Risk factors and results of hemispherotomy reoperations in children

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>The goal of this study was to perform an analysis of a single-center experience with hemispherotomy reoperations for refractory hemispheric pediatric epilepsy due to persistence of seizures after initial surgery. The authors also identify possible anatomical and neurophysiological reasons for hemispherotomy failure, as well as risk factors and surgical options for this subgroup of patients.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>A review was performed of the medical records in 18 consecutive cases in which candidates for redo hemispherotomy were treated between 2003 and 2018 at the authors’ epilepsy surgery center. Fourteen patients underwent reoperation due to seizure recurrence and were studied herein, whereas in 3 the initial surgical procedure was stopped because of uncontrollable bleeding, and the remaining patient refused to undergo a reoperation in spite of seizure recurrence and went on to have a vagus nerve stimulation device placed.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Among the 14 patients whose seizures recurred and in whom reoperations were done, the etiology of epilepsy consisted of 7 cases with malformations of cortical development (50%), 5 cases of Rasmussen encephalitis (35.8%), 1 case of porencephaly (7.1%), and 1 case of Sturge-Weber syndrome (7.1%). Eleven patients had radiological evidence of incomplete disconnection. After reoperation, 6 patients were Engel class IA, 1 was Engel II, 5 were Engel III, and 2 were Engel IV, within a mean follow-up of 48.4 months.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>Patients with malformations of cortical development have a higher risk of seizure recurrence, and these malformations comprised the main etiology in the reoperation series. Failure of an initial hemispherotomy usually occurs due to incomplete disconnection and needs to be extensively assessed. Outcomes of reoperation are most often favorable, with acceptable complication rates.</jats:p></jats:sec>

Comparison of the real‐world effectiveness of vertical versus lateral functional hemispherotomy techniques for pediatric drug‐resistant epilepsy: A post hoc analysis of the HOPS study

“…One putative explanation is the higher likelihood of incomplete disconnection in the lateral hemispherotomy group. Given that seizure recurrence and the need for reoperation have been attributed to incomplete resection, 28 this may theoretically contribute to the greater durability of seizure freedom in patients undergoing vertical approaches. Insular epileptogenic onset is likely an underrepresented cause of refractory epilepsy in children, 29 , 30 and residual insular cortex has been identified as a cause of failure following hemispherectomy.…”

“…Functional hemispherotomy is a complex procedure with intricate surgical steps required to successfully perform a complete hemispheric disconnection, a major predictor of seizure outcome. 28 , 34 Epilepsy program and surgical experience has been shown to play a significant role in obtaining a complete anatomical disconnection and obtaining higher likelihood of seizure freedom and better outcome. 35 , 36 , 37 Although this variable was not explicitly studied in this analysis, the learning curve could potentially explain the higher seizure recurrence rate in lateral than in vertical hemispherotomies.…”

Surgical Strategy for Hemispherotomy

“…However, even if residual seizures are observed, many patients exhibit responsiveness to antiepileptic drugs and will benefit from surgical therapy. 17 , 18 ) Another purpose is to protect the unaffected hemisphere by suppressing recurrent epileptic discharges and epileptic seizures. Psychomotor development may be delayed or regressed, particularly in patients with frequent epileptic discharges in the unaffected hemisphere.…”

Second surgery after vertical paramedian hemispherotomy for epilepsy recurrence

“…RE is one of the etiologies found in patients with seizure recurrence leading to reoperative hemispherotomy. It represented 14% in a series of 36 patients [ 20 ] and 36% in a series of 18 patients [ 10 ] with malformation of cortical development being the most represented etiology in these series. In our series, a third patient suffering from RE underwent reoperative hemispherotomy but was excluded for insufficient last follow-up as she left the country directly after the surgery to her homeland.…”

“…Disabling seizures persist in a minority of these patients who may be candidates for complementary resection. Santos et al [ 10 ], in 2020, report favorable outcomes of reoperation with acceptable complication rates. We review and discuss the workup and complementary surgical treatment after failed VPH supported by two cases managed in our center.…”