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Das N, Sharma A, Mann M, Gordillo A, Desai A, Serletis D, Moosa AN, Rammo R, Bingaman W. Postoperative shunt failure following hemispherectomy in pediatric patients with pre-existing hydrocephalus. Childs Nerv Syst 2024; 40:1507-1514. [PMID: 38273143 PMCID: PMC11026181 DOI: 10.1007/s00381-024-06295-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: 10/03/2023] [Accepted: 01/17/2024] [Indexed: 01/27/2024]
Abstract
OBJECTIVE The risk of hydrocephalus following hemispherectomy for drug resistant epilepsy (DRE) remains high. Patients with pre-existing hydrocephalus pose a postoperative challenge, as maintaining existing shunt patency is necessary but lacks a clearly defined strategy. This study examines the incidence and predictors of shunt failure in pediatric hemispherectomy patients with pre-existing ventricular shunts. METHODS We performed a retrospective chart review at our center to identify pediatric patients diagnosed with DRE who were treated with ventricular shunt prior to their first hemispherectomy surgery. Demographic and perioperative data were obtained including shunt history, hydrocephalus etiology, epilepsy duration, surgical technique, and postoperative outcomes. Univariate analysis was performed using Fisher's exact test and Pearson correlation, with Bonferroni correction to a = 0.00625 and a = 0.01, respectively. RESULTS Five of nineteen (26.3%) patients identified with ventriculoperitoneal shunting prior to hemispherectomy experienced postoperative shunt malfunction. All 5 of these patients underwent at least 1 shunt revision prior to hemispherectomy, with a significant association between pre- and post-hemispherectomy shunt revisions. There was no significant association between post-hemispherectomy shunt failure and valve type, intraoperative shunt alteration, postoperative external ventricular drain placement, hemispherectomy revision, lateralization of shunt relative to resection, postoperative complications, or postoperative aseptic meningitis. There was no significant correlation between number of post-hemispherectomy shunt revisions and age at shunt placement, age at hemispherectomy, epilepsy duration, or shunt duration prior to hemispherectomy. CONCLUSIONS Earlier shunt revision surgery may portend a subsequent need for shunt revision following hemispherectomy. These findings may guide neurosurgeons in counseling patients with pre-existing ventricular shunts prior to hemispherectomy surgery.
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Affiliation(s)
- Nikita Das
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Akshay Sharma
- Epilepsy Center, Cleveland Clinic Neurological Institute, Cleveland, OH, USA.
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA.
| | - Michael Mann
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Alan Gordillo
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Ansh Desai
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Demitre Serletis
- Epilepsy Center, Cleveland Clinic Neurological Institute, Cleveland, OH, USA
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Ahsan N Moosa
- Epilepsy Center, Cleveland Clinic Neurological Institute, Cleveland, OH, USA
| | - Richard Rammo
- Epilepsy Center, Cleveland Clinic Neurological Institute, Cleveland, OH, USA
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - William Bingaman
- Epilepsy Center, Cleveland Clinic Neurological Institute, Cleveland, OH, USA
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
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Goel K, Phillips HW, Chen JS, Ngo J, Edmonds B, Ha PX, Wang A, Weil A, Russell BE, Salamon N, Nariai H, Fallah A. Hemispheric epilepsy surgery for hemimegalencephaly: The UCLA experience. Epilepsia 2024; 65:57-72. [PMID: 37873610 DOI: 10.1111/epi.17807] [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: 08/09/2023] [Revised: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 10/25/2023]
Abstract
OBJECTIVES Hemimegalencephaly (HME) is a rare congenital brain malformation presenting predominantly with drug-resistant epilepsy. Hemispheric disconnective surgery is the mainstay of treatment; however, little is known about how postoperative outcomes compare across techniques. Thus we present the largest single-center cohort of patients with HME who underwent epilepsy surgery and characterize outcomes. METHODS This observational study included patients with HME at University of California Los Angeles (UCLA) from 1984 to 2021. Patients were stratified by surgical intervention: anatomic hemispherectomy (AH), functional hemispherectomy (FH), or less-than-hemispheric resection (LTH). Seizure freedom, functional outcomes, and operative