Epilepsy surgery in patients with normal or nonfocal MRI scans: Integrative strategies offer long‐term seizure relief

Abstract

SUMMARYPurpose: Excisional surgery achieves seizure freedom in a large proportion of children with intractable lesional epilepsy, but the outcome for children without a focal lesion on MRI is less clear. We report the outcome of a cohort predominantly of children with nonlesional intractable partial epilepsy undergoing resective surgery. Methods: We studied 102 patients with nonlesional intractable partial epilepsy who underwent excisional surgery. The epileptogenic region was identified by integrating clinical exam and video-EEG data complemented by ictal SPECT (n = 40), PET (n = 10), extraoperative subdural monitoring (n = 80), and electrocorticography (n = 22). All patients had follow-up greater than 2 years, 76 patients had 5-year follow-up, and 43 patients had 10-year follow-up. Results: A total of 66 resections were unilobar; 36 were multilobar. One patient died of causes unrelated to seizures or surgery. At 2-year follow-up, 44 of 101 patients were seizure-free, 15 experienced >90% reduction, 17 had >50% reduction, and 25 were unchanged. At 5-year follow-up, 35 of 76 patients were seizure-free, 12 experienced >90% reduction, 12 had >50% reduction, and 17 were unchanged. At 10-year follow-up, 16 of 43 patients were seizure-free, 13 experienced >90% reduction, 7 had >50% reduction, and 7 were unchanged. A discrete lesion on the MRI scan is arguably one of the most reliable features for defining the epileptogenic region (Engel et al

Expanding the role of surgery in intractable extratemporal pediatric epilepsy

“…Outcomes were classified in a manner similar to that used in the recent case series reported by Jayakar et al: Class I being characterized by freedom from seizures and Classes II, III, and IV being characterized by a reduction in seizure frequency of > 90%, > 50%, and Ͻ 50%, respectively. 13 At the most recent follow-up examination, 65% of the patients had an outcome ranging from excellent to good with 41% (15 of 37) being seizure-free, and another 24% (9) having experienced a > 90% reduction in seizures. Six (16%) had a > 50% reduction in seizures, and 7 had Ͻ 50% reduction.…”

“…9 All descriptions of outcomes below are based on the criteria of Jayakar and colleagues. 13 The majority (24 [60%] of 40) of the children had extratemporal resections (24/40), while 20% (8 of 40) had a temporal lobectomy, and 20% had extratemporal resection in addition to a temporal lobectomy. Three (38%) of the 8 children who initially underwent temporal lobectomy after invasive monitoring had recurrent seizures and had repeat invasive monitoring with additional extratemporal resections.…”

18F-FDG PET Reveals Frontotemporal Dysfunction in Children with Fever-Induced Refractory Epileptic Encephalopathy

“…Surprisingly, the cerebral cortex is usually respected (9). 18 F-FDG PET is highly sensitive at detecting abnormal metabolic patterns in childhood epilepsy with negative MRI results (10)(11)(12)(13)(14)(15). In bilateral epilepsies, visual analysis may be difficult and statistical parametric mapping (SPM) provides a reliable objective alternative.…”

The Arcuate Fasciculus and Language Development in a Cohort of Pediatric Patients with Malformations of Cortical Development

“…Regardless of whether such aberrant connectivity is established by genetic/developmental processes or by activity-dependent reorganization, and there is evidence to support a role for each, such abnormalities have obvious potential implications for neurocognitive development. [14][15][16][17][18][19] Recent work has demonstrated the potential for machine learning to translate quantitative data from whole-brain tractography into phenotypic information regarding language function in an individual patient. 20 Although highly accurate, this technique is time-consuming and requires substantial expertise in image processing and mathematics/statistics.…”