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Barba C, Pelliccia V, Grisotto L, De Palma L, Nobile G, Gozzo F, Revay M, Carfi-Pavia G, Cossu M, Giordano F, Consales A, De Benedictis A, Cavallini E, Mion C, Accolla C, Specchio N, Nobili L, Guerrini R, Tassi L. Trends, outcomes, and complications of surgery for lesional epilepsy in infants and toddlers: A multicenter study. Epilepsia Open 2024. [PMID: 38898721 DOI: 10.1002/epi4.12965] [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: 11/19/2023] [Revised: 04/13/2024] [Accepted: 05/03/2024] [Indexed: 06/21/2024] Open
Abstract
OBJECTIVE To assess seizure and developmental outcomes, their predictors, and complications in 160 children who, between 1998 and 2022, underwent surgery for lesional epilepsy with curative intent before the age of 3 years. To compare trends in epilepsy surgery in this age group before and after the year 2014. METHODS Retrospective multicenter study. Descriptive and univariate analyses, and multivariable models for all outcomes. RESULTS These 160 patients (76 F; 47.5%) underwent 169 surgeries (age at surgery 20.4 ± 9.4 months). At the last follow-up (77 ± 57.4 months), 121 patients (75.6%) were in Engel class I, 106 (66.2%) of whom were in Engel class Ia. Antiseizure medications were stopped in 84 patients (52.5%). Complications requiring reoperations were observed in 16 patients (10%; 9.5% of surgeries) and unexpected permanent deficits in 12 (7.5%; 7.1% of surgeries). Postoperative cognitive functions remained unchanged in 56 patients (44.4%), improved in 51 (40.5%), and worsened in 19 (15.1%). Multivariable analyses showed that the probability of achieving Engel class Ia was lower when the duration of epilepsy was longer, patients underwent preoperative video-EEG, and unexpected postoperative permanent deficits occurred. Cognitive improvement after surgery was associated with lower preoperative seizure frequency, better preoperative developmental level, and a longer postoperative follow-up. FCDII and tumors were the histopathologies carrying a higher probability of achieving seizure freedom, while polymicrogyria was associated with a lower probability of cognitive improvement. The number of patients operated on after 2014 was higher than before (61.3% vs. 38.7%), with stable outcomes. SIGNIFICANCE Epilepsy surgery is effective and safe in infants and toddlers, although the complication rate is higher than seen in older patients. Shorter duration of epilepsy, lower seizure frequency, no need for video-EEG, tumors, and some malformations of cortical development are robust predictors of seizure and cognitive outcome that may be exploited to increase earlier referral. PLAIN LANGUAGE SUMMARY This study analyzed the results of epilepsy surgery in 160 children who had been operated on before the age of 3 years at four Italian centers between 1998 and 2022. At the last follow-up (77 ± 57.4 months), 121 patients (75.6%) were free from disabling seizures, of which 106 (66.2%) were completely seizure-free since surgery. Major surgical complications occurred in 28 patients (17.5%), which is higher than observed with epilepsy surgery in general, but similar to hemispheric/multilobar surgery. Postoperative cognitive function remained unchanged in 56 patients (44.4%), improved in 51 (40.5%), and worsened in 19 (15.1%). Epilepsy surgery is effective and safe in infants and toddlers.
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Affiliation(s)
- Carmen Barba
- Neuroscience Department, Meyer Children's Hospital IRCCS, Florence, Italy
- University of Florence, Florence, Italy
| | | | - Laura Grisotto
- Department of Statistics, Computer Science, Application "G. Parenti" (DiSIA), University of Florence, Florence, Italy
| | - Luca De Palma
- Neurology, Epilepsy and Movement Disorders, EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giulia Nobile
- Child Neuropsychiatry, IRCCS, Istituto Giannina Gaslini, Genoa, Italy
| | - Francesca Gozzo
- "C. Munari" Epilepsy Surgery Center, Niguarda Hospital, Milan, Italy
| | - Martina Revay
- "C. Munari" Epilepsy Surgery Center, Niguarda Hospital, Milan, Italy
| | - Giusy Carfi-Pavia
- Neurology, Epilepsy and Movement Disorders, EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Massimo Cossu
- "C. Munari" Epilepsy Surgery Center, Niguarda Hospital, Milan, Italy
- Child Neurosurgery, IRCCS, Istituto Giannina Gaslini, Genoa, Italy
| | - Flavio Giordano
- University of Florence, Florence, Italy
- Neurosurgery Department, Meyer Children's Hospital IRCCS, Florence, Italy
| | | | | | | | | | | | - Nicola Specchio
- Neurology, Epilepsy and Movement Disorders, EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Lino Nobili
- Child Neuropsychiatry, IRCCS, Istituto Giannina Gaslini, Genoa, Italy
- DINOGMI, University of Genoa, Genoa, Italy
| | - Renzo Guerrini
- Neuroscience Department, Meyer Children's Hospital IRCCS, Florence, Italy
- University of Florence, Florence, Italy
| | - Laura Tassi
- "C. Munari" Epilepsy Surgery Center, Niguarda Hospital, Milan, Italy
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Borne A, Perrone-Bertolotti M, Ferrand-Sorbets S, Bulteau C, Baciu M. Insights on cognitive reorganization after hemispherectomy in Rasmussen's encephalitis. A narrative review. Rev Neurosci 2024; 0:revneuro-2024-0009. [PMID: 38749928 DOI: 10.1515/revneuro-2024-0009] [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: 01/16/2024] [Accepted: 04/26/2024] [Indexed: 05/24/2024]
Abstract
Rasmussen's encephalitis is a rare neurological pathology affecting one cerebral hemisphere, therefore, posing unique challenges. Patients may undergo hemispherectomy, a surgical procedure after which cognitive development occurs in the isolated contralateral hemisphere. This rare situation provides an excellent opportunity to evaluate brain plasticity and cognitive recovery at a hemispheric level. This literature review synthesizes the existing body of research on cognitive recovery following hemispherectomy in Rasmussen patients, considering cognitive domains and modulatory factors that influence cognitive outcomes. While language function has traditionally been the focus of postoperative assessments, there is a growing acknowledgment of the need to broaden the scope of language investigation in interaction with other cognitive domains and to consider cognitive scaffolding in development and recovery. By synthesizing findings reported in the literature, we delineate how language functions may find support from the right hemisphere after left hemispherectomy, but also how, beyond language, global cognitive functioning is affected. We highlight the critical influence of several factors on postoperative cognitive outcomes, including the timing of hemispherectomy and the baseline preoperative cognitive status, pointing to early surgical intervention as predictive of better cognitive outcomes. However, further specific studies are needed to confirm this correlation. This review aims to emphasize a better understanding of mechanisms underlying hemispheric specialization and plasticity in humans, which are particularly important for both clinical and research advancements. This narrative review underscores the need for an integrative approach based on cognitive scaffolding to provide a comprehensive understanding of mechanisms underlying the reorganization in Rasmussen patients after hemispherectomy.
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Affiliation(s)
- Anna Borne
- Univ. Grenoble Alpes, CNRS, LPNC, 38000 Grenoble, France
| | | | - Sarah Ferrand-Sorbets
- Hôpital Fondation Adolphe de Rothschild, Service de Neurochirurgie Pédiatrique, 75019 Paris, France
| | - Christine Bulteau
- Hôpital Fondation Adolphe de Rothschild, Service de Neurochirurgie Pédiatrique, 75019 Paris, France
- Université de Paris-Cité, MC2Lab EA 7536, Institut de Psychologie, F-92100 Boulogne-Billancourt, France
| | - Monica Baciu
- Univ. Grenoble Alpes, CNRS, LPNC, 38000 Grenoble, France
- Neurology Department, CMRR, University Hospital, 38000 Grenoble, France
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Jeno M, Zimmerman MB, Shandley S, Wong-Kisiel L, Singh RK, McNamara N, Fedak Romanowski E, Grinspan ZM, Eschbach K, Alexander A, McGoldrick P, Wolf S, Nangia S, Bolton J, Olaya J, Shrey DW, Karia S, Karakas C, Tatachar P, Ostendorf AP, Gedela S, Javarayee P, Reddy S, Manuel CM, Gonzalez-Giraldo E, Sullivan J, Coryell J, Depositario-Cabacar DFT, Hauptman JS, Samanta D, Armstrong D, Perry MS, Marashly A, Ciliberto M. Pediatric Palliative Epilepsy Surgery: A Report From the Pediatric Epilepsy Research Consortium (PERC) Surgery Database. Pediatr Neurol 2024; 157:70-78. [PMID: 38897096 DOI: 10.1016/j.pediatrneurol.2024.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 04/12/2024] [Accepted: 04/28/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Epilepsy surgery is an underutilized resource for children with drug-resistant epilepsy. Palliative and definitive surgical options can reduce seizure burden and improve quality of life. Palliative epilepsy surgery is often seen as a "last resort" compared to definitive surgical options. We compare patient characteristics between palliative and definitive epilepsy surgical patients and present palliative surgical outcomes from the Pediatric Epilepsy Research Consortium surgical database. METHODS The Pediatric Epilepsy Research Consortium Epilepsy Surgery database is a prospective registry of patients aged 0-18 years undergoing evaluation for epilepsy surgery at 20 pediatric epilepsy centers. We included all children with completed surgical therapy characterized as definitive or palliative. Demographics, epilepsy type, age of onset, age at referral, etiology of epilepsy, treatment history, time-to-referral/evaluation, number of failed anti-seizure medications (ASMs), imaging results, type of surgery, and postoperative outcome were acquired. RESULTS Six hundred forty patients undergoing epilepsy surgery were identified. Patients undergoing palliative procedures were younger at seizure onset (median: 2.1 vs 4 years, P= 0.0008), failed more ASM trials before referral for presurgical evaluation (P=<0.0001), and had longer duration of epilepsy before referral for surgery (P=<0.0001). During presurgical evaluation, patients undergoing palliative surgery had shorter median duration of video-EEG data collected (P=0.007) but number of cases where ictal data were acquired was similar between groups. The most commonly performed palliative procedure was corpus callosotmy (31%), followed by lobectomy (21%) and neuromodulation (82% responsive neurostimulation vs 18% deep brain stimulation). Palliative patients were further categorized into traditionally palliative procedures vs traditionally definitive procedures. The majority of palliative patients had 50% reduction or better in seizure burden. Seizure free outcomes were significantly higher among those with traditional definitive surgeries, 41% (95% confidence interval: 26% to 57%) compared with traditional palliative surgeries and 9% (95% confidence interval: 2% to 17%). Rate of seizure freedom was 46% at 24 months or greater of follow-up in the traditional definitive group. CONCLUSIONS Patients receiving palliative epilepsy surgery trialed more ASMs, were referred later after becoming drug resistant, and had longer gaps between drug resistance and epilepsy surgery compared with patients undergoing definitive epilepsy surgery. The extent of surgical evaluation is impacted if surgery is thought to be palliative. A majority of palliative surgery patients achieved >50% seizure reduction at follow-up, both in groups that received traditionally palliative and traditionally definitive surgical procedures. Palliative surgical patients can achieve greater seizure control and should be referred to an epilepsy surgery center promptly after failing two appropriate anti-seizure medications.
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Affiliation(s)
- Mary Jeno
- Division of Pediatric Neurology, Department of Neurology, University of San Francisco Benioff Children's Hospital Oakland, Oakland, California.
| | | | - Sabrina Shandley
- Neurosciences Research Center, Cook Children's Medical Center, Fort Worth, Texas
| | - Lily Wong-Kisiel
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Rani Kaur Singh
- Department of Pediatrics, Atrium Health-Levine Childrens Hospital, Wake Forest University School of Medicine, Charlotte, North Carolina
| | - Nancy McNamara
- Michigan Medicine Pediatric Neurology, CS Mott Children's Hospital, Ann Arbor, Michigan
| | - Erin Fedak Romanowski
- Michigan Medicine Pediatric Neurology, CS Mott Children's Hospital, Ann Arbor, Michigan; Division of Pediatric Neurology, Department of Pediatrics, University of Michigan Health, Ann Arbor, Michigan
| | - Zachary M Grinspan
- Department of Pediatrics, Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - Krista Eschbach
- Department of Pediatrics, Section of Neurology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Allyson Alexander
- Department of Neurosurgery, Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Patricia McGoldrick
- BCHP Neurology at Hawthorne, Boston Children's Health Physicians of New York and Connecticut, Valhalla, New York
| | - Steven Wolf
- Neurology at Hawthorne, Boston Children's Health Physicians of New York and Connecticut, Valhalla, New York
| | | | - Jeffrey Bolton
- Department of Neurology, Boston Children's, Boston, Massachusetts
| | - Joffre Olaya
- Department of Pediatrics, UC Irvine Children's Hospital of Orange County, Orange, California
| | - Daniel W Shrey
- Department of Pediatrics, UC Irvine Children's Hospital of Orange County, Orange, California
| | - Samir Karia
- Department of Neurology, Norton Neuroscience Institute and Children's Medical Center, University of Louisville, Louisville, Kentucky
| | - Cemal Karakas
- Division of Child Neurology, Department of Neurology, Norton Neuroscience Institute and Children's Medical Center, University of Louisville, Louisville, Kentucky
| | - Priyamvada Tatachar
- Division of Neurology - Epilepsy Center, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Adam P Ostendorf
- Associate Division Chief of Research, Inpatient Epilepsy and Epilepsy Surgery Program, Neurology Division, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Satyanarayana Gedela
- Department of Neurology, Nemours Children's Health, Nemours Children's Hospital, Orlando, Florida
| | - Pradeep Javarayee
- Division of Child Neurology, Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Shilpa Reddy
- Division of Pediatric Neurology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chad McNair Manuel
- Department Pediatric Neurology, Our Lady of the Lake Health, Baton Rouge, Louisiana
| | - Ernesto Gonzalez-Giraldo
- Department of Neurology, Division of Epilepsy, University of California-San Francisco, San Francisco, California
| | - Joseph Sullivan
- Department of Neurology, Division of Epilepsy, University of California-San Francisco, San Francisco, California; Benioff Children's Hospital Pediatric Epilepsy Center of Excellence, University of California San Francisco, San Francisco, California
| | - Jason Coryell
- Doernbecher Children's Hospital, Oregon Health and Sciences University, Portland, Oregon
| | | | - Jason Scott Hauptman
- University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Debopam Samanta
- Child Neurology Division, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Dallas Armstrong
- Department of Pediatrics and Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael Scott Perry
- Neurosciences Research Center, Cook Children's Medical Center, Fort Worth, Texas; Jane and John Justin Institute for Mind Health at Cook Children's Medical Center, Fort Worth, Texas
| | - Ahmad Marashly
- Neurology Department, Epilepsy Division, The Johns Hopkins University, Baltimore, Maryland
| | - Michael Ciliberto
- Department of Biostatistics, University of Iowa, Iowa City, Iowa; Child Neurology, Department of Pediatrics, University of Iowa, Iowa City, Iowa
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Goel K, Ghadiyaram A, Krishnakumar A, Morden FTC, Higashihara TJ, Harris WB, Shlobin NA, Wang A, Karunungan K, Dubey A, Phillips HW, Weil AG, Fallah A. Hemimegalencephaly: A Systematic Comparison of Functional and Anatomic Hemispherectomy for Drug-Resistant Epilepsy. Neurosurgery 2024; 94:666-678. [PMID: 37975663 DOI: 10.1227/neu.0000000000002759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 09/19/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Hemimegalencephaly (HME) is a rare diffuse malformation of cortical development characterized by unihemispheric hypertrophy, drug-resistant epilepsy (DRE), hemiparesis, and developmental delay. Definitive treatment for HME-related DRE is hemispheric surgery through either anatomic (AH) or functional hemispherectomy (FH). This individual patient data meta-analysis assessed seizure outcomes of AH and FH for HME with pharmacoresistant epilepsy, predictors of Engel I, and efficacy of different FH approaches. METHODS PubMed, Web of Science, and Cumulative Index to Nursing and Allied Health Literature were searched from inception to Jan 13th, 2023, for primary literature reporting seizure outcomes in >3 patients with HME receiving AH or FH. Demographics, neurophysiology findings, and Engel outcome at the last follow-up were extracted. Postsurgical seizure outcomes were compared through 2-tailed t -test and Fisher exact test. Univariate and multivariate Cox regression analyses were performed to identify independent predictors of Engel I outcome. RESULTS Data from 145 patients were extracted from 26 studies, of which 89 underwent FH (22 vertical, 33 lateral), 47 underwent AH, and 9 received an unspecified hemispherectomy with a median last follow-up of 44.0 months (FH cohort) and 45.0 months (AH cohort). Cohorts were similar in preoperative characteristics and at the last follow-up; 77% (n = 66) of the FH cohort and 81% (n = 38) and of the AH cohort were Engel I. On multivariate analysis, only the presence of bilateral ictal electroencephalography abnormalities (hazard ratio = 11.5; P = .002) was significantly associated with faster time-to-seizure recurrence. A number-needed-to-treat analysis to prevent 1 additional case of posthemispherectomy hydrocephalus reveals that FH, compared with AH, was 3. There was no statistical significance for any differences in time-to-seizure recurrence between lateral and vertical FH approaches (hazard ratio = 2.59; P = .101). CONCLUSION We show that hemispheric surgery is a highly effective treatment for HME-related DRE. Unilateral ictal electroencephalography changes and using the FH approach as initial surgical management may result in better outcomes due to significantly lower posthemispherectomy hydrocephalus probability. However, larger HME registries are needed to further delineate the predictors of seizure outcomes.
