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Santos MV, Garcia CAB, Hamad APA, Costa UT, Sakamoto AC, Dos Santos AC, Machado HR. Clinical and Surgical Approach for Cerebral Cortical Dysplasia. Adv Tech Stand Neurosurg 2023; 48:327-354. [PMID: 37770690 DOI: 10.1007/978-3-031-36785-4_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
The present article describes pathophysiological and clinical aspects of congenital malformations of the cerebral tissue (cortex and white matter) that cause epilepsy and very frequently require surgical treatment. A particular emphasis is given to focal cortical dysplasias, the most common pathology among these epilepsy-related malformations. Specific radiological and surgical features are also highlighted, so a thorough overview of cortical dysplasias is provided.
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Affiliation(s)
- Marcelo Volpon Santos
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University Hospital, University of São Paulo, São Paulo, SP, Brazil.
- Department of Surgery and Anantomy, Ribeirão Preto Medical School, University of São Paulo, São Paulo, SP, Brazil.
| | - Camila Araujo Bernardino Garcia
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University Hospital, University of São Paulo, São Paulo, SP, Brazil
| | - Ana Paula Andrade Hamad
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University Hospital, University of São Paulo, São Paulo, SP, Brazil
| | - Ursula Thome Costa
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University Hospital, University of São Paulo, São Paulo, SP, Brazil
| | - Americo Ceiki Sakamoto
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University Hospital, University of São Paulo, São Paulo, SP, Brazil
| | - Antonio Carlos Dos Santos
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University Hospital, University of São Paulo, São Paulo, SP, Brazil
| | - Helio Rubens Machado
- Center for Pediatric Epilepsy Surgery (CIREP), Ribeirão Preto Medical School, University Hospital, University of São Paulo, São Paulo, SP, Brazil
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2
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Lu VM, Brown EC, Ragheb J, Wang S. Repeat surgery for pediatric epilepsy: a systematic review and meta-analysis of resection and disconnection approaches. J Neurosurg Pediatr 2022; 30:616-623. [PMID: 36242580 DOI: 10.3171/2022.9.peds22344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 09/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Resection and disconnection surgeries for epilepsy in the pediatric demographic (patients ≤ 18 years of age) are two separate, definitive intervention options in medically refractory cases. Questions remain regarding the role of surgery when seizures persist after an initial incomplete surgery. The aim of this study was to review the contemporary literature and summarize the metadata on the outcomes of repeat surgery in this specific demographic. METHODS Searches of seven electronic databases from inception to July 2022 were conducted using PRISMA guidelines. Articles were screened using prespecified criteria. Metadata from the articles were abstracted and pooled by random-effects meta-analysis of proportions. RESULTS Eleven studies describing 12 cohorts satisfied all criteria, reporting outcomes of 170 pediatric patients with epilepsy who underwent repeat resection or disconnection surgery. Of these patients, 55% were male, and across all studies, median ages at initial and repeat surgeries were 7.2 and 9.4 years, respectively. The median follow-up duration after repeat surgery was 47.7 months. The most commonly reported etiology for epilepsy was cortical dysplasia. Overall, the estimated incidence of complete seizure freedom (Engel class I) following repeat surgery was 48% (95% CI 40%-56%, p value for heterogeneity = 0.93), and the estimated incidence of postoperative complications following repeat surgery was 25% (95% CI 12%-39%, p = 0.04). There were six cohorts each that described outcomes for repeat resection and repeat disconnection surgeries. There was no statistical difference between these two subgroups with respect to estimated incidence of complete seizure freedom (p value for interaction = 0.92), but postoperative complications were statistically more common following repeat resection (p ≤ 0.01). CONCLUSIONS For both resection and disconnection surgeries, repeat epilepsy surgery in children is likely to confer complete seizure freedom in approximately half of the patients who experience unsuccessful initial incomplete epilepsy surgery. More data are needed to elucidate the impact on efficacy based on surgical approach selection. Judicious discussion and planning between the patient, family, and a multidisciplinary team of epilepsy specialists is recommended to optimize expectations and outcomes in this setting.
