with focused ultrasound, which is also discussed in greater detail in the subsequent chapter in our series. We review several challenges of epilepsy surgery that must be thoughtfully addressed in order to ensure its success.
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Affiliation(s)
- Claudia M Kuzan-Fischer
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Whitney E Parker
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Caitlin E Hoffman
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA.
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21
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Liu S, Yu T, Guan Y, Zhang K, Ding P, Chen L, Shan Y, Guo Q, Liu Q, Yao Y, Yang M, Zhang S, Lin Y, Zhao R, Mao Z, Zhang J, Zhang C, Zhang R, Yang Z, Qian R, Li Y, Zhang G, Yuan L, Yang W, Tian H, Zhang H, Li W, Zhang X, Yin J, Guo Y, Zou L, Qin J, Fang F, Wang X, Ge M, Liang S. Resective epilepsy surgery in tuberous sclerosis complex: a nationwide multicentre retrospective study from China. Brain 2020; 143:570-581. [PMID: 31953931 DOI: 10.1093/brain/awz411] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 11/11/2019] [Accepted: 11/14/2019] [Indexed: 11/13/2022] Open
Abstract
At least 50% of patients with tuberous sclerosis complex present with intractable epilepsy; for these patients, resective surgery is a treatment option. Here, we report a nationwide multicentre retrospective study and analyse the long-term seizure and neuropsychological outcomes of epilepsy surgery in patients with tuberous sclerosis complex. There were 364 patients who underwent epilepsy surgery in the study. Patients' clinical data, postoperative seizure outcomes at 1-, 4-, and 10-year follow-ups, preoperative and postoperative intelligence quotients, and quality of life at 1-year follow-up were collected. The patients' ages at surgery were 10.35 ± 7.70 years (range: 0.5-47). The percentage of postoperative seizure freedom was 71% (258/364) at 1-year, 60% (118/196) at 4-year, and 51% (36/71) at 10-year follow-up. Influence factors of postoperative seizure freedom were the total removal of epileptogenic tubers and the presence of outstanding tuber on MRI at 1- and 4-year follow-ups. Furthermore, monthly seizure (versus daily seizure) was also a positive influence factor for postoperative seizure freedom at 1-year follow-up. The presence of an outstanding tuber on MRI was the only factor influencing seizure freedom at 10-year follow-up. Postoperative quality of life and intelligence quotient improvements were found in 43% (112/262) and 28% (67/242) of patients, respectively. Influence factors of postoperative quality of life and intelligence quotient improvement were postoperative seizure freedom and preoperative low intelligence quotient. The percentage of seizure freedom in the tuberectomy group was significantly lower compared to the tuberectomy plus and lobectomy groups at 1- and 4-year follow-ups. In conclusion, this study, the largest nationwide multi-centre study on resective epilepsy surgery, resulted in improved seizure outcomes and quality of life and intelligence quotient improvements in patients with tuberous sclerosis complex. Seizure freedom was often achieved in patients with an outstanding tuber on MRI, total removal of epileptogenic tubers, and tuberectomy plus. Quality of life and intelligence quotient improvements were frequently observed in patients with postoperative seizure freedom and preoperative low intelligence quotient.
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Affiliation(s)
- Shiyong Liu
- Department of Neurosurgery, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Tao Yu
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuguang Guan
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Kai Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ping Ding
- Department of Neurosurgery, Fourth Medical Center of PLA General Hospital, Beijing, China
| | - Lei Chen
- Department of Neurology, Western China Hospital, Sichuan University, Chengdu, China
| | - Yongzhi Shan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qiang Guo
- Department of Neurosurgery, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Qingzhu Liu
- Pediatric Epilepsy Surgery Center, First Affiliated Hospital of Peking University, Beijing, China
| | - Yi Yao
- Department of Neurosurgery, Xiamen Hongai Hospital, Xiamen, China
| | - Meihua Yang
- Department of Neurosurgery, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Shaohui Zhang
- Department of Neurosurgery, Fourth Medical Center of PLA General Hospital, Beijing, China
| | - Yuanxiang Lin
- Department of Neurosurgery, First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Rui Zhao
- Department of Neurosurgery, Children Hospital, Fudan University, Shanghai, China
| | - Zhiqi Mao
- Department of Neurosurgery, First Medical Center of PLA General Hospital, Beijing, China
| | - Juncheng Zhang
- Department of Neurosurgery, Affiliated Hospital of Jining Medical College, Jining, China
| | - Chunqing Zhang
- Department of Neurosurgery, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Rui Zhang
- Department of Functional Neurosurgery, Brain Hospital, Nanjing Medical University, Nanjing, China
| | - Zhiquan Yang
- Department of Neurosurgery, Xiangya Hospital, Central Southern University, Changsha, China
| | - Ruobing Qian
- Department of Neurosurgery, First Affiliated Hospital, University of Science and Technology of China, Hefei, China
| | - Yunlin Li
- Department of Neurosurgery, Children Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Guangming Zhang
- Department of Neurosurgery, Beijing Aviation General Hospital, Beijing, China
| | - Liu Yuan
- Department of Neurosurgery, Fourth Medical Center of PLA General Hospital, Beijing, China
| | - Weidong Yang
- Department of Neurosurgery, General Hospital, Tianjin Medical University, Tianjin, China
| | - Hong Tian
- Department of Neurosurgery, China-Japan Friendship Hospital, Beijing, China
| | - Hua Zhang
- Department of Neurosurgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Wenling Li
- Department of Neurosurgery, Second Affiliated Hospital, Hebei Medical University, Shijiazhuang, China
| | - Xinwei Zhang
- Department of Neurosurgery, Third Affiliated Hospital, Southern Medical University, Guangzhou, China
| | - Jian Yin
- Department of Neurosurgery, Second Affiliated Hospital, Dalian Medical University, Dalian, China
| | - Yanwu Guo
- Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Liping Zou
- Pediatrics Department, First Medical Center of PLA General Hospital, Beijing, China
| | - Jiong Qin
- Pediatrics Department, Beijing People's Hospital, Peking University, Beijing, China
| | - Fang Fang
- Neurology Department, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xu Wang
- Neurology Department, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Ming Ge
- Neurosurgery Department, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Shuli Liang
- Functional Neurosurgery Department, Beijing Children's Hospital, Capital Medical University, Beijing, China
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22
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Williams ME, Pearson DA, Capal JK, Byars AW, Murray DS, Kissinger R, O'Kelley SE, Hanson E, Bing NM, Kent B, Wu JY, Northrup H, Bebin EM, Sahin M, Krueger D. Impacting development in infants with tuberous sclerosis complex: Multidisciplinary research collaboration. ACTA ACUST UNITED AC 2020; 74:356-367. [PMID: 30945897 DOI: 10.1037/amp0000436] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The Tuberous Sclerosis Complex Autism Center of Excellence Network (TACERN) is a 6-site collaborative conducting longitudinal research on infants with tuberous sclerosis complex (TSC), focused on identifying early biomarkers for autism spectrum disorder (ASD). A multidisciplinary research team that includes the specialties of psychology, neurology, pediatrics, medical genetics, and speech-language pathology, its members work together to conduct studies on neurological status, brain structure and function, neurodevelopmental phenotype, and behavioral challenges in this population. This article provides insights into the roles of the multidisciplinary multisite team and lessons learned from the collaboration, in terms of research as well as training of future researchers and clinicians. In addition, the authors detail the major findings to date, including those related to the identification and measurement of early symptoms of ASD, relationship between seizures and early development, and early biomarkers for epilepsy and developmental delay in infants and young children with TSC. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Hope Northrup
- University of Texas Health Science Center at Houston
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23
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Lesion-Constrained Electrical Source Imaging: A Novel Approach in Epilepsy Surgery for Tuberous Sclerosis Complex. J Clin Neurophysiol 2020; 37:79-86. [PMID: 31261349 DOI: 10.1097/wnp.0000000000000615] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Electrical source imaging may yield ambiguous results in multilesional epilepsy. The aim of this study was to test the clinical utility of lesion-constrained electrical source imaging in epilepsy surgery in children with tuberous sclerosis complex. METHODS Lesion-constrained electrical source imaging is a novel method based on a proposed head model in which the source solution is constrained to lesions. Using a goodness of fit analysis, we rank-ordered individual tubers by their ability to approximate interictal and ictal EEG data. The overlap with the surgical resection cavity was determined qualitatively, and placed findings in the context of epilepsy surgical outcome, and compared with the low-resolution brain electromagnetic tomography solution. RESULTS Low-resolution brain electromagnetic tomography predicted the surgical cavity in only one patient with good outcome (true positive) and localized to outside of the cavity in two patients with a good outcome (false negative). In one patient with a poor outcome, the interictal low-resolution brain electromagnetic tomography solution overlapped with the cavity (false positive). Lesion-constrained electrical source imaging of ictal EEG data identified tubers concordant with the resection zone in three patients with a good surgical outcome (true positive) and appropriately discordant in three other patients with a poor outcome (true negative). CONCLUSIONS Lesion-constrained electrical source imaging on low-resolution EEG data provides complementary information in the presurgical workup for patients with tuberous sclerosis complex, although further validation is required. In the appropriate clinical context, the yield of source localization on low-resolution EEG data may be increased by reduction of the solution space.