complications were compared across surgical approaches. Regression analysis identified clinical and intraoperative variables that predict seizure outcomes. RESULTS Of 56 patients, 43 (77%) underwent FH, 8 (14%) underwent AH, 2 (4%) underwent LTH, 1 (2%) underwent unknown hemispherectomy type, and 2 (4%) were managed non-operatively. At median last follow-up of 55 months (interquartile range [IQR] 20-92 months), 24 patients (49%) were seizure-free, 17 (30%) required cerebrospinal fluid (CSF) shunting for hydrocephalus, 9 of 43 (21%) had severe developmental delay, 8 of 38 (21%) were non-verbal, and 15 of 38 (39%) were non-ambulatory. There was one (2%) intraoperative mortality due to exsanguination earlier in this cohort. Of 12 patients (29%) requiring revision surgery, 6 (50%) were seizure-free postoperatively. AH, compared to FH, was not associated with statistically significant improved seizure freedom (hazard ratio [HR] = .48, p = .328), although initial AH trended toward greater odds of seizure freedom (75% vs 46%, p = .272). Younger age at seizure onset (HR = .29, p = .029), lack of epilepsia partialis continua (EPC) (HR = .30, p = .022), and no contralateral seizures on electroencephalography (EEG) (HR = .33, p = .039) independently predicted longer duration of seizure freedom. SIGNIFICANCE This study helps inform physicians and parents of children who are undergoing surgery for HME by demonstrating that earlier age at seizure onset, absence of EPC, and no contralateral EEG seizures were associated with longer postoperative seizure freedom. At our center, initial AH for HME may provide greater odds of seizure freedom with complications and functional outcomes comparable to those of FH.
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Affiliation(s)
- Keshav Goel
- David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - H Westley Phillips
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jia-Shu Chen
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Jacqueline Ngo
- Department of Pediatrics, Division of Pediatric Neurology, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Benjamin Edmonds
- Department of Pediatrics, Division of Pediatric Neurology, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Phong X Ha
- Department of Radiology, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Andrew Wang
- David Geffen School of Medicine at the University of California, Los Angeles, California, USA
- College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California, USA
| | - Alexander Weil
- Brain and Development Research Axis, Sainte-Justine Research Center, Montréal, Québec, Canada
- Department of Surgery, Division of Neurosurgery, Sainte-Justine University Hospital Centre, Montréal, Québec, Canada
- Department of Surgery, Division of Neurosurgery, University of Montreal Hospital Centre (CHUM), Montréal, Québec, Canada
- Department of Neuroscience, University of Montreal, Montréal, Québec, Canada
| | - Bianca E Russell
- Department of Human Genetics, Division of Clinical Genetics, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Noriko Salamon
- Department of Radiology, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Hiroki Nariai
- Department of Pediatrics, Division of Pediatric Neurology, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Aria Fallah
- David Geffen School of Medicine at the University of California, Los Angeles, California, USA
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
- Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, California, USA
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Phillips HW, Chen JS, Tucker AM, Ding K, Kashanian A, Nagahama Y, Mathern GW, Weil AG, Fallah A. Preliminary Experience Suggests the Addition of Choroid Plexus Cauterization to Functional Hemispherectomy May Reduce Posthemispherectomy Hydrocephalus. Neurosurgery 2023; 92:300-307. [PMID: 36637266 PMCID: PMC10553136 DOI: 10.1227/neu.0000000000002193] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/20/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Cerebral hemispherectomy can effectively treat unihemispheric epilepsy. However, posthemispherectomy hydrocephalus (PHH), a serious life-long complication, remains prevalent, requiring careful considerations in technique selection and postoperative management. In 2016, we began incorporating open choroid plexus cauterization (CPC) into our institution's hemispherectomy procedure in an attempt to prevent PHH. OBJECTIVE To determine whether routine CPC prevented PHH without exacerbating hemispherectomy efficacy or safety. METHODS A retrospective review of consecutive patients who underwent hemispherectomy for intractable epilepsy between 2011 and 2021 was