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Affiliation(s)
- Victor M Lu
- 1Department of Neurological Surgery, University of Miami, Jackson Memorial Hospital; and
- 2Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, Florida
| | - Erik C Brown
- 2Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, Florida
| | - John Ragheb
- 1Department of Neurological Surgery, University of Miami, Jackson Memorial Hospital; and
- 2Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, Florida
| | - Shelly Wang
- 1Department of Neurological Surgery, University of Miami, Jackson Memorial Hospital; and
- 2Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, Florida
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3
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Yossofzai O, Fallah A, Maniquis C, Wang S, Ragheb J, Weil AG, Brunette-Clement T, Andrade A, Ibrahim GM, Mitsakakis N, Widjaja E. Development and validation of machine learning models for prediction of seizure outcome after pediatric epilepsy surgery. Epilepsia 2022; 63:1956-1969. [PMID: 35661152 DOI: 10.1111/epi.17320] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 06/02/2022] [Accepted: 06/03/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE There is substantial variability in reported seizure outcome following pediatric epilepsy surgery, and lack of individualized predictive tools that could evaluate the probability of seizure freedom postsurgery. The aim of this study was to develop and validate a supervised machine learning (ML) model for predicting seizure freedom after pediatric epilepsy surgery. METHODS This is a multicenter retrospective study of children who underwent epilepsy surgery at five pediatric epilepsy centers in North America. Clinical information, diagnostic investigations, and surgical characteristics were collected, and used as features to predict seizure-free outcome 1 year after surgery. The dataset was split randomly into 80% training and 20% testing data. Thirty-five combinations of five feature sets with seven ML classifiers were assessed on the training cohort using 10-fold cross-validation for model development. The performance of the optimal combination of ML classifier and feature set was evaluated in the testing cohort, and compared with logistic regression, a classical statistical approach. RESULTS Of the 801 patients included, 61.3% were seizure-free 1 year postsurgery. During model development, the best combination was XGBoost ML algorithm with five features from the univariate feature set, including number of antiseizure medications, magnetic resonance imaging lesion, age at seizure onset, video-electroencephalography concordance, and surgery type, with a mean area under the curve (AUC) of .73 (95% confidence interval [CI] = .69-.77). The combination of XGBoost and univariate feature set was then evaluated on the testing cohort and achieved an AUC of .74 (95% CI = .66-.82; sensitivity = .87, 95% CI = .81-.94; specificity = .58, 95% CI = .47-.71). The XGBoost model outperformed the logistic regression model (AUC = .72, 95% CI = .63-.80; sensitivity = .72, 95% CI = .63-.82; specificity = .66, 95% CI = .53-.77) in the testing cohort (p = .005). SIGNIFICANCE This study identified important features and validated an ML algorithm, XGBoost, for predicting the probability of seizure freedom after pediatric epilepsy surgery. Improved prognostication of epilepsy surgery is critical for presurgical counseling and will inform treatment decisions.
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Affiliation(s)
- Omar Yossofzai
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Aria Fallah
- Department of Neurosurgery, University of California, Los Angeles Mattel Children's Hospital, Los Angeles, California, USA
| | - Cassia Maniquis
- Department of Neurosurgery, University of California, Los Angeles Mattel Children's Hospital, Los Angeles, California, USA
| | - Shelly Wang
- Division of Neurosurgery, Brain Institute, Nicklaus Children's Hospital, Miami, Florida, USA
| | - John Ragheb
- Division of Neurosurgery, Brain Institute, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Alexander G Weil
- Department of Neurosurgery, Sainte-Justine University Hospital Center, Montreal, Quebec, Canada
| | | | - Andrea Andrade
- Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - George M Ibrahim
- Department of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nicholas Mitsakakis
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Elysa Widjaja
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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4
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Matern TS, DeCarlo R, Ciliberto MA, Singh RK. Palliative Epilepsy Surgery Procedures in Children. Semin Pediatr Neurol 2021; 39:100912. [PMID: 34620461 DOI: 10.1016/j.spen.2021.100912] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 10/20/2022]
Abstract
Surgical treatment of epilepsy typically focuses on identification of a seizure focus with subsequent resection and/or disconnection to "cure" the patient's epilepsy and achieve seizure freedom. Palliative epilepsy surgery modalities are efficacious in improving seizure frequency, severity, and quality of life. In this paper, we review palliative epilepsy surgical options for children: vagus nerve stimulation, responsive neurostimulation, deep brain stimulation, hemispherotomy, corpus callosotomy, lobectomy and/or lesionectomy and multiple subpial transection. Reoperation after surgical resection should also be considered. If curative resection is not a viable option for seizure freedom, these methods should be considered with equal emphasis and urgency in the treatment of drug-resistant epilepsy.
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Affiliation(s)
| | | | - Michael A Ciliberto
- Department of Pediatrics, Stead Family Children's Hospital/University of Iowa
| | - Rani K Singh
- Department of Pediatrics, Atrium Health System/Levine Children's Hospital.