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24
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van der Poest Clement E, Jansen FE, Braun KPJ, Peters JM. Update on Drug Management of Refractory Epilepsy in Tuberous Sclerosis Complex. Paediatr Drugs 2020; 22:73-84. [PMID: 31912454 DOI: 10.1007/s40272-019-00376-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Tuberous sclerosis complex (TSC) is a genetic neurocutaneous disorder with epilepsy as a common and early presenting symptom. The neurological phenotype, however, is variable and unpredictable. Early and refractory seizures, infantile spasms in particular, are associated with a poor neurological outcome. Preliminary data suggests early and aggressive seizure control may mitigate the detrimental neurodevelopmental effects of epilepsy. For infantile spasms, vigabatrin is the first line of treatment, and steroids and classic antiepileptic drugs (AEDs) are suitable for second line. Based on retrospective data, vigabatrin should be considered for other indications, especially in infants with focal seizures, as this may prevent infantile spasms, but also in children and adults with epileptic spasms and tonic seizures. Otherwise, for most seizure types, treatment is similar to that for patients without TSC, including the use of novel AEDs, although limited data are available. Three major developments are changing the field of epilepsy management in TSC. First, final recommendations on preventive treatment with vigabatrin will result from two multicenter trials in the US (PREVeNT, clinicaltrials.gov #NCT02849457) and Europe (EPISTOP, clinicaltrials.gov #NCT02098759). Second, treatment with everolimus, an inhibitor of the mechanistic target of rapamycin (mTOR), reduced seizures when compared to placebo. Further, mTOR inhibitors may have an overall disease-modifying effect. Third, the role of cannabidiol in the treatment of refractory seizures in TSC is yet to be established. With treatment recommendations in TSC, we keep an eye on the prize for the broader field of pediatric epilepsy: the lessons learned from TSC are likely applicable to other epileptic encephalopathies.
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Affiliation(s)
| | - Floor E Jansen
- Department of Child Neurology, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
| | - Kees P J Braun
- Department of Child Neurology, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
| | - Jurriaan M Peters
- Division of Epilepsy and Clinical Neurophysiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave, FE9, Boston, 02115, USA.
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25
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Liu S, Cai Y, Rong R, Hu P, Chen S, Wang X, Shi H. Tuberous sclerosis complex (TSC) with epilepsy on 18F-FDG simultaneous PET/MR. Eur J Nucl Med Mol Imaging 2020; 47:2471-2472. [PMID: 31953673 DOI: 10.1007/s00259-019-04539-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 09/13/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Siwei Liu
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yang Cai
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Rong Rong
- United Imaging Healthcare of American, Houston, TX, USA
| | - Pengcheng Hu
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shuguang Chen
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xin Wang
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Hongcheng Shi
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.
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26
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Cepeda C, Levinson S, Nariai H, Yazon VW, Tran C, Barry J, Oikonomou KD, Vinters HV, Fallah A, Mathern GW, Wu JY. Pathological high frequency oscillations associate with increased GABA synaptic activity in pediatric epilepsy surgery patients. Neurobiol Dis 2019; 134:104618. [PMID: 31629890 DOI: 10.1016/j.nbd.2019.104618] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/22/2019] [Accepted: 09/19/2019] [Indexed: 11/25/2022] Open
Abstract
Pathological high-frequency oscillations (HFOs), specifically fast ripples (FRs, >250 Hz), are pathognomonic of an active epileptogenic zone. However, the origin of FRs remains unknown. Here we explored the correlation between FRs recorded with intraoperative pre-resection electrocorticography (ECoG) and spontaneous synaptic activity recorded ex vivo from cortical tissue samples resected for the treatment of pharmacoresistant epilepsy. The cohort included 47 children (ages 0.22-9.99 yr) with focal cortical dysplasias (CD types I and II), tuberous sclerosis complex (TSC) and non-CD pathologies. Whole-cell patch clamp recordings were obtained from pyramidal neurons and interneurons in cortical regions that were positive or negative for pathological HFOs, defined as FR band oscillations (250-500 Hz) at ECoG. The frequency of spontaneous excitatory and inhibitory postsynaptic currents (sEPSCs and IPSCs, respectively) was compared between HFO+ and HFO- regions. Regardless of pathological substrate, regions positive for FRs displayed significantly increased frequencies of sIPSCs compared with regions negative for FRs. In contrast, the frequency of sEPSCs was similar in both regions. In about one third of cases (n = 17), pacemaker GABA synaptic activity (PGA) was observed. In the vast majority (n = 15), PGA occurred in HFO+ areas. Further, fast-spiking interneurons displayed signs of hyperexcitability exclusively in HFO+ areas. These results indicate that, in pediatric epilepsy patients, increased GABA synaptic activity is associated with interictal FRs in the epileptogenic zone and suggest an active role of GABAergic interneurons in the generation of pathological HFOs. Increased GABA synaptic activity could serve to dampen excessive excitability of cortical pyramidal neurons in the epileptogenic zone, but it could also promote neuronal network synchrony.
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Affiliation(s)
- Carlos Cepeda
- IDDRC, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA.
| | - Simon Levinson
- IDDRC, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Hiroki Nariai
- Division of Pediatric Neurology, Mattel Children's Hospital, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Vannah-Wila Yazon
- IDDRC, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Conny Tran
- IDDRC, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Joshua Barry
- IDDRC, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Katerina D Oikonomou
- IDDRC, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Harry V Vinters
- Section of Neuropathology, Department of Pathology and Laboratory Medicine and Department of Neurology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Gary W Mathern
- IDDRC, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA; Department of Neurosurgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Joyce Y Wu
- Division of Pediatric Neurology, Mattel Children's Hospital, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
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27
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中国抗癫痫协会结节性硬化专业委员会. [Chinese expert consensus on surgical treatment of tuberous sclerosis complex-related epilepsy]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2019; 21:735-742. [PMID: 31416495 PMCID: PMC7389894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/02/2019] [Indexed: 08/01/2024]
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28
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[Chinese expert consensus on surgical treatment of tuberous sclerosis complex-related epilepsy]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2019; 21:735-742. [PMID: 31416495 PMCID: PMC7389894 DOI: 10.7499/j.issn.1008-8830.2019.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/02/2019] [Indexed: 06/10/2023]
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Ostrowsky-Coste K, Neal A, Guenot M, Ryvlin P, Bouvard S, Bourdillon P, Jung J, Catenoix H, Montavont A, Isnard J, Arzimanoglou A, Rheims S. Resective surgery in tuberous Sclerosis complex, from Penfield to 2018: A critical review. Rev Neurol (Paris) 2019; 175:163-182. [DOI: 10.1016/j.neurol.2018.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/02/2018] [Accepted: 11/09/2018] [Indexed: 10/27/2022]
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30
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Mouthaan BE, Rados M, Boon P, Carrette E, Diehl B, Jung J, Kimiskidis V, Kobulashvili T, Kuchukhidze G, Larsson PG, Leitinger M, Ryvlin P, Rugg-Gunn F, Seeck M, Vulliémoz S, Huiskamp G, Leijten FSS, Van Eijsden P, Trinka E, Braun KPJ. Diagnostic accuracy of interictal source imaging in presurgical epilepsy evaluation: A systematic review from the E-PILEPSY consortium. Clin Neurophysiol 2019; 130:845-855. [PMID: 30824202 DOI: 10.1016/j.clinph.2018.12.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 11/16/2018] [Accepted: 12/20/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Interictal high resolution (HR-) electric source imaging (ESI) and magnetic source imaging (MSI) are non-invasive tools to aid epileptogenic zone localization in epilepsy surgery candidates. We carried out a systematic review on the diagnostic accuracy and quality of evidence of these modalities. METHODS Embase, Pubmed and the Cochrane database were searched on 13 February 2017. Diagnostic accuracy studies taking post-surgical seizure outcome as reference standard were selected. Quality appraisal was based on the QUADAS-2 framework. RESULTS Eleven studies were included: eight MSI (n = 267), three HR-ESI (n = 127) studies. None was free from bias. This mostly involved: selection of operated patients only, interference of source imaging with surgical decision, and exclusion of indeterminate results. Summary sensitivity and specificity estimates were 82% (95% CI: 75-88%) and 53% (95% CI: 37-68%) for overall source imaging, with no statistical difference between MSI and HR-ESI. Specificity is higher when partially concordant results were included as non-concordant (p < 0.05). Inclusion of indeterminate test results as non-concordant lowered sensitivity (p < 0.05). CONCLUSIONS Source imaging has a relatively high sensitivity but low specificity for identification of the epileptogenic zone. SIGNIFICANCE We need higher quality studies allowing unbiased test evaluation to determine the added value and diagnostic accuracy of source imaging in the presurgical workup of refractory focal epilepsy.