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Affiliation(s)
- Keshav Goel
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles , California , USA
| | - Ashwin Ghadiyaram
- Virginia Commonwealth University School of Medicine, Richmond , Virginia , USA
| | - Asha Krishnakumar
- Virginia Commonwealth University School of Medicine, Richmond , Virginia , USA
| | - Frances T C Morden
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu , Hawaii , USA
| | - Tate J Higashihara
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu , Hawaii , USA
| | - William B Harris
- Department of Neurosurgery, University of Colorado, Boulder , Colorado , USA
| | - Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago , Illinois , USA
| | - Andrew Wang
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles , California , USA
| | - Krystal Karunungan
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles , California , USA
| | - Anwesha Dubey
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles , California , USA
| | - H Westley Phillips
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Alexander G Weil
- Division of Neurosurgery, Department of Surgery, Sainte-Justine University Hospital Centre, Montréal , Québec , Canada
- Division of Neurosurgery, Department of Surgery, University of Montreal Hospital Centre (CHUM), Montréal , Québec , Canada
- Brain and Development Research Axis, Sainte-Justine Research Center, Montréal , Québec , Canada
- Department of Neuroscience, University of Montreal, Montréal , Québec , Canada
| | - Aria Fallah
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles , California , USA
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles , California , USA
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Stefanos-Yakoub I, Wingeier K, Held U, Latal B, Wirrell E, Smith ML, Ramantani G. Long-term intellectual and developmental outcomes after pediatric epilepsy surgery: A systematic review and meta-analysis. Epilepsia 2024; 65:251-265. [PMID: 38031640 DOI: 10.1111/epi.17834] [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: 07/27/2023] [Revised: 11/20/2023] [Accepted: 11/27/2023] [Indexed: 12/01/2023]
Abstract
In addition to the primary aim of seizure freedom, a key secondary aim of pediatric epilepsy surgery is to stabilize and, potentially, optimize cognitive development. Although the efficacy of surgical treatment for seizure control has been established, the long-term intellectual and developmental trajectories are yet to be delineated. We conducted a systematic review and meta-analysis of studies reporting pre- and postsurgical intelligence or developmental quotients (IQ/DQ) of children with focal lesional epilepsy aged ≤18 years at epilepsy surgery and assessed at >2 years after surgery. We determined the IQ/DQ change and conducted a random-effects meta-analysis and meta-regression to assess its determinants. We included 15 studies reporting on 341 patients. The weighted mean age at surgery was 7.1 years (range = .3-13.8). The weighted mean postsurgical follow-up duration was 5.6 years (range = 2.7-12.8). The overall estimate of the mean presurgical IQ/DQ was 60 (95% confidence interval [CI] = 47-73), the postsurgical IQ/DQ was 61 (95% CI = 48-73), and the change was +.94 IQ/DQ (95% CI = -1.70 to 3.58, p = .486). Children with presurgical IQ/DQ ≥ 70 showed a tendency for higher gains than those with presurgical IQ/DQ < 70 (p = .059). Higher gains were determined by cessation of antiseizure medication (ASM; p = .041), not just seizure freedom. Our findings indicate, on average, stabilization of intellectual and developmental functioning at long-term follow-up after epilepsy surgery. Once seizure freedom has been achieved, ASM cessation enables the optimization of intellectual and developmental trajectories in affected children.
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Affiliation(s)
- Ilona Stefanos-Yakoub
- Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland
| | - Kevin Wingeier
- Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland
- Department of Psychosomatics and Psychiatry, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ulrike Held
- Department of Biostatistics at Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Beatrice Latal
- Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Elaine Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mary Lou Smith
- Department of Psychology, University of Toronto Mississauga; Neurosciences and Mental Health Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Georgia Ramantani
- Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
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Lu R, Wang M, Zhang Y, Li H, Zhou Y, Wang Y, Zhao R. Safety, Accuracy, and Efficacy of Robot-Assisted Stereo Electroencephalography in Children of Different Ages. Neurosurgery 2024; 95:00006123-990000000-01038. [PMID: 38299855 PMCID: PMC11155594 DOI: 10.1227/neu.0000000000002853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 12/13/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Aimed to investigate the safety, accuracy, and efficacy of stereo electroencephalography (SEEG) in children of various ages, with particular emphasis on those younger than 3 years. There is limited guidance regarding whether SEEG can conducted on very young children. METHODS This retrospective study was conducted between July 2018 and August 2022. It involved 88 patients who underwent 99 robot-assisted SEEG procedures at our center. The patients were categorized into 3 groups based on their age at the time of the robot-assisted SEEG procedures: group 1 (3 years and younger, n = 28), group 2 (age 3-6 years, n = 27), and group 3 (older than 6 years, n = 44). Clinical data, SEEG demographics, complications, and seizure outcomes were analyzed. RESULTS A total of 675 electrodes were implanted, with an average of 6.82 ± 3.47 (2.00-16.00) electrodes per patient (P = .052). The average target point error for the 675 electrodes was 1.93 ± 1.11 mm, and the average entry point error was 1.30 ± 0.97 mm (P = .536 and P = .549, respectively). The overall percentage of complications was 6.06% (P = .879). No severe or long-term neurologic impairment was observed. Of the total 99 procedures included in this study, 78 were admitted for epilepsy surgery for the first time, while 9 patients were treated twice and 1 patient was treated 3 times. There were 21 radiofrequency thermocoagulation and 78 second-stage resective procedures performed after SEEG. There was no statistically significant difference in Engel class I outcomes among the patients who underwent SEEG in the 3 age groups (P = .621). CONCLUSION Robot-assisted SEEG were demonstrated to be safe, accurate, and efficient across different age groups of children. This technique is suitable for children younger than 3 years who have indications for SEEG placement.
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Affiliation(s)
- Rongrong Lu
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center (Shanghai), Shanghai, People's Republic of China
| | - Min Wang
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center (Shanghai), Shanghai, People's Republic of China
| | - Yi Zhang
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center (Shanghai), Shanghai, People's Republic of China
| | - Hao Li
- Department of Neurosurgery, Children's Hospital of Fudan University, National Children's Medical Center (Shanghai), Shanghai, People's Republic of China
| | - Yuanfeng Zhou
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center (Shanghai), Shanghai, People's Republic of China
| | - Yi Wang
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center (Shanghai), Shanghai, People's Republic of China
| | - Rui Zhao
- Department of Neurosurgery, Children's Hospital of Shanghai, Shanghai, People's Republic of China
- Department of Neurosurgery, Hainan Women and Children's Medical Center, Haikou, People's Republic of China
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7
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Ramantani G, Cserpan D, Tisdall M, Otte WM, Dorfmüller G, Cross JH, van Schooneveld M, van Eijsden P, Nees F, Reuner G, Krayenbühl N, Zentner J, Bulteau C, Braun KPJ. Determinants of Functional Outcome after Pediatric Hemispherotomy. Ann Neurol 2024; 95:377-387. [PMID: 37962290 DOI: 10.1002/ana.26830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 10/04/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023]
Abstract
OBJECTIVE We aimed to evaluate determinants of functional outcome after pediatric hemispherotomy in a large and recent multicenter cohort. METHODS We retrospectively investigated the functional outcomes of 455 children who underwent hemispherotomy at 5 epilepsy centers in 2000-2016. We identified determinants of unaided walking, voluntary grasping with the hemiplegic hand, and speaking through Bayesian multivariable regression modeling using missing data imputation. RESULTS Seventy-five percent of children were seizure-free, and 44% stopped antiseizure medication at a 5.1-year mean follow-up (range = 1-17.1). Seventy-seven percent of children could walk unaided, 8% could grasp voluntarily, and 68% could speak at the last follow-up. Children were unlikely to walk when they had contralateral magnetic resonance imaging (MRI) abnormalities (40/73, p = 0.04), recurrent seizures following hemispherotomy (62/109, p = 0.04), and moderately (50/61, p = 0.03) or severely impaired (127/199, p = 0.001) postsurgical intellectual functioning, but were likely to walk when they were older at outcome determination (p = 0.01). Children were unlikely to grasp voluntarily with the hand contralateral to surgery when they had Rasmussen encephalitis (0/61, p = 0.001) or Sturge-Weber syndrome (0/32, p = 0.007). Children were unlikely to speak when they had contralateral MRI abnormalities (30/69, p = 0.002) and longer epilepsy duration (p = 0.01), but likely to speak when they had Sturge-Weber syndrome (29/35, p = 0.01), were older at surgery (p = 0.04), and were older at outcome determination (p < 0.001). INTERPRETATION Etiology and bilaterality of structural brain abnormalities were key determinants of functional outcome after hemispherotomy. Longer epilepsy duration affected language outcomes. Not surprisingly, walking and talking ability increased with older age at outcome evaluation. ANN NEUROL 2024;95:377-387.
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Affiliation(s)
- Georgia Ramantani
- Department of Neuropediatrics, University Children's Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Dorottya Cserpan
- Department of Neuropediatrics, University Children's Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Martin Tisdall
- Department of Neurosurgery, Great Ormond Street Hospital for Children National Health Service Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Willem M Otte
- Department of Child Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, Member of European Reference Network EpiCARE, Utrecht, the Netherlands
| | - Georg Dorfmüller
- Department of Pediatric Neurosurgery, Rothschild Foundation Hospital, Member of European Reference Network EpiCARE, Paris, France
| | - J Helen Cross
- Department of Neurology, Great Ormond Street Hospital for Children National Health Service Foundation Trust, Great Ormond Street and University College London National Institute for Health and Care Research Biomedical Research Centre Great Ormond Street Institute of Child Health, London, United Kingdom of Great Britain and Northern Ireland
| | - Monique van Schooneveld
- Department of Child Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, Member of European Reference Network EpiCARE, Utrecht, the Netherlands
| | - Pieter van Eijsden
- Department of Child Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, Member of European Reference Network EpiCARE, Utrecht, the Netherlands
| | - Frauke Nees
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Institute of Medical Psychology and Medical Sociology, University Medical Center Schleswig-Holstein, Kiel University, Kiel, Germany
| | - Gitta Reuner
- Institute of Education Studies, Faculty of Behavioral and Cultural Studies, University of Heidelberg, Heidelberg, Germany
| | - Niklaus Krayenbühl
- Department of Neurosurgery, University Children's Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Josef Zentner
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Christine Bulteau
- Department of Pediatric Neurosurgery, Rothschild Foundation Hospital, Member of European Reference Network EpiCARE, Paris, France
- University of Paris, MC2Lab, Institute of Psychology, Boulogne-Billancourt, France
| | - Kees P J Braun
- Department of Child Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, Member of European Reference Network EpiCARE, Utrecht, the Netherlands
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8
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McLaren JR, Kahle KT, Richardson RM, Chu CJ. Epilepsy Surgery for Cognitive Improvement in Epileptic Encephalopathy. Neurosurg Clin N Am 2024; 35:49-59. [PMID: 38000841 DOI: 10.1016/j.nec.2023.08.002] [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] [Indexed: 11/26/2023]
Abstract
Epileptic encephalopathies are defined by the presence of frequent epileptiform activity that causes neurodevelopmental slowing or regression. Here, we review evidence that epilepsy surgery improves neurodevelopment in children with epileptic encephalopathies. We describe an example patient with epileptic encephalopathy without drug refractory seizures, who underwent successful diagnostic and therapeutic surgeries. In patients with epileptic encephalopathy, cognitive improvement alone is a sufficient indication to recommend surgical intervention in experienced centers.
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Affiliation(s)
- John R McLaren
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; Harvard Medical School
| | - Kristopher T Kahle
- Harvard Medical School; Department of Neurosurgery, Massachusetts General Hospital, 55 Fruit Street, Wang Building Room 333, Boston, MA 02114, USA
| | - R Mark Richardson
- Harvard Medical School; Department of Neurosurgery, Massachusetts General Hospital, 55 Fruit Street, Their Building, 4th Floor, Boston, MA 02114, USA
| | - Catherine J Chu
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; Harvard Medical School.
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9
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Shin HJ, Kim SH, Kang HC, Lee JS, Kim HD. Surgical Treatment of Epilepsy with Bilateral MRI Abnormalities. World Neurosurg 2023; 180:e37-e45. [PMID: 37495100 DOI: 10.1016/j.wneu.2023.07.062] [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: 03/18/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To investigate the surgical outcomes of patients with drug-resistant epilepsy and bilateral brain magnetic resonance imaging (MRI) abnormalities who had undergone various epilepsy surgeries. METHODS Patients with drug-resistant epilepsy and bilateral brain abnormalities on MRI who underwent epilepsy surgery at the Severance Children's Hospital between October 2003 and December 2021 were included. The age of seizure onset was 18 years or younger. Engel's classification was used to assess seizure outcomes at 1, 2, and 5 years after surgery. RESULTS A total of 40 patients met the inclusion criteria. The median age at surgery was 10.9 years (interquartile range [IQR] 6.9-15.1); the median interval to surgery was 7.1 years (IQR 2.7-11.5). One year after surgery, a favorable outcome of Engel class I-II was observed in 53% (21/40) of patients. At the 2- and 5-year follow-ups, 56% (20/36) and 63% (17/27) of patients showed good postoperative outcomes, respectively. CONCLUSIONS Approximately, half of the patients with bilateral brain MRI abnormalities achieved seizure freedom after epilepsy surgery. The existence of bilateral brain MRI abnormalities should not hinder resective epilepsy surgery.
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Affiliation(s)
- Hui Jin Shin
- Division of Pediatric Neurology, Department of Pediatrics, Epilepsy Research Institute, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Se Hee Kim
- Division of Pediatric Neurology, Department of Pediatrics, Epilepsy Research Institute, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hoon-Chul Kang
- Division of Pediatric Neurology, Department of Pediatrics, Epilepsy Research Institute, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Soo Lee
- Division of Pediatric Neurology, Department of Pediatrics, Epilepsy Research Institute, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Heung Dong Kim
- Division of Pediatric Neurology, Department of Pediatrics, Epilepsy Research Institute, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea; Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea.
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10
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Chourasia N, Stone SSD, Tsuboyama M, Madsen JR, Ryan M, Zhang B, Libenson MH, Bolton J, Harini C. Influence of extent and age at corpus callosotomy on seizure outcomes. A single center experience. Epilepsia Open 2023; 8:1596-1601. [PMID: 37602493 PMCID: PMC10690660 DOI: 10.1002/epi4.12819] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/16/2023] [Indexed: 08/22/2023] Open
Abstract
Corpus callosotomy (CC) is a palliative treatment for drop seizures in patients with drug-resistant nonlocalizable epilepsy. We compared drop seizure outcomes between patients undergoing anterior CC versus complete CC and examined factors impacting outcomes for drop seizures including age at CC and duration of epilepsy. A retrospective review of patients who underwent CC between 2003 and 2022 with a minimum of 6 months postsurgical follow-up was included. Outcome measure for drop seizures included seizure reduction ≥50% from baseline as well as elimination of drop seizures. Thirty-eight patients were included. Overall, ≥50% reduction in drop seizures occurred in nearly 70% (23 out of 33) patients with complete elimination in 58% (19 out of 33). Compared with anterior CC (n = 13), patients undergoing complete CC (n = 25) had increased likelihood of ≥50% reduction (p = 0.006) or elimination (p = 0.024) of drop seizures. Regression analysis showed that complete CC was the primary predictor for improved drop seizure outcomes (elimination, p = 0.014 or ≥50% reduction, p = 0.006), while age at CC and duration of epilepsy did not impact the outcomes. Compared to anterior CC, complete CC was significantly more likely to lead to improvement/freedom from drop seizures. Age at CC or duration of epilepsy did not influence drop seizure outcomes.
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Affiliation(s)
- Nitish Chourasia
- Division of Epilepsy and Clinical Neurophysiology, Department of NeurologyBoston Children's HospitalMassachusettsBostonUSA
- Present address:
Le Bonheur Neuroscience Institute, Le Bonheur Children's HospitalTennesseeMemphisUSA
| | - Scellig S. D. Stone
- Division of Epilepsy and Clinical Neurophysiology, Department of NeurologyBoston Children's HospitalMassachusettsBostonUSA
| | - Melissa Tsuboyama
- Division of Epilepsy and Clinical Neurophysiology, Department of NeurologyBoston Children's HospitalMassachusettsBostonUSA
| | - Joseph R. Madsen
- Division of Epilepsy and Clinical Neurophysiology, Department of NeurologyBoston Children's HospitalMassachusettsBostonUSA
| | - Morgan Ryan
- Department of NeurologyBoston Children’s HospitalBostonMassachusettsUSA
- Biostatistics and Research Design CenterInstitutional Centers for Clinical and Translational Research, Boston Children’s HospitalBostonMassachusettsUSA
| | - Bo Zhang
- Department of NeurologyBoston Children’s HospitalBostonMassachusettsUSA
- Biostatistics and Research Design CenterInstitutional Centers for Clinical and Translational Research, Boston Children’s HospitalBostonMassachusettsUSA
| | - Mark H. Libenson
- Division of Epilepsy and Clinical Neurophysiology, Department of NeurologyBoston Children's HospitalMassachusettsBostonUSA
| | - Jeffrey Bolton
- Division of Epilepsy and Clinical Neurophysiology, Department of NeurologyBoston Children's HospitalMassachusettsBostonUSA
| | - Chellamani Harini
- Division of Epilepsy and Clinical Neurophysiology, Department of NeurologyBoston Children's HospitalMassachusettsBostonUSA
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11
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Salim O, Chari A, Zvi IB, Batchelor R, Baldeweg T, Helen Cross J, Tisdall M. Clinician views regarding early surgery for paediatric epilepsy. Seizure 2023; 113:80-85. [PMID: 38000223 DOI: 10.1016/j.seizure.2023.11.011] [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: 08/29/2023] [Revised: 11/03/2023] [Accepted: 11/18/2023] [Indexed: 11/26/2023] Open
Abstract
OBJECTIVE Many children with lesional epilepsies progress to drug resistance, a criterion required for surgical referral. Expedited surgery may reduce exposure of the developing brain to uncontrolled seizures, improving cognitive outcomes. Designing a trial comparing early surgery with standard care necessitates input from specialist clinicians regarding feasibility and measurable outcomes, which this study investigated. METHODS Online surveys were disseminated from June-July 2022 via regional paediatric epilepsy networks and professional societies. 51 UK clinicians responded, mostly paediatricians, paediatric neurologists and epilepsy specialist nurses. Candidacy for epilepsy surgery, outcome measures and support for the proposed study were surveyed. Clinician views were compared by speciality, using Pearson's chi-squared tests to explore differences. RESULTS 76-98 % of clinicians would refer children for presurgical evaluation at/before drug resistance development across four subgroups (those younger/older than two years, and those with/without a detectable lesion). Earlier referral, at/before epilepsy diagnosis, was considered mostly in those with visible lesions (53 %) and those under two years (31 %). 73 % would consider early surgery before drug resistance is established. Top outcomes to measure were seizure freedom (39 %) and quality of life (22 %). Views of paediatric neurologists and paediatricians did not differ (p > .05). SIGNIFICANCE Clinician opinions generally aligned with published guidance regarding epilepsy surgery referral. Some remain cautious to refer young children with lesions prior to trialling more than one antiseizure medication. Most support early surgery in appropriate patients, with seizure and quality of life outcomes rated highly. Incorporating these perspectives will aid future trial design, recruitment and clinical utility.