performed. Multivariate logistic regression was used to identify factors independently associated with PHH requiring cerebrospinal fluid (CSF) shunting. RESULTS Sixty-eight patients were included in this study, of whom 26 (38.2%) underwent CPC. Fewer patients required CSF shunting in the CPC group (7.7% vs 28.7%, P = .033) and no patients who underwent de novo hemispherectomy with CPC developed PHH. Both cohorts experienced seizure freedom (65.4% vs 59.5%, P = .634) and postoperative complications, including infection (3.8% vs 2.4%, P = .728), hemorrhage (0.0% vs 2.4%, P = .428), and revision hemispherectomy (19.2% vs 14.3%, P = .591) at similar rates. Patients without CPC had greater odds of developing PHH requiring CSF shunting (odds ratio = 8.36, P = .026). The number needed to treat with CPC to prevent an additional case of PHH was 4.8, suggesting high effectiveness. CONCLUSION Preventing PHH is critical. Our early experience demonstrated that routinely incorporating CPC into hemispherectomy effectively prevents PHH without causing additional complications, especially in first-time hemispherectomies. A multicenter randomized controlled trial with long-term follow-up is required to corroborate the findings of our single-institutional case series and determine whether greater adoption of this technique is justified.
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Affiliation(s)
- H. Westley Phillips
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA;
| | - Jia-Shu Chen
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA;
| | - Alexander M. Tucker
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA;
| | - Kevin Ding
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA;
| | - Alon Kashanian
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA;
| | - Yasunori Nagahama
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA;
| | - Gary W. Mathern
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA;
- The Intellectual Disabilities and Developmental Research Center, Department of Psychiatry and Biobehavioral Medicine, University of California, Los Angeles, Los Angeles, California, USA;
| | - Alexander G. Weil
- Department of Neurosurgery, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada;
| | - Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA;
- Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
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Phillips HW, Maniquis CA, Chen JS, Duby SL, Nagahama Y, Bergeron D, Ibrahim GM, Weil AG, Fallah A. Midline Brain Shift After Hemispheric Surgery: Natural History, Clinical Significance, and Association With Cerebrospinal Fluid Diversion. Oper Neurosurg (Hagerstown) 2022; 22:269-276. [PMID: 35315814 PMCID: PMC9514754 DOI: 10.1227/ons.0000000000000134] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/28/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hemispherectomy and its modern variants are effective surgical treatments for medically intractable unihemispheric epilepsy. Although some complications such as posthemispherectomy hydrocephalus are well documented, midline brain shift (MLBS) after hemispheric surgery has only been described anecdotally and never formally studied. OBJECTIVE To assess the natural history and clinical relevance of MLBS and determine whether cerebrospinal fluid (CSF) shunting of the ipsilateral surgical cavity exacerbates MLBS posthemispheric surgery. METHODS A retrospective review of consecutive pediatric patients who underwent hemispheric surgery for intractable epilepsy and at least 6 months of follow-up at UCLA between 1994 and 2018 was performed. Patients were grouped by MLBS severity, shunt placement, valve type, and valve opening pressure (VOP). MLBS was evaluated using the paired samples t-test and analysis of covariance adjusting for follow-up time and baseline postoperative MLBS. RESULTS Seventy patients were analyzed, of which 23 (33%) required CSF shunt placement in the ipsilateral surgical cavity for posthemispherectomy hydrocephalus. MLBS increased between first and last follow-up for nonshunted (5.3 ± 4.9-9.7 ± 6.6 mm, P < .001) and shunted (6.6 ± 3.5-16.3 ± 9.4 mm, P < .001) patients. MLBS progression was greater in shunted patients (P = .001). Shunts with higher VOPs did not increase MLBS relative to nonshunted patients (P = .834), whereas MLBS increased with lower VOPs (P = .001). Severe MLBS was associated with debilitating headaches (P = .048). CONCLUSION Patients undergoing hemispheric surgery often develop postoperative MLBS, ie, exacerbated by CSF shunting of the ipsilateral surgical cavity, specifically when using lower VOP settings. MLBS exacerbation may be related to overshunting. Severe MLBS is associated with debilitating headaches.