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Affiliation(s)
- Brian E Mouthaan
- Department of (Child) Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO Box 85090, 3508 AB Utrecht, The Netherlands
| | - Matea Rados
- Department of (Child) Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO Box 85090, 3508 AB Utrecht, The Netherlands
| | - Paul Boon
- Reference Center for Refractory Epilepsy, Department of Neurology, Ghent University Hospital, Belgium
| | - Evelien Carrette
- Reference Center for Refractory Epilepsy, Department of Neurology, Ghent University Hospital, Belgium
| | - Beate Diehl
- National Hospital for Neurology and Neurosurgery, University College London Hospitals, London, United Kingdom; Department of Clinical and Experimental Epilepsy, University College, London, UK
| | - Julien Jung
- Department of Functional Neurology and Epileptology, Institute of Epilepsies (IDEE), Hospices Civils de Lyon, Lyon, France
| | - Vasilios Kimiskidis
- Laboratory of Clinical Neurophysiology, Medical School, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
| | - Teia Kobulashvili
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, and Centre for Cognitive Neuroscience, Salzburg, Austria
| | - Giorgi Kuchukhidze
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, and Centre for Cognitive Neuroscience, Salzburg, Austria
| | - Pål G Larsson
- Department of Neurosurgery, Clinic of Surgery and Neuroscience, Oslo University Hospital, Norway
| | - Markus Leitinger
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, and Centre for Cognitive Neuroscience, Salzburg, Austria
| | - Philippe Ryvlin
- Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - Fergus Rugg-Gunn
- National Hospital for Neurology and Neurosurgery, University College London Hospitals, London, United Kingdom; Department of Clinical and Experimental Epilepsy, University College, London, UK
| | - Margitta Seeck
- EEG and Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Switzerland
| | - Serge Vulliémoz
- EEG and Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Switzerland
| | - Geertjan Huiskamp
- Department of (Child) Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO Box 85090, 3508 AB Utrecht, The Netherlands
| | - Frans S S Leijten
- Department of (Child) Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO Box 85090, 3508 AB Utrecht, The Netherlands
| | - Pieter Van Eijsden
- Department of (Child) Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO Box 85090, 3508 AB Utrecht, The Netherlands
| | - Eugen Trinka
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, and Centre for Cognitive Neuroscience, Salzburg, Austria; Institute of Public Health, Medical Decision Making and HTA, UMIT, Private University for Health Sciences, Medical Informatics and Technology, Hall in Tyrol, Austria
| | - Kees P J Braun
- Department of (Child) Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO Box 85090, 3508 AB Utrecht, The Netherlands.
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31
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Canevini MP, Kotulska-Jozwiak K, Curatolo P, La Briola F, Peron A, Słowińska M, Strzelecka J, Vignoli A, Jóźwiak S. Current concepts on epilepsy management in tuberous sclerosis complex. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2018; 178:299-308. [PMID: 30255982 DOI: 10.1002/ajmg.c.31652] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/21/2018] [Accepted: 08/23/2018] [Indexed: 12/12/2022]
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant neurocutaneous disease affecting approximately 1 in 6,000 people, and represents one of the most common genetic causes of epilepsy. Epilepsy affects 90% of the patients and appears in the first 2 years of life in the majority of them. Early onset of epilepsy in the first 12 months of life is associated with high risk of cognitive decline and neuropsychiatric problems including autism. Prenatal or early infantile diagnosis of TSC, before the onset of epilepsy, provides a unique opportunity to monitor EEG before the onset of clinical seizures, thus enabling early intervention in the process of epileptogenesis. In this review, we discuss the current status of knowledge on epileptogenesis in TSC, and present recommendations of American and European experts in the field of epilepsy.
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Affiliation(s)
- Maria Paola Canevini
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | | | - Paolo Curatolo
- Department of Pediatric Neuropsychiatry, Tor Vergata University, Rome, Italy
| | - Francesca La Briola
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Angela Peron
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy.,Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Monika Słowińska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland.,Department of Pediatric Neurology, Warsaw Medical University, Warsaw, Poland
| | - Jolanta Strzelecka
- Department of Pediatric Neurology, Warsaw Medical University, Warsaw, Poland
| | - Aglaia Vignoli
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Sergiusz Jóźwiak
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland.,Department of Pediatric Neurology, Warsaw Medical University, Warsaw, Poland
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Cepeda C, Levinson S, Yazon VW, Barry J, Mathern GW, Fallah A, Vinters HV, Levine MS, Wu JY. Cellular antiseizure mechanisms of everolimus in pediatric tuberous sclerosis complex, cortical dysplasia, and non-mTOR-mediated etiologies. Epilepsia Open 2018; 3:180-190. [PMID: 30564777 PMCID: PMC6293070 DOI: 10.1002/epi4.12253] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2018] [Indexed: 11/25/2022] Open
Abstract
The present study was designed to examine the potential cellular antiseizure mechanisms of everolimus, a mechanistic target of rapamycin (mTOR) pathway blocker, in pediatric epilepsy cases. Cortical tissue samples obtained from pediatric patients (n = 11, ages 0.67–6.75 years) undergoing surgical resections for the treatment of their pharmacoresistant epilepsy were examined electrophysiologically in ex vivo slices. The cohort included mTOR‐mediated pathologies (tuberous sclerosis complex [TSC] and severe cortical dysplasia [CD]) as well as non–mTOR‐mediated pathologies (tumor and perinatal infarct). Bath application of everolimus (2 μm) had practically no effect on spontaneous inhibitory postsynaptic activity. In contrast, long‐term application of everolimus reduced spontaneous excitatory postsynaptic activity, burst discharges induced by blockade of γ‐aminobutyric acid A (GABAA) receptors, and epileptiform activity generated by 4‐aminopyridine, a K+ channel blocker. The antiseizure effects were more pronounced in TSC and CD cases, whereas in non–mTOR‐mediated pathologies, the effects were subtle at best. These results support further clinical trials of everolimus in mTOR pathway–mediated pathologies and emphasize that the effects require sustained exposure over time.