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Affiliation(s)
- Omar Salim
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Aswin Chari
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK; Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK.
| | - Ido Ben Zvi
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK
| | - Rachel Batchelor
- Department of Psychology, Royal Holloway, University of London, London, UK
| | - Torsten Baldeweg
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - J Helen Cross
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK; Department of Neurology, Great Ormond Street Hospital, London, UK
| | - Martin Tisdall
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK; Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
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12
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Chen JS, Harris WB, Wu KJ, Phillips HW, Tseng CH, Weil AG, Fallah A. Comparison of Hemispheric Surgery Techniques for Pediatric Drug-Resistant Epilepsy: An Individual Patient Data Meta-analysis. Neurology 2023; 101:e410-e424. [PMID: 37202158 PMCID: PMC10435062 DOI: 10.1212/wnl.0000000000207425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 04/03/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Hemispheric surgery effectively treats unihemispheric pediatric drug-resistant epilepsy (DRE) by resecting and/or disconnecting the epileptic hemisphere. Modifications to the original anatomic hemispherectomy have generated multiple functionally equivalent, disconnective techniques for performing hemispheric surgery, termed functional hemispherotomy. While a myriad of hemispherotomy variants exist, all of them can be categorized according to the anatomic plane they are performed in, which includes vertical approaches at or near the interhemispheric fissure and lateral approaches at or near the Sylvian fissure. This meta-analysis of individual patient data (IPD) aimed to compare seizure outcomes and complications between the hemispherotomy approaches to better characterize their relative efficacy and safety in the modern neurosurgical treatment of pediatric DRE, given emerging evidence that outcomes may differ between them. METHODS CINAHL, Embase, PubMed, and Web of Science were searched from inception to September 9, 2020, for studies reporting IPD from pediatric patients with DRE who underwent hemispheric surgery. Outcomes of interest were seizure freedom at last follow-up, time-to-seizure recurrence, and complications including hydrocephalus, infection, and mortality. The χ2 test compared the frequency of seizure freedom and complications. Multivariable mixed-effects Cox regression controlling for predictors of seizure outcome was performed on propensity score-matched patients to compare time-to-seizure recurrence between approaches. Kaplan-Meier curves were made to visualize differences in time-to-seizure recurrence. RESULTS Fifty-five studies reporting on 686 unique pediatric patients treated with hemispheric surgery were included for meta-analysis. Among the hemispherotomy subgroup, vertical approaches resulted in a greater proportion of seizure free patients (81.2% vs 70.7%, p = 0.014) than lateral approaches. While there were no differences in complications, lateral hemispherotomy had higher rates of revision hemispheric surgery due to incomplete disconnection and/or recurrent seizures than vertical hemispherotomy (16.3% vs 1.2%, p < 0.001). After propensity score matching, vertical hemispherotomy approaches independently conferred longer time-to-seizure recurrence than lateral hemispherotomy approaches (hazard ratio 0.44, 95% CI 0.19-0.98). DISCUSSION Among functional hemispherotomy techniques, vertical hemispherotomy approaches confer more durable seizure freedom than lateral approaches without compromising safety. Future prospective studies are required to definitively determine whether vertical approaches are indeed superior and how it should influence clinical guidelines for performing hemispheric surgery.
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Affiliation(s)
- Jia-Shu Chen
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles
| | - William B Harris
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles
| | - Katherine J Wu
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles
| | - H Westley Phillips
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles
| | - Chi-Hong Tseng
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles
| | - Alexander G Weil
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles
| | - Aria Fallah
- From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles.
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13
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Stefanos-Yakoub I, Wingeier K, Cserpan D, Gennari AG, Latal B, Reuner G, Ramantani G. Lesion Extent Negatively Impacts Intellectual Skills in Pediatric Focal Epilepsy. Pediatr Neurol 2023; 145:67-73. [PMID: 37285765 DOI: 10.1016/j.pediatrneurol.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/08/2023] [Accepted: 05/10/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Cognitive development in children and adolescents with focal lesional epilepsy is determined by the underlying epileptogenic lesion, in addition to epilepsy itself. However, the impact of lesion-related variables on intelligence quotient (IQ) and developmental quotient (DQ) remains largely unexplored. Here, we aimed to determine the effect of lesion-related predictors and their relation with epilepsy-related predictors of intellectual functioning. METHODS We retrospectively analyzed data from children with focal lesional epilepsy who underwent standardized cognitive evaluation yielding IQ/DQ in our institution. RESULTS We included 50 consecutive patients aged 0.5 to 17.5 years (mean, 9.3; S.D., 4.9) at cognitive assessment. Epilepsy duration was 0 to 15.5 years (mean, 3.8; S.D., 4.1). Of the total cohort, 30 (60%) patients had unilobar lesions, seven (14%) multilobar, 10 (20%) hemispheric, and three (6%) bilateral. Etiology was congenital in 32 (64%) cases, acquired in 14 (28%), and progressive in four (8%). For patients with unilobar lesions, the mean IQ/DQ was 97.1 ± 15.7, for multilobar 98.9 ± 20.2, for hemispheric 76.1 ± 20.5, and for bilateral 76.3 ± 4.5. Larger lesion extent, earlier epilepsy onset, and longer epilepsy duration correlated with lower IQ/DQ in the univariate analysis, whereas only lesion extent and epilepsy duration contributed significantly to the explanatory model in the multivariable analysis. CONCLUSIONS The present study demonstrates that lesion extent and epilepsy duration are important risk factors for intellectual impairment in pediatric patients with focal lesional epilepsy. These findings are useful for family counseling and the early consideration of interventions that may limit the duration of epilepsy.
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Affiliation(s)
- Ilona Stefanos-Yakoub
- Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland
| | - Kevin Wingeier
- Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland
| | - Dorottya Cserpan
- Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland
| | - Antonio Giulio Gennari
- Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland; MR Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Beatrice Latal
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland; University of Zurich, Zurich, Switzerland; Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Gitta Reuner
- Faculty of Behavioral and Cultural Studies, Institute of Education Studies, University of Heidelberg, Heidelberg, Germany
| | - Georgia Ramantani
- Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland; University of Zurich, Zurich, Switzerland.
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14
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Frank NA, Greuter L, Guzman R, Soleman J. Early surgical approaches in pediatric epilepsy - a systematic review and meta-analysis. Childs Nerv Syst 2023; 39:677-688. [PMID: 36219224 DOI: 10.1007/s00381-022-05699-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/03/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Drug-resistant epilepsy occurs in up to 30% of children suffering from seizures and about 10% qualify for surgical treatment. The aim of this systematic review and meta-analysis is to analyze the potential benefit of early epilepsy surgery in children concerning primarily seizure and developmental outcome. METHODS PubMed and Embase databases were searched using a systematic search strategy to identify studies on pediatric epilepsy surgery under 3 years from their inception up to 2022. Outcome measures were seizure outcome, postoperative complications, seizure onset, and reduction rate of antiepileptic drugs. A meta-analysis was thereafter performed for all included cohort studies. A p-value of < 0.05 was considered as statistically significant. RESULTS A total of 532 patients were analyzed with 401 patients (75%) receiving resective or disconnective surgery under the age of 3 years and 80 patients (15%) receiving surgery older than 3 years. The remaining 51 patients (9%) underwent VNS implantation. Pooled outcome analysis for resective/disconnective surgery showed favorable outcome in 68% (95% CI [0.63; 0.73]), while comparative analysis between the age groups showed no significant difference (77% early group and 75% late group; RR 1.03, 95% CI [0.73; 1.46] p = 0.75). Favorable outcome for the VNS cohort was seen in 52%, 65% in the early and 45.1% in the late group (RR 1.4393, 95% CI [0.87; 2.4] z = 1.42, p = 0.16). Developmental outcome was improved in 26%. Morbidity rate was moderate and showed no significant difference comparing the age groups, and overall surgical mortality rate was very low (0.1%). CONCLUSION Epilepsy surgery in pediatric age, especially under the age of 3 years, is a feasible and safe way to treat intractable epilepsy. Further comparative studies of prospective nature, analyzing not only seizure but also developmental outcome, should be the focus of future studies.
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Affiliation(s)
| | - Ladina Greuter
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
- Department of Pediatric Neurosurgery, University Children's Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
- Department of Pediatric Neurosurgery, University Children's Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
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15
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Arfaie S, Amin P, Kwan ATH, Solgi A, Sarabi A, Hakak-Zargar B, Brunette-Clément T, Pushenko D, Mir-Moghtadaei K, Mashayekhi MS, Mofatteh M, Honarvar F, Ren LY, Noiseux-Lush C, Azizi Z, Pearl PL, Baldeweg T, Weil AG, Fallah A. Long-term full-scale intelligent quotient outcomes following pediatric and childhood epilepsy surgery: A systematic review and meta-analysis. Seizure 2023; 106:58-67. [PMID: 36774775 DOI: 10.1016/j.seizure.2023.01.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 12/28/2022] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Cognitive measures are an important primary outcome of pediatric, adolescents, and childhood epilepsy surgery. The purpose of this systematic review and meta-analysis is to assess whether there are long-term alterations (≥ 5 years) in the Full-Scale Intelligence Quotient (FSIQ) of pediatric patients undergoing epilepsy surgery. METHODS Electronic databases (EMBASE, MEDLINE, and Scopus) were searched for English articles from inception to October 2022 that examined intelligence outcomes in pediatric epilepsy surgery patients. Inclusion criteria were defined as the patient sample size of ≥ 5, average follow- up of ≥5 years, and surgeries performed on individuals ≤ 18 years old at the time of surgery. Exclusion criteria consisted of palliative surgery, animal studies, and studies not reporting surgical or FSIQ outcomes. Publication bias was assessed using a funnel plot and the Quality in Prognosis Studies (QUIPS) toolset was used for quality appraisal of the selected articles. A random-effects network meta-analysis was performed to compare FSIQ between surgical patients at baseline and follow-up and Mean Difference (MD) was used to calculate the effect size of each study. Point estimates for effects and 95% confidence intervals for moderation analysis were performed on variables putatively associated with the effect size. RESULTS 21,408 studies were screened for abstract and title. Of these, 797 fit our inclusion and exclusion criteria and proceeded to full-text screening. Overall, seven studies met our requirements and were selected. Quantitative analysis was performed on these studies (N = 330). The mean long-term difference between pre- and post- operative FSIQ scores across all studies was noted at 3.36 [95% CI: (0.14, 6.57), p = 0.04, I2 = 0%] and heterogeneity was low. CONCLUSION To our knowledge, this is the first meta-analysis to measure the long-term impacts of FSIQ in pediatric and adolescent epilepsy patients. Our overall results in this meta-analysis indicate that while most studies do not show long-term FSIQ deterioration in pediatric patients who underwent epilepsy surgery, there was an increase of 3.36 FSIQ points, however, the observed changes were not clinically significant. Moreover, at the individual patient level analysis, while most children did not show long-term FSIQ deterioration, few had significant decline. These findings indicate the importance of surgery as a viable option for pediatric patients with medically refractory epilepsy.
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Affiliation(s)
- Saman Arfaie
- Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada; Faculty of Medicine, McGill University, Montreal, QC, Canada; Department of Molecular and Cell Biology, University of California Berkeley, Berkeley, CA, United States of America
| | - Pouya Amin
- Department of Molecular and Cell Biology, University of California Berkeley, Berkeley, CA, United States of America
| | - Angela T H Kwan
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Chemical and Physical Sciences, University of Toronto, Toronto, ON, Canada
| | - Arad Solgi
- School of Kinesiology & Health Science, York University, Toronto, ON, Canada
| | - Ali Sarabi
- School of Computing and Augmented Intelligence, Arizona State University, Tempe, AZ, United States of America
| | | | | | - Denys Pushenko
- Department of Chemical and Physical Sciences, University of Toronto, Toronto, ON, Canada; Department of Biology, University of Toronto, Toronto, ON, Canada
| | | | | | - Mohammad Mofatteh
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, United Kingdom.
| | - Faraz Honarvar
- Faculty of Medicine, Queen's University, Kingston, ON, Canada
| | - Lily Yuxi Ren
- Lane Medical Library and Knowledge Management Center, Stanford Medicine, Stanford University, Palo Alto, CA, United States of America
| | | | - Zahra Azizi
- Stanford Medicine, Stanford University, Palo Alto, CA, United States of America; School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, United Kingdom
| | - Phillip Lawrence Pearl
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Torsten Baldeweg
- Department of Developmental Neuroscience, UCL Great Ormond Street Institute for Child Health, London WC1N 1EH, United Kingdom; Great Ormond Street Hospital NHS Foundation Trust, London WC1N 3JH, United Kingdom
| | - Alexander G Weil
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Montreal, QC, Canada
| | - Aria Fallah
- Department of Neurosurgery and Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, CA, United States of America
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16
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Tsou AY, Kessler SK, Wu M, Abend NS, Massey SL, Treadwell JR. Surgical Treatments for Epilepsies in Children Aged 1-36 Months: A Systematic Review. Neurology 2023; 100:e1-e15. [PMID: 36270898 PMCID: PMC9827129 DOI: 10.1212/wnl.0000000000201012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 06/09/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Early life epilepsies (epilepsies in children 1-36 months old) are common and may be refractory to antiseizure medications. We summarize findings of a systematic review commissioned by the American Epilepsy Society to assess evidence and identify evidence gaps for surgical treatments for epilepsy in children aged 1-36 months without infantile spasms. METHODS EMBASE, MEDLINE, PubMed, and the Cochrane Library were searched for studies published from 1/1/1999 to 8/19/21. We included studies reporting data on children aged 1 month to ≤36 months undergoing surgical interventions or neurostimulation for epilepsy and enrolling ≥10 patients per procedure. We excluded studies of infants with infantile spasms or status epilepticus. For effectiveness outcomes (seizure freedom, seizure frequency), studies were required to report follow-up at ≥ 12 weeks. For harm outcomes, no minimum follow-up was required. Outcomes for all epilepsy types, regardless of etiology, were reported together. RESULTS Eighteen studies (in 19 articles) met the inclusion criteria. Sixteen prestudies/poststudies reported on efficacy, and 12 studies addressed harms. Surgeries were performed from 1979 to 2020. Seizure freedom for infants undergoing hemispherectomy/hemispherotomy ranged from 7% to 76% at 1 year after surgery. For nonhemispheric surgeries, seizure freedom ranged from 40% to 70%. For efficacy, we concluded low strength of evidence (SOE) suggests some infants achieve seizure freedom after epilepsy surgery. Over half of infants undergoing hemispherectomy/hemispherotomy achieved a favorable outcome (Engel I or II, International League Against Epilepsy I to IV, or >50% seizure reduction) at follow-up of >1 year, although studies had key limitations. Surgical mortality was rare for functional hemispherectomy/hemispherotomy and nonhemispheric resections. Low SOE suggests postoperative hydrocephalus is uncommon for infants undergoing nonhemispheric procedures for epilepsy. DISCUSSION Although existing evidence remains sparse and low quality, some infants achieve seizure freedom after surgery and ≥50% achieve favorable outcomes. Future prospective studies in this age group are needed. In addition to seizure outcomes, studies should evaluate other important outcomes (developmental outcomes, quality of life [QOL], sleep, functional performance, and caregiver QOL). TRIAL REGISTRATION INFORMATION This systematic review was registered in PROSPERO (CRD42021220352) on March 5, 2021.
