Lateral versus vertical hemispheric disconnection for epilepsy: a systematic review and meta-analysis

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.

Not surgical technique, but etiology, contralateral MRI, prior surgery, and side of surgery determine seizure outcome after pediatric hemispherotomy

“…Although complication data, not reported in the recent large multicentric study, 21 are critical for weighing the potential benefit of the different hemispherotomy techniques against their associated risks, overall major complication rates did not differ significantly between hemispherotomy techniques in our study, although hydrocephalus occurred more often in the vertical hemispherotomy cohort. This observation is in line with previous cohort studies 3,5,7,13,42,43 and a recent meta-analysis 18 suggesting comparable overall rates of major surgical complications in vertical vs lateral hemispherotomy cohorts. Our findings thus corroborate that the vertical and lateral hemispherotomy techniques are similarly effective for seizure control, with acceptable and comparable safety profiles, when performed by skilled epilepsy neurosurgeons.…”

“…However, because each center commonly uses only one approach, these techniques have not been compared regarding their efficacy and morbidity until recently. In contrast to the findings of a multicentric Italian study 17 and four consecutive meta-analyses, 10,[18][19][20] a recent multicentric international study 21 reported shorter time-to-seizure recurrence and increased seizure recurrence odds for lateral compared to vertical hemispherotomy, fueling an ongoing debate on the impact of surgical techniques on seizure outcomes. The findings of that 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.…”

“…range reported by a recently published large multicentric study 21,22 and three meta-analyses, 10,18,19 all including patients who underwent hemispheric procedures as early as the 1970s. This finding is particularly reassuring, considering the broader spectrum of etiologies and the increased complexity of surgical cases in recent years.…”

Epilepsy surgery in older patients – English Version

“…Hemispheric disconnections are "radical" procedures for unilateral pathologies. They are associated with a very good seizure prognosis (Engel I in around 80%), although one must accept the expected consequences of these interventions (overview in [10]). Only individual cases of patients aged over 50 years are found here (e.g., [38]), indicating that a meaningful statement about this age group is not possible.…”

Surgical Strategy for Hemispherotomy

“…Hemispherotomy is highly effective in suppressing seizures in intractable epilepsy, with extensive epileptogenic regions in the unilateral cerebral hemisphere. 1 ) In addition, it is expected to contribute to growth and brain development by protecting the contralateral cerebral hemisphere. 2 ) In theory, hemispherotomy involves complete disconnection of neural fibers from the contralateral cerebral hemisphere and ipsilateral basal ganglia/thalamus.…”