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Affiliation(s)
- Carlos Cepeda
- IDDRC Semel Institute for Neuroscience and Human Behavior UCLA School of Medicine University of California Los Angeles Los Angeles California, U.S.A
| | - Simon Levinson
- IDDRC Semel Institute for Neuroscience and Human Behavior UCLA School of Medicine University of California Los Angeles Los Angeles California, U.S.A
| | - Vannah-Wila Yazon
- IDDRC Semel Institute for Neuroscience and Human Behavior UCLA School of Medicine University of California Los Angeles Los Angeles California, U.S.A
| | - Joshua Barry
- IDDRC Semel Institute for Neuroscience and Human Behavior UCLA School of Medicine University of California Los Angeles Los Angeles California, U.S.A
| | - Gary W Mathern
- IDDRC Semel Institute for Neuroscience and Human Behavior UCLA School of Medicine University of California Los Angeles Los Angeles California, U.S.A.,Department of Neurosurgery David Geffen School of Medicine at University of California Los Angeles Los Angeles California, U.S.A
| | - Aria Fallah
- Department of Neurosurgery David Geffen School of Medicine at University of California Los Angeles Los Angeles California, U.S.A
| | - Harry V Vinters
- Section of Neuropathology Department of Pathology and Laboratory Medicine and Department of Neurology David Geffen School of Medicine at University of California Los Angeles Los Angeles California, U.S.A
| | - Michael S Levine
- IDDRC Semel Institute for Neuroscience and Human Behavior UCLA School of Medicine University of California Los Angeles Los Angeles California, U.S.A
| | - Joyce Y Wu
- Division of Pediatric Neurology Mattel Children's Hospital David Geffen School of Medicine at University of California Los Angeles Los Angeles California U.S.A
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Management of epilepsy associated with tuberous sclerosis complex: Updated clinical recommendations. Eur J Paediatr Neurol 2018; 22:738-748. [PMID: 29880258 DOI: 10.1016/j.ejpn.2018.05.006] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 04/12/2018] [Accepted: 05/20/2018] [Indexed: 11/23/2022]
Abstract
Patients with tuberous sclerosis complex (TSC) are at very high risk for developing epilepsy, and the majority experience seizure onset during the first year of life. Early targeted interventions increase the probability of seizure-freedom and may protect neurodevelopment. In 2012, clinical recommendations for the management of epilepsy in patients with TSC were published by a panel of European experts. Since that time novel studies, reports, and expert opinions in preclinical and clinical TSC-related sciences prompted the need for updated recommendations, including epileptogenesis in TSC, the potential role of predictive biomarkers, the possible benefits of presymptomatic diagnosis and preventive treatment, and new treatment options including mTOR inhibitors. A reconvened panel reviewed the current literature to answer specific questions and five panelists discussed the findings, followed by a general discussion during which all issues were debated to achieve consensus regarding recommendations. A draft manuscript based on these discussions and recommendations was then circulated several times among the panelists, who added their own comments. All the panelists/authors agreed with the final manuscript, which was then submitted for publication. The panel concluded that the need for early diagnosis of TSC-associated seizures is now established, electroencephalographic monitoring has good predictive value for epilepsy before seizure onset in TSC, and, until conclusive data from the EPISTOP trial are available, administration of vigabatrin may be considered in children with subclinical epileptiform EEG discharges. The panel also supported the role of adjunctive everolimus for TSC-associated drug-refractory seizures and emphasized the necessity of early surgical evaluation.
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Savini MN, Mingarelli A, Vignoli A, La Briola F, Chiesa V, Peron A, Mai R, Tassi L, Mastrangelo M, Zambrelli E, Turner K, Canevini MP. Ictal signs in tuberous sclerosis complex: Clinical and video-EEG features in a large series of recorded seizures. Epilepsy Behav 2018; 85:14-20. [PMID: 29906696 DOI: 10.1016/j.yebeh.2018.05.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/26/2018] [Accepted: 05/14/2018] [Indexed: 11/26/2022]
Abstract
Epilepsy is the most common neurological symptom in tuberous sclerosis complex (TSC), occurring in 72-85% of affected individuals. Despite the large number of patients reported, their electroclinical phenotype has been rarely described. We analyzed seizure semiology through ictal video-electroencephalography (V-EEG) recordings in a large series of patients. In this multicenter study, we reviewed V-EEGs of 51 patients: ictal recordings were analyzed in correlation with their clinical variables. The median age of epilepsy onset was six months (one day-16 years), with onset in the first year of life in 71% patients (36/51), in 10 of them during the neonatal period. Sixty-five percent of patients (33/51) experienced epileptic spasms in their life, with late-onset (>two years) in five; 42% of the epileptic spasms persisted after age two years, despite the onset in the first year of life. We identified four different electroclinical subsets: focal epilepsy (35%, 18/51), Lennox-Gastaut Syndrome evolution (27%, 14/51), focal seizures with persisting spasms (33%, 17/51), and spasms only (4%, 2/51). We reviewed 45 focal seizures, 13 clusters of epileptic spasms, and seven generalized seizures. In 12 patients, we recorded different seizure types. In 71% of the focal seizures (32/45), the ictal pattern was focal without diffusion. In 38% of the patients (5/13) epileptic spasms were related to typical diffuse slow wave pattern associated with superimposed fast activity, with focal predominance. Focal seizures and focal spasms resulted as the most frequent seizure types in TSC. Seizure onset was variable but showing a predominant involvement of the frontocentral regions (40%). Discrete clinical signs characterized the seizures, and behavioral arrest was the predominant first clinical objective sign. Epileptic spasms were a typical presentation at all ages, frequently asymmetrical and associated with lateralizing features, especially in older patients.
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Affiliation(s)
- Miriam Nella Savini
- Epilepsy Center-Child Neuropsychiatric Unit, ASST Santi Paolo e Carlo, Milan, Italy; Department of Health Sciences, University of Milan, Italy
| | - Alessia Mingarelli
- Epilepsy Center-Child Neuropsychiatric Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - Aglaia Vignoli
- Epilepsy Center-Child Neuropsychiatric Unit, ASST Santi Paolo e Carlo, Milan, Italy; Department of Health Sciences, University of Milan, Italy.
| | - Francesca La Briola
- Epilepsy Center-Child Neuropsychiatric Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - Valentina Chiesa
- Epilepsy Center-Child Neuropsychiatric Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - Angela Peron
- Epilepsy Center-Child Neuropsychiatric Unit, ASST Santi Paolo e Carlo, Milan, Italy; Department of Health Sciences, University of Milan, Italy
| | - Roberto Mai
- "C. Munari" Epilepsy Surgery Center, GOM Niguarda, Milan, Italy
| | - Laura Tassi
- "C. Munari" Epilepsy Surgery Center, GOM Niguarda, Milan, Italy
| | | | - Elena Zambrelli
- Epilepsy Center-Child Neuropsychiatric Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - Katherine Turner
- Epilepsy Center-Child Neuropsychiatric Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - Maria Paola Canevini
- Epilepsy Center-Child Neuropsychiatric Unit, ASST Santi Paolo e Carlo, Milan, Italy; Department of Health Sciences, University of Milan, Italy
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Fohlen M, Taussig D, Ferrand-Sorbets S, Chipaux M, Dorison N, Delalande O, Dorfmüller G. Refractory epilepsy in preschool children with tuberous sclerosis complex: Early surgical treatment and outcome. Seizure 2018; 60:71-79. [PMID: 29929109 DOI: 10.1016/j.seizure.2018.06.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 06/05/2018] [Accepted: 06/07/2018] [Indexed: 10/14/2022] Open
Abstract
PURPOSE Epilepsy surgery has been shown to be effective in treating focal epilepsy related to tuberous sclerosis complex (TSC). We analyzed the advantage of early surgical management in terms of seizure frequency and development. METHOD We retrospectively studied the 15 patients younger than 6 years who underwent resective surgery between 2006 and 2016. Fourteen of them had invasive monitoring while the 15th was operated on under corticography. RESULTS Epilepsy began before 5 months of age in all patients. Overall 13 patients (86%) had a dramatic improvement of epilepsy after surgery (Engel 1 and 2) including 9 patients (60%) seizure free (Engel 1 A). In the group of 9 patients younger than 20 months at the time of surgery who presented with catastrophic epilepsies, 77% are Engel 1 A and the other 23% Engel 2. In this subpopulation, no one developed autism and four (44%) regained normal development. CONCLUSIONS In early onset epilepsies associated with TSC, surgical treatment is highly effective, in particular when performed early. Invasive monitoring contributes to the successful outcome. Those data have to be confirmed by multicentric studies including quantitative analyses of the recordings.