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Starnes K, Depositario-Cabacar D, Wong-Kisiel L. Presurgical Evaluation Strategies for Intractable Epilepsy of Childhood. Semin Pediatr Neurol 2021; 39:100915. [PMID: 34620457 DOI: 10.1016/j.spen.2021.100915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 08/11/2021] [Accepted: 08/11/2021] [Indexed: 11/29/2022]
Abstract
For children who continue to experience seizures despite treatment with antiseizure medications, epilepsy surgery can be considered. The goals of the presurgical evaluation are to determine the best surgical approach to render a good outcome. In patients with drug resistant focal epilepsy, the epileptogenic zone defines the minimal brain volume which must be resected for surgical success and to delineate the relationship of this region with functional cortex. A number of noninvasive tools for these tasks have emerged over the past decade, and existing technologies have been revised and improved. In this review, we examine the recent published evidence for these techniques, specifically as applied to the pediatric population. Discussed herein are the diagnostic value of methods such as video electroencephalography, magnetic resonance imaging, and supportive neuroimaging techniques including single photon emission tomography, photon emission tomography, and magnetoencephalography. Functional testing including functional magnetic resonance imaging, electrical stimulation mapping, and transcranial magnetic stimulation are considered in the context of pediatric epilepsy. The application of emerging techniques to preoperative testing such as source localization, image post-processing, and artificial intelligence is covered. We summarize the relative value of presurgical testing based on patient characteristics, including lesional or nonlesional MRI, temporal or extratemporal epilepsy, and other factors relevant in pediatric epilepsy such as pathological substrate and age.
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Affiliation(s)
| | | | - Lily Wong-Kisiel
- Department of Neurology and Pediatrics, Mayo Clinic, Rochester, MN.
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6
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Tsai JD, Fan PC, Lee WT, Hung PL, Hung KL, Wang HS, Lin KL. Vagus nerve stimulation in pediatric patients with failed epilepsy surgery. Acta Neurol Belg 2021; 121:1305-1309. [PMID: 32130668 DOI: 10.1007/s13760-020-01303-8] [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: 01/02/2020] [Accepted: 02/09/2020] [Indexed: 10/24/2022]
Abstract
Adequate control of pharmacoresistant epilepsy continues to be a challenge. Multiple studies have reported the benefits of epilepsy surgery and vagus nerve stimulation for children with pharmacoresistant epilepsy. Little is known about the role of vagus nerve stimulation for children with failed epilepsy surgeries. The aim of this study was to examine the effects of vagus nerve stimulation on seizure frequency reduction for children with failed epilepsy surgeries. We retrospectively reviewed 85 children with pharmacoresistant epilepsy who underwent vagus nerve stimulation. Six of these patients underwent epilepsy surgery before vagus nerve stimulation (group I) and 79 patients received only vagus nerve stimulation (group II). We recorded seizure frequency at 3, 12, 24 and 36 months after vagus nerve stimulator implantation. Both groups had reduced seizure frequencies at the 3-, 12-, 24- and 36-month follow-up (p = 0.044 for group I trends and 0.008 for group II trends). Vagus nerve stimulator implantations significantly improve seizure frequency for children with or without previous epilepsy surgery at 3, 12, 24 and 36 months. These findings suggest that vagus nerve stimulation should be considered an alternative therapy for pediatric patients with previous failed surgeries.
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Changes in the Functional Brain Network of Children Undergoing Repeated Epilepsy Surgery: An EEG Source Connectivity Study. Diagnostics (Basel) 2021; 11:diagnostics11071234. [PMID: 34359317 PMCID: PMC8306224 DOI: 10.3390/diagnostics11071234] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/29/2021] [Accepted: 07/05/2021] [Indexed: 11/19/2022] Open
Abstract
About 30% of children with drug-resistant epilepsy (DRE) continue to have seizures after epilepsy surgery. Since epilepsy is increasingly conceptualized as a network disorder, understanding how brain regions interact may be critical for planning re-operation in these patients. We aimed to estimate functional brain connectivity using scalp EEG and its evolution over time in patients who had repeated surgery (RS-group, n = 9) and patients who had one successful surgery (seizure-free, SF-group, n = 12). We analyzed EEGs without epileptiform activity at varying time points (before and after each surgery). We estimated functional connectivity between cortical regions and their relative centrality within the network. We compared the pre- and post-surgical centrality of all the non-resected (untouched) regions (far or adjacent to resection) for each group (using the Wilcoxon signed rank test). In alpha, theta, and beta frequency bands, the post-surgical centrality of the untouched cortical regions increased in the SF group (p < 0.001) whereas they decreased (p < 0.05) or did not change (p > 0.05) in the RS group after failed surgeries; when re-operation was successful, the post-surgical centrality of far regions increased (p < 0.05). Our data suggest that removal of the epileptogenic focus in children with DRE leads to a gain in the network centrality of the untouched areas. In contrast, unaltered or decreased connectivity is seen when seizures persist after surgery.
