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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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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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Ramantani G, Bulteau C, Cserpan D, Otte WM, Dorfmüller G, Cross JH, Zentner J, Tisdall M, Braun KPJ. Not surgical technique, but etiology, contralateral MRI, prior surgery, and side of surgery determine seizure outcome after pediatric hemispherotomy. Epilepsia 2023; 64:1214-1224. [PMID: 36869851 DOI: 10.1111/epi.17574] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/02/2023] [Accepted: 03/02/2023] [Indexed: 03/05/2023]
Abstract
OBJECTIVE We aimed to assess determinants of seizure outcome following pediatric hemispherotomy in a contemporary cohort. METHODS We retrospectively analyzed the seizure outcomes of 457 children who underwent hemispheric surgery in five European epilepsy centers between 2000 and 2016. We identified variables related to seizure outcome through multivariable regression modeling with missing data imputation and optimal group matching, and we further investigated the role of surgical technique by Bayes factor (BF) analysis. RESULTS One hundred seventy seven children (39%) underwent vertical and 280 children (61%) underwent lateral hemispherotomy. Three hundred forty-four children (75%) achieved seizure freedom at a mean follow-up of 5.1 years (range 1 to 17.1). We identified acquired etiology other than stroke (odds ratio [OR] 4.4, 95% confidence interval (CI) 1.1-18.0), hemimegalencephaly (OR 2.8, 95% CI 1.1-7.3), contralateral magnetic resonance imaging (MRI) findings (OR 5.5, 95% CI 2.7-11.1), prior resective surgery (OR 5.0, 95% CI 1.8-14.0), and left hemispherotomy (OR 2.3, 95% CI 1.3-3.9) as significant determinants of seizure recurrence. We found no evidence of an impact of the hemispherotomy technique on seizure outcome (the BF for a model including the hemispherotomy technique over the null model was 1.1), with comparable overall major complication rates for different approaches. SIGNIFICANCE Knowledge about the independent determinants of seizure outcome following pediatric hemispherotomy will improve the counseling of patients and families. In contrast to previous reports, we found no statistically relevant difference in seizure-freedom rates between the vertical and horizontal hemispherotomy techniques when accounting for different clinical features between groups.
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Affiliation(s)
- Georgia Ramantani
- Department of Neuropediatrics, University Children's Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Christine Bulteau
- Member of ERN EpiCare, Department of Pediatric Neurosurgery, Hospital Fondation Adolphe de Rothschild, Paris, France
| | - Dorottya Cserpan
- Department of Neuropediatrics, University Children's Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Willem M Otte
- Member of ERN EpiCare, Department of Child Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, and Utrecht University, Utrecht, The Netherlands
| | - Georg Dorfmüller
- Member of ERN EpiCare, Department of Pediatric Neurosurgery, Hospital Fondation Adolphe de Rothschild, Paris, France
| | - J Helen Cross
- Department of Neurology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street & UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK
| | - Josef Zentner
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Martin Tisdall
- Department of Neurosurgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Kees P J Braun
- Member of ERN EpiCare, Department of Child Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, and Utrecht University, Utrecht, The Netherlands
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Sousa S, Sá Pinto V, Chaves J, Martins da Silva A, Ramalheira J, Lopes J, Temudo T, Lopes Lima JM, Calheiros A, Rangel R. Long term outcome of functional hemispherectomy for refractory epilepsy: Experience from a single center. NEUROCIRUGIA (ENGLISH EDITION) 2022; 33:82-89. [PMID: 35248302 DOI: 10.1016/j.neucie.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/25/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Hemispherectomy has an established role as a treatment of last resort in patients with unilateral hemispheric lesions suffering from refractory epilepsy. METHODS Seven patients were evaluated at our Epilepsy Unit. We compared the seizure outcome at 6 months, 1, 2, 5 years post-surgery, as well as at end follow-up (mean 7.1 years) using Engel classification. Reduction of antiepileptic drugs (AEDs) was also assessed utilizing equal time frames. RESULTS The mean age of seizure onset was 5.4 years. Engel I was achieved in 5 patients at 6 months (71.4%). Engel at 1 year was predicted by the Engel at 6 months (p=0.013) with a similar number of patients being classified as Engel I outcome. Engel at 2 years was also predicted by Engel at 6 months and at 1 year (p=0.030). At end follow-up only 3 patients (42.9%) remained categorized as Engel I outcome. There was a trend toward a stability in Engel classification. All patients with developmental causes for their epilepsy experienced some deterioration of the surgical outcomes. Conversely, all patients with acquired causes were stable throughout follow-up. Seizure outcome at 6 months was worse in the patients who had post-op complications (p=0.044). Adult and pediatric populations did not differ significantly in any tested variable. CONCLUSIONS Hemispherectomy is a valuable resource for seizure control in properly selected patients. Engel patient's evolution could be predicted at 6 months interval. Hemispherectomy could be considered a useful attitude in difficult cases.
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Affiliation(s)
- Sérgio Sousa
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurosurgery, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal.
| | - Vasco Sá Pinto
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurosurgery, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal
| | - João Chaves
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurology, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal; UMIB/ICBAS - University of Porto, Porto, Portugal
| | - António Martins da Silva
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurophysiology, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal; UMIB/ICBAS - University of Porto, Porto, Portugal
| | - João Ramalheira
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurophysiology, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal
| | - João Lopes
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurophysiology, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal
| | - Teresa Temudo
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neuropediatrics Department, Centro Hospitalar Universitário do Porto, Portugal
| | - José Manuel Lopes Lima
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal
| | - Alfredo Calheiros
- Neurosurgery, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal
| | - Rui Rangel
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurosurgery, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal
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Cossu M, Nichelatti M, De Benedictis A, Rizzi M. Lateral versus vertical hemispheric disconnection for epilepsy: a systematic review and meta-analysis. J Neurosurg 2021:1-11. [PMID: 34653979 DOI: 10.3171/2021.5.jns21949] [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] [Received: 04/14/2021] [Accepted: 05/18/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Lateral periinsular hemispherotomy (LPH) and vertical parasagittal hemispherotomy (VPH) are the most popular disconnective techniques for intractable epilepsies associated with unilateral hemispheric pathologies. The authors aimed to investigate possible differences in seizure outcome and complication rates between patients who underwent LPH and VPH. METHODS A comprehensive literature search of PubMed and Embase identified English-language articles published from database inception to December 2019 that reported series (minimum 12 patients with follow-up ≥ 12 months) on either LPH or VPH. Pooled rates of seizure freedom and complications (with a particular focus on hydrocephalus) were analyzed using meta-analysis to calculate both fixed and random effects. Heterogeneity (Cochran's Q test) and inconsistency (fraction of Q due to actual heterogeneity) were also calculated. RESULTS Twenty-five studies were included. Data from 825 patients were available for seizure outcome analysis (583 underwent LPH and 242 underwent VPH), and data from 692 patients were available for complication analysis (453 underwent LPH and 239 underwent VPH). No differences were found in the pooled rates of Engel class I seizure outcome between patients who underwent LPH (80.02% and 79.44% with fixed and random effects, respectively) and VPH (79.89% and 80.69% with fixed and random effects, respectively) (p = 0.953). No differences were observed in the pooled rates of shunted hydrocephalus between patients who underwent LPH (11.34% and 10.63% with fixed and random effects, respectively) and VPH (11.07% and 9.98% with fixed and random effects, respectively) (p = 0.898). Significant heterogeneity and moderate inconsistency were determined for hydrocephalus occurrence in patients who underwent both LPH and VPH. CONCLUSIONS LPH and VPH techniques present similar excellent seizure outcomes, with comparable and acceptable safety profiles.