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Affiliation(s)
- Amy Y Tsou
- From the ECRI Evidence Based Practice Center (A.Y.T., M.W., J.R.T.), Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Biostatistics (N.S.A.), Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine.
| | - Sudha Kilaru Kessler
- From the ECRI Evidence Based Practice Center (A.Y.T., M.W., J.R.T.), Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Biostatistics (N.S.A.), Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | - Mingche Wu
- From the ECRI Evidence Based Practice Center (A.Y.T., M.W., J.R.T.), Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Biostatistics (N.S.A.), Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | - Nicholas S Abend
- From the ECRI Evidence Based Practice Center (A.Y.T., M.W., J.R.T.), Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Biostatistics (N.S.A.), Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | - Shavonne L Massey
- From the ECRI Evidence Based Practice Center (A.Y.T., M.W., J.R.T.), Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Biostatistics (N.S.A.), Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | - Jonathan R Treadwell
- From the ECRI Evidence Based Practice Center (A.Y.T., M.W., J.R.T.), Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Biostatistics (N.S.A.), Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
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17
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Pepi C, De Benedictis A, Rossi-Espagnet MC, Cappelletti S, Da Rold M, Falcicchio G, Vigevano F, Marras CE, Specchio N, De Palma L. Hemispherotomy in Infants with Hemimegalencephaly: Long-Term Seizure and Developmental Outcome in Early Treated Patients. Brain Sci 2022; 13:brainsci13010073. [PMID: 36672056 PMCID: PMC9856354 DOI: 10.3390/brainsci13010073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 12/21/2022] [Accepted: 12/26/2022] [Indexed: 01/01/2023] Open
Abstract
Hemimegalencephaly (HME) is a rare brain congenital malformation, consisting in altered neuronal migration and proliferation within one hemisphere, which is responsible for early onset drug-resistant epilepsy. Hemispherotomy is an effective treatment option for patients with HME and drug-resistant epilepsy. Surgical outcome may be variable among different surgical series, and the long-term neuropsychological trajectory has been rarely defined using a standardized neurocognitive test. We report the epileptological and neuropsychological long-term outcomes of four consecutive HME patients, operated on before the age of three years. All patients were seizure-free and drug-free, and the minimum follow-up duration was of five years. Despite the excellent post-surgical seizure outcome, the long-term developmental outcome is quite variable between patients, ranging from mild to severe intellectual disabilities. Patients showed improvement mainly in communication skills, while visuo-perceptive and coordination abilities were more impaired. Epileptological outcome seems to be improved in early treated patients; however, neuropsychological outcome in HME patients may be highly variable despite early surgery.
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Affiliation(s)
- Chiara Pepi
- Rare and Complex Epilepsies Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, IRCCS, Full Member of European Reference Network EpiCARE, 00165 Rome, Italy
| | | | | | - Simona Cappelletti
- Unit of Clinical Psychology, Department of Neuroscience, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Martina Da Rold
- Scientific Institute, IRCCS “E. Medea”, Association “La Nostra Famiglia”, 31015 Conegliano, Italy
| | - Giovanni Falcicchio
- Department of Basic Medical Sciences, Neurosciences and Sense Organs—University of Bari Aldo Moro, 70121 Bari, Italy
| | - Federico Vigevano
- Rare and Complex Epilepsies Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, IRCCS, Full Member of European Reference Network EpiCARE, 00165 Rome, Italy
| | - Carlo Efisio Marras
- Neurosurgery Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Nicola Specchio
- Rare and Complex Epilepsies Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, IRCCS, Full Member of European Reference Network EpiCARE, 00165 Rome, Italy
- Correspondence: ; Tel.: +39-06-68592645; Fax: +39-06-68592463
| | - Luca De Palma
- Rare and Complex Epilepsies Unit, Department of Neuroscience, Bambino Gesù Children’s Hospital, IRCCS, Full Member of European Reference Network EpiCARE, 00165 Rome, Italy
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18
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Mamaril-Davis J, Vessell M, Ball T, Palade A, Shafer C, Aguilar-Salinas P, Fowler B, Mirro E, Neimat J, Sagi V, Bina RW. Combined Responsive Neurostimulation and Focal Resection for Super Refractory Status Epilepticus: A Systematic Review and Illustrative Case Report. World Neurosurg 2022; 167:195-204.e7. [PMID: 35948220 DOI: 10.1016/j.wneu.2022.07.141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Super-refractory status epilepticus (SRSE) is a neurologic emergency with high mortality and morbidity. Although medical algorithms typically are effective, when they do fail, options may be limited, and neurosurgical intervention should be considered. METHODS We report a case of SRSE treated acutely with responsive neurostimulation (RNS) and focal surgical resection after intracranial monitoring. We also conducted a systematic review of the literature for neurosurgical treatment of SRSE (e.g., neurostimulation). Only published manuscripts were considered. RESULTS Our patient's seizure semiology consisted of left facial twitching with frequent evolution to bilateral tonic-clonic convulsions. Stereoelectroencephalography and grid monitoring identified multiple seizure foci. The patient underwent right RNS placement with cortical strip leads over the lateral primary motor and premotor cortex as well as simultaneous right superior temporal and frontopolar resection. Status epilepticus resolved 21 days after surgical resection and placement of the RNS. The systematic review revealed 15 case reports describing 17 patients with SRSE who underwent acute neurosurgical intervention. There were 3 patients with SRSE with RNS placement as a single modality, all of whom experienced cessation of SE. Four patients with SRSE received vagus nerve stimulation (3 as a single modality and 1 with combined corpus callosotomy), of whom 1 had SE recurrence at 2weeks. Two patients with SRSE received deep brain stimulation, and the remaining 8 underwent surgical resection; none had recurrence of SE. CONCLUSIONS RNS System placement with or without resection can be a viable treatment option for select patients with SRSE. Early neurosurgical intervention may improve seizure outcomes and reduce complications.
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Affiliation(s)
- James Mamaril-Davis
- College of Medicine, The University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - Meena Vessell
- Department of Neurosurgery, University of Louisville Restorative Neuroscience, Louisville, Kentucky, USA
| | - Tyler Ball
- Department of Neurosurgery, University of Louisville Restorative Neuroscience, Louisville, Kentucky, USA
| | - Adriana Palade
- Department of Neurology, University of Louisville, Louisville, Kentucky, USA
| | - Christopher Shafer
- Department of Neurology, University of Louisville, Louisville, Kentucky, USA
| | - Pedro Aguilar-Salinas
- Department of Neurosurgery, Banner University Medical Center/The University of Arizona, Tucson, Arizona, USA
| | | | - Emily Mirro
- Neuropace, Inc., Mountain View, California, USA
| | - Joseph Neimat
- Department of Neurosurgery, University of Louisville Restorative Neuroscience, Louisville, Kentucky, USA
| | - Vishwanath Sagi
- Department of Neurology, University of Louisville, Louisville, Kentucky, USA
| | - Robert W Bina
- Department of Neurosurgery, Banner University Medical Center/The University of Arizona-Phoenix, Phoenix, Arizona, USA.
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19
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Pepper J, Lo WB, Agrawal S, Mohamed R, Horton J, Balloo S, Philip S, Basnet A, Wimalachandra WSB, Lawley A, Seri S, Walsh AR. Functional hemispherotomy for epilepsy in the very young. J Neurosurg Pediatr 2022; 30:400-409. [PMID: 35932273 DOI: 10.3171/2022.6.peds21521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 06/02/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Epilepsy is one of the most common neurological disorders in children. Among very young children, one-third are resistant to medical treatment, and lack of effective treatment may result in adverse outcomes. Although functional hemispherotomy is an established treatment for epilepsy, its outcome in the very young child has not been widely reported. In this study the authors investigated seizure and developmental results after hemispherotomy in children younger than 3 years. METHODS The authors reviewed a prospective database of all children younger than 3 years with medically intractable epilepsy who underwent functional hemispherotomy at the authors' institution during the period between 2012 and 2020. Demographic data, epilepsy history, underlying etiology, operative and transfusion details, and seizure and developmental outcomes were analyzed. RESULTS Twelve patients were included in this study. The mean age (± SD) at seizure onset was 3 ± 2.6 months and at surgery was 1.3 ± 0.77 years, with a mean follow-up of 4 years. Diagnoses included hemimegalencephaly (n = 5), hemidysplasia (n = 2), hypoxic/hemorrhagic (n = 2), traumatic (n = 1), Sturge-Weber syndrome (n = 1), and mild hemispheric structural abnormality with EEG/PET correlates (n = 1). Eleven patients achieved an Engel class I outcome, and 1 patient achieved Engel class IV at last follow-up. No deaths, infections, cerebrovascular events, or unexpected long-term neurological deficits were recorded. All children progressed neurodevelopmentally following surgery, but their developmental levels remained behind their chronological age, with an overall mean composite Vineland Adaptive Behavior Scale score of 58 (normal: 86-114, low: < 70). One patient required insertion of a subdural peritoneal shunt, 1 patient required dural repair for a CSF fluid leak, and 1 patient required aspiration of a pseudomeningocele. In 2 patients, both of whom weighed less than 5.7 kg, the first operation was incomplete due to blood loss. CONCLUSIONS Hemispherotomy in children younger than 3 years offers excellent seizure control and an acceptable risk-to-benefit ratio in well-selected patients. Families of children weighing less than 6 kg should be counseled regarding the possibility of staged surgery. Postoperatively, children continue to make appropriate, despite delayed, developmental progress.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Stefano Seri
- 4Department of Neurophysiology, Birmingham Children's Hospital, Birmingham, United Kingdom
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20
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Ramantani G, Bölsterli BK, Alber M, Klepper J, Korinthenberg R, Kurlemann G, Tibussek D, Wolff M, Schmitt B. Treatment of Infantile Spasm Syndrome: Update from the Interdisciplinary Guideline Committee Coordinated by the German-Speaking Society of Neuropediatrics. Neuropediatrics 2022; 53:389-401. [PMID: 35882373 PMCID: PMC9643068 DOI: 10.1055/a-1909-2977] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECTIVES The manuscript serves as an update on the current management practices for infantile spasm syndrome (ISS). It includes a detailed summary of the level of current evidence of different treatment options for ISS and gives recommendations for the treatment and care of patients with ISS. METHODS A literature search was performed using the Cochrane and Medline Databases (2014 to July 2020). All studies were objectively rated using the Scottish Intercollegiate Guidelines Network. For recommendations, the evidence from these studies was combined with the evidence from studies used in the 2014 guideline. RECOMMENDATIONS If ISS is suspected, electroencephalography (EEG) should be performed within a few days and, if confirmed, treatment should be initiated immediately. Response to first-line treatment should be evaluated clinically and electroencephalographically after 14 days. The preferred first-line treatment for ISS consists of either hormone-based monotherapy (AdrenoCorticoTropic Hormone [ACTH] or prednisolone) or a combination of hormone and vigabatrin. Children with tuberous sclerosis complex and those with contraindications against hormone treatment should be treated with vigabatrin. If first-line drugs are ineffective, second-line treatment options such as ketogenic dietary therapies, sulthiame, topiramate, valproate, zonisamide, or benzodiazepines should be considered. Children refractory to drug therapy should be evaluated early for epilepsy surgery, especially if focal brain lesions are present. Parents should be informed about the disease, the efficacy and adverse effects of the medication, and support options for the family. Regular follow-up controls are recommended.
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Affiliation(s)
- Georgia Ramantani
- Division of Clinical Neurophysiology and Epilepsy, University Children's Hospital, Zurich, Switzerland,Address for correspondence Georgia Ramantani, MD, PhD Department of Neuropediatrics, Steinwiesstrasse 758032 ZurichSwitzerland
| | - Bigna K. Bölsterli
- Division of Clinical Neurophysiology and Epilepsy, University Children's Hospital, Zurich, Switzerland
| | - Michael Alber
- Department of Pediatric Neurology and Developmental Medicine, University Children's Hospital, Tubingen, Germany
| | - Joerg Klepper
- Department of Pediatrics, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Germany
| | - Rudolf Korinthenberg
- Department of Neuropediatrics and Muscular Diseases, Centre of Pediatrics and Adolescent Medicine, University Medical Centre, Freiburg, Germany
| | - Gerhard Kurlemann
- St. Bonifatius Hospital Lingen, Children's Hospital, Lingen, Germany
| | - Daniel Tibussek
- Center for Pediatric and Teenage Health Care, Child Neurology, Sankt Augustin, Germany
| | - Markus Wolff
- Department of Pediatric Neurology, Vivantes Hospital Neukölln, Berlin, Germany
| | - Bernhard Schmitt
- Division of Clinical Neurophysiology and Epilepsy, University Children's Hospital, Zurich, Switzerland
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21
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Makridis KL, Atalay DA, Thomale UW, Tietze A, Elger CE, Kaindl AM. Epilepsy surgery in the first six months of life: A systematic review and meta-analysis. Seizure 2022; 96:109-117. [DOI: 10.1016/j.seizure.2022.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/11/2022] [Accepted: 02/13/2022] [Indexed: 11/16/2022] Open
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22
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Makridis KL, Prager C, Tietze A, Atalay DA, Triller S, Elger CE, Thomale UW, Kaindl AM. Case Report: Hemispherotomy in the First Days of Life to Treat Drug-Resistant Lesional Epilepsy. Front Neurol 2022; 12:818972. [PMID: 35002946 PMCID: PMC8740526 DOI: 10.3389/fneur.2021.818972] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 12/10/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Neonatal drug-resistant epilepsy is often caused by perinatal epileptogenic insults such as stroke, ischemia, hemorrhage, and/or genetic defects. Rapid seizure control is particularly important for cognitive development. Since early surgical intervention and thus a short duration of epilepsy should lead to an optimal developmental outcome, we present our experience with hemispherotomy in an infant at the corrected age of 1 week. Methods: We report successful hemispherotomy for drug-resistant epilepsy in an infant with hemimegalencephaly at a corrected age of 1 week. Results: The infant was diagnosed with drug-resistant lesional epilepsy due to hemimegalencephaly affecting the left hemisphere. Given congruent electroclinical findings, we performed a left vertical parasagittal transventricular hemispherotomy after critical interdisciplinary discussion. No complications occurred during the surgery. Intraoperatively; 118 ml of red blood cells (30 ml/kg) and 80 ml of plasma were transfused. The patient has been seizure-free since discharge without further neurological deficits. Conclusion: We demonstrate that early epilepsy surgery is a safe procedure in very young infants if performed in a specialized center experienced with age-specific surgical conditions and perioperative management. The specific surgical difficulties should be weighed against the risk of life-long developmental drawbacks of ongoing detrimental epilepsy.
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Affiliation(s)
- Konstantin L Makridis
- Department of Pediatric Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Chronically Sick Children, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Institute of Cell- and Neurobiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christine Prager
- Department of Pediatric Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Chronically Sick Children, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Tietze
- Neuroradiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Deniz A Atalay
- Department of Pediatric Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Chronically Sick Children, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian Triller
- Department of Pediatric Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Chronically Sick Children, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian E Elger
- Department of Pediatric Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Chronically Sick Children, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Beta Neurologie - Kompetenzzentrum für Epilepsie, Beta Klinik GmbH, Bonn, Germany
| | | | - Angela M Kaindl
- Department of Pediatric Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Chronically Sick Children, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Institute of Cell- and Neurobiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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23
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Cloppenborg T, van Schooneveld M, Hagemann A, Hopf JL, Kalbhenn T, Otte WM, Polster T, Bien CG, Braun KPJ. Development and Validation of Prediction Models for Developmental and Intellectual Outcome Following Pediatric Epilepsy Surgery. Neurology 2021; 98:e225-e235. [PMID: 34795046 DOI: 10.1212/wnl.0000000000013065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 11/12/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To (1) identify predictors of postoperative intelligence and developmental quotients (IQ/DQ) and (2) develop and validate clinically applicable IQ/DQ prediction models. METHODS We retrospectively analyzed neuropsychological outcomes and their possible determinants for children treated in Bethel and Utrecht since 1990. We performed separate analyses for patients with IQ and those with only DQ available. We developed prediction models based on presurgical determinants to predict dichotomized levels of performance (IQ≥85, IQ≥70, DQ≥50). RESULTS IQ/DQ data before and two years after surgery were available for 492 patients (IQ n=365, DQ n=127). At a cutoff-level ±10 points, the chance of improvement was considerably higher than the chance of deterioration (IQ 37.3% vs. 6.6% and DQ 31.5% vs. 15.0%, respectively). Presurgical IQ/DQ was the strongest predictor of postoperative cognition (IQ r=0.85, p<.001, DQ: r=0.57, p<.001).Two IQ models were developed in the Bethel cohort (n=258) and externally validated in the Utrecht cohort (n=102). For DQ, we developed the model in the Bethel cohort and used 10-fold cross-validation. Models allowed good prediction at all three cutoff-levels (correct classification for IQ≥85=86%, IQ≥70=91%, DQ≥50=76%). External validation of the IQ models showed high accuracy (IQ≥85: 0.82, CI 0.75-0.91, IQ≥70: 0.84, CI 0.77-0.92) and excellent discrimination (ROC curves IQ≥85: AUC 0.90, CI 0.84-0.96; IQ≥70: AUC 0.92, CI 0.87-0.97). DISCUSSION After epilepsy surgery in children, the risk of cognitive deterioration is very low. Presurgical development has a strong impact on the postoperative trajectory. The presented models can improve presurgical counseling of patients and parents by reliably predicting cognitive outcomes. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that for children undergoing epilepsy surgery presurgical IQ/DQ was the strongest predictor of postoperative cognition.