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8
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Otsubo H, Ogawa H, Pang E, Wong SM, Ibrahim GM, Widjaja E. A review of magnetoencephalography use in pediatric epilepsy: an update on best practice. Expert Rev Neurother 2021; 21:1225-1240. [PMID: 33780318 DOI: 10.1080/14737175.2021.1910024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Magnetoencephalography (MEG) is a noninvasive technique that is used for presurgical evaluation of children with drug-resistant epilepsy (DRE).Areas covered: The contributions of MEG for localizing the epileptogenic zone are discussed, in particular in extra-temporal lobe epilepsy and focal cortical dysplasia, which are common in children, as well as in difficult to localize epilepsy such as operculo-insular epilepsy. Further, the authors review current evidence on MEG for mapping eloquent cortex, its performance, application in clinical practice, and potential challenges.Expert opinion: MEG could change the clinical management of children with DRE by directing placement of intracranial electrodes thereby enhancing their yield. With improved identification of a circumscribed epileptogenic zone, MEG could render more patients as suitable candidates for epilepsy surgery and increase utilization of surgery.
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Affiliation(s)
- Hiroshi Otsubo
- Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada
| | - Hiroshi Ogawa
- Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada
| | - Elizabeth Pang
- Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada.,Neuroscience and Mental Health, Hospital for Sick Children, Toronto, Canada
| | - Simeon M Wong
- Neuroscience and Mental Health, Hospital for Sick Children, Toronto, Canada
| | - George M Ibrahim
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Canada.,Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada
| | - Elysa Widjaja
- Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada.,Neuroscience and Mental Health, Hospital for Sick Children, Toronto, Canada.,Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada
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Kankirawatana P, Mohamed IS, Lauer J, Aban I, Kim H, Li R, Harrison A, Goyal M, Rozzelle CJ, Knowlton R, Blount JP. Relative contribution of individual versus combined functional imaging studies in predicting seizure freedom in pediatric epilepsy surgery: an area under the curve analysis. Neurosurg Focus 2021; 48:E13. [PMID: 32234993 DOI: 10.3171/2020.1.focus19974] [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: 12/01/2019] [Accepted: 01/28/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to evaluate the predictive value and relative contribution of noninvasive presurgical functional imaging modalities based on the authors' institutional experience in pursuing seizure-free surgical outcomes in children with medically refractory epilepsy. METHODS This was a retrospective, single-institution, observational cohort study of pediatric patients who underwent evaluation and surgical treatment for medically refractory partial epilepsy between December 2003 and June 2016. During this interval, 108 children with medically refractory partial epilepsy underwent evaluation for localization and resective epilepsy surgery. Different noninvasive functional imaging modalities, including ictal SPECT, FDG-PET, and magnetoencephalography-magnetic source imaging, were utilized to augment a standardized paradigm (electroencephalography/semiology, MRI, and neuropsychology findings) for localization. Outcomes were evaluated at a minimum of 2 years (mean 7.5 years) utilizing area under the receiver operating characteristic curve analysis. Localizing modalities and other clinical covariates were examined in relation to long-term surgical outcomes. RESULTS There was variation in the contribution of each test, and no single presurgical workup modality could singularly and reliably predict a seizure-free outcome. However, concordance of presurgical modalities yielded a high predictive value. No difference in long-term outcomes between inconclusive (normal or diffusely abnormal) and abnormal focal MRI results were found. Long-term survival analyses revealed a statistically significant association between seizure freedom and patients with focal ictal EEG, early surgical intervention, and no history of generalized convulsions. CONCLUSIONS Comprehensive preoperative evaluation utilizing multiple noninvasive functional imaging modalities is not redundant and can improve pediatric epilepsy surgical outcomes.
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Affiliation(s)
- Pongkiat Kankirawatana
- 1Division of Pediatric Neurology, Department of Pediatrics, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Ismail S Mohamed
- 1Division of Pediatric Neurology, Department of Pediatrics, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Jason Lauer
- 2Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Inmaculada Aban
- 3Division of Biostatistics, UAB School of Public Health, The University of Alabama at Birmingham, Alabama
| | - Hyunmi Kim
- 4Division of Child Neurology, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Rong Li
- 5Department of Pathology, The University of Alabama at Birmingham, Alabama
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- 1Division of Pediatric Neurology, Department of Pediatrics, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Monisha Goyal
- 1Division of Pediatric Neurology, Department of Pediatrics, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Curtis J Rozzelle
- 6Division of Pediatric Neurosurgery, Department of Neurosurgery, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama; and
| | - Robert Knowlton
- 7Department of Neurology, University of California, San Francisco, California
| | - Jeffrey P Blount
- 6Division of Pediatric Neurosurgery, Department of Neurosurgery, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama; and
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Bagić AI, Funke ME, Kirsch HE, Tenney JR, Zillgitt AJ, Burgess RC. The 10 Common Evidence-Supported Indications for MEG in Epilepsy Surgery: An Illustrated Compendium. J Clin Neurophysiol 2021; 37:483-497. [PMID: 33165222 DOI: 10.1097/wnp.0000000000000726] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Unfamiliarity with the indications for and benefits of magnetoencephalography (MEG) persists, even in the epilepsy community, and hinders its acceptance to clinical practice, despite the evidence. The wide treatment gap for patients with drug-resistant epilepsy and immense underutilization of epilepsy surgery had similar effects. Thus, educating referring physicians (epileptologists, neurologists, and neurosurgeons) both about the value of epilepsy surgery and about the potential benefits of MEG can achieve synergy and greatly improve the process of selecting surgical candidates. As a practical step toward a comprehensive educational process to benefit potential MEG users, current MEG referrers, and newcomers to MEG, the authors have elected to provide an illustrated guide to 10 everyday situations where MEG can help in the evaluation of people with drug-resistant epilepsy. They are as follows: (1) lacking or imprecise hypothesis regarding a seizure onset; (2) negative MRI with a mesial temporal onset suspected; (3) multiple lesions on MRI; (4) large lesion on MRI; (5) diagnostic or therapeutic reoperation; (6) ambiguous EEG findings suggestive of "bilateral" or "generalized" pattern; (7) intrasylvian onset suspected; (8) interhemispheric onset suspected; (9) insular onset suspected; and (10) negative (i.e., spikeless) EEG. Only their practical implementation and furtherance of personal and collective education will lead to the potentially impactful synergy of the two-MEG and epilepsy surgery. Thus, while fulfilling our mission as physicians, we must not forget that ignoring the wealth of evidence about the vast underutilization of epilepsy surgery - and about the usefulness and value of MEG in selecting surgical candidates - is far from benign neglect.