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Affiliation(s)
- Massimo Cossu
- 1"Claudio Munari" Epilepsy Surgery Centre, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Michele Nichelatti
- 2Service of Biostatistics, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano, Niguarda, Milan, Italy; and
| | - Alessandro De Benedictis
- 3Neurosurgery Unit, Department of Neurosciences, Bambino Gesù Children Hospital IRCCS, Rome, Italy
| | - Michele Rizzi
- 1"Claudio Munari" Epilepsy Surgery Centre, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Fallah A, Lewis E, Ibrahim GM, Kola O, Tseng CH, Harris WB, Chen JS, Lin KM, Cai LX, Liu QZ, Lin JL, Zhou WJ, Mathern GW, Smyth MD, O'Neill BR, Dudley RWR, Ragheb J, Bhatia S, Delev D, Ramantani G, Zentner J, Wang AC, Dorfer C, Feucht M, Czech T, Bollo RJ, Issabekov G, Zhu H, Connolly M, Steinbok P, Zhang JG, Zhang K, Hidalgo ET, Weiner HL, Wong-Kisiel L, Lapalme-Remis S, Tripathi M, Sarat Chandra P, Hader W, Wang FP, Yao Y, Champagne PO, Brunette-Clément T, Guo Q, Li SC, Budke M, Pérez-Jiménez MA, Raftopoulos C, Finet P, Michel P, Schaller K, Stienen MN, Baro V, Cantillano Malone C, Pociecha J, Chamorro N, Muro VL, von Lehe M, Vieker S, Oluigbo C, Gaillard WD, Al-Khateeb M, Al Otaibi F, Krayenbühl N, Bolton J, Pearl PL, Weil AG. Comparison of the real-world effectiveness of vertical versus lateral functional hemispherotomy techniques for pediatric drug-resistant epilepsy: A post hoc analysis of the HOPS study. Epilepsia 2021; 62:2707-2718. [PMID: 34510448 PMCID: PMC9290517 DOI: 10.1111/epi.17021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/24/2021] [Accepted: 07/15/2021] [Indexed: 11/26/2022]
Abstract
Objective This study was undertaken to determine whether the vertical parasagittal approach or the lateral peri‐insular/peri‐Sylvian approach to hemispheric surgery is the superior technique in achieving long‐term seizure freedom. Methods We conducted a post hoc subgroup analysis of the HOPS (Hemispheric Surgery Outcome Prediction Scale) study, an international, multicenter, retrospective cohort study that identified predictors of seizure freedom through logistic regression modeling. Only patients undergoing vertical parasagittal, lateral peri‐insular/peri‐Sylvian, or lateral trans‐Sylvian hemispherotomy were included in this post hoc analysis. Differences in seizure freedom rates were assessed using a time‐to‐event method and calculated using the Kaplan–Meier survival method. Results Data for 672 participants across 23 centers were collected on the specific hemispherotomy approach. Of these, 72 (10.7%) underwent vertical parasagittal hemispherotomy and 600 (89.3%) underwent lateral peri‐insular/peri‐Sylvian or trans‐Sylvian hemispherotomy. Seizure freedom was obtained in 62.4% (95% confidence interval [CI] = 53.5%–70.2%) of the entire cohort at 10‐year follow‐up. Seizure freedom was 88.8% (95% CI = 78.9%–94.3%) at 1‐year follow‐up and persisted at 85.5% (95% CI = 74.7%–92.0%) across 5‐ and 10‐year follow‐up in the vertical subgroup. In contrast, seizure freedom decreased from 89.2% (95% CI = 86.3%–91.5%) at 1‐year to 72.1% (95% CI = 66.9%–76.7%) at 5‐year to 57.2% (95% CI = 46.6%–66.4%) at 10‐year follow‐up for the lateral subgroup. Log‐rank test found that vertical hemispherotomy was associated with durable seizure‐free progression compared to the lateral approach (p = .01). Patients undergoing the lateral hemispherotomy technique had a shorter time‐to‐seizure recurrence (hazard ratio = 2.56, 95% CI = 1.08–6.04, p = .03) and increased seizure recurrence odds (odds ratio = 3.67, 95% CI = 1.05–12.86, p = .04) compared to those undergoing the vertical hemispherotomy technique. Significance This pilot study demonstrated more durable seizure freedom of the vertical technique compared to lateral hemispherotomy techniques. Further studies, such as prospective expertise‐based observational studies or a randomized clinical trial, are required to determine whether a vertical approach to hemispheric surgery provides superior long‐term seizure outcomes.
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Affiliation(s)
- Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Evan Lewis
- Neurology Center of Toronto, Toronto, Ontario, Canada
| | - George M Ibrahim
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Olivia Kola
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Chi-Hong Tseng
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - William B Harris
- Department of Medicine, John A. Burns School of Medicine at University of Hawaii, Honolulu, Hawaii, USA
| | - Jia-Shu Chen
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Kao-Min Lin
- Department of Functional Neurosurgery, Xiamen Humanity Hospital, Xiamen, China
| | - Li-Xin Cai
- Department of Pediatric Epilepsy Center, Peking University First Hospital, Beijing, China
| | - Qing-Zhu Liu
- Department of Pediatric Epilepsy Center, Peking University First Hospital, Beijing, China
| | - Jiu-Luan Lin
- Department of Epilepsy Center, Yuquan Hospital, Tsinghua University, Beijing, China
| | - Wen-Jing Zhou
- Department of Epilepsy Center, Yuquan Hospital, Tsinghua University, Beijing, China
| | - Gary W Mathern
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Matthew D Smyth
- Department of Neurological Surgery, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Brent R O'Neill
- Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Roy W R Dudley
- Division of Neurosurgery, Department of Pediatric Surgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - John Ragheb
- Department of Neurosurgery, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Sanjiv Bhatia
- Department of Neurosurgery, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Daniel Delev
- Department of Neurosurgery, University Medical Center Freiburg and Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Georgia Ramantani
- Department of Neurosurgery, University Medical Center Freiburg and Medical Faculty, University of Freiburg, Freiburg, Germany.,Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland
| | - Josef Zentner
- Department of Neurosurgery, University Medical Center Freiburg and Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Anthony C Wang
- Department of Neurosurgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Christian Dorfer
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Martha Feucht
- Department of Pediatrics, Medical University Vienna, Vienna, Austria
| | - Thomas Czech
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Robert J Bollo
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Galymzhan Issabekov
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongwei Zhu
- Department of Functional Neurosurgery, Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Mary Connolly
- Division of Neurosurgery, Department of Surgery, BC Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Paul Steinbok
- Division of Neurosurgery, Department of Surgery, BC Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Jian-Guo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kai Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Eveline Teresa Hidalgo
- Division of Pediatric Neurosurgery, Department of Surgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, New York, USA
| | - Howard L Weiner
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Lily Wong-Kisiel
- Division of Child Neurology and Epilepsy, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Samuel Lapalme-Remis
- Division of Neurology, Department of Medicine, University of Montreal Hospital Centre, Montreal, Quebec, Canada
| | - Manjari Tripathi
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Poodipedi Sarat Chandra
- Department of Neurosurgery (Center of Excellence for Epilepsy & Magnetoencephalography), All India Institute of Medical Sciences and National Brain Research Center, New Delhi, India
| | - Walter Hader
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Feng-Peng Wang
- Department of Functional Neurosurgery, Xiamen Humanity Hospital, Xiamen, China
| | - Yi Yao
- Department of Neurosurgery, Guangdong Shenzhen Children Hospital, Shenzhen, China
| | | | | | - Qiang Guo
- Department of Neurosurgery, Guangdong Sanjiu Brain Hospital, Guangzhou Shi, China
| | - Shao-Chun Li
- Department of Neurosurgery, Guangdong Sanjiu Brain Hospital, Guangzhou Shi, China
| | - Marcelo Budke
- Department of Neurosurgery, Niño Jesus University Children's Hospital, Madrid, Spain
| | | | - Christian Raftopoulos
- Department of Neurosurgery, Brussels Saint-Luc University Hospital, Brussels, Belgium