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Affiliation(s)
- Martine Fohlen
- Pediatric Neurosurgery Unit, Rothschild Foundation Hospital, Paris, France.
| | - Delphine Taussig
- Pediatric Neurosurgery Unit, Rothschild Foundation Hospital, Paris, France
| | | | - Mathilde Chipaux
- Pediatric Neurosurgery Unit, Rothschild Foundation Hospital, Paris, France
| | - Nathalie Dorison
- Pediatric Neurosurgery Unit, Rothschild Foundation Hospital, Paris, France
| | - Olivier Delalande
- Pediatric Neurosurgery Unit, Rothschild Foundation Hospital, Paris, France
| | - Georg Dorfmüller
- Pediatric Neurosurgery Unit, Rothschild Foundation Hospital, Paris, France
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Bernardo D, Nariai H, Hussain SA, Sankar R, Salamon N, Krueger DA, Sahin M, Northrup H, Bebin EM, Wu JY. Visual and semi-automatic non-invasive detection of interictal fast ripples: A potential biomarker of epilepsy in children with tuberous sclerosis complex. Clin Neurophysiol 2018; 129:1458-1466. [PMID: 29673547 DOI: 10.1016/j.clinph.2018.03.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 02/22/2018] [Accepted: 03/07/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVES We aim to establish that interictal fast ripples (FR; 250-500 Hz) are detectable on scalp EEG, and to investigate their association to epilepsy. METHODS Scalp EEG recordings of a subset of children with tuberous sclerosis complex (TSC)-associated epilepsy from two large multicenter observational TSC studies were analyzed and compared to control children without epilepsy or any other brain-based diagnoses. FR were identified both by human visual review and compared with semi-automated review utilizing a deep learning-based FR detector. RESULTS Seven out of 7 children with TSC-associated epilepsy had scalp FR compared to 0 out of 4 children in the control group (p = 0.003). The automatic detector has a sensitivity of 98% and false positive rate with average of 11.2 false positives per minute. CONCLUSIONS Non-invasive detection of interictal scalp FR was feasible, by both visual and semi-automatic detection. Interictal scalp FR occurred exclusively in children with TSC-associated epilepsy and were absent in controls without epilepsy. The proposed detector achieves high sensitivity of FR detection; however, expert review of the results to reduce false positives is advised. SIGNIFICANCE Interictal FR are detectable on scalp EEG and may potentially serve as a biomarker of epilepsy in children with TSC.
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Affiliation(s)
- Danilo Bernardo
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | - Hiroki Nariai
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Shaun A Hussain
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Raman Sankar
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Noriko Salamon
- Division of Neuroradiology, Department of Radiology, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Darcy A Krueger
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mustafa Sahin
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hope Northrup
- Division of Medical Genetics, Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - E Martina Bebin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joyce Y Wu
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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Intraoperative fast ripples independently predict postsurgical epilepsy outcome: Comparison with other electrocorticographic phenomena. Epilepsy Res 2017. [PMID: 28644979 DOI: 10.1016/j.eplepsyres.2017.06.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In the surgical management of epilepsy, the resection of cortex exhibiting interictal fast ripples (250-500Hz) on electrocorticography has been linked to postoperative seizure-freedom. Although fast ripples appear to accurately identify the epileptogenic zone-the minimum tissue that must be removed at surgery to achieve seizure-freedom-it has not been established that fast ripples are a superior biomarker in comparison with multimodal presurgical neuroimaging and other electrocorticography abnormalities. Hence, in the prediction of postoperative seizure-freedom, we compared the value of fast ripples with other intraoperative electocorticography abnormalities including focal slowing, paroxysmal fast activity, intermittent spike discharges, continuous epileptiform discharges, focal attenuation, and intraoperative seizures, as well as complete resection of the lesion defined by MRI and other neuroimaging. In a cohort of 60 children with lesional epilepsy and median postsurgical follow-up exceeding 4 years, who underwent resective epilepsy surgery with intraoperative electrocorticography, we evaluated the extent to which removal of each intraoperative electrocorticography abnormality impacts time to first postoperative seizure using the Kaplan-Meier method and Cox proportional hazards regression. Secondly, we contrasted the predictive value of resection of each competing electrocorticography abnormality using standard test metrics (sensitivity, specificity, positive predictive value, and negative predictive value). In contrast with all other intraoperative electrocorticography abnormalities, fast ripples demonstrated the most favorable combination of positive predictive value (100%) and negative predictive value (76%) in the prediction of postoperative seizures. Among all candidate electrocorticography features, time to first postoperative seizure was most strongly associated with incomplete resection of fast ripples (hazard ratio=19.8, p<0.001). In multivariate survival analyses, postoperative seizures were independently predicted by incomplete resection of cortex generating fast ripples (hazard ratio=25.4, 95%CI 6.71-96.0, p<0.001) and focal slowing (hazard ratio=5.79, 95%CI 1.76-19.0, p=0.004), even after adjustment for the impact of an otherwise complete resection. All children with incomplete resection of interictal FR-generating cortex exhibited postoperative seizures within six months. Notably, this cohort included many patients with large resections and thus limited opportunity to exhibit unresected fast ripples. Future study in a cohort with small resection volume, or a clinical trial in which resection margins are guided by fast ripple distribution, would likely yield a more precise estimate of the risk posed by unresected fast ripples. With a high detection rate during brief intraoperative electrocorticography and favorable positive and negative predictive value, interictal fast ripple characterization during surgery is a feasible and useful adjunct to standard methods for epilepsy surgery planning, and represents a valuable spatially-localizing biomarker of the epileptogenic zone, without the need for prolonged extraoperative electrocorticography.
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Liang S, Zhang J, Yang Z, Zhang S, Cui Z, Cui J, Zhang J, Liu N, Ding P. Long-term outcomes of epilepsy surgery in tuberous sclerosis complex. J Neurol 2017; 264:1146-1154. [DOI: 10.1007/s00415-017-8507-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/03/2017] [Accepted: 05/04/2017] [Indexed: 10/19/2022]
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Boom M, Raskin JS, Curry DJ, Weiner HL, Peters JM. Technological advances in pediatric epilepsy surgery: implications for tuberous sclerosis complex. FUTURE NEUROLOGY 2017. [DOI: 10.2217/fnl-2017-0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In selected children with tuberous sclerosis complex, epilepsy surgery leads to seizure freedom or seizure reduction. The current standard involves a multimodal pre-surgical workup followed by invasive electrocorticographic monitoring and resective surgery. Recent insights in the disorder and novel technologies are changing the approach to pediatric epilepsy surgery in tuberous sclerosis complex. New evidence suggests tubers are poorly delineated, and epileptogenic activity may originate in the perituber tissue. Novel imaging modalities relevant to surgical planning include high-resolution MRI, α-methyl-l-tryptophan or fluorodeoxyglucose PET with diffusion tensor imaging. Advanced neurophysiological techniques have improved identification of the surgical target, including magnetoencephalography, electrical source imaging of high-density electroencephalograph data, and high-frequency oscillations in electrocorticography data. Simultaneously, novel surgical tools including stereo-electroencephalography and laser-induced thermal therapy have become available for children. This article reviews the literature in the light of these rapidly changing technologies.