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Affiliation(s)
- Anto I Bagić
- University of Pittsburgh Comprehensive Epilepsy Center (UPCEC), Department of Neurology, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, U.S.A
| | - Michael E Funke
- MEG Center, McGovern Medical School, UT Houston, Houston, Texas, U.S.A
| | - Heidi E Kirsch
- UCSF Biomagnetic Imaging Laboratory, UCSF, San Francisco, California, U.S.A
| | - Jeffrey R Tenney
- MEG Center, Cincinnati Children's Hospital Medical Center , Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Andrew J Zillgitt
- Department of Neurology, Beaumont Health Adult Comprehensive Epilepsy Center, Neurosicence Center, Royal Oak, Michigan, U.S.A.; and
| | - Richard C Burgess
- Magnetoencephalography Laboratory, Cleveland Clinic Epilepsy Center, Cleveland, Ohio, U.S.A
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11
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Khachatryan VA, Mamatkhanov MR, Larionov SN, Lebedev KE. [Redo surgery in children with epilepsy]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2020; 84:21-27. [PMID: 33095530 DOI: 10.17116/neiro20208405121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To analyze the causes of ineffective operations and the results of redo surgery in children with recurrent epileptic seizures. MATERIAL AND METHODS The results of redo surgery were analyzed in 41 (10.6%) out of 387 children with drug resistant epilepsy treated surgically at the Russian Polenov Neurosurgical Institute for the period from 1994 to 2014. Patients with recurrent epilepsy after temporal resection (n=20), extratemporal resection (n=7), multifocal resection (n=6), callosotomy and stereotaxic destruction (n=8) were selected for analysis. RESULTS Seizure-free period ranged from early postoperative period to 4 years. According to MRI data, lesions were not completely resected during primary surgery in 23 (56.1%) children. The causes of inefficiency of primary operations were inaccurate identification of epileptic focus in 15 (36.6%) patients; incomplete resection of epileptogenic and / or epileptic foci or incomplete disconnection of paroxysmal activity distribution pathways in 14 (34.1%) cases; epileptic foci de novo in 8 (19.5%) cases; inadequate surgical strategy in 4 (9.8%) patients. Redo surgery usually implied an extended previous resection in 34 (82.9%) patients. Engel I outcome after 3 years was achieved in 41.1% of patients, after 5 years - 38.3%, after 10 years - 36.4%. CONCLUSION Redo surgery is quite effective and minimally traumatic. Therefore, patients with recurrent epileptic seizures should be considered as candidates for repeated operations if previous interventions turned out to be ineffective.