| | - Patrice Finet
- Department of Neurosurgery, Brussels Saint-Luc University Hospital, Brussels, Belgium
| | - Pauline Michel
- Department of Neurosurgery, Brussels Saint-Luc University Hospital, Brussels, Belgium
| | - Karl Schaller
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Martin N Stienen
- Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Valentina Baro
- Academic Neurosurgery, Department of Neuroscience, University of Padova, Padova, Italy
| | - Christian Cantillano Malone
- Department of Neurosurgery, Pontifical Catholic University of Chile, Sotero del Rio Hospital, Santiago, Chile
| | - Juan Pociecha
- Epilepsy Department, Neurology Neurophysiology Epilepsy Service Foundation Against Childhood Neurological Diseases, Buenos Aires, Argentina
| | - Noelia Chamorro
- Epilepsy Department, Neurology Neurophysiology Epilepsy Service Foundation Against Childhood Neurological Diseases, Buenos Aires, Argentina
| | - Valeria L Muro
- Epilepsy Department, Neurology Neurophysiology Epilepsy Service Foundation Against Childhood Neurological Diseases, Buenos Aires, Argentina
| | - Marec von Lehe
- Department of Neurosurgery, Brandenburg Medical School, Neuruppin, Germany
| | - Silvia Vieker
- Department of Neurosurgery, Brandenburg Medical School, Neuruppin, Germany
| | - Chima Oluigbo
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA
| | - William D Gaillard
- Divisions of Child Neurology and Epilepsy and Neurophysiology, Children's National Medical Center, Washington, District of Columbia, USA
| | - Mashael Al-Khateeb
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Alfaisal University, Riyadh, Saudi Arabia
| | - Faisal Al Otaibi
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Alfaisal University, Riyadh, Saudi Arabia
| | - Niklaus Krayenbühl
- Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Jeffrey Bolton
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Phillip L Pearl
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alexander G Weil
- Department of Neurosurgery, Saint Justine University Hospital Centre, Montreal, Quebec, Canada
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7
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Hemispherotomy for pediatric epilepsy: a systematic review and critical analysis. Childs Nerv Syst 2021; 37:2153-2161. [PMID: 33907902 DOI: 10.1007/s00381-021-05176-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/18/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Several variations of functional disconnection surgery have been described for the treatment of lateralized, hemispheric, drug-resistant epilepsy in children. The purpose of this study is to investigate the existing literature regarding patient selection, approach, and outcomes after hemispherotomy. METHODS A systematic review of the English literature through February 2019 was performed in accordance with the PRISMA statement. The articles were classified by level of evidence and summarized in an evidentiary table. Seizure outcomes, functional outcomes, surgical techniques, complications, and patient selection were critically analyzed. RESULTS A total of 173 papers were reviewed, of which 37 met criteria of inclusion and exclusion. Thirteen studies were classified as level III evidence, the remaining reached level IV. Vertical and lateral hemispherotomy achieve similar rates of seizure freedom and functional outcomes, though parasagittal and interhemispheric approaches may have shorter operative times and less blood loss. Etiology, bilateral MRI abnormalities, and nonlateralizing EEG did not predict worse seizure or functional outcomes. CONCLUSIONS Both vertical and lateral hemispherotomy approaches result in durable, reproducible benefits to epilepsy severity and functional status in appropriately selected pediatric patients.
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8
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Sousa S, Sá Pinto V, Chaves J, Martins da Silva A, Ramalheira J, Lopes J, Temudo T, Lopes Lima JM, Calheiros A, Rangel R. Long term outcome of functional hemispherectomy for refractory epilepsy: Experience from a single center. Neurocirugia (Astur) 2021; 33:S1130-1473(21)00025-7. [PMID: 33745843 DOI: 10.1016/j.neucir.2021.01.004] [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: 11/06/2020] [Revised: 01/24/2021] [Accepted: 01/25/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Hemispherectomy has an established role as a treatment of last resort in patients with unilateral hemispheric lesions suffering from refractory epilepsy. METHODS Seven patients were evaluated at our Epilepsy Unit. We compared the seizure outcome at 6 months, 1, 2, 5 years post-surgery, as well as at end follow-up (mean 7.1 years) using Engel classification. Reduction of antiepileptic drugs (AEDs) was also assessed utilizing equal time frames. RESULTS The mean age of seizure onset was 5.4 years. Engel I was achieved in 5 patients at 6 months (71.4%). Engel at 1 year was predicted by the Engel at 6 months (p=0.013) with a similar number of patients being classified as Engel I outcome. Engel at 2 years was also predicted by Engel at 6 months and at 1 year (p=0.030). At end follow-up only 3 patients (42.9%) remained categorized as Engel I outcome. There was a trend toward a stability in Engel classification. All patients with developmental causes for their epilepsy experienced some deterioration of the surgical outcomes. Conversely, all patients with acquired causes were stable throughout follow-up. Seizure outcome at 6 months was worse in the patients who had post-op complications (p=0.044). Adult and pediatric populations did not differ significantly in any tested variable. CONCLUSIONS Hemispherectomy is a valuable resource for seizure control in properly selected patients. Engel patient's evolution could be predicted at 6 months interval. Hemispherectomy could be considered a useful attitude in difficult cases.
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Affiliation(s)
- Sérgio Sousa
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurosurgery, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal.
| | - Vasco Sá Pinto
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurosurgery, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal
| | - João Chaves
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurology, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal; UMIB/ICBAS - University of Porto, Porto, Portugal
| | - António Martins da Silva
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurophysiology, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal; UMIB/ICBAS - University of Porto, Porto, Portugal
| | - João Ramalheira
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurophysiology, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal
| | - João Lopes
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurophysiology, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal
| | - Teresa Temudo
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neuropediatrics Department, Centro Hospitalar Universitário do Porto, Portugal
| | - José Manuel Lopes Lima
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal
| | - Alfredo Calheiros
- Neurosurgery, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal
| | - Rui Rangel
- Epilepsy Unit, Porto Epicare Centre for Refractory Epilepsy, Centro Hospitalar Universitário do Porto, Portugal; Neurosurgery, Neurosciences Department, Centro Hospitalar Universitário do Porto, Portugal
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9
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Abstract
Hemispherectomy is a unique epilepsy surgery procedure that has undergone significant modification and evolution since Dandy's early description. This procedure is mainly indicated to treat early childhood and infancy medically intractable epilepsy. Various epileptic syndromes have been treated with this procedure, including hemimegalencephaly (HME), Rasmussen's encephalitis, Sturge-Weber syndrome (SWS), perinatal stroke, and hemispheric cortical dysplasia. In terms of seizure reduction, hemispherectomy remains one of the most successful epilepsy surgery procedures. The modification of this procedure over many years has resulted in lower mortality and morbidity rates. HME might increase morbidity and lower the success rate. Future studies should identify the predictors of outcomes based on the pathology and the type of hemispherectomy. Here, based on a literature review, we discuss the evolution of hemispherectomy techniques and their outcomes and complications.