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Affiliation(s)
- H. Westley Phillips
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA;
| | - Cassia A.B. Maniquis
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA;
| | - Jia-Shu Chen
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA;
| | - Shannon L. Duby
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA;
| | - Yasunori Nagahama
- Department of Neurosurgery, Rutgers—Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA;
| | - David Bergeron
- Division of Neurosurgery, University of Montreal, Montreal, Canada;
| | - George M. Ibrahim
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada;
| | - Alexander G. Weil
- Division of Neurosurgery, Ste. Justine Hospital, University of Montreal, Montreal, Canada;
| | - Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA;
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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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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Beatty CW, Lockrow JP, Gedela S, Gehred A, Ostendorf AP. The Missed Value of Underutilizing Pediatric Epilepsy Surgery: A Systematic Review. Semin Pediatr Neurol 2021; 39:100917. [PMID: 34620465 DOI: 10.1016/j.spen.2021.100917] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 10/20/2022]
Abstract
Pediatric epilepsy surgery is underutilized. Only 1%-11% of children with drug resistant epilepsy (DRE) undergo surgical treatment, or less than half of those estimated to benefit. We conducted a systematic review of articles published in PubMed, EMBASE, and Web of Science in order to study the factors related to surgery underutilization as well as the impact on both the individual and the healthcare system. Our review demonstrates multiple factors leading to underutilization, including family misconceptions about epilepsy surgery, lack of provider knowledge, as well as systemic health disparities. While the upfront cost of epilepsy surgery is significant, the long-term financial benefits and reduced health resource utilization tilt the economic advantage in favor of surgery in children with DRE. Additionally, timely interventions improve seizure and cognitive outcomes with low risk of complications. Further interventions are needed at the levels of family, provider, and the healthcare system to increase access to pediatric epilepsy surgery.
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Affiliation(s)
- Christopher W Beatty
- The Ohio State University and Nationwide Children's Hospital, Division of Neurology, Department of Pediatrics, Columbus, OH
| | - Jason P Lockrow
- Department of Neurology, Section of Pediatric Neurology, University of Washington, Seattle, WA
| | - Satyanarayana Gedela
- Emory University and Children's Healthcare of Atlanta, Division of Neurology, Department of Pediatrics, Atlanta, GA
| | - Alison Gehred
- Medical Library Division, Nationwide Children's Hospital, Columbus, OH
| | - Adam P Ostendorf
- The Ohio State University and Nationwide Children's Hospital, Division of Neurology, Department of Pediatrics, Columbus, OH.
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Melikyan AG, Kushel YV, Sorokin VS, Vlasov PA, Demin MO, Shults EI, Shevchenko AM, Strunina YV. [Lessons learnt from 101 hemispheric pediatric epilepsy surgeries part ii: pitfalls and complications]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2021; 85:44-52. [PMID: 34951759 DOI: 10.17116/neiro20218506144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To evaluate the spectrum of pitfalls and complications after hemisherotomy basing on a retrospective study of a large consecutive pediatric cohort of patients from a single institution. MATERIAL AND METHODS One hundred and one patients (med. age - 43 months) with refractory seizures underwent hemispherotomy. Developmental pathology was the anatomical substrate of disorder in 42 patients. The infantile post-stroke scarring and gliosis was the origin of epilepsy in the majority of 43 cases with acquired etiology. The progressive pathology (RE, S-W and TS) was the etiology in the rest of children (16 cases). The lateral periinsular technique was used to isolate the sick hemisphere in 55 patients; the vertical parasagittal approach was employed in 46 cases. Median perioperative blood loss constituted 10.5 ml/kg, but was markedly larger in kids with hemimegaly (52.8 ml/kg); 57 patients needed hemotransfusion during surgery. Median length of stay in ICU was 14.7 hours, and the length of stay in the hospital until discharge - 6.5 days. Eight patients underwent second-look surgery to complete sectioning of undercut commissural fibers. FU is known in 91 patients (med. length - 1.5 years). RESULTS Major surgical complications with serious hemorrhage and/or surgery induced life-threatening events developed in 7 patients (one of them has died on the 5th day post-surgery for the causes of brain edema and uncontrolled hyponatremia). Various early and late infectious complications were noted in 4 cases. Ten patients experienced new not anticipated but temporary neurological deficit. Nine patients needed shunting for the causes of hydrocephalus within several first months post-hemispherotomy. Early seizure onset was associated with probability of all complications in general (p=0.02), and developmental etiology - with intraoperative bleeding and hemorrhagic complications (p=0.03). CONCLUSION Children with developmental etiology, particularly those with hemimegalencephaly, are most challengeable in terms of perioperative hemorrhage and serious complications. Patients with relapse or persisting seizures should be evaluated for the possibility of incomplete hemispheric isolation and have good chances to become SF by re-doing hemispherotomy.
