Outcome after hemispherectomy in hemiplegic adult patients with refractory epilepsy associated with early middle cerebral artery infarcts

Abstract

SUMMARYPurpose: To study the outcome after hemispherectomy (HP) in a homogeneous adult patient population with refractory hemispheric epilepsy. Methods: Fourteen adult patients submitted to HP were studied. Patients had to be at least 18 years old, and have refractory epilepsy, clearly focal lateralized seizures and unilateral porencephalus consistent with early middle cerebral artery infarct on magnetic resonance imaging (MRI). All patients were submitted to functional hemispherectomy. We analyzed age of seizure onset, age by the time of surgery, gender, seizure type and frequency, interictal and ictal electroencephalography (EEG) findings, MRI and IQ scores preoperatively; seizure frequency, drug regimen, and IQ outcome were studied postoperatively. Results: Mean follow-up was 64 months. All patients had frequent daily seizures preoperatively. All patients had unilateral simple partial motor seizures (SPS); 11 patients had secondarily generalized tonic-clonic (GTC) seizures and five patients had complex partial seizures (CPS), preoperatively. All patients had hemiplegia and hemianopsia. Twelve patients had unilateral EEG findings, and in two epileptic discharges were seen exclusively over the apparently normal hemisphere. Twelve patients were seizure-free after surgery and two patients had at least 90% improvement in seizure frequency. Pre-and postoperative mean general IQ was 84 and 88, respectively. Five of the twelve Engel I patients were receiving no drugs at last follow-up. There was no mortality or major morbidity. Conclusions: Our results suggest that wellselected adult patients might also get good results after HP. Although good results were obtained in our adult series, the same procedure yielded a much more striking result if performed earlier in life.

Long-term outcome of hemispheric surgery at different ages in 61 epilepsy patients

“…Several authors have advocated early hemispheric surgery and short epilepsy duration and some evidence seems to suggest advantages with regard to postoperative development and adaptive functioning 7 10 14–15 20–24 33. We found a slightly better seizure outcome in ES patients but reported better intellectual, academic and psychosocial outcomes for LS patients.…”

“…Advantageous cognitive and psychosocial outcomes in hemispherectomy patients operated at a higher age have been previously reported 29 33–38. For example, Cuckiert et al 33 found no cognitive decline in any of the 14 adult hemispherectomy patients. Chiricozzi et al 36 described a case of remarkable cognitive improvement after hemispherectomy at age 14 years, and Telfeian et al 34 reported recovery of language in a patient with hemispherectomy at age 16 years.…”

Evolution of epilepsy in hemimegalencephaly from infancy to adulthood: Case report and review of the literature

“…Hydrocephalus is commonly seen, as are infections, fever, anemia and temporary worsening of previous deficits [1], [15]. In adults, hemianopia, loss of pincer grasp and worsening gait, all expected effects of hemispherectomy [16], [17], cause more impairment than in children. However, overall motor and intellectual function has been seen to improve after surgery [17].…”

“…In adults, hemianopia, loss of pincer grasp and worsening gait, all expected effects of hemispherectomy [16], [17], cause more impairment than in children. However, overall motor and intellectual function has been seen to improve after surgery [17].…”

Refractory epilepsy and deep brain stimulation

“…22 Most studies relate to children, three published adult studies reporting respectively four of four, five of nine and five of 12 patients becoming seizure free. [23][24][25] Multiple subpial transection aims to limit the horizontal spread of epileptiform activity across functional columns of eloquent cortex. A meta-analysis of adults and children has shown >95% seizure frequency reduction in 87% of patients with generalised seizures and 68% with partial seizures, compared to cortical transections alone.…”