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10
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Sturge-Weber syndrome: an update on the relevant issues for neurosurgeons. Childs Nerv Syst 2020; 36:2553-2570. [PMID: 32564157 DOI: 10.1007/s00381-020-04695-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/21/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Sturge-Weber syndrome (SWS) is a neurocutaneous facomatosis characterized by facial and leptomeningeal angioma, glaucoma, seizures, and neurological disability. Therefore, a challenging multidisciplinary interaction is required for its management. The goal of this paper is to review the main aspects of SWS and to present an illustrative pediatric series. METHODS The pertinent literature has been analyzed, focused mainly on etiopathogenesis, pathology, clinical features, diagnostic tools, management, and outcome of the disease. Moreover, a series of 11 children operated on for refractory epilepsy between 2005 and 2015 (minimum follow-up 5 years, mean follow-up 9.6 years) is reported. The series consists of six boys and five girls with 6.5-month and 16.2-month mean age at seizure onset and at surgery, respectively. Seizures affected all children, followed by hemiparesis and psychomotor delay (81%), glaucoma (54%), and other neurological deficits (45%). RESULTS All children underwent hemispherectomy (anatomical in three cases, functional in two cases, hemispherotomy in six cases); one patient needed a redo hemispherotomy. Mortality was nil; disseminated intravascular coagulation and interstitial pneumonia occurred in one patient each; three children had subdural fluid collection. Eight patients (72%) are in the ILAE Class 1 (completely seizure and aura free), two in Class 2 (only auras, no seizure), and one in Class 3 (1-3 seizure days per year). AEDs discontinuation was possible in 73% of cases. The most important news from the literature concerned the pathogenesis (role of the mutation of the GNAQ gene in the abnormal SWS vasculogenesis), the clinical findings (the features and pathogenesis of the stroke-like episodes are being understood), the diagnostic tools (quantitative MRI and EEG), and both the medical (migraine, seizures) and surgical management (epilepsy). The epileptic outcome of SWS patients is very good (80% are seizure-free), if compared with other hemispheric syndromes. The quality of life is affected by the neurological and cognitive deficits. CONCLUSIONS SWS still is an etiological and clinical challenge. However, the improvements over the time are consistent. In particular, the neurosurgical treatment of refractory epilepsy provides very good results as long as the indication to treatment is correct.
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11
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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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12
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Arifin MT, Muttaqin Z, Hanaya R, Bakhtiar Y, Bintoro AC, Iida K, Kurisu K, Arita K, Andar EBPS, B HK, Priambada D, Risdianto A, Kusnarto G, Bunyamin J. Hemispherotomy for drug-resistant epilepsy in an Indonesian population. Epilepsy Behav Rep 2019; 12:100337. [PMID: 31828236 PMCID: PMC6888712 DOI: 10.1016/j.ebr.2019.100337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/03/2019] [Accepted: 09/20/2019] [Indexed: 11/29/2022] Open
Abstract
Hemispherotomy is a surgical treatment indicated in patients with drug-resistant epilepsy due to unilateral hemispheric pathology. Hemispherotomy is less invasive compared with hemispherectomy. We reviewed our experience performing 24 hemispherotomy and report the results of 16 patients with prolonged follow-up of this relatively uncommon procedure in two centers in Indonesia. This is a retrospective observational study conducted from 1999 to July 2019 in two epilepsy neurosurgical centers in Semarang, Indonesia. Surgical techniques included vertical parasagittal hemispherotomy (VPH), peri-insular hemispherotomy (PIH), and modified PIH called the Shimizu approach (SA). The postoperative assessment was carried out using the Engel classification system of seizure outcome. Seizure freedom (Engel class I) outcome was achieved in 10 patients (62.5%), class II in 3 patients (18.7%), class III in 2 patients (12.5%), and class IV in 1 patient (6.3%) with follow-up duration spanning from 24 to 160 months. To the best of our knowledge, this series is the most extensive documentation of hemispherotomy in an Indonesian population. We report our experience performing hemispherotomy in selected cases in two centers in Indonesia To the best of our knowledge, this is the largest case series of hemispherotomy for drug-resistant epilepsy in Indonesia. Engel class I outcome was seen in 62.5% for 16 patients of which 81.3% of patients improved regarding reduction in pre-operative seizure frequency
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Affiliation(s)
| | - Zainal Muttaqin
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Indonesia
| | - Ryosuke Hanaya
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Japan
| | - Yuriz Bakhtiar
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Indonesia
| | - Aris Catur Bintoro
- Department of Neurology, Faculty of Medicine, Diponegoro University, Indonesia
| | - Koji Iida
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Kaoru Kurisu
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Kazunori Arita
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Japan
| | - Erie B P S Andar
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Indonesia
| | - Happy Kurnia B
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Indonesia
| | - Dody Priambada
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Indonesia
| | - Ajid Risdianto
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Indonesia
| | - Gunadi Kusnarto
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Indonesia
| | - Jacob Bunyamin
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Indonesia
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13
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Hwang JK, Kim DS. From Resection to Disconnection for Seizure Control in Pediatric Epilepsy Children. J Korean Neurosurg Soc 2019; 62:336-343. [PMID: 31085960 PMCID: PMC6514314 DOI: 10.3340/jkns.2019.0031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 03/21/2019] [Indexed: 11/27/2022] Open
Abstract
Epilepsy surgery revealed dramatically improved seizure outcomes over medical therapy in drug-resistant epilepsy patients. Children with epilepsy, however, have multiple epileptic focuses which require multilobar resection for better seizure outcome. Multilobar resection has not only the several severe surgical complications, such as hydrocephalus and shunt-related craniosynostosis, due to intracranial volume reduction. Isolation method (disconnection surgery) was progressively studied over epileptic focus removal (resective surgery) for seizure control. This concept was first introduced for functional hemispherotomy, and its primary principle is to preserve the vital vascularized brain that is functionally disconnected from the contralateral healthy brain. Currently in most epilepsy centers, the predominant disconnection surgical methods, including functional hemispherotomy, are continually being refined and are showing excellent results. They allow the functional isolation of the hemisphere or multi-lobe, affected by severe epilepsy. This review describes recent findings concerning the indication, surgical technique, seizure outcome and complications in several disconnection surgeries including the functional hemispherotomy for refractory pediatric epilepsy.