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Affiliation(s)
- Merel Boom
- Division of Epilepsy & Clinical Neurophysiology, Boston Children’s Hospital & Harvard Medical School, 300 Longwood Avenue, BCH 3063, Boston, MA 02115, USA
| | - Jeffrey S Raskin
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children’s Hospital & Department of Neurosurgery, Baylor College of Medicine, 6701 Fannin St. Suite 1230.01, Houston, TX 77030, USA
| | - Daniel J Curry
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children’s Hospital & Department of Neurosurgery, Baylor College of Medicine, 6701 Fannin St. Suite 1230.01, Houston, TX 77030, USA
| | - Howard L Weiner
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children’s Hospital & Department of Neurosurgery, Baylor College of Medicine, 6701 Fannin St. Suite 1230.01, Houston, TX 77030, USA
| | - Jurriaan M Peters
- Division of Epilepsy & Clinical Neurophysiology, Boston Children’s Hospital & Harvard Medical School, 300 Longwood Avenue, BCH 3063, Boston, MA 02115, USA
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital and Harvard Medical School,300 Longwood Avenue, BCH 3429, Boston, MA 02115, SA
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Kumar A, Chugani HT. The Role of Radionuclide Imaging in Epilepsy, Part 2: Epilepsy Syndromes. J Nucl Med Technol 2017; 45:22-29. [DOI: 10.2967/jnumed.113.129593] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 07/31/2013] [Indexed: 11/16/2022] Open
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Resection of ictal high frequency oscillations is associated with favorable surgical outcome in pediatric drug resistant epilepsy secondary to tuberous sclerosis complex. Epilepsy Res 2016; 126:90-7. [DOI: 10.1016/j.eplepsyres.2016.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 07/06/2016] [Accepted: 07/14/2016] [Indexed: 11/22/2022]
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Okanishi T, Akiyama T, Mayo E, Honda Y, Ueda-Kawada C, Nakajima M, Homma Y, Ochi A, Go C, Widjaja E, Chuang SH, Rutka JT, Drake J, Snead OC, Otsubo H. Magnetoencephalography spike sources interrelate the extensive epileptogenic zone of tuberous sclerosis complex. Epilepsy Res 2016; 127:302-310. [PMID: 27693986 DOI: 10.1016/j.eplepsyres.2016.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 08/16/2016] [Accepted: 09/05/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVE We hypothesized that the extensive epileptic network in patients with tuberous sclerosis complex (TSC) manifests as clustered and scattered distributions of magnetoencephalography spike sources (MEGSS). METHODS We retrospectively analyzed pre-surgical MEG in 15 patients with TSC. We performed single moving dipole analysis to localize and classify clustered and scattered MEGSS. We compared the number of electrodes within the resected area (RA) and the proportions of clustered and scattered MEGSS within RA with the seizure outcome. RESULTS The number of electrodes within RA ranged from 29 to 83 (mean=51). The MEGSS were distributed over multiple lobes (3-8; mean=5.9) and bilaterally in 14 patients. Clusters of MEGSS ranged from 1 to 4 (mean=1.4). The number of MEGSS ranged in total from 28 to 139 (mean=70); in the clusters, 10-128 (mean=49); and in the scatters, 0-45 (mean=21). Four patients achieved an Engel class I surgical outcome, four, a class II outcome; five, a class III outcome; and two, a class IV outcome. The proportion of MEGSS ranged in total from 0 to 92% (mean=57%) within RA; 0-100% (mean=67%) in the resection hemisphere; 0-100% (mean=63%) in the clusters; and 0-81% (mean=28%) in the scatters. Univariate ordinal logistic regression analyses showed that the proportion of scattered MEGSS within RA (p=0.049) significantly correlated with seizure outcomes. Multivariate analyses using three covariates (number of electrodes, proportions of clustered and scattered MEGSS within RA) showed that only the proportion of scattered MEGSS within RA significantly correlated with seizure outcomes (p=0.016). SIGNIFICANCE MEG data showed a wide distribution of multilobar MEGSS in patients with TSC. The seizure outcome was not related to the clustered MEGSS within RA, since the grids were essentially planned to cover and resect the clustered MEGSS surrounding tubers. The maximal possible resection of scattered MEGSS correlated with improved seizure outcome in TSC. Some parts of the epileptogenic zone disrupted by multiple tubers did not have a sufficiently large area to produce clustered MEGSS. Although the wide distribution of scattered MEGSS is not interpreted as epileptogenic, they might be interrelated with clustered MEGSS to project a complex epilepsy network and be part of the extensive epileptogenic zones found in TSC.
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Affiliation(s)
- Tohru Okanishi
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada.
| | - Tomoyuki Akiyama
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada; Department of Child Neurology, Okayama University Hospital, PO Box 700, 0914 Okayama, Japan
| | - Ellen Mayo
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - Yasunori Honda
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - Chihiro Ueda-Kawada
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - Midori Nakajima
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - Yoichiro Homma
- Department of General Internal Medicine, Seirei-Hamamatsu General Hospital, PO Box 430, 8558, Hamamatsu, Shizuoka, Japan
| | - Ayako Ochi
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - Cristina Go
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - Elysa Widjaja
- Division of Diagnostic Imaging, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - Sylvester H Chuang
- Division of Diagnostic Imaging, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - James T Rutka
- Division of Neurosurgery, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - James Drake
- Division of Neurosurgery, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - O Carter Snead
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - Hiroshi Otsubo
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
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Abstract
Nuclear medicine imaging can provide important complementary information in the management of pediatric patients with neurological diseases. Pre-surgical localization of the epileptogenic focus in medically refractory epilepsy patients is the most common indication for nuclear medicine imaging in pediatric neurology. In patients with temporal lobe epilepsy, nuclear medicine imaging is particularly useful when magnetic resonance imaging findings are normal or its findings are discordant with electroencephalogram findings. In pediatric patients with brain tumors, nuclear medicine imaging can be clinically helpful in the diagnosis, directing biopsy, planning therapy, differentiating tumor recurrence from post-treatment sequelae, and assessment of response to therapy. Among other neurological diseases in which nuclear medicine has proved to be useful are patients with head trauma, inflammatory-infectious diseases and hypoxic-ischemic encephalopathy.
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Affiliation(s)
- Ümit Özgür Akdemir
- Gazi University Faculty of Medicine, Department of Nuclear Medicine, Ankara, Turkey Phone: +90 312 202 61 75 E-mail:
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Kannan L, Vogrin S, Bailey C, Maixner W, Harvey AS. Centre of epileptogenic tubers generate and propagate seizures in tuberous sclerosis. Brain 2016; 139:2653-2667. [DOI: 10.1093/brain/aww192] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 06/20/2016] [Indexed: 01/14/2023] Open
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Ellingson BM, Hirata Y, Yogi A, Karavaeva E, Leu K, Woodworth DC, Harris RJ, Enzmann DR, Wu JY, Mathern GW, Salamon N. Topographical Distribution of Epileptogenic Tubers in Patients With Tuberous Sclerosis Complex. J Child Neurol 2016; 31:636-45. [PMID: 26472749 DOI: 10.1177/0883073815609151] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 08/22/2015] [Indexed: 11/16/2022]
Abstract
Tuberous sclerosis complex is a multisystem genetic syndrome often affecting the central nervous system. The purpose of the current study was to identify topographical patterns in the distribution specific to epileptogenic (n = 37) and nonepileptogenic (n = 544) tubers throughout the brain for a cohort of 23 tuberous sclerosis complex patients with a history of seizures. Tubers localized to the inferior parietal lobes, middle frontal lobes, middle temporal lobes, or central sulcus regions were associated with a high frequency of epileptogenic tubers. Epileptogenic tubers occurred statistically more frequently within the inferior parietal lobe and within the central sulcus region in children younger than 1 or between 1 and 3 years old, respectively. Results imply seizure activity in tuberous sclerosis complex patients can be associated with the location of cortical tubers.