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Affiliation(s)
| | - Yu V Kushel
- Burdenko Neurosurgical Center, Moscow, Russia
| | - V S Sorokin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - P A Vlasov
- Burdenko Neurosurgical Center, Moscow, Russia
| | - M O Demin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - E I Shults
- Burdenko Neurosurgical Center, Moscow, Russia
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Anatomical hemispherectomy revisited-outcome, blood loss, hydrocephalus, and absence of chronic hemosiderosis. Childs Nerv Syst 2019; 35:1341-1349. [PMID: 31243582 DOI: 10.1007/s00381-019-04256-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 06/06/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate microsurgical trans-sylvian trans-ventricular anatomical hemispherectomy with regard to seizure outcome, risk of hydrocephalus, blood loss, and risk of chronic hemosiderosis in patients with intractable seizures selected for surgery using current preoperative assessment techniques. METHODS Out of 86 patients who underwent hemispherectomy between February 2000 and April 2019, by a single surgeon, at a tertiary care referral center, 77 patients (ages 0.2-20 years; 40 females) who had an anatomical hemispherectomy were analyzed. Five of these were 'palliative' surgeries. One-stage anatomical hemispherectomy was performed in 55 children, two-stage anatomical hemispherectomy after extraoperative intracranial monitoring in 16, and six hemispherectomies were done following failed previous resection. Mean follow-up duration was 5.7 years (range 1-16.84 years). Forty-six patients had postoperative MRI scans. RESULTS Ninety percent of children with non-palliative hemispherectomy achieved ILAE Class-1 outcome. Twenty-seven patients were no longer taking anticonvulsant medications. Surgical failures (n = 4) included one patient with previous meningoencephalitis, one with anti-GAD antibody encephalitis, one with idiopathic neonatal thalamic hemorrhage, and one with extensive tuberous sclerosis. There were no failures among patients with malformations of cortical development. Estimated average blood loss during surgery was 387 ml. Ten (21%) children developed hydrocephalus and required a shunt following one-stage hemispherectomy, whereas 10 (50%) patients developed hydrocephalus among those who had extraoperative intracranial monitoring. Only 20% of the shunts malfunctioned in the first year. Early malfunctions were related to the valve and later to fracture disconnection of the shunt. One patent had a traumatic subdural hematoma. None of the patients developed clinical signs of chronic 'superficial cerebral hemosiderosis' nor was there evidence of radiologically persistent chronic hemosiderosis in patients who had postoperative MRI imaging. CONCLUSION Surgical results of anatomical hemispherectomy are excellent in carefully selected cases. Post-operative complications of hydrocephalus and intraoperative blood loss are comparable to those reported for hemispheric disconnective surgery (hemispherotomy). The rate of shunt malfunction was less than that reported for patients with hydrocephalus of other etiologies Absence of chronic 'superficial hemosiderosis', even on long-term follow-up, suggests that anatomical hemispherectomy should be revisited as a viable option in patients with intractable seizures and altered anatomy such as in malformations of cortical development, a group that has a reported high rate of seizure recurrence related to incomplete disconnection following hemispheric disconnective surgery.