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Affiliation(s)
- Jun Kyu Hwang
- Department of Pediatric Neurosurgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong-Seok Kim
- Department of Pediatric Neurosurgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
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14
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Kim JS, Park EK, Shim KW, Kim DS. Hemispherotomy and Functional Hemispherectomy: Indications and Outcomes. J Epilepsy Res 2018; 8:1-5. [PMID: 30090755 PMCID: PMC6066693 DOI: 10.14581/jer.18001] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 03/27/2018] [Indexed: 11/30/2022] Open
Abstract
Hemispherectomy constitutes an established surgical method in the management of patients with medically intractable epilepsy secondary to severe unilateral hemisphere damage. As opposed to focal resections, in hemispherotomies, the entire hemisphere is disconnected from the remaining nervous system, including the functional regions and fibers. Despite this, hemispherotomy is recommended for certain indications, and has good functional and epilepsy outcomes. Here we describe the indications, epilepsy outcomes, and surgical techniques for several hemispheric surgeries.
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Affiliation(s)
- Ju-Seong Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University, College of Medicine, Seoul, Korea
| | - Eun-Kyung Park
- Department of Pediatric Neurosurgery, Severance Children's Hospital, Yonsei University, College of Medicine, Seoul, Korea
| | - Kyu-Won Shim
- Department of Pediatric Neurosurgery, Severance Children's Hospital, Yonsei University, College of Medicine, Seoul, Korea
| | - Dong Seok Kim
- Department of Pediatric Neurosurgery, Severance Children's Hospital, Yonsei University, College of Medicine, Seoul, Korea
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15
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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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16
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Baumgartner JE, Blount JP, Blauwblomme T, Chandra PS. Technical descriptions of four hemispherectomy approaches: From the Pediatric Epilepsy Surgery Meeting at Gothenburg 2014. Epilepsia 2017; 58 Suppl 1:46-55. [DOI: 10.1111/epi.13679] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2016] [Indexed: 11/28/2022]
Affiliation(s)
| | - Jeffrey P. Blount
- Division of Neurosurgery; University of Alabama Birmingham Medical School; Birmingham Alabama U.S.A
| | - Thomas Blauwblomme
- Pediatric Neurosurgery; AP-HP Hopital Necker-Enfants Malades; Paris France
- PRES Sorbonne Paris Cité; University Paris Descartes; Paris France
| | - P. Sarat Chandra
- Department of Neurosurgery; All India Institute of Medical Sciences; New Delhi India
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17
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Hu WH, Zhang C, Zhang K, Shao XQ, Zhang JG. Hemispheric surgery for refractory epilepsy: a systematic review and meta-analysis with emphasis on seizure predictors and outcomes. J Neurosurg 2016; 124:952-61. [DOI: 10.3171/2015.4.jns14438] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Conflicting conclusions have been reported regarding several factors that may predict seizure outcomes after hemispheric surgery for refractory epilepsy. The goal of this study was to identify the possible predictors of seizure outcome by pooling the rates of postoperative seizure freedom found in the published literature.
METHODS
A comprehensive literature search of PubMed, Embase, and the Cochrane Library identified English-language articles published since 1970 that describe seizure outcomes in patients who underwent hemispheric surgery for refractory epilepsy. Two reviewers independently assessed article eligibility and extracted the data. The authors pooled rates of seizure freedom from papers included in the study. Eight potential prognostic variables were identified and dichotomized for analyses. The authors also compared continuous variables within seizure-free and seizure-recurrent groups. Random- or fixed-effects models were used in the analyses depending on the presence or absence of heterogeneity.
RESULTS
The pooled seizure-free rate among the 1528 patients (from 56 studies) who underwent hemispheric surgery was 73%. Patients with an epilepsy etiology of developmental disorders, generalized seizures, nonlateralization on electroencephalography, and contralateral MRI abnormalities had reduced odds of being seizure-free after surgery.
CONCLUSIONS
Hemispheric surgery is an effective therapeutic modality for medically intractable epilepsy. This meta-analysis provides useful evidence-based information for the selection of candidates for hemispheric surgery, presurgical counseling, and explanation of seizure outcomes.
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Affiliation(s)
| | | | | | - Xiao-Qiu Shao
- 3Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian-Guo Zhang
- 1Beijing Neurosurgical Institute and
- Departments of 2Neurosurgery and
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18
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Cukiert A, Rydenhag B, Harkness W, Cross JH, Gaillard WD. Technical aspects of pediatric epilepsy surgery: Report of a multicenter, multinational web-based survey by the ILAE Task Force on Pediatric Epilepsy Surgery. Epilepsia 2016; 57:194-200. [DOI: 10.1111/epi.13292] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Arthur Cukiert
- Department of Neurosurgery; ABC Faculty of Medicine; Sao Paulo Brazil
| | - Bertil Rydenhag
- Institute of Neuroscience and Physiology; Sahlgrenska Academy of Gothenburg University; Gothenburg Sweden
- Department of Neurosurgery; Sahlgrenska University Hospital; Gothenburg Sweden
| | - William Harkness
- Department of Neurosurgery; Great Ormond Street Hospital for Children NHS Foundation Trust; London United Kingdom
| | - J. Helen Cross
- UCL-Institute of Child Health; Great Ormond Street Hospital for Children NHS Foundation Trust; London United Kingdom
- Young Epilepsy; Lingfield United Kingdom
| | - William D. Gaillard
- Center for Neuroscience and Behavioral Health; Children's National Health System; The George Washington University School of Medicine and Health Sciences; Washington District of Columbia U.S.A
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19
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Chandra PS, Kurwale N, Garg A, Dwivedi R, Malviya SV, Tripathi M. Endoscopy-Assisted Interhemispheric Transcallosal Hemispherotomy. Neurosurgery 2015; 76:485-94; discussion 494-5. [DOI: 10.1227/neu.0000000000000675] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Various hemispherotomy techniques have been developed to reduce complication rates and achieve the best possible seizure control.
OBJECTIVE:
To present a novel and minimally invasive endoscopy-assisted approach to perform this procedure.
METHODS:
Endoscopy-assisted interhemispheric transcallosal hemispherotomy was performed in 5 children (April 2013-June 2014). The procedure consisted of performing a small craniotomy (4 × 3 cm) just lateral to midline using a transverse skin incision. After dural opening, the surgery was performed with the assistance of a rigid high-definition endoscope, and bayoneted self-irrigating bipolar forceps and other standard endoscopic instruments. Steps included a complete corpus callosotomy followed by the disconnection of the hemisphere at the level of the basal nuclei and thalamus. The surgeries were performed in a dedicated operating room with intraoperative magnetic resonance imaging and neuronavigation. Intraoperative magnetic resonance imaging confirmed a total disconnection.
RESULTS:
The pathologies for which surgeries were performed included sequelae of middle a cerebral artery infarct (n = 2), Rasmussen syndrome (n = 1), and hemimegalencephaly (2). Four patients had an Engel class I and 1 patient had a class II outcome at a mean follow-up of 10.2 months (range, 3-14 months). The mean blood loss was 80 mL, and mean operating time was 220 minutes. There were no complications in this study.
CONCLUSION:
This study describes a pilot novel technique and the feasibility of performing a minimally invasive, endoscopy-assisted hemispherotomy.