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Affiliation(s)
- Benjamin M Ellingson
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA Department of Bioengineering, Henry Samueli School of Engineering and Applied Science, University of California, Los Angeles, Los Angeles, CA, USA
| | - Yoko Hirata
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA Department of Neurosurgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Akira Yogi
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Nakagami-gun, Okinawa, Japan
| | - Elena Karavaeva
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Kevin Leu
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA Department of Bioengineering, Henry Samueli School of Engineering and Applied Science, University of California, Los Angeles, Los Angeles, CA, USA
| | - Davis C Woodworth
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA Department of Biomedical Physics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Robert J Harris
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA Department of Biomedical Physics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Dieter R Enzmann
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Joyce Y Wu
- Department of Pediatrics, Division of Pediatric Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Gary W Mathern
- Departments of Neurosurgery and Psychiatry and Biobehavioral Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Noriko Salamon
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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Abstract
Seizures are common in patients with brain tumors, and epilepsy can significantly impact patient quality of life. Therefore, a thorough understanding of rates and predictors of seizures, and the likelihood of seizure freedom after resection, is critical in the treatment of brain tumors. Among all tumor types, seizures are most common with glioneuronal tumors (70-80%), particularly in patients with frontotemporal or insular lesions. Seizures are also common in individuals with glioma, with the highest rates of epilepsy (60-75%) observed in patients with low-grade gliomas located in superficial cortical or insular regions. Approximately 20-50% of patients with meningioma and 20-35% of those with brain metastases also suffer from seizures. After tumor resection, approximately 60-90% are rendered seizure-free, with most favorable seizure outcomes seen in individuals with glioneuronal tumors. Gross total resection, earlier surgical therapy, and a lack of generalized seizures are common predictors of a favorable seizure outcome. With regard to anticonvulsant medication selection, evidence-based guidelines for the treatment of focal epilepsy should be followed, and individual patient factors should also be considered, including patient age, sex, organ dysfunction, comorbidity, or cotherapy. As concomitant chemotherapy commonly forms an essential part of glioma treatment, enzyme-inducing anticonvulsants should be avoided when possible. Seizure freedom is the ultimate goal in the treatment of brain tumor patients with epilepsy, given the adverse effects of seizures on quality of life.
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Affiliation(s)
- Dario J Englot
- UCSF Comprehensive Epilepsy Center, University of California San Francisco, San Francisco, California, USA; Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Edward F Chang
- UCSF Comprehensive Epilepsy Center, University of California San Francisco, San Francisco, California, USA; Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Charles J Vecht
- Service Neurologie Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
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Yogi A, Hirata Y, Karavaeva E, Harris RJ, Wu JY, Yudovin SL, Linetsky M, Mathern GW, Ellingson BM, Salamon N. DTI of tuber and perituberal tissue can predict epileptogenicity in tuberous sclerosis complex. Neurology 2015; 85:2011-5. [PMID: 26546629 DOI: 10.1212/wnl.0000000000002202] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 08/17/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate whether diffusion tensor imaging (DTI) can predict epileptogenic tubers by measuring apparent diffusion coefficient (ADC), fractional anisotropy, axial diffusivity, and radial diffusivity in both tubers and perituberal tissue in pediatric patients with tuberous sclerosis complex (TSC) undergoing epilepsy surgery. METHODS We retrospectively selected 23 consecutive patients (aged 0.4-19.6 years, mean age of 5.2; 13 female, 10 male) who underwent presurgical DTI and subsequent surgical resection between 2004 and 2013 from the University of California-Los Angeles TSC Clinic. We evaluated presurgical examinations including video-EEG, brain MRI, (18)F-fluorodeoxyglucose-PET, magnetic source imaging, and intraoperative electrocorticography for determining epileptogenic tubers. A total of 545 tubers, 33 epileptogenic and 512 nonepileptogenic, were identified. Two observers generated the regions of interest (ROIs) of tubers (ROI(tuber)), the 4-mm-thick ring-shaped ROIs surrounding the tubers (ROI(perituber)), and the combined ROIs (ROI(tuber+perituber)) in consensus and calculated maximum, minimum, mean, and median values of each DTI measure in each ROI for all tubers. RESULTS The Mann-Whitney U test demonstrated that the epileptogenic group showed higher maximum ADC and radial diffusivity values in all ROIs, and that maximum ADC in ROI(tuber+perituber) showed the strongest difference (p = 0.001). Receiver operating characteristic analysis demonstrated that maximum ADC measurements in ROI(tuber+perituber) (area under curve = 0.68 ± 0.05, p < 0.001) had 81% sensitivity and 44% specificity for correctly identifying epileptogenic tubers with a cutoff value of 1.32 μm(2)/ms. CONCLUSIONS DTI analysis of tubers and perituberal tissue may help to identify epileptogenic tubers in presurgical patients with TSC more easily and effectively than current invasive methods.
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Affiliation(s)
- Akira Yogi
- From the Department of Neuroradiology (A.Y., Y.H., E.K., R.J.H., M.L., B.M.E., N.S.), Department of Pediatrics, Division of Pediatric Neurology (J.Y.W., S.L.Y.), and Department of Neurosurgery (G.W.M.), David Geffen School of Medicine, University of California, Los Angeles.
| | - Yoko Hirata
- From the Department of Neuroradiology (A.Y., Y.H., E.K., R.J.H., M.L., B.M.E., N.S.), Department of Pediatrics, Division of Pediatric Neurology (J.Y.W., S.L.Y.), and Department of Neurosurgery (G.W.M.), David Geffen School of Medicine, University of California, Los Angeles
| | - Elena Karavaeva
- From the Department of Neuroradiology (A.Y., Y.H., E.K., R.J.H., M.L., B.M.E., N.S.), Department of Pediatrics, Division of Pediatric Neurology (J.Y.W., S.L.Y.), and Department of Neurosurgery (G.W.M.), David Geffen School of Medicine, University of California, Los Angeles
| | - Robert J Harris
- From the Department of Neuroradiology (A.Y., Y.H., E.K., R.J.H., M.L., B.M.E., N.S.), Department of Pediatrics, Division of Pediatric Neurology (J.Y.W., S.L.Y.), and Department of Neurosurgery (G.W.M.), David Geffen School of Medicine, University of California, Los Angeles
| | - Joyce Y Wu
- From the Department of Neuroradiology (A.Y., Y.H., E.K., R.J.H., M.L., B.M.E., N.S.), Department of Pediatrics, Division of Pediatric Neurology (J.Y.W., S.L.Y.), and Department of Neurosurgery (G.W.M.), David Geffen School of Medicine, University of California, Los Angeles
| | - Sue L Yudovin
- From the Department of Neuroradiology (A.Y., Y.H., E.K., R.J.H., M.L., B.M.E., N.S.), Department of Pediatrics, Division of Pediatric Neurology (J.Y.W., S.L.Y.), and Department of Neurosurgery (G.W.M.), David Geffen School of Medicine, University of California, Los Angeles
| | - Michael Linetsky
- From the Department of Neuroradiology (A.Y., Y.H., E.K., R.J.H., M.L., B.M.E., N.S.), Department of Pediatrics, Division of Pediatric Neurology (J.Y.W., S.L.Y.), and Department of Neurosurgery (G.W.M.), David Geffen School of Medicine, University of California, Los Angeles
| | - Gary W Mathern
- From the Department of Neuroradiology (A.Y., Y.H., E.K., R.J.H., M.L., B.M.E., N.S.), Department of Pediatrics, Division of Pediatric Neurology (J.Y.W., S.L.Y.), and Department of Neurosurgery (G.W.M.), David Geffen School of Medicine, University of California, Los Angeles
| | - Benjamin M Ellingson
- From the Department of Neuroradiology (A.Y., Y.H., E.K., R.J.H., M.L., B.M.E., N.S.), Department of Pediatrics, Division of Pediatric Neurology (J.Y.W., S.L.Y.), and Department of Neurosurgery (G.W.M.), David Geffen School of Medicine, University of California, Los Angeles
| | - Noriko Salamon
- From the Department of Neuroradiology (A.Y., Y.H., E.K., R.J.H., M.L., B.M.E., N.S.), Department of Pediatrics, Division of Pediatric Neurology (J.Y.W., S.L.Y.), and Department of Neurosurgery (G.W.M.), David Geffen School of Medicine, University of California, Los Angeles
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Seizure outcomes in children with epilepsy after resective brain surgery. Eur J Paediatr Neurol 2015; 19:577-83. [PMID: 26095098 DOI: 10.1016/j.ejpn.2015.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 04/25/2015] [Accepted: 05/27/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE To assess the role of resective brain surgery in childhood epilepsy. METHODOLOGY We retrospectively analysed the seizure outcomes in 55 children with epilepsy who had resective brain surgery between 1997 and 2012, at our centre. The children were 1.5-18 years at the time of surgery; their seizure onset was between 0.2 andto 15 years of age. 48 had refractory epilepsy. One child died of tumour progression. Follow-up duration in the survivors ranged from 2 to -16 years (mean: 9).Presurgical evaluation included clinical profiles, non-invasive V-EEG monitoring, neuroimaging with MRIs in all; SPECT and PET in selected patients. 54 had intraoperative ECoG. RESULTS An Engel Class 1 outcome was seen in 78% of the cohort, with 67% being off all AEDs at the most recent follow-up. Children with tumours constituted the majority (56%), with 87% of this group showing a Class 1 outcome and 84% being off AEDs. Children with cortical dysplasia had a Class 1 outcome in 56%. CONCLUSION Resective brain surgery is an efficacious option in some children with epilepsy. We found ECoG useful to tailor the cortical resection and in our opinion ECoG contributed to the good seizure outcomes.