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Affiliation(s)
- Thomas Cloppenborg
- Bielefeld University, Medical School, Department of Epileptology (Krankenhaus Mara), Bielefeld, Germany
| | - Monique van Schooneveld
- University Medical Center Utrecht, Department of Pediatric Neurology, The Netherlands, member of the ERN EpiCARE
| | | | - Johanna Lena Hopf
- Bielefeld University, Medical School, Department of Epileptology (Krankenhaus Mara), Bielefeld, Germany
| | - Thilo Kalbhenn
- Bielefeld University, Medical School, Department of Neurosurgery (Evangelisches Klinikum Bethel), Bielefeld, Germany
| | - Willem M Otte
- University Medical Center Utrecht, Department of Pediatric Neurology, The Netherlands, member of the ERN EpiCARE
| | - Tilman Polster
- Bielefeld University, Medical School, Department of Epileptology (Krankenhaus Mara), Bielefeld, Germany
| | - Christian G Bien
- Bielefeld University, Medical School, Department of Epileptology (Krankenhaus Mara), Bielefeld, Germany
| | - Kees P J Braun
- University Medical Center Utrecht, Department of Pediatric Neurology, The Netherlands, member of the ERN EpiCARE
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24
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Perry MS, Shandley S, Perelman M, Singh RK, Wong-Kisiel L, Sullivan J, Gonzalez-Giraldo E, Romanowski EF, McNamara NA, Marashly A, Ostendorf AP, Alexander A, Eschbach K, Bolton J, Wolf S, McGoldrick P, Depositario-Cabacar DF, Ciliberto MA, Gedela S, Sannagowdara K, Karia S, Shrey DW, Tatachar P, Nangia S, Grinspan Z, Reddy SB, Shital P, Coryell J. Surgical evaluation in children <3 years of age with drug-resistant epilepsy: Patient characteristics, diagnostic utilization, and potential for treatment delays. Epilepsia 2021; 63:96-107. [PMID: 34778945 DOI: 10.1111/epi.17124] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 10/06/2021] [Accepted: 11/02/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Drug-resistant epilepsy (DRE) occurs at higher rates in children <3 years old. Epilepsy surgery is effective, but rarely utilized in young children despite developmental benefits of early seizure freedom. The present study aims to identify unique patient characteristics and evaluation strategies in children <3 years old who undergo epilepsy surgery evaluation as a means to assess contributors and potential solutions to health care disparities in this group. METHODS The Pediatric Epilepsy Research Consortium Epilepsy Surgery Database, a multicentered, cross-sectional collaboration of 21 US pediatric epilepsy centers, collects prospective data on children <18 years of age referred for epilepsy surgery evaluation. We compared patient characteristics, diagnostic utilization, and surgical treatment between children <3 years old and those older undergoing initial presurgical evaluation. We evaluated patient characteristics leading to delayed referral (>1 year) after DRE diagnosis in the very young. RESULTS The cohort included 437 children, of whom 71 (16%) were <3 years of age at referral. Children evaluated before the age of 3 years more commonly had abnormal neurological examinations (p = .002) and daily seizures (p = .001). At least one ancillary test was used in 44% of evaluations. Fifty-nine percent were seizure-free following surgery (n = 34), with 35% undergoing limited focal resections. Children with delayed referrals more often had focal aware (p < .001) seizures and recommendation for palliative surgeries (p < .001). SIGNIFICANCE There are relatively few studies of epilepsy surgery in the very young. Surgery is effective, but may be disproportionally offered to those with severe presentations. Relatively low utilization of ancillary testing may contribute to reduced surgical therapy for those without evident lesions on magnetic resonance imaging. Despite this, a sizeable portion of patients have favorable outcome after focal epilepsy surgery resections.
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Affiliation(s)
- Michael Scott Perry
- Justin Neuroscience Center, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Sabrina Shandley
- Justin Neuroscience Center, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Max Perelman
- Doernbecher Children's Hospital, Oregon Health Science Center, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Rani K Singh
- Division of Neurology, Department of Pediatrics, Atrium Health/Levine Children's Hospital, Charlotte, North Carolina, USA
| | - Lily Wong-Kisiel
- Divisions of Child Neurology and Epilepsy, Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Joseph Sullivan
- Benioff Children's Hospital, University of California, San Francisco Weill Institute for Neurosciences, San Francisco, California, USA
| | - Ernesto Gonzalez-Giraldo
- Benioff Children's Hospital, University of California, San Francisco Weill Institute for Neurosciences, San Francisco, California, USA
| | - Erin Fedak Romanowski
- Division of Pediatric Neurology, Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nancy A McNamara
- Division of Pediatric Neurology, Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ahmad Marashly
- Division of Pediatric Neurology, University of Washington/Seattle Children's Hospital, Seattle, Washington, USA
| | - Adam P Ostendorf
- Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Allyson Alexander
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Krista Eschbach
- Department of Neurology, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jeffrey Bolton
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Steven Wolf
- Boston Children's Health Physicians of New York and Connecticut, Maria Fareri Children's Hospital, New York Medical College, Valhalla, New York, USA
| | - Patricia McGoldrick
- Boston Children's Health Physicians of New York and Connecticut, Maria Fareri Children's Hospital, New York Medical College, Valhalla, New York, USA
| | - Dewi F Depositario-Cabacar
- Center for Neuroscience, Children's National Hospital, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Michael A Ciliberto
- Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Satyanarayana Gedela
- Department of Pediatrics, Emory University College of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kumar Sannagowdara
- Department of Pediatric Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Samir Karia
- Department of Neurology, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Daniel W Shrey
- Children's Hospital of Orange County, Orange, California, USA
| | - Priya Tatachar
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
| | | | | | - Shilpa B Reddy
- Department of Pediatric Neurology, Monroe Carell Jr. Children's Hospital, Vanderbilt University, Nashville, Tennessee, USA
| | - Patel Shital
- Department of Pediatric Neurology, Monroe Carell Jr. Children's Hospital, Vanderbilt University, Nashville, Tennessee, USA
| | - Jason Coryell
- Doernbecher Children's Hospital, Oregon Health Science Center, Oregon Health and Sciences University, Portland, Oregon, USA
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Hartlieb T, Kudernatsch M, Staudt M. [Hemispherotomy in pediatric epilepsy surgery-Surgical, epileptological and functional aspects]. DER NERVENARZT 2021; 93:142-150. [PMID: 34718829 DOI: 10.1007/s00115-021-01219-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 11/30/2022]
Abstract
Hemispherotomies represent a major part of surgical interventions for epilepsy in childhood (16-21%). The anatomical resection has been replaced by minimally invasive disconnection techniques with lower perioperative mortality and fewer postoperative complications. Today the procedure is not only carried out from the lateral aspect via the Sylvian fissure/insula but also via a vertical parasagittal approach. Depending on the publication, hemispherotomy leads to freedom from postoperative seizures in 60-90% of patients. Despite changes in the surgical technique, disturbances of the cerebrospinal fluid circulation continue to be the main complication in 5-15% of cases. Hemispheric epileptogenic lesions usually lead to early onset and difficult to treat epilepsy in childhood. These epilepsies are characterized by a high frequency of seizures and propagation of epileptic discharges to the healthy hemisphere. The aim of a hemispherotomy is, in addition to postoperative freedom from seizures, the complete disconnection of the affected hemisphere. When deciding on a hemispherotomy, the expected functional consequences play a major role in addition to epileptological aspects. In the case of deficits already present preoperatively (hemianopia, hemiparesis) or reorganization of functions in the contralesional hemisphere (language), no new deficits are to be expected from the operation. In terms of cognition, a hemispherotomy can improve function by releasing the neuroplastic potential of the healthy hemisphere. In order to keep the negative and often irreversible effects of epilepsy as low as possible and to be able to use as much potential for neuroplasticity of the healthy hemisphere as possible, surgery should be considered as early as possible.
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Affiliation(s)
- Till Hartlieb
- Fachzentrum für pädiatrische Neurologie, Neuro-Rehabilitation und Epileptologie, Schön Klinik Vogtareuth, Krankenhausstr. 20, 83569, Vogtareuth, Deutschland.
- Institut für Rehabilitation, Transition und Palliation von neurologisch kranken Kindern, Paracelsus Medizinische Privatuniversität Salzburg, Salzburg, Österreich.
| | - Manfred Kudernatsch
- Institut für Rehabilitation, Transition und Palliation von neurologisch kranken Kindern, Paracelsus Medizinische Privatuniversität Salzburg, Salzburg, Österreich
- Fachzentrum für Neurochirurgie und Epilepsiechirurgie, Schön Klinik Vogtareuth, Vogtareuth, Deutschland
| | - Martin Staudt
- Fachzentrum für pädiatrische Neurologie, Neuro-Rehabilitation und Epileptologie, Schön Klinik Vogtareuth, Krankenhausstr. 20, 83569, Vogtareuth, Deutschland
- Abteilung Neuropädiatrie, Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Tübingen, Tübingen, Deutschland
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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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27
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Underrepresented Populations in Pediatric Epilepsy Surgery. Semin Pediatr Neurol 2021; 39:100916. [PMID: 34620462 DOI: 10.1016/j.spen.2021.100916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 11/24/2022]
Abstract
As awareness of pediatric epilepsy increases, accompanied by advancements in technology and research, it is important to identify certain types of patients that are overlooked for surgical management of epilepsy. Identifying these populations will allow us to study and elucidate the factors contributing to the underutilization and/or delayed application of surgical interventions. Demographically, African-American and Hispanic patients, as well as patients of certain Asian ethnicities, have relatively lower rates of undergoing epilepsy surgery than non-Hispanic and white patients. Among patients with epilepsy, those with higher odds of seizure-freedom following surgery are more likely to be referred for surgical evaluation by their neurologists, with the most common diagnosis being lesional focal epilepsy. However, patients with multifocal or generalized epilepsy, genetic etiologies, or normal (non-lesional) brain magnetic resonance imaging (MRI) are less likely be to referred for evaluation for resective surgery. With an increasing number of high-quality imaging modalities to help localize the epileptogenic zone as well as new techniques for both curative and palliative epilepsy surgery, there are very few populations of patients and/or types of epilepsy that should be precluded from evaluation to determine the suitability of epilepsy surgery. Ultimately, a clearer understanding of the populations who are underrepresented among those considered for epilepsy surgery, coupled with further study of the underlying reasons for this trend, will lead to less disparity in access to this critical treatment among patients with epilepsy.
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Nguyen RD, Smyth MD, Zhu L, Pao LP, Swisher SK, Kennady EH, Mitra A, Patel RP, Lankford JE, Von Allmen G, Watkins MW, Funke ME, Shah MN. A comparison of machine learning classifiers for pediatric epilepsy using resting-state functional MRI latency data. Biomed Rep 2021; 15:77. [PMID: 34405049 PMCID: PMC8330002 DOI: 10.3892/br.2021.1453] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 07/09/2021] [Indexed: 01/03/2023] Open
Abstract
Epilepsy affects 1 in 150 children under the age of 10 and is the most common chronic pediatric neurological condition; poor seizure control can irreversibly disrupt normal brain development. The present study compared the ability of different machine learning algorithms trained with resting-state functional MRI (rfMRI) latency data to detect epilepsy. Preoperative rfMRI and anatomical MRI scans were obtained for 63 patients with epilepsy and 259 healthy controls. The normal distribution of latency z-scores from the epilepsy and healthy control cohorts were analyzed for overlap in 36 seed regions. In these seed regions, overlap between the study cohorts ranged from 0.44-0.58. Machine learning features were extracted from latency z-score maps using principal component analysis. Extreme Gradient Boosting (XGBoost), Support Vector Machines (SVM), and Random Forest algorithms were trained with these features. Area under the receiver operating characteristics curve (AUC), accuracy, sensitivity, specificity and F1-scores were used to evaluate model performance. The XGBoost model outperformed all other models with a test AUC of 0.79, accuracy of 74%, specificity of 73%, and a sensitivity of 77%. The Random Forest model performed comparably to XGBoost across multiple metrics, but it had a test sensitivity of 31%. The SVM model did not perform >70% in any of the test metrics. The XGBoost model had the highest sensitivity and accuracy for the detection of epilepsy. Development of machine learning algorithms trained with rfMRI latency data could provide an adjunctive method for the diagnosis and evaluation of epilepsy with the goal of enabling timely and appropriate care for patients.
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Affiliation(s)
- Ryan D. Nguyen
- Division of Pediatric Neurosurgery, McGovern Medical School at UTHealth, Houston, TX 77030, USA
| | - Matthew D. Smyth
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Liang Zhu
- Biostatistics and Epidemiology Research Design Core, Institute for Clinical and Translational Sciences, McGovern Medical School at UTHealth, Houston, TX 77030, USA
| | - Ludovic P. Pao
- Division of Pediatric Neurosurgery, McGovern Medical School at UTHealth, Houston, TX 77030, USA
| | - Shannon K. Swisher
- Division of Pediatric Neurosurgery, McGovern Medical School at UTHealth, Houston, TX 77030, USA
| | - Emmett H. Kennady
- Division of Pediatric Neurosurgery, McGovern Medical School at UTHealth, Houston, TX 77030, USA
| | - Anish Mitra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Rajan P. Patel
- Department of Diagnostic and Interventional Imaging, McGovern Medical School at UTHealth, Houston, TX 77030, USA
| | - Jeremy E. Lankford
- Department of Pediatric Neurology, McGovern Medical School at UTHealth, Houston, TX 77030, USA
| | - Gretchen Von Allmen
- Department of Pediatric Neurology, McGovern Medical School at UTHealth, Houston, TX 77030, USA
| | - Michael W. Watkins
- Department of Pediatric Neurology, McGovern Medical School at UTHealth, Houston, TX 77030, USA
| | - Michael E. Funke
- Department of Pediatric Neurology, McGovern Medical School at UTHealth, Houston, TX 77030, USA
| | - Manish N. Shah
- Division of Pediatric Neurosurgery, McGovern Medical School at UTHealth, Houston, TX 77030, USA
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Iwasaki M, Iijima K, Kawashima T, Tachimori H, Takayama Y, Kimura Y, Kaneko Y, Ikegaya N, Sumitomo N, Saito T, Nakagawa E, Takahashi A, Sugai K, Otsuki T. Epilepsy surgery in children under 3 years of age: surgical and developmental outcomes. J Neurosurg Pediatr 2021; 28:395-403. [PMID: 34388720 DOI: 10.3171/2021.4.peds21123] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/13/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pediatric epilepsy surgery is known to be effective, but early surgery in infancy is not well characterized. Extensive cortical dysplasia, such as hemimegalencephaly, can cause refractory epilepsy shortly after birth, and early surgical intervention is indicated. However, the complication rate of early pediatric surgery is significant. In this study, the authors assessed the risk-benefit balance of early pediatric epilepsy surgery as relates to developmental outcomes. METHODS This is a retrospective descriptive study of 75 patients who underwent their first curative epilepsy surgery at an age under 3 years at the authors' institution between 2006 and 2019 and had a minimum 1-year follow-up of seizure and developmental outcomes. Clinical information including surgical complications, seizure outcomes, and developmental quotient (DQ) was collected from medical records. The effects of clinical factors on DQ at 1 year after surgery were evaluated. RESULTS The median age at surgery was 6 months, peaking at between 3 and 4 months. Operative procedures included 27 cases of hemispherotomy, 19 cases of multilobar surgery, and 29 cases of unilobar surgery. Seizure freedom was achieved in 82.7% of patients at 1 year and in 71.0% of patients at a mean follow-up of 62.8 months. The number of antiseizure medications (ASMs) decreased significantly after surgery, and 19 patients (30.6%) had discontinued their ASMs by the last follow-up. Postoperative complications requiring cerebrospinal fluid (CSF) diversion surgery, such as hydrocephalus and cyst formation, were observed in 13 patients (17.3%). The mean DQ values were 74.2 ± 34.3 preoperatively, 60.3 ± 23.3 at 1 year after surgery, and 53.4 ± 25.1 at the last follow-up. Multiple regression analysis revealed that the 1-year postoperative DQ was significantly influenced by preoperative DQ and postoperative seizure freedom but not by the occurrence of any surgical complication requiring CSF diversion surgery. CONCLUSIONS Early pediatric epilepsy surgery has an acceptable risk-benefit balance. Seizure control after surgery is important for postoperative development.
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Affiliation(s)
- Masaki Iwasaki
- 1Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo
| | - Keiya Iijima
- 1Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo
| | - Takahiro Kawashima
- 2Department of Clinical Epidemiology, Translational Medical Center, NCNP, Kodaira, Tokyo
| | - Hisateru Tachimori
- 2Department of Clinical Epidemiology, Translational Medical Center, NCNP, Kodaira, Tokyo
| | - Yutaro Takayama
- 1Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo
| | - Yuiko Kimura
- 1Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo
| | - Yuu Kaneko
- 1Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo
| | - Naoki Ikegaya
- 3Department of Neurosurgery, Yokohama City University Hospital, Yokohama, Kanagawa
| | - Noriko Sumitomo
- 4Department of Child Neurology, National Center Hospital, NCNP, Kodaira, Tokyo
| | - Takashi Saito
- 4Department of Child Neurology, National Center Hospital, NCNP, Kodaira, Tokyo
| | - Eiji Nakagawa
- 4Department of Child Neurology, National Center Hospital, NCNP, Kodaira, Tokyo
| | - Akio Takahashi
- 5Department of Neurosurgery, Shibukawa Medical Center, Shibukawa, Gunma; and
| | - Kenji Sugai
- 4Department of Child Neurology, National Center Hospital, NCNP, Kodaira, Tokyo
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Bernal B. Practical Aspects of Functional Magnetic Resonance Imaging in Children. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1733853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AbstractFunctional magnetic resonance imaging (fMRI) has become a broadly accepted presurgical mapping tool for pediatric populations with brain pathology. The aim of this article is to provide general guidelines on the pragmatic aspects of performing and processing fMRI, as well as interpreting its results across children of all age groups. Based on the author's accumulated experience of more than 20 years on this specific field, these guidelines consider many factors that include the particular physiology and anatomy of the child's brain, and how specific peculiarities may pose disadvantages or even certain advantages when performing fMRI procedures. The author carefully details the various challenges that the practitioner might face in dealing with limited volitional behavior and language comprehension of infants and small children and remedial strategies. The type and proper choice of task-based paradigms in keeping with the age and performance of the patient are discussed, as well as the appropriate selection and dosage of sedative agents and their inherent limitations. Recommendations about the scanner and settings for specific sequences are provided, as well as the required devices for appropriate stimulus delivery, response, and motion control. Practical aspects of fMRI postprocessing and quality control are discussed. Finally, given the relevance of resting-state-fMRI for use in noncooperative patients, a praxis-oriented guide to obtain, classify, and understand the spontaneous neural networks (utilizing independent component analysis) is also provided. The article concludes with a thorough discussion about the possible pitfalls at different stages of the fMRI process.