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Iyer RS, Rao RM, Muthukalathi K, Kumar P. Trapped ipsilateral lateral ventricle: a delayed complication of hemispherotomy for Rasmussen's encephalitis. BMJ Case Rep 2017; 2017:bcr-2017-222040. [PMID: 29054955 DOI: 10.1136/bcr-2017-222040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Hemispherotomy is the currently preferred surgical treatment option for refractory unihemispheric epilepsies. The incidence of hydrocephalus is greatly reduced in this disconnective procedure when compared with the resective procedure of anatomical hemispherectomy. We describe the occurrence of ipsilateral trapped lateral ventricle months after hemispherotomy for Rasmussen's encephalitis. There is enough evidence to suggest that this rare and interesting complication is due to the local inflammatory changes associated with the surgical trauma.
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Affiliation(s)
| | - Ravi Mohan Rao
- Department of Neurosurgery, Apollo Hospitals, Bangalore, Karnataka, India
| | | | - Praveen Kumar
- Department of Radiology, KG Hospital, Coimbatore, Tamil nadu, India
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10
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Nagahama Y, Peters D, Kumonda S, Vesole A, Joshi C, J Dlouhy B, Kawasaki H. Delayed diagnosis of shunt overdrainage following functional hemispherotomy and ventriculoperitoneal shunt placement in a hemimegalencephaly patient. EPILEPSY & BEHAVIOR CASE REPORTS 2017; 7:34-36. [PMID: 28348960 PMCID: PMC5357741 DOI: 10.1016/j.ebcr.2016.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/26/2016] [Accepted: 12/24/2016] [Indexed: 11/16/2022]
Abstract
Shunt overdrainage represents a nebulous condition of variable clinical and imaging presentations, where the diagnosis is primarily clinical. The condition presents a diagnostic challenge particularly in patients with cognitive impairment and developmental delays. Here we present a 3-year-old boy with drug-resistant focal onset seizures due to hemimegalencephaly who previously underwent functional hemispherotomy followed by ventriculoperitoneal shunt placement for postoperative hydrocephalus. The subsequent clinical course was complicated by delayed diagnosis of shunt overdrainage in the absence of significant image findings. Maintaining a high index of suspicion for the possibility of shunt overdrainage is critical even in the face of unremarkable imaging findings.
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Affiliation(s)
- Yasunori Nagahama
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - David Peters
- Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Sho Kumonda
- Surgery residency program, Teine Keijinkai Hospital, Sapporo, Japan
| | - Adam Vesole
- Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Charuta Joshi
- Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Brian J Dlouhy
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Hiroto Kawasaki
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Kiehna EN, Widjaja E, Holowka S, Carter Snead O, Drake J, Weiss SK, Ochi A, Thompson EM, Go C, Otsubo H, Donner EJ, Rutka JT. Utility of diffusion tensor imaging studies linked to neuronavigation and other modalities in repeat hemispherotomy for intractable epilepsy. J Neurosurg Pediatr 2016; 17:483-90. [PMID: 26651159 DOI: 10.3171/2015.7.peds15101] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Hemispherectomy for unilateral, medically refractory epilepsy is associated with excellent long-term seizure control. However, for patients with recurrent seizures following disconnection, workup and investigation can be challenging, and surgical options may be limited. Few studies have examined the role of repeat hemispherotomy in these patients. The authors hypothesized that residual fiber connections between the hemispheres could be the underlying cause of recurrent epilepsy in these patients. Diffusion tensor imaging (DTI) was used to test this hypothesis, and to target residual connections at reoperation using neuronavigation. METHODS The authors identified 8 patients with recurrent seizures following hemispherectomy who underwent surgery between 1995 and 2012. Prolonged video electroencephalography recordings documented persistent seizures arising from the affected hemisphere. In all patients, DTI demonstrated residual white matter association fibers connecting the hemispheres. A repeat craniotomy and neuronavigation-guided targeted disconnection of these residual fibers was performed. Engel class was used to determine outcome after surgery at a minimum of 2 years of follow-up. RESULTS Two patients underwent initial