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Fallah A, Rodgers SD, Weil AG, Vadera S, Mansouri A, Connolly MB, Major P, Ma T, Devinsky O, Weiner HL, Gonzalez-Martinez JA, Bingaman WE, Najm I, Gupta A, Ragheb J, Bhatia S, Steinbok P, Witiw CD, Widjaja E, Snead OC, Rutka JT. Resective Epilepsy Surgery for Tuberous Sclerosis in Children. Neurosurgery 2015; 77:517-24; discussion 524. [DOI: 10.1227/neu.0000000000000875] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Abstract
BACKGROUND:
There are no established variables that predict the success of curative resective epilepsy surgery in children with tuberous sclerosis complex (TSC).
OBJECTIVE:
We performed a multicenter observational study to identify preoperative factors associated with seizure outcome in children with TSC undergoing resective epilepsy surgery.
METHODS:
A retrospective chart review was performed in eligible children at New York Medical Center, Miami Children's Hospital, Cleveland Clinic Foundation, BC Children's Hospital, Hospital for Sick Children, and Sainte-Justine Hospital between January 2005 and December 2013. A time-to-event analysis was performed. The “event” was defined as seizures after resective epilepsy surgery.
RESULTS:
Seventy-four patients (41 male) were included. The median age of the patients at the time of surgery was 120 months (range, 3-216 months). The median time to seizure recurrence was 24.0 ± 12.7 months. Engel Class I outcome was achieved in 48 (65%) and 37 (50%) patients at 1- and 2-year follow-up, respectively. On univariate analyses, younger age at seizure onset (hazard ratio [HR]: 2.03, 95% confidence interval [CI]: 1.03-4.00, P = .04), larger size of predominant tuber (HR: 1.03, 95% CI: 0.99-1.06, P = .12), and resection larger than a tuberectomy (HR: 1.86, 95% CI: 0.92-3.74, P = .084) were associated with a longer duration of seizure freedom. In multivariate analyses, resection larger than a tuberectomy (HR: 2.90, 95% CI: 1.17-7.18, P = .022) was independently associated with a longer duration of seizure freedom.
CONCLUSION:
In this large consecutive cohort of children with TSC and medically intractable epilepsy, a greater extent of resection (more than just the tuber) is associated with a greater probability of seizure freedom. This suggests that the epileptogenic zone may include the cortex surrounding the presumed offending tuber.
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Affiliation(s)
- Aria Fallah
- Department of Neurosurgery, Miami Children's Hospital, Miami, Florida
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Shaun D. Rodgers
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Alexander G. Weil
- Department of Neurosurgery, Miami Children's Hospital, Miami, Florida
| | - Sumeet Vadera
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alireza Mansouri
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mary B. Connolly
- Division of Neurology, BC Children's Hospital, Vancouver, BC, Canada
| | - Philippe Major
- Division of Neurology, CHU Sainte-Justine, Montreal, QC, Canada
| | - Tracy Ma
- Department of Neurosurgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Orrin Devinsky
- Department of Neurology, New York University Langone Medical Center, New York, New York
| | - Howard L. Weiner
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | | | | | - Imad Najm
- Department of Neurology, New York University Langone Medical Center, New York, New York
| | - Ajay Gupta
- Department of Neurology, New York University Langone Medical Center, New York, New York
| | - John Ragheb
- Department of Neurosurgery, Miami Children's Hospital, Miami, Florida
| | - Sanjiv Bhatia
- Department of Neurosurgery, Miami Children's Hospital, Miami, Florida
| | - Paul Steinbok
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Elysa Widjaja
- Division of Neurosurgery, BC Children's Hospital, Vancouver, BC, Canada
| | - O. Carter Snead
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada
| | - James T. Rutka
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, ON, Canada
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Fernández S, Donaire A, Serès E, Setoain X, Bargalló N, Falcón C, Sanmartí F, Maestro I, Rumià J, Pintor L, Boget T, Aparicio J, Carreño M. PET/MRI and PET/MRI/SISCOM coregistration in the presurgical evaluation of refractory focal epilepsy. Epilepsy Res 2015; 111:1-9. [PMID: 25769367 DOI: 10.1016/j.eplepsyres.2014.12.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Revised: 11/19/2014] [Accepted: 12/12/2014] [Indexed: 12/19/2022]
Abstract
We aimed to investigate the usefulness of coregistration of positron emission tomography (PET) and magnetic resonance imaging (MRI) findings (PET/MRI) and of coregistration of PET/MRI with subtraction ictal single-photon emission computed tomography (SPECT) coregistered to MRI (SISCOM) (PET/MRI/SISCOM) in localizing the potential epileptogenic zone in patients with drug-resistant epilepsy. We prospectively included 35 consecutive patients with refractory focal epilepsy whose presurgical evaluation included a PET study. Separately acquired PET and structural MRI images were coregistered for each patient. When possible, ictal SPECT and SISCOM were obtained and coregistered with PET/MRI. The potential location of the epileptogenic zone determined by neuroimaging was compared with the seizure onset zone determined by long-term video-EEG monitoring and with invasive EEG studies in patients who were implanted. Structural MRI showed no lesions in 15 patients. In these patients, PET/MRI coregistration showed a hypometabolic area in 12 (80%) patients that was concordant with seizure onset zone on EEG in 9. In 7 patients without MRI lesions, PET/MRI detected a hypometabolism that was undetected on PET alone. SISCOM, obtained in 25 patients, showed an area of hyperperfusion concordant with the seizure onset zone on EEG in 7 (58%) of the 12 of these patients who had normal MRI findings. SISCOM hyperperfusion was less extensive than PET hypometabolism. A total of 19 patients underwent surgery; 11 of these underwent invasive-EEG monitoring and the seizure onset zone was concordant with PET/MRI in all cases. PET/MRI/SISCOM coregistration, performed in 4 of these patients, was concordant in 3 (75%). After epilepsy surgery, 13 (68%) patients are seizure-free after a mean follow-up of 4.5 years. PET/MRI and PET/MRI/SISCOM coregistration are useful for determining the potential epileptogenic zone and thus for planning invasive EEG studies and surgery more precisely, especially in patients without lesions on MRI.
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Affiliation(s)
- S Fernández
- Epilepsy Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Neurology Unit, Medical Division, Hospital Plató, Barcelona, Spain.
| | - A Donaire
- Epilepsy Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic de Barcelona, Barcelona, Spain.
| | - E Serès
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic de Barcelona, Barcelona, Spain.
| | - X Setoain
- Epilepsy Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic de Barcelona, Barcelona, Spain.
| | - N Bargalló
- Epilepsy Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic de Barcelona, Barcelona, Spain.
| | - C Falcón
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic de Barcelona, Barcelona, Spain.
| | - F Sanmartí
- Pediatric Epilepsy Unit, Hospital Sant Joan de Déu, Barcelona, Spain.
| | - I Maestro
- Epilepsy Unit, Hospital Clinic de Barcelona, Barcelona, Spain.
| | - J Rumià
- Epilepsy Unit, Hospital Clinic de Barcelona, Barcelona, Spain.
| | - L Pintor
- Epilepsy Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic de Barcelona, Barcelona, Spain.
| | - T Boget
- Epilepsy Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic de Barcelona, Barcelona, Spain.
| | - J Aparicio
- Epilepsy Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic de Barcelona, Barcelona, Spain.
| | - M Carreño
- Epilepsy Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic de Barcelona, Barcelona, Spain.
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