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Affiliation(s)
| | | | | | | | | | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Mathon B, Bédos-Ulvin L, Baulac M, Dupont S, Navarro V, Carpentier A, Cornu P, Clemenceau S. Évolution des idées et des techniques, et perspectives d’avenir en chirurgie de l’épilepsie. Rev Neurol (Paris) 2015; 171:141-56. [DOI: 10.1016/j.neurol.2014.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 08/10/2014] [Accepted: 09/30/2014] [Indexed: 10/24/2022]
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Hamad AP, Caboclo LO, Centeno R, Costa LV, Ladeia-Frota C, Carrete H, Gomez NG, Marinho M, Yacubian EMT, Sakamoto AC. Hemispheric surgery for refractory epilepsy in children and adolescents: Outcome regarding seizures, motor skills and adaptive function. Seizure 2013; 22:752-6. [DOI: 10.1016/j.seizure.2013.06.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 05/31/2013] [Accepted: 06/03/2013] [Indexed: 11/26/2022] Open
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Surgical management of cortical dysplasia in infancy and early childhood. Brain Dev 2013; 35:802-9. [PMID: 23694756 DOI: 10.1016/j.braindev.2013.04.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 04/02/2013] [Accepted: 04/15/2013] [Indexed: 11/22/2022]
Abstract
PURPOSE To describe operative procedures, seizure control and complications of surgery for cortical dysplasia (CD) causing intractable epilepsy in infancy and early childhood. METHODS Fifty-six consecutive children (less than 6years old) underwent resective epilepsy surgery for CD from December 2000 to August 2011. Age at surgery ranged from 2 to 69months (mean 23months) and the follow-up was from 1 to 11years (mean 4years 4months). RESULTS Half of the children underwent surgery during infancy at an age less than 10months, and the majority (80%) of these infants needed extensive surgical procedures, such as hemispherotomy and multi-lobar disconnection. Seizure free (ILAE class 1) outcome was obtained in 66% of the cases (class 1a; 55%): 85% with focal resection (n=13), 50% with lobar resection (n=18), 71% with multilobar disconnection (n=7) and 67% with hemispherotomy (n=18). Peri-ventricular and insular structures were resected in 23% of focal and 61% of lobar resections. Repeated surgery was performed in 9 children and 5 (56%) became seizure free. Histological subtypes included hemimegalencephaly (16 patients), polymicrogyria (5 patients), and FCD type I (6 patients), type IIA (19 patients), type IIB (10 patients). Polymicrogyria had the worst seizure outcome compared to other pathologies. Surgical complications included 1 post-operative hydrocephalus, 1 chronic subdural hematoma, 2 intracranial cysts, and 1 case of meningitis. No mortality or severe morbidities occurred. CONCLUSIONS Early surgical intervention in children with CD and intractable seizures in infancy and early childhood can yield favorable seizure outcome without mortality or severe morbidities although younger children often need extensive surgical procedures.
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Epilepsy surgery for hemispheric syndromes in infants: hemimegalencepahly and hemispheric cortical dysplasia. Brain Dev 2013; 35:742-7. [PMID: 23777678 DOI: 10.1016/j.braindev.2013.05.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 05/09/2013] [Accepted: 05/11/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Hemimegalencepahly (HME) and Hemispheric Cortical Dysplasia (HCD) are rare congenital diseases that occur with intractable epilepsy. They manifest by early epilepsy, mental retardation, hemianopsia and contralateral hemiplegia. Hemispheric disconnection (mainly anatomical hemispherectomy, peri-insular hemispherotomy, modified lateral hemispherotomy and vertical parasagittal hemispherotomy) have been reported to be efficient on seizures and also to prevent additional cognitive injury and developmental delay. METHOD We reviewed literature about clinical presentation, predictors of outcome and expectation about epileptic seizures and cognitive outcome. RESULTS Clinical presentation and seizures outcome have been described in almost 600 children for the last thirty years. Epilepsy improved in most cases depending on the series and the follow-up duration. Percentage of seizure-free patients with HME or HCD was lower than in other groups (Rasmussen Encephalitis, Vascular Sequellae). Post-operative complications decreased with the hemispherotomy surgical procedures. EEG abnormalities on the "save" hemisphere did not negatively influence postsurgical outcome. Seizure free outcome did not seem to depend on the surgical procedure but the presence of residual insular cortex seemed to be associated with persistent postoperative seizures. Contralateral MRI abnormalities seemed to be associated with poorer prognosis for seizure free outcome and lack of cognitive improvement. CONCLUSION Hemispheric disconnection remains the best treatment in order to control epileptic seizures. Hemispheric surgical procedures are safe and can be performed from the first month of life. Prospective studies of cognition are needed to emphasize benefits on long term outcome.
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Pediatric functional hemispherectomy: outcome in 92 patients. Acta Neurochir (Wien) 2012; 154:2017-28. [PMID: 22941395 DOI: 10.1007/s00701-012-1481-3] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 08/10/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The revival of epilepsy surgery after the introduction of modern presurgical evaluation procedures has led to an increase in hemispherectomy or hemispherotomy procedures. Since a large part of our pediatric series was done using a newer hemispherotomy technique, we focus mainly on the outcomes after a recently developed hemispherotomy technique (transsylvian keyhole). METHODS Ninety-six pediatric patients (aged 4 months to 18 years, mean 7.3) were operated on between 1990 and 2009; 92 were available with follow-up. RESULTS The most frequent diagnosis was porencephaly in 46 % of all patients. Progressive etiologies were present in 20 % and developmental etiologies in 22 %. At last available outcome (LAO), 85 % of the patients were seizure free (ILAE class 1). Year-to-year outcome was rather stable; usually over 80 % were class 1 for up to 13 years (n = 24). Of 92 assessable patients, 71 were treated with the transsylvian keyhole technique, with 89 % being seizure free. The overall shunt rate was 5.3 % for the whole series and 3 % for the keyhole technique subgroup. Mortality was 1 of 96 patients. Excluding patients with hemimegalencephaly (HME), patients with the shortest duration of epilepsy and the lowest age at seizure onset had the highest rates of seizure freedom. The etiology does influence outcome, with HME patients having the poorest seizure outcome and patients with Sturge-Weber syndrome and porencephaly having excellent seizure control. CONCLUSION Hemispherotomies/functional hemispherectomies are very effective and safe procedures for treating drug-resistant epilepsy with extensive unihemispheric pathology. Etiology and surgery type clearly influence seizure outcome.
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Lew SM, Matthews AE, Hartman AL, Haranhalli N. Posthemispherectomy hydrocephalus: results of a comprehensive, multiinstitutional review. Epilepsia 2012; 54:383-9. [PMID: 23106378 DOI: 10.1111/epi.12010] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Hemispherectomy surgery for medically intractable epilepsy is known to cause hydrocephalus in a subset of patients. Existing data regarding the incidence of, and risk factors for, developing posthemispherectomy hydrocephalus have been limited by the relatively small number of cases performed by any single center. Our goal was to better understand this phenomenon and to identify risk factors that may predispose patients to developing hydrocephalus after hemispherectomy surgery. METHODS Fifteen pediatric epilepsy centers participated in this study. A retrospective chart review was performed on all available patients who had hemispherectomy surgery. Data collected included surgical techniques, etiology of seizures, prior brain surgery, symptoms and signs of hydrocephalus, timing of shunt placement, and basic demographics. KEY FINDINGS Data were collected from 736 patients who underwent hemispherectomy surgery between 1986 and 2011. Forty-six patients had preexisting shunted hydrocephalus and were excluded from analysis, yielding 690 patients for this study. One hundred sixty-two patients (23%) required hydrocephalus treatment. The timing of hydrocephalus ranged from the immediate postoperative period to 8.5 years after surgery, with 43 patients (27%) receiving shunts >90 days after surgery. Multivariate regression analysis revealed anatomic hemispherectomies (odds ratio [OR] 4.1, p < 0.0001) and previous brain surgery (OR 1.7, p = 0.04) as independent significant risk factors for developing hydrocephalus. There was a trend toward significance for the use of hemostatic agents (OR 2.2, p = 0.07) and the involvement of basal ganglia or thalamus in the resection (OR 2.2, p = 0.08) as risk factors. SIGNIFICANCE Hydrocephalus is a common sequela of hemispherectomy surgery. Surgical technique and prior brain surgery influence the occurrence of posthemispherectomy hydrocephalus. A significant portion of patients develop hydrocephalus on a delayed basis, indicating the need for long-term surveillance.