hemidecortication and 6 had periinsular hemispherotomy as their first procedures at a median age of 9.7 months. Initial pathologies included hemimegalencephaly (n = 4), multilobar cortical dysplasia (n = 3), and Rasmussen's encephalitis (n = 1). The mean duration of seizure freedom for the group after the initial procedure was 32.5 months (range 6-77 months). In all patients, DTI showed limited but definite residual connections between the 2 hemispheres, primarily across the rostrum/genu of the corpus callosum. The median age at reoperation was 6.8 years (range 1.3-14 years). The average time taken for reoperation was 3 hours (range 1.8-4.3 hours), with a mean blood loss of 150 ml (range 50-250 ml). One patient required a blood transfusion. Five patients are seizure free, and the remaining 3 patients are Engel Class II, with a minimum follow-up of 24 months for the group. CONCLUSIONS Repeat hemispherotomy is an option for consideration in patients with recurrent intractable epilepsy following failed surgery for catastrophic epilepsy. In conjunction with other modalities to establish seizure onset zones, advanced MRI and DTI sequences may be of value in identifying patients with residual connectivity between the affected and unaffected hemispheres. Targeted disconnection of these residual areas of connectivity using neuronavigation may result in improved seizure outcomes, with minimal and acceptable morbidity.
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Affiliation(s)
- Erin N Kiehna
- Division of Neurosurgery, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California and
| | | | | | | | - James Drake
- Pediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | | | | | - Eric M Thompson
- Pediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | | | | | | | - James T Rutka
- Pediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
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Vadera S, Griffith SD, Rosenbaum BP, Seicean A, Kshettry VR, Kelly ML, Weil RJ, Bingaman W, Jehi L. National Trends and In-hospital Complication Rates in More Than 1600 Hemispherectomies From 1988 to 2010. Neurosurgery 2015; 77:185-91; discussion 191. [DOI: 10.1227/neu.0000000000000815] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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13
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Phung J, Krogstad P, Mathern GW. Fevers and abnormal blood and cerebrospinal fluid studies after pediatric cerebral hemispherectomy: impact of etiology and age at surgery. J Neurosurg Pediatr 2013; 12:595-603. [PMID: 24116983 DOI: 10.3171/2013.9.peds13264] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The object of this study was to determine if etiology and age at surgery were linked with fevers and altered white blood cell and CSF laboratory values after cerebral hemispherectomy. METHODS Seizure etiologies (n = 76) were classified into hemimegalencephaly (HME), cortical dysplasia (CD), infarcts (stroke), Rasmussen encephalitis (RE), history of infections, and Sturge-Weber syndrome (SWS) and were compared with clinical variables, maximum daily temperature (Tmax), and blood and CSF studies through Day 12 posthemispherectomy. RESULTS The Tmax on Days 2-4 and 9-12 postsurgery were higher for HME and RE cases than for stroke cases. Patients with RE showed positive correlations, whereas those with SWS had negative correlations between Tmax and age at surgery. Blood WBC counts on postsurgery Days 3, 6, and 9-12 were higher in the HME and CD cases than in the stroke and RE cases. The percentage of blood polymorphonuclear cells (%bloodPMNs) was higher in the RE cases than in the HME, CD, and SWS cases. The RE, HME, and CD cases showed positive correlations between %bloodPMNs and age at surgery. The percentage of blood monocytes (%bloodMono) was higher in the patients with HME than in those with stroke or RE. The HME and CD cases showed negative correlations between %bloodMono and age at surgery. The CSF red blood cell counts were higher in the RE than in the CD and stroke cases. The percentage of CSF monocytes was higher in patients with CD than in those with stroke and RE. The percentage of CSF lymphocytes positively correlated with age at surgery. CONCLUSIONS Seizure etiology and age at surgery were associated with developing fevers and altered blood and CSF values after pediatric cerebral hemispherectomy. These findings indicate that besides infections, other clinical variables have an impact on developing fevers and abnormal laboratory values posthemispherectomy. Cultures appear to be the most reliable predictor of infections.
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