Outcome of hemispheric surgeries for refractory epilepsy in pediatric patients

Abstract

We analyzed demographic data, interictal and ictal EEG findings, age at surgery, surgical technique and complications, and postsurgical seizure outcome. There were 74.4% males. Tonic and focal motor seizures occurred in 30.8 and 20.5% of the patients. Most frequent etiologies were Rasmussen encephalitis (30.8%) and malformation of cortical development (23.1%). Postsurgical outcomes were Engel classes I and II for 61.5% of the patients. In general, 89.5% of the patients exhibited at least a 90% reduction in seizure frequency. All patients had acute worsening of hemiparesis after surgery. Basically, two surgical techniques have been employed, both with similar results, although a trend has been noted toward one of the procedures which produced consistently complete disconnection. Patients with hemispheric brain lesions usually have abnormal neurological development and intractable epilepsy. When video-EEG monitoring and magnetic resonance imaging show unilateral disease, the patient may evolve with a good surgical outcome. We showed that a marked reduction in seizure frequency may be achieved, with acceptable neurological impairments.

Utility of diffusion tensor imaging studies linked to neuronavigation and other modalities in repeat hemispherotomy for intractable epilepsy

“…In this group of patients, one can expect a 70%-85% chance of seizure freedom following hemispherectomy. 3,5,9,12,14,15,18,19,27,30,31 The technique of hemispherectomy has evolved over the past 30 years to include approaches that primarily disconnect the affected hemisphere from the contralateral side, and that have become more minimally invasive, requiring less cerebral tissue to be removed. Al- though these advancements have led to expedited patient recovery and diminished length of stay in hospital, just as with anatomical hemispherectomy, there are instances of seizure recurrences or failures that arise after PIH or other functional disconnection procedures.…”

Seizures in Children with Brain Tumours — Epidemiology, Significance, Management, and Outcomes

“…Over the years, attempts have been made to optimize the resection of epileptogenic lesions by both better delineating their margins and identifying extra-tumoral epileptogenic tissue, using intra-operative tools like electrocorticography (ECoG) to identify potential seizure-inducing tissue irregularities like cortical dysplasia [63,77,93,132,1 [6] 3 , 184,214,216,240,241]. This has led to debate regarding the relative benefits and safety of performing epilepsy surgery rather than just lesionectomies in patients with tumour-triggered seizures [242]; though, in fact, many surgeons have been utilizing additional surgical steps like lobectomies, amygdylohypocampectomies and, in extreme cases, hemispherectomies for decades [63,86,94,117,132,148,149,168,182,185,214,217,218,222,227,243]. To date, almost no direct empirical comparisons have been undertaken.…”

“…In terms of the former, attempts are usually made to resect any residual or newly-discovered tumour, as well as to identify and resect other epileptogenic foci. Approaches range from simple lesionectomies to lobectomies and, in the most severe cases, hemispherectomies [243]. Half of these studies were exclusive to paediatric patients, while the other half included children, adolescents and adults.…”

Rasmussen’s Encephalitis: An Overview

“…(Bien et al, 2005b;Bien et al, 2009a) The severity of each of the expected deficits after surgery should be weighed in relation to the severity of epilepsy. (Bien et al, 2005b;Bien et al, 2009a;Terra-Bustamante et al, 2009;Terra-Bustamante et al, 2007) This requires extensive and in-depth discussions with the patient and his family. Whereas the prediction of postoperative aphasia in a still communicable child (RE of the language dominant hemisphere) will usually preclude surgery, the perspective of a fixed dense hemiparesis with preserved walking abilities may be an acceptable price for seizure freedom.…”

“…This is particularly clear in cases, in which continuous or near-continuous motor seizures impair hand and leg function anyway. (Bien et al, 2005b;Bien et al, 2009a;Terra-Bustamante et al, 2009;Terra-Bustamante et al, 2007) Regardless of the affected side, the probably least relevant consequence of surgery is hemianopia, which is usually well compensated in everyday life. In conclusion, especially in patients with impairing seizures and affection of the non-dominant hemisphere, surgery will often emerge as the superior long-term option compared to ongoing conservative treatment.…”