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Affiliation(s)
- Sean M Lew
- Department of Neurosurgery, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.
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Ciliberto MA, Limbrick D, Powers A, Titus JB, Munro R, Smyth MD. Palliative hemispherotomy in children with bilateral seizure onset. J Neurosurg Pediatr 2012; 9:381-8. [PMID: 22462702 DOI: 10.3171/2011.12.peds11334] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intractable epilepsy is a significant burden on families and on the cognitive development and quality of life (QOL) of patients. Periinsular hemispherotomy (PIH) for medically intractable epilepsy can benefit patients who qualify for this procedure. The ideal hemispherotomy candidate has ipsilateral ictal and interictal epileptiform activity, unilateral MR imaging abnormalities, contralateral hemiplegia, and a normal contralateral hemisphere. However, certain patients present with a mixed picture of bilateral electroencephalography (EEG) findings and severe intractable epilepsy, prompting consideration of a more aggressive treatment approach. This report introduces the possibility of surgery for patients who normally would not meet criteria for this treatment modality. METHODS In this retrospective chart review, the authors report on 7 patients with bilateral seizure onset noted on routine or video-EEG monitoring. A QOL phone questionnaire, based on the Quality of Life in Childhood Epilepsy tool, was administered to a parent. The authors reviewed each patient's chart for surgical complications, changes in examination, QOL, limited neuropsychological outcomes, and seizure outcomes. They also investigated each chart for MR imaging and EEG findings as well as the patient's epilepsy clinic notes for seizure semiology and frequency. RESULTS All patients enjoyed a decrease in seizure frequency and a subjective increase in QOL after PIH. Five patients (71%) achieved Engel Class I or II seizure control. The mean follow-up was 3.64 years (2-5.3 years). One patient is now off all antiseizure medication. No patient had a decrement in Full Scale IQ on postsurgical testing, and 2 (28.5%) of 7 individuals had increased adaptive and social functioning. Postsurgical examination changes included hemiplegia and homonymous hemianopia. CONCLUSIONS Hemispherotomy in patients with intractable epilepsy is generally reserved for individuals with unilateral epileptiform abnormalities or lesions on MR imaging. Seven patients in this study benefited from surgery despite bilateral seizure onset with improvement in seizure control and overall QOL. Thus, bilateral ictal onset does not necessarily preclude consideration for hemispherotomy in selected patients with severe medically refractory epilepsy.
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Affiliation(s)
- Michael Anthony Ciliberto
- Departments of Developmental and Pediatric Neurology, Washington University, St. Louis, MO 63110, USA.
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Torres CV, Fallah A, Ibrahim GM, Cheshier S, Otsubo H, Ochi A, Chuang S, Snead OC, Holowka S, Rutka JT. The role of magnetoencephalography in children undergoing hemispherectomy. J Neurosurg Pediatr 2011; 8:575-83. [PMID: 22132915 DOI: 10.3171/2011.8.peds11128] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Hemispherectomy is an established neurosurgical procedure for medication-resistant epilepsy in children. Despite the effectiveness of this technique, there are patients who do not achieve an optimum outcome after surgery; possible causes of suboptimal results include the presence of bilateral independent epileptogenic foci. Magnetoencephalography (MEG) is an emerging tool that has been found to be useful in the management of lesional and nonlesional epilepsy. The authors analyzed the relative contribution of MEG in patient selection for hemispherectomy. METHODS The medical records of children undergoing hemispherectomy at the Hospital for Sick Children were reviewed. Those patients who underwent MEG as part of the presurgical evaluation were selected. RESULTS Thirteen patients were included in the study. Nine patients were boys. The mean age at the time of surgery was 66 months (range 10-149 months). Seizure etiology was Rasmussen encephalitis in 6 patients, hemimegalencephaly in 2 patients, and cortical dysplasia in 4 patients. In 8 patients, video-EEG and MEG results were consistent to localize the primary epileptogenic hemisphere. In 2 patients, video-EEG lateralized the ictal onset, but MEG showed bilateral spikes. Two patients had bilateral video-EEG and MEG spikes. Engel Class I, II, and IV outcomes were seen in 10, 2, and 1 patients, respectively. In 2 of the patients who had an outcome other than Engel Class I, the MEG clusters were concentrated in the disconnected hemisphere. The third patient had bilateral clusters and potentially independent epileptogenic foci from bilateral cortical dysplasia. CONCLUSIONS The presence of unilateral MEG spike waves correlated with good outcomes following hemispherectomy. In some cases, MEG provides information that differs from that obtained from video-EEG and conventional MR imaging studies. Further studies with a greater number of patients are needed to assess the role of MEG in the preoperative assessment of candidates for hemispherectomy.
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Affiliation(s)
- Cristina V Torres
- Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
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Kwan A, Ng WH, Otsubo H, Ochi A, Snead OC, Tamber MS, Rutka JT. Hemispherectomy for the control of intractable epilepsy in childhood: comparison of 2 surgical techniques in a single institution. Neurosurgery 2011; 67:429-36. [PMID: 21099569 DOI: 10.1227/neu.0b013e3181f743dc] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hemispherectomy is an established neurosurgical procedure for catastrophic epilepsy in childhood. However, the technique used to achieve an optimum outcome remains to be determined. OBJECTIVE We examined the influence of hemidecortication (HD) vs peri-insular hemispherotomy (PIH) on patient outcome. METHODS The medical records of 41 children undergoing hemispherectomy were reviewed for patient demographics, clinical criteria, and surgical outcomes. RESULTS HD and PIH were performed in 21 and 20 children, respectively. The mean age at surgery for HD was 54 months and 61 months for PIH. The median durations of surgery for HD and PIH were 5 hours and 7 hours, respectively (P < .001). For HD, 6 patients required a second surgery and 3 required a third. One PIH patient required a second procedure. Postoperative shunting was required in 5 HD patients, but only 1 PIH patient. All patients had increased hemiparesis after surgery. The overall mean follow-up time was 72 months. Engel class I or II outcomes after initial surgery were better after PIH (85%) compared with HD (48%) (P < .02). After subsequent surgeries for seizure control, 4 HD patients and 1 PIH patient improved to Engel class I or II. CONCLUSION Hemispherectomy is an effective surgical procedure for childhood intractable catastrophic epilepsy. In patients with diffuse hemispheric disorder, PIH tends to have fewer major complications, more favorable seizure outcomes, and a decreased need for subsequent surgical procedures, including shunting for hydrocephalus, compared with HD.