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Affiliation(s)
- Byron Bernal
- Department of Radiology, Brain Institute, Nicklaus Children's Hospital, Miami, Florida, United States
- Florida International University, Herbert Wertheim College of Medicine, Miami, Florida, United States
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31
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Erdemir G, Pestana-Knight E, Honomichl R, Thompson NR, Lachhwani D, Kotagal P, Wyllie E, Gupta A, Bingaman WE, Moosa ANV. Surgical candidates in children with epileptic spasms can be selected without invasive monitoring: A report of 70 cases. Epilepsy Res 2021; 176:106731. [PMID: 34339941 DOI: 10.1016/j.eplepsyres.2021.106731] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/14/2021] [Accepted: 07/23/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Prior surgical series in children with drug-resistant epileptic spasms have reported use of intracranial EEG monitoring in up to two-third of patients. We report outcome after epilepsy surgery for drug-resistant epileptic spasms in a cohort of children without the use of intracranial EEG monitoring in any of the patients. METHODS Medical records of all consecutive children aged 5 years or under who had epilepsy surgery for epileptic spasms at Cleveland Clinic between 2000 and 2018 were reviewed. Post-operative seizure outcome and predictors of prognosis of seizure outcome were analyzed. RESULTS Seventy children with active epileptic spasms underwent surgical resections during the study period. Mean age at seizure onset was 6.8 (+9.31) months and median age at surgery was 18.5 months. An epileptogenic lesion was identified on brain MRI in all patients; 17 (24%) had bilateral abnormalities. Etiologies included malformations of cortical development (58%), perinatal infarct/encephalomalacia (39%), and tumor (3%). None of the patients had intracranial EEG. Surgical procedures included hemispherectomy (44%), lobectomy/ lesionectomy (33%), and multilobar resections (23%). Twelve children needed repeat surgery; six (50%) became seizure free after the second surgery. At six months follow-up, 73% (51/70) were seizure-free since surgery. At a mean follow-up of 4.7 years, 60% (42/70) had Engel 1 outcome. In those with seizure recurrence, 17 (60%) reported improvement. Shorter epilepsy duration (p = 0.05) and lobar or sub-lobar epileptogenic lesions (p = 0.02) predicted favorable seizure outcome at 6 months after surgery. For long term outcome, patients with bilateral abnormalities on MRI (p = 0.001), and multilobar extent on MRI (p = 0.02) were at higher risk for recurrence. SIGNIFICANCE Children with drug-resistant epileptic spasms secondary to an epileptogenic lesion detected on MRI could be selected for epilepsy surgery without undergoing intracranial EEG monitoring. A surgical selection paradigm without intracranial monitoring may allow early surgery without the risks of invasive monitoring.
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Affiliation(s)
- Gozde Erdemir
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, 44195, United States; Division of Pediatric Neurology, University of Maryland, Baltimore, MD, United States
| | | | - Ryan Honomichl
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Nicolas R Thompson
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Deepak Lachhwani
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, 44195, United States
| | - Prakash Kotagal
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, 44195, United States
| | - Elaine Wyllie
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, 44195, United States
| | - Ajay Gupta
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, 44195, United States
| | | | - Ahsan N V Moosa
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, 44195, United States.
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Nelson F, Gray V, Woolfall K. Parents' experiences of their child's assessment on an epilepsy surgery pathway: A qualitative study. Seizure 2021; 91:456-461. [PMID: 34340191 DOI: 10.1016/j.seizure.2021.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 07/05/2021] [Accepted: 07/10/2021] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Children's epilepsy surgery services (CESS) in the UK aim to improve outcomes for young children by increasing access to surgery. Consideration for surgery is complex and time consuming, yet there is lack of research exploring how this process might impact on families. This study aimed to explore parents' experiences of their child consideration for epilepsy surgery to inform future service development and delivery. METHODS Semi-structured interviews with parents of children (aged < six years) considered for surgery within the previous three years. Recruitment was through social media and purposive sampling of medical records. Data were analysed using a thematic and iterative approach. RESULTS 15 parents of 14 children were interviewed (13 mothers and 2 fathers). Initial discussions of epilepsy surgery were described as 'shocking' but also as a source of hope. However, unclear communication between staff and parents, including lack of information about the steps, assessments/investigations and timeframes involved in the process of assessment for surgery led to some feeling 'out of control,' uncertain and in some cases distressed. Parents described examples of positive support from staff, yet many felt they needed additional general and emotional support throughout the epilepsy surgery pathway. CONCLUSIONS Findings highlight the importance of providing clear and consistent information about the epilepsy surgery assessment to minimise parental distress and help facilitate a sense of control. Recommendations include providing parents with advance warning that surgery will be discussed at their next appointment, improved access to psychosocial and clinical psychological support and a step-by-step guide of the process with realistic timelines.
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Affiliation(s)
- Fiona Nelson
- Department of Clinical Psychology, University of Liverpool, Liverpool L69 3GB, United Kingdom
| | - Victoria Gray
- Clinical Health Psychology, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool L12 2AP, United Kingdom
| | - Kerry Woolfall
- Institute of Population Health, Department of Public Health, Policy and Systems, University of Liverpool, Liverpool L69 3G, United Kingdom.
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Abstract
OBJECTIVES This research aimed to study the short-term seizure outcomes following treatment with 8 mg/kg/day prednisolone in children with infantile spasms (IS) refractory to vigabatrin. We hypothesized that high-dose prednisolone may result in similar rates of electroclinical remission when compared to published ACTH rates. METHODS All consecutive children with hypsarrhythmia or hypsarrhythmia variant on EEG with/without IS, who had been treated with vigabatrin as first-line anti-seizure medication (ASM) followed by high-dose oral prednisolone (8 mg/kg/day; maximum 60 mg/day) in cases who did not respond to vigabatrin, were included. Clinical and electroclinical response (ECR) at 2 weeks following initiation of treatment and adverse effects were assessed. RESULTS Sixty-five children were included. A genetic etiology was seen in 38.5% cases. Complete ECR was seen in 30.8% (20/65) of the patients 2 weeks after vigabatrin. Complete ECR was noted in 77.8% (35/45) of the patients, 2 weeks after prednisolone initiation in children who failed vigabatrin, and this was sustained at 6 weeks in 66.7% (30/45) patients. Prednisolone was generally well tolerated. CONCLUSIONS High-dose (8 mg/kg/day) oral prednisolone resulted in sustained complete ECR (at 6 weeks) in two-thirds of the children with hypsarrhythmia or hypsarrhythmia variant on EEG with/without parentally reported IS. It was generally well tolerated and found to be safe.
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Jehi L, Braun K. Does etiology really matter for epilepsy surgery outcome? Brain Pathol 2021; 31:e12965. [PMID: 34196987 PMCID: PMC8412085 DOI: 10.1111/bpa.12965] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 04/01/2021] [Indexed: 12/17/2022] Open
Abstract
Multiple factors influence the outcomes of epilepsy surgery. Prognostic indicators varying from clinical characteristics, imaging findings, ictal, and interictal electrophysiological activity have been linked to surgical outcomes. In this review, we focus on the relatively under‐studied role of the underlying epilepsy histopathology in driving post‐surgical outcomes, specifically focusing on the broad categories of seizure outcomes and cognitive outcomes. For each of these two outcomes of interest, we answer two questions: 1)‐ does etiology matter? and 2)‐ how could it matter? The goal is to review the existing literature on the relationship between etiology and surgical outcomes to provide the best possible judgment as to whether a causal relationship exists between histopathology and the ultimate surgical outcome as an initial step. Then, we delve into the possible mechanisms via which such relationships can be explained. We conclude with a call to action to the epilepsy surgery and histopathology research community to push the mechanistic understanding of the pathology‐outcome interaction and identify actionable knowledge and biomarkers that could inform patient care in a timely fashion. In this review, we focus on the relatively under‐studied role of the underlying epilepsy histopathology in driving post‐surgical outcomes, specifically focusing on the broad categories of seizure outcomes and cognitive outcomes. For each of these two outcomes of interest, we answer two questions: (1) does etiology matter? and (2) how could it matter? We then delve into the mechanisms of these answers.
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Affiliation(s)
- Lara Jehi
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | - Kees Braun
- Dept. of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht University, the Netherlands
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Roth J, Constantini S, Ekstein M, Weiner HL, Tripathi M, Chandra PS, Cossu M, Rizzi M, Bollo RJ, Machado HR, Santos MV, Keating RF, Oluigbo CO, Rutka JT, Drake JM, Jallo GI, Shimony N, Treiber JM, Consales A, Mangano FT, Wisoff JH, Teresa Hidalgo E, Bingaman WE, Gupta A, Erdemir G, Sundar SJ, Benifla M, Shapira V, Lam SK, Fallah A, Maniquis CAB, Tisdall M, Chari A, Cinalli G, Blount JP, Dorfmüller G, Christine Bulteau, Uliel-Sibony S. Epilepsy surgery in infants up to 3 months of age: Safety, feasibility, and outcomes: A multicenter, multinational study. Epilepsia 2021; 62:1897-1906. [PMID: 34128544 DOI: 10.1111/epi.16959] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/18/2021] [Accepted: 05/23/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Drug-resistant epilepsy (DRE) during the first few months of life is challenging and necessitates aggressive treatment, including surgery. Because the most common causes of DRE in infancy are related to extensive developmental anomalies, surgery often entails extensive tissue resections or disconnection. The literature on "ultra-early" epilepsy surgery is sparse, with limited data concerning efficacy controlling the seizures, and safety. The current study's goal is to review the safety and efficacy of ultra-early epilepsy surgery performed before the age of 3 months. METHODS To achieve a large sample size and external validity, a multinational, multicenter retrospective study was performed, focusing on epilepsy surgery for infants younger than 3 months of age. Collected data included epilepsy characteristics, surgical details, epilepsy outcome, and complications. RESULTS Sixty-four patients underwent 69 surgeries before the age of 3 months. The most common pathologies were cortical dysplasia (28), hemimegalencephaly (17), and tubers (5). The most common procedures were hemispheric surgeries (48 procedures). Two cases were intentionally staged, and one was unexpectedly aborted. Nearly all patients received blood products. There were no perioperative deaths and no major unexpected permanent morbidities. Twenty-five percent of patients undergoing hemispheric surgeries developed hydrocephalus. Excellent epilepsy outcome (International League Against Epilepsy [ILAE] grade I) was achieved in 66% of cases over a median follow-up of 41 months (19-104 interquartile range [IQR]). The number of antiseizure medications was significantly reduced (median 2 drugs, 1-3 IQR, p < .0001). Outcome was not significantly associated with the type of surgery (hemispheric or more limited resections). SIGNIFICANCE Epilepsy surgery during the first few months of life is associated with excellent seizure control, and when performed by highly experienced teams, is not associated with more permanent morbidity than surgery in older infants. Thus surgical treatment should not be postponed to treat DRE in very young infants based on their age.
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Affiliation(s)
- Jonathan Roth
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Constantini
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Margaret Ekstein
- Pediatric Anesthesia Unit, Department of Anesthesia, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Howard L Weiner
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Manjari Tripathi
- Center of Excellence for Epilepsy and MEG, AIIMS, New Delhi, India
| | | | - Massimo Cossu
- "C. Munari" Centre for Epilepsy Surgery, Niguarda Hospital, Milan, Italy
| | - Michele Rizzi
- "C. Munari" Centre for Epilepsy Surgery, Niguarda Hospital, Milan, Italy
| | - Robert J Bollo
- Division of Pediatric Neurosurgery, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Hélio Rubens Machado
- Pediatric Neurosurgery, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirão Preto, Sao Paulo, Brazil
| | - Marcelo Volpon Santos
- Pediatric Neurosurgery, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirão Preto, Sao Paulo, Brazil
| | - Robert F Keating
- Department of Neurosurgery, Children's National Medical Center, Washington, DC, USA
| | - Chima O Oluigbo
- Department of Neurosurgery, Children's National Medical Center, Washington, DC, USA
| | - James T Rutka
- Department of Surgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - James M Drake
- Department of Surgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - George I Jallo
- Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nir Shimony
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Neurosurgery, Geisinger Commonwealth School of Medicine, Danville, Pennsylvania, USA
| | - Jeffrey M Treiber
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Alessandro Consales
- Department of Pediatric Neurosurgery, IRRCS Istituto Giannina Gaslini, Genoa, Italy
| | - Francesco T Mangano
- Department of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jeffrey H Wisoff
- Division of Pediatric Neurosurgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, NY, USA
| | - Eveline Teresa Hidalgo
- Division of Pediatric Neurosurgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, NY, USA
| | - William E Bingaman
- Department of Neurological Surgery, Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | - Ajay Gupta
- Department of Neurology, Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | - Gozde Erdemir
- Department of Neurology, Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | - Swetha J Sundar
- Department of Neurological Surgery, Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | - Mony Benifla
- Pediatric Neurosurgery Department, Rambam Health Care Campus, Haifa, Israel
| | - Vladimir Shapira
- Pediatric Neurosurgery Department, Rambam Health Care Campus, Haifa, Israel
| | - Sandi K Lam
- Department of Pediatric Neurosurgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Cassia A B Maniquis
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Martin Tisdall
- Department of Neurosurgery, Great Ormond Street Hospital & Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Aswin Chari
- Department of Neurosurgery, Great Ormond Street Hospital & Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Giuseppe Cinalli
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Jeffrey P Blount
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Al, USA
| | - Georg Dorfmüller
- Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France
| | - Christine Bulteau
- Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France.,MC2Lab, University of Paris, Boulogne-Billancourt, France
| | - Shimrit Uliel-Sibony
- Pediatric Neurology Unit, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
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Honda R, Baba H, Adachi K, Koshimoto R, Ono T, Toda K, Tanaka S, Baba S, Yamasaki K, Yatsuhashi H. Developmental outcome after corpus callosotomy for infants and young children with drug-resistant epilepsy. Epilepsy Behav 2021; 117:107799. [PMID: 33610103 DOI: 10.1016/j.yebeh.2021.107799] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/26/2020] [Accepted: 01/10/2021] [Indexed: 12/21/2022]
Abstract
AIM To examine the developmental and seizure outcomes after corpus callosotomy (CC) in early childhood. METHODS We retrospectively identified 106 patients who underwent CC for drug-resistant epilepsy before the age of 6 years, at the Nagasaki Medical Center, between July 2002 and July 2016. Patients' developmental outcomes were evaluated one year after CC using the Kinder Infant Development Scale. RESULTS The mean preoperative developmental quotient (DQ) was 25.0 (standard deviation [SD], 20.8), and the mean difference between preoperative DQ and one-year postoperative DQ was -1.6 points (SD, 11.6). However, 42.5% of patients had a mean DQ increase of 6.5 points (SD, 6.4), one year after CC from that before surgery. Factors related to the improvement in postoperative DQ were 'low preoperative DQ', 'developmental gain 1 month postoperatively', and 'postoperative seizure-free state'. Approximately 21.7% of patients were seizure-free 1 year after CC. INTERPRETATION Performing CC, in infancy and early childhood for patients with drug-resistant epilepsy and severe developmental impairment, was associated with improved development in 42.5% of patients. Remission of seizures, even if only for a short period, contributed to developmental improvement. From a developmental perspective, CC for drug-resistant epilepsy in early childhood is an effective treatment.
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Affiliation(s)
- Ryoko Honda
- Department of Pediatrics, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan; Nagasaki University School of Medicine Graduate School of Biomedical Sciences, Nagasaki, Japan.
| | - Hiroshi Baba
- Department of Neurosurgery, Nishiisahaya Hospital, Nagasaki, Japan; Department of Neurosurgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Kohei Adachi
- Department of Comprehensive Community Care Services, Nagasaki Junshin Catholic University, Japan
| | - Rika Koshimoto
- Psychological Counselling Center, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Tomonori Ono
- Department of Neurosurgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Keisuke Toda
- Department of Neurosurgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan; Department of Neurosurgery, National Hospital Organization Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Shigeki Tanaka
- Department of Pediatrics, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Shiro Baba
- Department of Neurosurgery, Nagasaki University School of Medicine Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazumi Yamasaki
- Clinical Research Center, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Hiroshi Yatsuhashi
- Nagasaki University School of Medicine Graduate School of Biomedical Sciences, Nagasaki, Japan; Clinical Research Center, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
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Samanta D, Singh R, Gedela S, Scott Perry M, Arya R. Underutilization of epilepsy surgery: Part II: Strategies to overcome barriers. Epilepsy Behav 2021; 117:107853. [PMID: 33678576 PMCID: PMC8035223 DOI: 10.1016/j.yebeh.2021.107853] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/05/2021] [Accepted: 02/06/2021] [Indexed: 12/12/2022]
Abstract
Interventions focused on utilization of epilepsy surgery can be divided into groups: those that improve patients' access to surgical evaluation and those that facilitate completion of the surgical evaluation and treatment. Educational intervention, technological innovation, and effective coordination and communication can significantly improve patients' access to surgery. Patient and public facing, individualized (analog and/or digital) communication can raise awareness and acceptance of epilepsy surgery. Educational interventions aimed at providers may mitigate knowledge gaps using practical and concise consensus statements and guidelines, while specific training can improve awareness around implicit bias. Innovative technology, such as clinical decision-making toolkits within the electronic medical record (EMR), machine learning techniques, online decision-support tools, nomograms, and scoring algorithms can facilitate timely identification of appropriate candidates for epilepsy surgery with individualized guidance regarding referral appropriateness, postoperative seizure freedom rate, and risks of complication after surgery. There are specific strategies applicable for epilepsy centers' success: building a multidisciplinary setup, maintaining/tracking volume and complexity of cases, collaborating with other centers, improving surgical outcome with reduced complications, utilizing advanced diagnostics tools, and considering minimally invasive surgical techniques. Established centers may use other strategies, such as multi-stage procedures for multifocal epilepsy, advanced functional mapping with tailored surgery for epilepsy involving the eloquent cortex, and generation of fresh hypotheses in cases of surgical failure. Finally, improved access to epilepsy surgery can be accomplished with policy changes (e.g., anti-discrimination policy, exemption in transportation cost, telehealth reimbursement policy, patient-centered epilepsy care models, pay-per-performance models, affordability and access to insurance, and increased funding for research). Every intervention should receive regular evaluation and feedback-driven modification to ensure appropriate utilization of epilepsy surgery.