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Affiliation(s)
- V A Khachatryan
- Almazov National Medical Research Center, St. Petersburg, Russia
| | - M R Mamatkhanov
- Almazov National Medical Research Center, St. Petersburg, Russia
| | - S N Larionov
- Almazov National Medical Research Center, St. Petersburg, Russia
| | - K E Lebedev
- Almazov National Medical Research Center, St. Petersburg, Russia
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Hsieh HY, Chang CW, Cheng MY, Yan JL, Lim SN, Tseng WEJ, Chiang HI, Li HT, Chang BL, Lee CH, Lin CY, Wu T, Chang CN. Aggressive cytoreduction and multiple subpial cortical transections may obtain good surgical outcomes in refractory epilepsy with multiple epileptic foci. Biomed J 2020; 44:346-352. [PMID: 34183308 PMCID: PMC8358210 DOI: 10.1016/j.bj.2020.03.003] [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: 11/23/2018] [Revised: 03/01/2020] [Accepted: 03/02/2020] [Indexed: 11/25/2022] Open
Abstract
Backgrounds Epilepsy surgery is the most efficacious therapeutic modality for patients with medical refractory epilepsy, especially resective surgery. However, the variable etiologies and multiple epileptic foci are usually associated with the outcomes. The aim of this study was to demonstrate that combination of different intervention procedures might be an alternative option for patients of refractory epilepsy. Methods We retrospectively analyzed pre-operative and post-surgical outcomes in 30 patients who received epilepsy surgery between January 1, 2010 and December 31, 2014 at Chang Gung Memorial Hospital (CGMH), Linkou, according to Engel's classification. Results Twenty-six of the 30 patients (86.7%) had good outcomes, sum of class I and class II after epilepsy surgery. The good outcome rate of our complicated group was 80.0% (12/15), compared to 93.3% (14/15) in the simple group, but no significant differences between the two groups (p = 0.569). Four patients whose epileptic foci involved eloquent area and received multiple subpial cortical transection, and good outcome rate was 75% (3/4). At last, six patients had previously failed epilepsy surgery and received a reoperation, with a good outcome rate of 83.3% (5/6). Conclusion After complete pre-surgical evaluation and combined interventional procedures, the patients with refractory epilepsy had satisfactory outcomes and few neurological complications. Moreover, re-operation can improve the outcome in some patients who previously failed epilepsy surgery.
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Affiliation(s)
- Hsiang-Yao Hsieh
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Wei Chang
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Mei-Yun Cheng
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Institute of Molecular Medicine, National Tsing Hua University, Hsinchu, Taiwan
| | - Jiun-Lin Yan
- Department of Neurosurgery, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Siew-Na Lim
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wei-En Johnny Tseng
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Program in Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsing-I Chiang
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Han-Tao Li
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Bao-Luen Chang
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Hong Lee
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih Yin Lin
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tony Wu
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Department of Neurology, Xiamen Chang Gung Hospital, China; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Chen-Nen Chang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Department of Neurosurgery, Xiamen Chang Gung Hospital, China; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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13
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Volpon Santos M, Teixeira TL, Ioriatti ES, Thome U, Paula de Andrade Hamad A, Machado HR. Risk factors and results of hemispherotomy reoperations in children. Neurosurg Focus 2020; 48:E5. [DOI: 10.3171/2020.1.focus19944] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 01/27/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe goal of this study was to perform an analysis of a single-center experience with hemispherotomy reoperations for refractory hemispheric pediatric epilepsy due to persistence of seizures after initial surgery. The authors also identify possible anatomical and neurophysiological reasons for hemispherotomy failure, as well as risk factors and surgical options for this subgroup of patients.METHODSA review was performed of the medical records in 18 consecutive cases in which candidates for redo hemispherotomy were treated between 2003 and 2018 at the authors’ epilepsy surgery center. Fourteen patients underwent reoperation due to seizure recurrence and were studied herein, whereas in 3 the initial surgical procedure was stopped because of uncontrollable bleeding, and the remaining patient refused to undergo a reoperation in spite of seizure recurrence and went on to have a vagus nerve stimulation device placed.RESULTSAmong the 14 patients whose seizures recurred and in whom reoperations were done, the etiology of epilepsy consisted of 7 cases with malformations of cortical development (50%), 5 cases of Rasmussen encephalitis (35.8%), 1 case of porencephaly (7.1%), and 1 case of Sturge-Weber syndrome (7.1%). Eleven patients had radiological evidence of incomplete disconnection. After reoperation, 6 patients were Engel class IA, 1 was Engel II, 5 were Engel III, and 2 were Engel IV, within a mean follow-up of 48.4 months.CONCLUSIONSPatients with malformations of cortical development have a higher risk of seizure recurrence, and these malformations comprised the main etiology in the reoperation series. Failure of an initial hemispherotomy usually occurs due to incomplete disconnection and needs to be extensively assessed. Outcomes of reoperation are most often favorable, with acceptable complication rates.
