Periinsular hemispherotomy in children with stroke-induced refractory epilepsy

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Ischemic cerebral vascular accidents (CVAs) in children result in epilepsy in 25% of patients, which is refractory in 7% of cases. Repeated seizures worsen the global and cognitive prognosis of these patients. To evaluate the prognosis of epilepsy and cognitive development in children with refractory seizures following a CVA, the authors retrospectively studied the effectiveness of periinsular hemispherotomy in the treatment of these patients.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>Between March 1995 and November 2007, 8 children who suffered from stroke-induced refractory epilepsy underwent a periinsular hemispherotomy. All patients' charts were reviewed in a retrospective manner. Age at the time of the CVA, imaging studies, cause of the ischemic event, onset of the first seizure, patient's handedness, the extent of the parenchymal damage, electroencephalography findings, type of epileptic seizures, number of seizures per day, number of antiepileptic medications, preoperative neuropsychological evaluation, and surgical outcome with regard to the patient's seizure activity were analyzed.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>There were 7 boys and 1 girl in this study. The mean age at stroke was 23 months (range birth–5 years). The mean age at onset of epilepsy was 22 months (range 0–60 months). The mean age at the time of the hemispherotomy was 7 years (range 54–130 months). The average delay prior to the hemispherotomy was 5 years and 3 months (range 23–115 months). Prior to surgery, the average number of seizures per day was 35 (range 5–100). The average number of antiepileptic medications introduced before the hemispherotomy was 8 (range 6–12). Six patients required only 1 surgical intervention and 2 necessitated 2 separate operations:1 underwent a 2-staged hemispherotomy and the other underwent a prior callosotomy. There were no reported surgical complications in this series. Seven children are seizure free. However, the remaining child, after a 3.5-year disease-free interval, has recently started having seizures. No child demonstrated an improvement in neuropsychological evaluation.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>The periinsular hemispherotomy must be considered an alternative in the therapeutic approach to stroke-induced pediatric refractory epilepsy. It is effective in controlling seizure activity. The authors believe the delay before hemispherotomy must be shortened in children with post-CVA refractory epilepsy.</jats:p></jats:sec>

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

“…In addition, functional independence remained profoundly constricted as more than half of the patients required assistance in specific daily activities and lived in assisted settings, and one third required permanent attendance. This corresponds with other reports of limited functional independence23 31 and mainstream school education attainable only for a minority 3 15 24. Thus, on a group level, developmental or intellectual catch-up to healthy peers after hemispherectomy cannot normally be expected.…”

“…In particular, the optimal timing of surgery with regard to neurocognitive development, despite being a pressing clinical issue, remains uncertain so far. General neuropsychological considerations suggest that younger patients might benefit from the maturing brain's higher plasticity and an earlier release from the negative impact of epilepsy (ie, seizures, antiepileptic drugs) on brain development,17–19 and several authors have argued in favour of early surgical intervention and short epilepsy duration for hemispheric surgery patients 7 10 14 15 20–24…”

Surgical management of medically refractory epilepsy due to early childhood stroke

“…1,35,36 Hemispheric disconnection/anatomical resection has been the mainstay of surgical therapy for large perinatal porencephalic cysts after MCA stroke. 18,34,35 In this subgroup, outstanding seizure control rates with Engel Class IA outcomes in almost 90% of patients have been reported. 6,34 We used this technique in 4 patients in this series after invasive mapping and in 3 others in a single stage with equally good outcomes.…”

“…18,34,35 In this subgroup, outstanding seizure control rates with Engel Class IA outcomes in almost 90% of patients have been reported. 6,34 We used this technique in 4 patients in this series after invasive mapping and in 3 others in a single stage with equally good outcomes. Two of these patients presented for surgery at an advanced age, so the team was hesitant to recommend a 1-stage hemispherotomy, and in all 4 patients who underwent invasive monitoring, the parents were reluctant to agree to hemispherotomy without electrographic evidence to justify it.…”

Pediatric Stroke and Seizures

“…The limited studies in children post stroke suggest that refractory epilepsy occurs in approximately 5-7 % of patients [35,83]. Although children tend to have better recovery of language and volitional movement after stroke presumably due to their brain plasticity [84], long-term neurological and cognitive sequelae remain a significant burden.…”