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Affiliation(s)
- Debopam Samanta
- Neurology Division, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States.
| | - Rani Singh
- Department of Pediatrics, Atrium Health/Levine Children's Hospital, United States
| | - Satyanarayana Gedela
- Department of Pediatrics, Emory University College of Medicine, Atlanta, GA, United States; Children's Healthcare of Atlanta, United States
| | - M Scott Perry
- Cook Children's Medical Center, Fort Worth, TX, United States
| | - Ravindra Arya
- Division of Neurology, Comprehensive Epilepsy Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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Cossu G, González-López P, Pralong E, Kalser J, Messerer M, Daniel RT. Unilateral prefrontal lobotomy for epilepsy: technique and surgical anatomy. Neurosurg Focus 2021; 48:E10. [PMID: 32234977 DOI: 10.3171/2020.1.focus19938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 01/24/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgery for frontal lobe epilepsy remains a challenge because of the variable seizure outcomes after surgery. Disconnective procedures are increasingly applied to isolate the epileptogenic focus and avoid complications related to extensive brain resection. Previously, the authors described the anterior quadrant disconnection procedure to treat large frontal lobe lesions extending up to but not involving the primary motor cortex. In this article, they describe a surgical technique for unilateral disconnection of the prefrontal cortex, while providing an accurate description of the surgical and functional anatomy of this disconnective procedure. METHODS The authors report the surgical treatment of a 5-month-old boy who presented with refractory epilepsy due to extensive cortical dysplasia of the left prefrontal lobe. In addition, with the aim of both describing the subcortical intrinsic anatomy and illustrating the different connections between the prefrontal lobe and the rest of the brain, the authors dissected six human cadaveric brain hemispheres. These dissections were performed from lateral to medial and from medial to lateral to reveal the various tracts sectioned during the three different steps in the surgery, namely the intrafrontal disconnection, anterior callosotomy, and frontobasal disconnection. RESULTS The first step of the dissection involves cutting the U-fibers. During the anterior intrafrontal disconnection, the superior longitudinal fasciculus in the depth of the middle frontal gyrus, the uncinate fasciculus, and the inferior frontooccipital fasciculus in the depth of the inferior frontal gyrus at the level of the anterior insular point are visualized and sectioned, followed by sectioning of the anterior limb of the internal capsule. Once the frontal horn is reached, the anterior callosotomy can be performed to disconnect the genu and the rostrum of the corpus callosum. The intrafrontal disconnection is deepened toward the falx, and at the medial surface, the cingulum is sectioned. The frontobasal disconnection involves cutting the anterior limb of the anterior commissure. CONCLUSIONS This technique allows selective isolation of the epileptogenic focus located in the prefrontal lobe to avoid secondary propagation. Understanding the surface and white matter fiber anatomy is essential to safely perform the procedure and obtain a favorable seizure outcome.
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Affiliation(s)
- Giulia Cossu
- 1Department of Neurosurgery, University Hospital of Lausanne
| | | | - Etienne Pralong
- 1Department of Neurosurgery, University Hospital of Lausanne
| | - Judith Kalser
- 3Department of Pediatrics, Section of Neuro-Pediatrics, University Hospital of Lausanne, Switzerland; and
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Kim HJ, Jang HN, Ahn H, Yum MS, Ko TS. Over 10-Year Outcomes of Infantile-Onset Epilepsies. J Clin Med 2021; 10:jcm10030430. [PMID: 33499362 PMCID: PMC7865548 DOI: 10.3390/jcm10030430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 11/24/2022] Open
Abstract
Seizures in infancy have highly variable courses and underlying etiologies. However, there are only a few long-term follow-up studies regarding infantile-onset epilepsy. Therefore, we aimed to describe the clinical courses, seizure outcomes, and risk factors of infantile-onset epilepsy followed up for more than 10 years in a tertiary center. Methods: Data of the patients with epilepsy, diagnosed under the age of 12 months and followed up for more than 10 years, were retrieved from the electronic medical records of Asan Medical Center Children’s Hospital. The patients’ medical records were retrospectively reviewed, and clinical outcomes were assessed based on the duration of seizure freedom at the last follow-up. Results: Of the 146 patients, 103 (70.5%) entered at least one remission, of whom epilepsy was resolved in 46 (31.5%). Forty-nine (33.6%) were found to be intractable at last contact. Delayed development, neurological deficits, and later onset (>3 months) were significantly associated with intractable epilepsies (p < 0.01). Conclusions: This study demonstrated that many patients with infantile-onset epilepsy can experience seizure remission. However, in some cases, early onset epilepsy was highly associated with various comorbidities and intractable seizures. Therefore, appropriate diagnosis and treatment are necessary to prevent further neuropsychiatric complications.
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Affiliation(s)
- Hyun-Jin Kim
- Department of Pediatrics, Myongji Hospital, Goyang 10475, Korea;
| | - Han Na Jang
- Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.N.J.); (H.A.)
| | - Hyunji Ahn
- Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.N.J.); (H.A.)
| | - Mi-Sun Yum
- Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.N.J.); (H.A.)
- Correspondence: (M.-S.Y.); (T.-S.K.); Tel.: +82-2-3010-3386 (M.-S.Y. & T.-S.K.); Fax: +82-2-473-3725 (M.-S.Y. & T.-S.K.)
| | - Tae-Sung Ko
- Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.N.J.); (H.A.)
- Correspondence: (M.-S.Y.); (T.-S.K.); Tel.: +82-2-3010-3386 (M.-S.Y. & T.-S.K.); Fax: +82-2-473-3725 (M.-S.Y. & T.-S.K.)
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Howell KB, Freeman JL, Mackay MT, Fahey MC, Archer J, Berkovic SF, Chan E, Dabscheck G, Eggers S, Hayman M, Holberton J, Hunt RW, Jacobs SE, Kornberg AJ, Leventer RJ, Mandelstam S, McMahon JM, Mefford HC, Panetta J, Riseley J, Rodriguez-Casero V, Ryan MM, Schneider AL, Smith LJ, Stark Z, Wong F, Yiu EM, Scheffer IE, Harvey AS. The severe epilepsy syndromes of infancy: A population-based study. Epilepsia 2021; 62:358-370. [PMID: 33475165 DOI: 10.1111/epi.16810] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/07/2020] [Accepted: 12/22/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To study the epilepsy syndromes among the severe epilepsies of infancy and assess their incidence, etiologies, and outcomes. METHODS A population-based cohort study was undertaken of severe epilepsies with onset before age 18 months in Victoria, Australia. Two epileptologists reviewed clinical features, seizure videos, and electroencephalograms to diagnose International League Against Epilepsy epilepsy syndromes. Incidence, etiologies, and outcomes at age 2 years were determined. RESULTS Seventy-three of 114 (64%) infants fulfilled diagnostic criteria for epilepsy syndromes at presentation, and 16 (14%) had "variants" of epilepsy syndromes in which there was one missing or different feature, or where all classical features had not yet emerged. West syndrome (WS) and "WS-like" epilepsy (infantile spasms without hypsarrhythmia or modified hypsarrhythmia) were the most common syndromes, with a combined incidence of 32.7/100 000 live births/year. The incidence of epilepsy of infancy with migrating focal seizures (EIMFS) was 4.5/100 000 and of early infantile epileptic encephalopathy (EIEE) was 3.6/100 000. Structural etiologies were common in "WS-like" epilepsy (100%), unifocal epilepsy (83%), and WS (39%), whereas single gene disorders predominated in EIMFS, EIEE, and Dravet syndrome. Eighteen (16%) infants died before age 2 years. Development was delayed or borderline in 85 of 96 (89%) survivors, being severe-profound in 40 of 96 (42%). All infants with EIEE or EIMFS had severe-profound delay or were deceased, but only 19 of 64 (30%) infants with WS, "WS-like," or "unifocal epilepsy" had severe-profound delay, and only two of 64 (3%) were deceased. SIGNIFICANCE Three quarters of severe epilepsies of infancy could be assigned an epilepsy syndrome or "variant syndrome" at presentation. In this era of genomic testing and advanced brain imaging, diagnosing epilepsy syndromes at presentation remains clinically useful for guiding etiologic investigation, initial treatment, and prognostication.
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Affiliation(s)
- Katherine B Howell
- Department of Neurology, Royal Children's Hospital, Melbourne, Vic, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Jeremy L Freeman
- Department of Neurology, Royal Children's Hospital, Melbourne, Vic, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Mark T Mackay
- Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Michael C Fahey
- Department of Neurology, Monash Children's Hospital, Melbourne, Vic, Australia.,Department of Paediatrics, Monash University, Melbourne, Vic, Australia
| | - John Archer
- Department of Medicine, Epilepsy Research Centre, Austin Health, University of Melbourne, Melbourne, Vic, Australia
| | - Samuel F Berkovic
- Department of Medicine, Epilepsy Research Centre, Austin Health, University of Melbourne, Melbourne, Vic, Australia.,Florey Institute of Neuroscience and Mental Health, Melbourne, Vic, Australia
| | - Eunice Chan
- Department of Neurology, Royal Children's Hospital, Melbourne, Vic, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Gabriel Dabscheck
- Department of Neurology, Royal Children's Hospital, Melbourne, Vic, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Stefanie Eggers
- Victorian Clinical Genetics Service, Melbourne, Vic, Australia
| | - Michael Hayman
- Department of Neurology, Royal Children's Hospital, Melbourne, Vic, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia.,Department of Neurology, Monash Children's Hospital, Melbourne, Vic, Australia
| | - James Holberton
- Department of Neonatology, Mercy Hospital for Women, Melbourne, Vic, Australia
| | - Rodney W Hunt
- Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia.,Department of Neonatology, Royal Children's Hospital, Melbourne, Vic, Australia
| | - Susan E Jacobs
- Neonatal Services, Royal Women's Hospital, Melbourne, Vic, Australia
| | - Andrew J Kornberg
- Department of Neurology, Royal Children's Hospital, Melbourne, Vic, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Richard J Leventer
- Department of Neurology, Royal Children's Hospital, Melbourne, Vic, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Simone Mandelstam
- Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia.,Florey Institute of Neuroscience and Mental Health, Melbourne, Vic, Australia.,Department of Radiology, Royal Children's Hospital, Melbourne, Vic, Australia
| | - Jacinta M McMahon
- Department of Medicine, Epilepsy Research Centre, Austin Health, University of Melbourne, Melbourne, Vic, Australia
| | - Heather C Mefford
- Division of Genetic Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | | | - Jessica Riseley
- Victorian Clinical Genetics Service, Melbourne, Vic, Australia
| | - Victoria Rodriguez-Casero
- Department of Neurology, Royal Children's Hospital, Melbourne, Vic, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Monique M Ryan
- Department of Neurology, Royal Children's Hospital, Melbourne, Vic, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Amy L Schneider
- Department of Medicine, Epilepsy Research Centre, Austin Health, University of Melbourne, Melbourne, Vic, Australia
| | - Lindsay J Smith
- Department of Neurology, Monash Children's Hospital, Melbourne, Vic, Australia
| | - Zornitza Stark
- Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Flora Wong
- Department of Paediatrics, Monash University, Melbourne, Vic, Australia.,Monash Newborn, Monash Children's Hospital, Melbourne, Vic, Australia
| | - Eppie M Yiu
- Department of Neurology, Royal Children's Hospital, Melbourne, Vic, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Ingrid E Scheffer
- Department of Neurology, Royal Children's Hospital, Melbourne, Vic, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia.,Department of Medicine, Epilepsy Research Centre, Austin Health, University of Melbourne, Melbourne, Vic, Australia.,Florey Institute of Neuroscience and Mental Health, Melbourne, Vic, Australia
| | - A Simon Harvey
- Department of Neurology, Royal Children's Hospital, Melbourne, Vic, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia
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Frankel HG, Lam S. Seizure Outcomes of Epilepsy Surgery in Children. Pediatr Neurol Briefs 2021; 35:2. [PMID: 33424197 PMCID: PMC7787675 DOI: 10.15844/pedneurbriefs-35-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Investigators from the Hospital for Sick Children in Toronto reviewed the literature pertaining to seizure outcomes following epilepsy surgery in the pediatric population.
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Affiliation(s)
- Hyman G Frankel
- Division of Pediatric Neurosurgery, Ann & Robert H Lurie Children's Hospital, Chicago, IL.,Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sandi Lam
- Division of Pediatric Neurosurgery, Ann & Robert H Lurie Children's Hospital, Chicago, IL.,Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL
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42
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Ueda R, Iwasaki M, Kita Y, Takeichi H, Saito T, Nakagawa E, Sugai K, Okada T, Sasaki M. Improvement of brain function after surgery in infants with posterior quadrant cortical dysplasia. Clin Neurophysiol 2020; 132:332-337. [PMID: 33450555 DOI: 10.1016/j.clinph.2020.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/02/2020] [Accepted: 11/10/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To reveal whether neurodevelopmental outcome of infants after epilepsy surgery can be quantitatively assessed by electroencephalography (EEG) functional connectivity analysis. METHODS We enrolled 13 infants with posterior quadrant dysplasia aged <2 years who were treated using posterior quadrantectomy and 21 age-matched infants. EEG was performed both before and one year after surgery. Developmental quotient (DQ) was assessed both before and 3 years after surgery. The phase lag index (PLI) of three different pairs of electrodes in the nonsurgical hemisphere, i.e., the anterior short distance (ASD), posterior short distance (PSD), and long distance (LD) pairs, were calculated as indices of brain connectivity. The relationship between the PLI and DQ was evaluated. RESULTS Overall, 77% infants experienced seizure freedom after surgery. The beta- and gamma- range PLI of PSD pairs increased preoperatively. All these pairs normalized postoperatively. Simple linear regression analysis revealed a significant relationship between the postoperative DQ and the postoperative beta-band PLI of ASD pairs. CONCLUSION Preoperative abnormal hyper-connectivity was normalized to the control level after surgery. The postoperative hyperconnectivity was associated with long-term neurodevelopmental improvement. SIGNIFICANCE PLI quantifies neurodevelopmental improvements after posterior quadrantectomy.
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Affiliation(s)
- Riyo Ueda
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551, Japan; Department of Developmental Disorders, National Institute of Mental Health, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8553, Japan.
| | - Masaki Iwasaki
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551, Japan.
| | - Yosuke Kita
- Department of Developmental Disorders, National Institute of Mental Health, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8553, Japan; Cognitive Brain Research Unit (CBRU), Faculty of Medicine, University of Helsinki, Haartmaninkatu 3, FI-00290 Helsinki, Finland; Mori Arinori Center for Higher Education and Global Mobility, Hitotsubashi University, 2-1, Kunitachi, Tokyo 186-8601, Japan.
| | - Hiroshige Takeichi
- Department of Developmental Disorders, National Institute of Mental Health, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8553, Japan.
| | - Takashi Saito
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551, Japan.
| | - Eiji Nakagawa
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551, Japan.
| | - Kenji Sugai
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551, Japan.
| | - Takashi Okada
- Department of Developmental Disorders, National Institute of Mental Health, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8553, Japan.
| | - Masayuki Sasaki
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551, Japan.
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Peng SJ, Wong TT, Huang CC, Chang H, Hsieh KLC, Tsai ML, Yang YS, Chen CL. Quantitative analysis of intraoperative electrocorticography mirrors histopathology and seizure outcome after epileptic surgery in children. J Formos Med Assoc 2020; 120:1500-1511. [PMID: 33214033 DOI: 10.1016/j.jfma.2020.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/21/2020] [Accepted: 11/01/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Epileptic surgery is the potentially curative treatment for children with refractory seizures. The study aimed to quantify and analyze high frequency oscillation (HFO) ripples and interictal epileptiform discharges (EDs) in intraoperative electrocorticography (ECoG) between malformation of cortical dysplasia (MCD) and non-MCD children with MRI-lesional focal epilepsy, and evaluate of seizure outcomes after epileptic surgery. METHODS The intraoperative ECoG was performed before and after lesionectomy. Quantifications of HFO ripples and interictal EDs of ECoG by frequency, amplitude, and foci of intraoperative ECoG were performed based on electrode location, and the characteristics of ECoG recordings were analyzed in each patient based on their histopathology. Seizure outcome after surgery according to their quantitative ECoG findings was analyzed. RESULTS Frequency of EDs and HFO ripple rates in preresection ECoG were significantly higher in children with MCD compared with non-MCD (p = 0.018 and p = 0.002, respectively). Higher frequencies of EDs and ripple rates in preresection ECoG were observed in residual seizures than in seizure-free children (p = 0.045 and p = 0.005, respectively). Clinically, children with residual seizures after surgery were significantly younger at the onset, had a trend of higher seizure frequency and higher spike frequency of presurgical videoEEG. CONCLUSION Our results suggested that quantification of intraoperative ECoG predicted seizure outcomes and reflected different ED pattern and frequencies between MCD and non-dysplastic histopathology among children who underwent resective epileptic surgery. The results of our study were encouraging and indicated that intraoperative ECoG improved the outcomes of surgery in children with epilepsy.