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Affiliation(s)
- Marcelo Volpon Santos
- 1Division of Pediatric Neurosurgery, Ribeirao Preto Medical School; and
- 2Center for Pediatric Epilepsy Surgery, University Hospital, Ribeirao Preto Medical School, University of São Paulo, Brazil
| | | | | | - Ursula Thome
- 2Center for Pediatric Epilepsy Surgery, University Hospital, Ribeirao Preto Medical School, University of São Paulo, Brazil
| | - Ana Paula de Andrade Hamad
- 2Center for Pediatric Epilepsy Surgery, University Hospital, Ribeirao Preto Medical School, University of São Paulo, Brazil
| | - Helio Rubens Machado
- 1Division of Pediatric Neurosurgery, Ribeirao Preto Medical School; and
- 2Center for Pediatric Epilepsy Surgery, University Hospital, Ribeirao Preto Medical School, University of São Paulo, Brazil
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14
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Yardi R, Morita-Sherman ME, Fitzgerald Z, Punia V, Bena J, Morrison S, Najm I, Bingaman W, Jehi L. Long-term outcomes of reoperations in epilepsy surgery. Epilepsia 2020; 61:465-478. [PMID: 32108946 DOI: 10.1111/epi.16452] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 01/28/2020] [Accepted: 01/28/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To analyze longitudinal seizure outcomes following epilepsy surgery, including reoperations, in patients with intractable focal epilepsy. METHODS Clinicoradiological characteristics of patients who underwent epilepsy surgery from 1995 to 2016 with follow-up of ≥1 year were reviewed. In patients undergoing reoperations, the latest resection was considered the index surgery. The primary outcome was complete seizure freedom (Engel I) at last follow-up. Potentially significant outcome variables were first identified using univariate analyses and then fit in multivariate Cox proportional hazards models. RESULTS Of 898 patients fulfilling study criteria, 110 had reoperations; 92 had one resection prior to the index surgery and 18 patients had two or more prior resective surgeries. Two years after the index surgery, 69% of patients with no prior surgeries had an Engel score of I, as opposed to only 42% of those with one prior surgery, and 33% of those with two or more prior resections (P < .001). Among surgical outcome predictors, the number of prior epilepsy surgeries, female sex, lesional initial magnetic resonance imaging, no prior history of generalization, and pathology correlated with better seizure outcomes on univariate analysis. However, only sex (P = .011), history of generalization (P = .016), and number of prior surgeries (P = .002) remained statistically significant in the multivariate model. SIGNIFICANCE Although long-term seizure control is possible in patients with failed prior epilepsy surgery, the chances of success diminish with every subsequent resection. Outcome is additionally determined by inherent biological markers (sex and secondary generalization tendency), rather than traditional outcome predictors, supporting a hypothesis of "surgical refractoriness."
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Affiliation(s)
- Ruta Yardi
- Epilepsy Center, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Vineet Punia
- Epilepsy Center, Cleveland Clinic, Cleveland, Ohio
| | - James Bena
- Quantitative Health Sciences, Cleveland, Ohio
| | | | - Imad Najm
- Epilepsy Center, Cleveland Clinic, Cleveland, Ohio
| | | | - Lara Jehi
- Epilepsy Center, Cleveland Clinic, Cleveland, Ohio
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15
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Cohen NT, Ziobro JM, Depositario-Cabacar DF, Havens K, Kao A, Schreiber JM, Tsuchida TN, Zelleke TG, Oluigbo CO, Gaillard WD. Measure thrice, cut twice: On the benefit of reoperation for failed pediatric epilepsy surgery. Epilepsy Res 2020; 161:106289. [PMID: 32088518 DOI: 10.1016/j.eplepsyres.2020.106289] [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: 10/11/2019] [Revised: 12/19/2019] [Accepted: 02/09/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine whether clinical outcomes are improved after repeat surgery for medically refractory epilepsy in children. METHODS This is a single-center retrospective cohort analysis of all patients who received repeat resective surgery for ongoing seizures from 2000-2017. From a total of 251 consecutive individual epilepsy surgical patients for focal resection, 53 patients met study inclusion criteria and had adequate follow-up documented. RESULTS Median age of seizure-onset was 2.0-years-old (IQR 0.3-5.5 years). The median age at first epilepsy surgery was 6.3-years-old (IQR 2.9-9.2 years) and at second epilepsy surgery was 8.4-years-old (IQR 4.7-12.6 years). Overall, 53 % (n = 28) of this series achieved Engel Class I (seizure freedom); with improved seizure control (Engel Class I-II) in 83 % (n = 44) of the cohort. 64 % (n = 34) had one reoperation; 26 % (n = 14) had two; and 9% (n = 5) had three. Pathology: 58 % (n = 31) had focal cortical dysplasia; 13 % (n = 10) tumor; 9% (n = 5) encephalitis; 6% (n = 3) gliosis; 4% (n = 2) mesial temporal sclerosis; and 2% (n = 1) hemimegalencephaly. Tumor pathology was associated with increased chance (p = 0.01) for seizure freedom (90 % of tumor patients had Engel Class I outcome). MTS had worse outcome with both patients having ongoing seizures (Engel II-IV). There were 6 patients who developed post-operative hemiparesis; one was unplanned but resolved. SIGNIFICANCE Reoperation for pediatric epilepsy surgery can lead to seizure freedom in many cases and improved seizure control in most cases. Reoperation for brain tumor pathology is associated with a high rate of seizure freedom.