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Affiliation(s)
- Allison Kwan
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Bortel A, Longo D, de Guzman P, Dubeau F, Biagini G, Avoli M. Selective changes in inhibition as determinants for limited hyperexcitability in the insular cortex of epileptic rats. Eur J Neurosci 2010; 31:2014-23. [PMID: 20497472 DOI: 10.1111/j.1460-9568.2010.07225.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The insular cortex (IC) is involved in the generalization of epileptic discharges in temporal lobe epilepsy (TLE), whereas seizures originating in the IC can mimic the epileptic phenotype seen in some patients with TLE. However, few studies have addressed the changes occurring in the IC in TLE animal models. Here, we analyzed the immunohistochemical and electrophysiological properties of IC networks in non-epileptic control and pilocarpine-treated epileptic rats. Neurons identified with a neuron-specific nuclear protein antibody showed similar counts in the two types of tissue but parvalbumin- and neuropeptide Y-positive interneurons were significantly decreased (parvalbumin, approximately -35%; neuropeptide Y, approximately -38%; P < 0.01) in the epileptic IC. Non-adapting neurons were seen more frequently in the epileptic IC during intracellular injection of depolarizing current pulses. In addition, single-shock electrical stimuli elicited network-driven epileptiform responses in 87% of epileptic and 22% of non-epileptic control neurons (P < 0.01) but spontaneous postsynaptic potentials had similar amplitude, duration and intervals of occurrence in the two groups. Finally, pharmacologically isolated, GABA(A) receptor-mediated inhibitory postsynaptic potentials had more negative reversal potential (P < 0.01) and higher peak conductance (P < 0.05) in epileptic tissue. These data reveal moderate increased network excitability in the IC of pilocarpine-treated epileptic rats. We propose that this limited degree of hyperexcitability originates from the loss of parvalbumin- and neuropeptide Y-positive interneurons that is compensated by an increased drive for GABA(A) receptor-mediated inhibition.
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Affiliation(s)
- Aleksandra Bortel
- Montreal Neurological Institute and Department of Neurology & Neurosurgery, McGill University, 3801 University, Room 794, Montreal, QC, H3A 2B4, Canada
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Limbrick DD, Narayan P, Powers AK, Ojemann JG, Park TS, Bertrand M, Smyth MD. Hemispherotomy: efficacy and analysis of seizure recurrence. J Neurosurg Pediatr 2009; 4:323-32. [PMID: 19795963 DOI: 10.3171/2009.5.peds0942] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Hemispherotomy generally is performed in hemiparetic patients with severe, intractable epilepsy arising from one cerebral hemisphere. In this study, the authors evaluate the efficacy of hemispherotomy and present an analysis of the factors influencing seizure recurrence following the operation. METHODS The authors performed a retrospective review of 49 patients (ages 0.2-20.5 years) who underwent functional hemispherotomy at their institution. The first 14 cases were traditional functional hemispherotomies, and included temporal lobectomy, while the latter 35 were performed using a modified periinsular technique that the authors adopted in 2003. RESULTS Thirty-eight of the 49 patients (77.6%) were seizure free at the termination of the study (mean follow-up 28.6 months). Of the 11 patients who were not seizure free, all had significant improvement in seizure frequency, with 6 patients (12.2%) achieving Engel Class II outcome and 5 patients (10.2%) achieving Engel Class III. There were no cases of Engel Class IV outcome. The effect of hemispherotomy was durable over time with no significant change in Engel class over the postoperative follow-up period. There was no statistical difference in outcome between surgery types. Analysis of factors contributing to seizure recurrence after hemispherotomy revealed no statistically significant predictors of treatment failure, although bilateral electrographic abnormalities on the preoperative electroencephalogram demonstrated a trend toward a worse outcome. CONCLUSIONS In the present study, hemispherotomy resulted in freedom from seizures in nearly 78% of patients; worthwhile improvement was demonstrated in all patients. The seizure reduction observed after hemispherotomy was durable over time, with only rare late failure. Bilateral electrographic abnormalities may be predictive of posthemispherotomy recurrent seizures.
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Affiliation(s)
- David D Limbrick
- Department of Neurosurgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri 63110-1077, USA.
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Cukiert A, Cukiert CM, Argentoni M, Baise-Zung C, Forster CR, Mello VA, Burattini JA, Mariani PP. Outcome after hemispherectomy in hemiplegic adult patients with refractory epilepsy associated with early middle cerebral artery infarcts. Epilepsia 2009; 50:1381-4. [DOI: 10.1111/j.1528-1167.2008.01795.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Park YS, Lee YH, Shim KW, Lee YJ, Kim HD, Lee JS, Kim DS. Insular epilepsy surgery under neuronavigation guidance using depth electrode. Childs Nerv Syst 2009; 25:591-7. [PMID: 19139907 DOI: 10.1007/s00381-008-0764-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The unfavorable surgical results that have been reported with insular epilepsy surgery may be related to inadequate monitoring. Insular epilepsy surgery requires the precise monitoring and tailored removal of the epileptic zone. The purposes of this study were to precisely monitor the hidden cortex and determine the effectiveness of using different monitoring methods, including subpial depth electrodes. MATERIALS AND METHODS This is a study of a single center series of six patients (three men, three women) who underwent insular surgery between May 2006 and December 2007. All patients had experienced medically intractable seizures without any evidence of a tumorous condition based on previous examination. We used strip electrode implantation in one patient and stereotactic depth electrode insertion in two patients, which resulted in partial removal of the insular. The other three patients underwent open direct subpial depth electrode insertion, which resulted in total removal of the insular cortex. RESULTS There were no surgery-related complications with the insulectomy after insertion of the subpial depth electrodes, regardless of the monitoring method or extent of removal. All patients except for one showed considerable improvement in epilepsy (83.3% Engle class I, 16.5% Engle class II). In the three patients who had open direct subpial depth electrodes inserted, we achieved total insulectomy without increasing the surgical morbidity, while in the other three patients, the insular removal was only partial. CONCLUSION We demonstrate that image-guided insular surgery with safe and accurate depth electrode guidance results in an optimal outcome and complete resection of the insular cortex.
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Affiliation(s)
- Young Seok Park
- Pediatric Neurosurgery, Pediatric Epilepsy Clinic, Severance Children's Hospital, Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, 134, Shinchon-dong, Seodaemoon-gu, Seoul 120-752, Republic of Korea
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Abstract
The surgical treatment of intractable epilepsy has evolved as new technical innovations have been made. Hemispherotomy techniques have been developed to replace hemispherectomy in order to reduce the complication rates while maintaining good seizure control. Disconnective procedures are based on the interruption of the epileptic network rather than the removal of the epileptogenic zone. They can be applied to hemispheric pathologies, leading to hemispherotomy, but they can also be applied to posterior quadrant epilepsies, or hypothalamic hamartomas. In this paper, the authors review the literature, present an overview of the historical background, and discuss the different techniques along with their outcomes and complications.
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Affiliation(s)
- Sandrine De Ribaupierre
- Department of Clinical Neurological Sciences, University of Western Ontario, London Health Sciences Centre, London, Ontario, Canada.
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Pollo C, Debatisse D, Pralong E, Levivier M. L’hémisphérotomie péri-insulaire : technique chirurgicale, monitoring EEG intraopératoire et résultats sur le contrôle de l’épilepsie. Neurochirurgie 2008; 54:303-10. [DOI: 10.1016/j.neuchi.2008.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Évaluation à long terme des déconnexions hémisphériques. Neurochirurgie 2008; 54:358-61. [DOI: 10.1016/j.neuchi.2008.02.051] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Accepted: 02/26/2008] [Indexed: 11/24/2022]
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