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Affiliation(s)
- Syu-Jyun Peng
- Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tai-Tong Wong
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Neuroscience Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chao-Ching Huang
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsi Chang
- Neuroscience Research Center, Taipei Medical University Hospital, Taipei, Taiwan; Division of Pediatric Neurology, Department of Pediatrics, Taipei Medical University Hospital, Taipei Medical University, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Kevin Li-Chun Hsieh
- Neuroscience Research Center, Taipei Medical University Hospital, Taipei, Taiwan; Department of Medical Imaging, Taipei Medical University Hospital, Taipei, Taiwan; Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Min-Lan Tsai
- Neuroscience Research Center, Taipei Medical University Hospital, Taipei, Taiwan; Division of Pediatric Neurology, Department of Pediatrics, Taipei Medical University Hospital, Taipei Medical University, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| | - Yi-Shang Yang
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chi-Long Chen
- Department of Pathology, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan; Department of Pathology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Abstract
Because of next-generation sequencing and the discovery of many new causative genes, genetic testing in epilepsy patients has become widespread. Pathologic variants resulting in epilepsy cause a variety of changes that can be broadly classified into syndromic disorders (i.e., chromosomal abnormalities), metabolic disorders, brain malformations, and abnormal cellular signaling. Here, we review the available genetic testing, reasons to pursue genetic testing, common genetic causes of epilepsy, the data behind what patients are found to have genetic epilepsies based on current testing, and discussing these results with patients. We propose an algorithm for testing patients with epilepsy to maximize yield and limit costs based on their phenotype (including electroencephalography and magnetic resonance imaging findings), age of seizure onset, and presence of other neurologic comorbidities. Being able to discern which type of genetic testing to order, using that information to give targeted and cost-effective patient care, and interpreting results accurately will be a crucial skill for the modern neurologist.
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Affiliation(s)
- David M Ritter
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Katherine Holland
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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45
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Bercu MM, Friedman D, Silverberg A, Drees C, Geller EB, Dugan PC, Devinsky O, Doyle WH. Responsive neurostimulation for refractory epilepsy in the pediatric population: A single-center experience. Epilepsy Behav 2020; 112:107389. [PMID: 32890796 DOI: 10.1016/j.yebeh.2020.107389] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/07/2020] [Accepted: 07/26/2020] [Indexed: 11/17/2022]
Abstract
Drug-resistant focal epilepsy (DRFE) in children can impair cognition and behavior, and lead to premature death. Increased pediatric epilepsy surgery numbers reflect the improvements in seizure control and long-term developmental outcomes. Yet, many children with DRFE are not candidates for surgical resection due to overlap of the seizure network with eloquent cortex or multiple seizure-onset zones, making surgery dangerous or ineffective. In adults, responsive neurostimulation (RNS System) therapy is safe and effective treatment for DRFE with one or two seizure foci, especially when the seizure focus is in eloquent cortex. We present six pediatric patients with DRFE who underwent RNS implantation. Our outcomes demonstrate safety, decreased clinical seizure frequency, as well as improved functional status and quality of life. Changes in the clinical seizure semiology and frequency occurred in conjunction with adjustments to the stimulation parameters, supporting the efficacy of responsive neuromodulation in children.
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Affiliation(s)
- Marian Michael Bercu
- Division of Pediatric Neurosurgery, Department of Neurosurgery, NYU Langone Health, New York, NY, United States of America; Division of Pediatric Neurosurgery, Pediatric Neurosciences Center, Helen DeVos Children's Hospital, Spectrum Health, Grand Rapids, MI, United States of America.
| | - Daniel Friedman
- Comprehensive Epilepsy Center, NYU Langone Health, New York, NY, United States of America
| | - Alyson Silverberg
- Department of Neurosurgery, NYU Langone Health, New York, NY, United States of America
| | - Cornelia Drees
- Department of Neurology, Epilepsy Section, University of Colorado Denver School of Medicine, Aurora, CO, United States of America
| | - Eric B Geller
- Institute of Neurology and Neurosurgery at Saint Barnabas, Livingston, NJ, United States of America
| | - Patricia C Dugan
- Comprehensive Epilepsy Center, NYU Langone Health, New York, NY, United States of America
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, NYU Langone Health, New York, NY, United States of America
| | - Werner H Doyle
- Comprehensive Epilepsy Center, NYU Langone Health, New York, NY, United States of America; Department of Neurosurgery, NYU Langone Health, New York, NY, United States of America
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Rémi J, Shen S, Tacke M, Probst P, Gerstl L, Peraud A, Kunz M, Vollmar C, Noachtar S, Borggraefe I. Congruence and Discrepancy of Interictal and Ictal EEG With MRI Lesions in Pediatric Epilepsies. Clin EEG Neurosci 2020; 51:412-419. [PMID: 32420750 PMCID: PMC7457449 DOI: 10.1177/1550059420921712] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose. To evaluate the congruence or discrepancy of the localization of magnetic resonance imaging (MRI) lesions with interictal epileptiform discharges (IEDs) or epileptic seizure patterns (ESPs) in surface EEG in lesional pediatric epilepsy patients. Methods. We retrospectively analyzed presurgical MRI and video-EEG monitoring findings of patients up to age 18 years. Localization of MRI lesions were compared with ictal and interictal noninvasive EEG findings of patients with frontal, temporal, parietal, or occipital lesions. Results. A total of 71 patients were included. Localization of ESPs showed better congruence with MRI in patients with frontal lesions (n = 21, 77.5%) than in patients with temporal lesions (n = 24; 40.7%) (P = .009). No significant IED distribution differences between MRI localizations could be found. Conclusions. MRI lesions and EEG findings are rarely fully congruent. Congruence of MRI lesions and ESPs was highest in children with frontal lesions. This is in contrast to adults, in whom temporal lesions showed the highest congruency with the EEG localization of ESP. Lesional pediatric patients should be acknowledged as surgical candidates despite incongruent findings of interictal and ictal surface EEG.
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Affiliation(s)
- Jan Rémi
- Department of Neurology, Ludwig Maximilians University (LMU) Munich, Klinikum Großhadern, Munich, Germany.,Ludwig Maximilians University (LMU) Munich, Epilepsy Center, Munich, Germany
| | - Sophie Shen
- Department of Pediatrics, Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Ludwig Maximilians University (LMU) Munich, Dr von Hauner Children's Hospital, Munich, Germany
| | - Moritz Tacke
- Department of Pediatrics, Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Ludwig Maximilians University (LMU) Munich, Dr von Hauner Children's Hospital, Munich, Germany
| | - Philipp Probst
- Department of Medical Informatics, Biometry and Epidemiology, Ludwig Maximilians University (LMU) Munich, Klinikum Großhadern, Munich, Germany
| | - Lucia Gerstl
- Department of Pediatrics, Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Ludwig Maximilians University (LMU) Munich, Dr von Hauner Children's Hospital, Munich, Germany
| | - Aurelia Peraud
- Department of Neurosurgery, Pediatric Section, University of Ulm, Ulm, Germany
| | - Mathias Kunz
- Department of Neurosurgery, Ludwig Maximilians University (LMU) Munich, Klinikum Großhadern, Munich, Germany
| | - Christian Vollmar
- Department of Neurology, Ludwig Maximilians University (LMU) Munich, Klinikum Großhadern, Munich, Germany.,Ludwig Maximilians University (LMU) Munich, Epilepsy Center, Munich, Germany
| | - Soheyl Noachtar
- Department of Neurology, Ludwig Maximilians University (LMU) Munich, Klinikum Großhadern, Munich, Germany.,Ludwig Maximilians University (LMU) Munich, Epilepsy Center, Munich, Germany
| | - Ingo Borggraefe
- Ludwig Maximilians University (LMU) Munich, Epilepsy Center, Munich, Germany.,Department of Pediatrics, Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Ludwig Maximilians University (LMU) Munich, Dr von Hauner Children's Hospital, Munich, Germany
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47
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Uribe-Cardenas R, Boyke AE, Schwarz JT, Morgenstern PF, Greenfield JP, Schwartz TH, Rutka JT, Drake J, Hoffman CE. Utility of invasive electroencephalography in children 3 years old and younger with refractory epilepsy. J Neurosurg Pediatr 2020; 26:648-653. [PMID: 32947255 DOI: 10.3171/2020.6.peds19504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 06/01/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Early surgical intervention for pediatric refractory epilepsy is increasingly advocated as surgery has become safer and data have demonstrated improved outcomes with early seizure control. There is concern that the risks associated with staged invasive electroencephalography (EEG) in very young children outweigh the potential benefits. Here, the authors present a cohort of children with refractory epilepsy who were referred for invasive monitoring, and they evaluate the role and safety of staged invasive EEG in those 3 years old and younger. METHODS The authors conducted a retrospective review of children 3 years and younger with epilepsy, who had been managed surgically at two institutions between 2001 and 2015. A cohort of pediatric patients older than 3 years of age was used for comparison. Demographics, seizure etiology, surgical management, surgical complications, and adverse events were recorded. Statistical analysis was completed using Stata version 13. A p < 0.05 was considered statistically significant. Fisher's exact test was used to compare proportions. RESULTS Ninety-four patients (45 patients aged ≤ 3 [47.9%]) and 208 procedures were included for analysis. Eighty-six procedures (41.3%) were performed in children younger than 3 years versus 122 in the older cohort (58.7%). Forty-two patients underwent grid placement (14 patients aged ≤ 3 [33.3%]); 3 of them developed complications associated with the implant (3/42 [7.14%]), none of whom were among the younger cohort. Across all procedures, 11 complications occurred in the younger cohort versus 5 in the older patients (11/86 [12.8%] vs 5/122 [4.1%], p = 0.032). Two adverse events occurred in the younger group versus 1 in the older group (2/86 [2.32%] vs 1/122 [0.82%], p = 0.571). Following grid placement, 13/14 younger patients underwent guided resections compared to 20/28 older patients (92.9% vs 71.4%, p = 0.23). CONCLUSIONS While overall complication rates were higher in the younger cohort, subdural grid placement was not associated with an increased risk of surgical complications in that population. Invasive electrocorticography informs management in very young children with refractory, localization-related epilepsy and should therefore be used when clinically indicated.
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Affiliation(s)
- Rafael Uribe-Cardenas
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | | | - Justin T Schwarz
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | - Peter F Morgenstern
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | - Jeffrey P Greenfield
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | - Theodore H Schwartz
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | - James T Rutka
- 3Department of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - James Drake
- 3Department of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Caitlin E Hoffman
- 1Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York
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de Knegt VE, Hoei-Hansen CE, Knudsen M, Jakobsen AV, Mûller E, Thomsen KM, Jespersen B, Uldall PV, Børresen ML. Increase in cognitive function is seen in many single-operated pediatric patients after epilepsy surgery. Seizure 2020; 81:254-262. [PMID: 32911236 DOI: 10.1016/j.seizure.2020.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 08/02/2020] [Accepted: 08/04/2020] [Indexed: 02/08/2023] Open
Abstract
PURPOSE The recurrent seizures of pediatric drug-resistant epilepsy (DRE) are known to impair brain development and can lead to a loss in cognitive functioning. Surgery is increasingly being used to treat children with DRE. This study investigates the pre- and postoperative cognitive function in a pediatric epilepsy surgery cohort as well as predictive determinants of change in intelligence quotient (IQ) following surgery. METHODS A consecutive series of 91 Danish children who underwent focal resective epilepsy surgery between January 1996 and December 2016 were included. All underwent preoperative cognitive evaluation and were reevaluated at 1-year and/or 2-year follow-up. Single-operated and multi-operated patients were examined separately. RESULTS 79 of 91 patients were single-operated. Single-operated patients received less anti-epileptic drugs (AED) and experienced a decrease in seizure frequency postoperatively, p < 0.001. IQ increased postoperatively (IQ change ± standard deviation: 3.3 ± 14.0), p < 0.05. High preoperative seizure frequency was a significant predictor for decreased IQ, p < 0.01. Multi-operated patients did not experience a reduction in AED treatment. Surgery and continued AED treatment did, however, result in significantly better seizure control, p < 0.01. IQ remained unchanged in multi-operated patients. CONCLUSION Epilepsy surgery allowed for IQ gains in single-operated patients. Preoperative seizure frequency was a significant predictor of IQ change following surgery. Interactions between other, not included, possible predictors remain to be examined. Single-operated patients had the best cognitive outcome. The inclusion of a non-surgical control group is needed to assess the extent of the beneficial effects of surgery on cognitive ability.
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Affiliation(s)
| | | | - Marianne Knudsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Anne Vagner Jakobsen
- Department of Neuropediatrics, The Danish Epilepsy Center, Filadelfia, Dianalund, Denmark
| | - Elisabeth Mûller
- Department of Neuropediatrics, The Danish Epilepsy Center, Filadelfia, Dianalund, Denmark
| | - Katrine Moe Thomsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Bo Jespersen
- Department of Neurosurgery, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Vilhelm Uldall
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Neuropediatrics, The Danish Epilepsy Center, Filadelfia, Dianalund, Denmark
| | - Malene Landbo Børresen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.
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49
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Sakpichaisakul K, Byars AW, Horn PS, Aungaroon G, Greiner HM, Mangano FT, Holland KD, Arya R. Neuropsychological outcomes after pediatric epilepsy surgery: Role of electrical stimulation language mapping. Seizure 2020; 80:183-191. [PMID: 32604001 DOI: 10.1016/j.seizure.2020.06.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 06/22/2020] [Accepted: 06/24/2020] [Indexed: 01/06/2023] Open
Abstract
PURPOSE We studied the association between electrical stimulation mapping (ESM) with a visual naming task and post-operative neuropsychological outcomes after pediatric epilepsy surgery. METHODS Children who underwent epilepsy surgery, having pre- and 1-year post-surgery neuropsychological evaluation (NPE) available, were included. NPE scores were transformed using principal components (PC) analysis. The relationship between post-surgical PC scores, adjusted for pre-surgery PC scores, and ESM was analyzed. Clinical variables influencing this relationship were also sought. RESULTS One hundred and four children (89 patients >5 years-old, and 15 patients 3-5 years-old) were included. Among children >5 years-of-age, a significant effect of language ESM was observed on all 3 post-surgery PC scores adjusted for respective pre-surgery PC scores. Specifically, only 30 % patients who underwent language ESM had a decrease in PC1 scores ≥1-year after epilepsy surgery, compared to 68 % those who did not undergo language ESM (p = 0.001). Seizure outcomes, age at the time of surgery, predominant seizure type, and family history of epilepsy were other significant determinants of post-surgical PC scores including a change in PC scores from pre-surgery baseline. Combinations of pre-surgical variables were able to predict post-surgical PC scores with high specificity. In children aged 3-5 years, no significant effect of language ESM was seen on post-surgery PC scores adjusted for respective pre-surgery PC scores. CONCLUSIONS Speech/language ESM should be performed more widely in patients >5 years-of-age undergoing epilepsy surgery. Also, more efficient brain mapping techniques and language paradigms are needed for younger children.
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Affiliation(s)
- Kullasate Sakpichaisakul
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Division of Neurology, Department of Pediatrics, Queen Sirikit National Institute of Child Health, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Anna W Byars
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Paul S Horn
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gewalin Aungaroon
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Hansel M Greiner
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Francesco T Mangano
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Katherine D Holland
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ravindra Arya
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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50
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Burns TG, Semmel ES, Reisner A. A longitudinal evaluation of a penetrating traumatic brain injury: Theories of plasticity and vulnerability. APPLIED NEUROPSYCHOLOGY-ADULT 2020; 29:881-886. [PMID: 32546024 DOI: 10.1080/23279095.2020.1780239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Penetrating traumatic brain injury (TBI) is uncommon in infancy. The consequences may be devastating, especially when the injury is extensive and affects eloquent areas of the brain. There is the potential for neuropsychological dysfunction that may impact the individual's development and well-being into adulthood. In the context of early brain injury, the developing brain is both remarkably resilient and vulnerable. The present case study describes a patient who experienced a penetrating TBI at 9 days of age, subsequently developed intractable seizures, and underwent left hemispherectomy. Neuropsychological testing at ages 5, 10, 11, and 19 years are presented alongside fMRI and Wada testing. While the patient initially developed cognitive functions in the low-average range by age 5, scores on neuropsychological assessments began to decrease thereafter. This case is discussed with attention to vulnerability and plasticity theories. It highlights the ability of the brain to reorganize and allow the development of functions that would normally be sub-served by damaged areas and the limits of plasticity. Further, this case illustrates the vulnerability of the early brain to insult, the potential to grow into deficits, and the need to consider a variety of factors when predicting outcomes for cases of pediatric brain injury.
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Affiliation(s)
- Thomas G Burns
- Department of Neuropsychology, Emory University School of Medicine, Atlanta, GA, USA.,Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Eric S Semmel
- Department of Psychology & The Neuroscience Institute, Georgia State University, Atlanta, GA, USA
| | - Andrew Reisner
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Children's Healthcare of Atlanta, Atlanta, GA, USA.,Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
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