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Affiliation(s)
- Nathan T Cohen
- Division of Child Neurology, Children's National Hospital, Washington, DC, United States.
| | - Julie M Ziobro
- Department of Pediatrics, Michigan Medicine, Ann Arbor, MI, United States
| | | | - Kathryn Havens
- Division of Child Neurology, Children's National Hospital, Washington, DC, United States
| | - Amy Kao
- Division of Child Neurology, Children's National Hospital, Washington, DC, United States
| | - John M Schreiber
- Division of Child Neurology, Children's National Hospital, Washington, DC, United States
| | - Tammy N Tsuchida
- Division of Child Neurology, Children's National Hospital, Washington, DC, United States
| | - Tesfaye G Zelleke
- Division of Child Neurology, Children's National Hospital, Washington, DC, United States
| | - Chima O Oluigbo
- Division of Neurosurgery, Children's National Hospital, Washington, DC, United States
| | - William D Gaillard
- Division of Child Neurology, Children's National Hospital, Washington, DC, United States
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16
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Rampp S, Stefan H, Wu X, Kaltenhäuser M, Maess B, Schmitt FC, Wolters CH, Hamer H, Kasper BS, Schwab S, Doerfler A, Blümcke I, Rössler K, Buchfelder M. Magnetoencephalography for epileptic focus localization in a series of 1000 cases. Brain 2019; 142:3059-3071. [PMID: 31373622 DOI: 10.1093/brain/awz231] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 05/29/2019] [Accepted: 06/02/2019] [Indexed: 02/05/2023] Open
Abstract
Abstract
The aim of epilepsy surgery in patients with focal, pharmacoresistant epilepsies is to remove the complete epileptogenic zone to achieve long-term seizure freedom. In addition to a spectrum of diagnostic methods, magnetoencephalography focus localization is used for planning of epilepsy surgery. We present results from a retrospective observational cohort study of 1000 patients, evaluated using magnetoencephalography at the University Hospital Erlangen over the time span of 28 years. One thousand consecutive cases were included in the study, evaluated at the University Hospital Erlangen between 1990 and 2018. All patients underwent magnetoencephalography as part of clinical workup for epilepsy surgery. Of these, 405 underwent epilepsy surgery after magnetoencephalography, with postsurgical follow-ups of up to 20 years. Sensitivity for interictal epileptic activity was evaluated, in addition to concordance of localization with the consensus of presurgical workup on a lobar level. We evaluate magnetoencephalography characteristics of patients who underwent epilepsy surgery versus patients who did not proceed to surgery. In operated patients, resection of magnetoencephalography localizations were related to postsurgical seizure outcomes, including long-term results after several years. In comparison, association of lesionectomy with seizure outcomes was analysed. Measures of diagnostic accuracy were calculated for magnetoencephalography resection and lesionectomy. Sensitivity for interictal epileptic activity was 72% with significant differences between temporal and extra-temporal lobe epilepsy. Magnetoencephalography was concordant with the presurgical consensus in 51% and showed additional or more focal involvement in an additional 32%. Patients who proceeded to surgery showed a significantly higher percentage of monofocal magnetoencephalography results. Complete magnetoencephalography resection was associated with significantly higher chances to achieve seizure freedom in the short and long-term. Diagnostic accuracy was significant in temporal and extra-temporal lobe cases, but was significantly higher in extra-temporal lobe epilepsy (diagnostic odds ratios of 4.4 and 41.6). Odds ratios were also higher in non-lesional versus lesional cases (42.0 versus 6.2). The results show that magnetoencephalography provides non-redundant information, which significantly contributes to patient selection, focus localization and ultimately long-term seizure freedom after epilepsy surgery. Specifically in extra-temporal lobe epilepsy and non-lesional cases, magnetoencephalography provides excellent accuracy.
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Affiliation(s)
- Stefan Rampp
- Department of Neurosurgery, University Hospital Erlangen, Germany
- Department of Neurosurgery, University Hospital Halle (Saale), Germany
| | - Hermann Stefan
- Department of Neurology, University Hospital Erlangen, Germany
| | - Xintong Wu
- Department of Neurosurgery, University Hospital Erlangen, Germany
- Department of Neurology, West China Hospital, Sichuan University, Sichuan, China
| | | | - Burkhard Maess
- Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | | | - Carsten H Wolters
- Institute for Biomagnetism and Biosignalanalysis, University Münster, Germany
| | - Hajo Hamer
- Department of Neurology, Epilepsy Center, University Hospital Erlangen, Germany
| | - Burkhard S Kasper
- Department of Neurology, Epilepsy Center, University Hospital Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Germany
| | - Arndt Doerfler
- Department of Neuroradiology, University Hospital Erlangen, Germany
| | - Ingmar Blümcke
- Department of Neuropathology, University Hospital Erlangen, Germany
| | - Karl Rössler
- Department of Neurosurgery, University Hospital Erlangen, Germany
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