Additional resective surgery after the failure of initial surgery in patients with intractable epilepsy

2017 ◽  
Vol 39 (12) ◽  
pp. 1049-1055
Author(s):  
Masafumi Fukuda ◽  
Hiroshi Masuda ◽  
Hiroshi Shirozu ◽  
Yosuke Ito ◽  
Yoko Nakayama ◽  
...  
2015 ◽  
Vol 16 (1) ◽  
pp. 94-100 ◽  
Author(s):  
Regina S. Bower ◽  
Elaine C. Wirrell ◽  
Laurence J. Eckel ◽  
Lily C. Wong-Kisiel ◽  
Katherine C. Nickels ◽  
...  

OBJECT Resection can sometimes offer the best chance of meaningful seizure reduction in children with medically intractable epilepsy. However, when surgery fails to achieve the desired outcome, reoperation may be an option. The authors sought to investigate outcomes following resective reoperation in pediatric patients with refractory epilepsy, excluding tumoral epilepsies. Differences in preoperative workup between surgeries are analyzed to identify factors influencing outcomes and complications in this complex group. METHODS Medical records were reviewed for all pediatric patients undergoing a repeat resective surgery for refractory epilepsy at the authors' institution between 2005 and 2012. Tumor and vascular etiologies were excluded. Preoperative evaluation and outcomes were analyzed for each surgery and compared. RESULTS Ten patients met all inclusion criteria. The median age at seizure onset was 4.5 months. Preoperative MRI revealed no lesion in 30%. Nonspecific gliosis and cortical dysplasia were the most common pathologies. The majority of preoperative workups included MRI, video-electroencephalography (EEG), and SISCOM. Intracranial EEG was performed for 60% for the first presurgical evaluation and 70% for the second evaluation. The goal of surgery was palliative in 4 patients with widespread cortical dysplasia. The final Engel outcome was Class I in 50%. The rate of favorable outcome (Engel Class I–II) was 70%. The complication rate for the initial surgery was 10%. However, the rate increased to 50% with the second surgery, and 3 of these 5 complications were pseudomeningoceles requiring shunt placement (2 of the 3 patients underwent hemispherotomy). CONCLUSIONS Resective reoperation for pediatric refractory epilepsy has a high rate of favorable outcome and should be considered in appropriate candidates, even as a palliative measure. Intracranial EEG monitoring should be considered on initial workup in cases where the results of imaging or EEG studies are ambiguous or conflicting. Epilepsy secondary to cortical dysplasia, especially if the dysplasia is not seen clearly on MRI, can be difficult to cure surgically. Therefore, in these cases, as large a resection as can be safely accomplished should be done, particularly when the goal is palliative. The rate of complications, particularly pseudomeningocele ultimately requiring shunt placement, is much higher following reoperation, and patients should be counseled accordingly.


1981 ◽  
Vol 74 (8) ◽  
pp. 574-579 ◽  
Author(s):  
C E Polkey

Selection criteria are the key to success in resective surgery for intractable epilepsy. Using such criteria about 50% of patients admitted for assessment are considered unsuitable, half of these for neurophysiological reasons or because there is evidence of more than one area of structural abnormality. Selection for a good result from temporal lobectomy can be judged, both on the proportion of positive pathological lesions in the resected temporal lobes and on a high degree of seizure relief together with a low incidence of side effects. The same holds for other resections. The relationship between these factors is reviewed.


2016 ◽  
Vol 18 (5) ◽  
pp. 523-535 ◽  
Author(s):  
Alexander G. Weil ◽  
Ngoc Minh D. Le ◽  
Prasanna Jayakar ◽  
Trevor Resnick ◽  
Ian Miller ◽  
...  

OBJECTIVE Seizure onset in the insular cortex as a cause of refractory epilepsy is underrepresented in the pediatric population, possibly due to difficulties localizing seizure onset in deep anatomical structures and limited surgical access to the insula, a complex anatomical structure with a rich overlying vascular network. Insular seizure semiology may mimic frontal, temporal, or parietal lobe semiology, resulting in false localization, incomplete resection, and poor outcome. METHODS The authors retrospectively reviewed the records of all pediatric patients who underwent insular cortical resections for intractable epilepsy at Miami Children's Hospital from 2009 to 2015. Presurgical evaluation included video electroencephalography monitoring and anatomical/functional neuroimaging. All patients underwent excisional procedures utilizing intraoperative electrocorticography or extraoperative subdural/depth electrode recording. RESULTS Thirteen children (age range 6 months–16 years) with intractable focal epilepsy underwent insular-opercular resection. Seven children described symptoms that were suggestive of insular seizure origin. Discharges on scalp EEG revealed wide fields. Four patients were MRI negative (i.e., there were no insular or brain abnormalities on MRI), 4 demonstrated insular signal abnormalities, and 5 had extrainsular abnormalities. Ten patients had insular involvement on PET/SPECT. All patients underwent invasive investigation with insular sampling; in 2 patients resection was based on intraoperative electrocorticography, whereas 11 underwent surgery after invasive EEG monitoring with extraoperative monitoring. Four patients required an extended insular resection after a failed initial surgery. Postoperatively, 2 patients had transient hemiplegia. No patients had new permanent neurological deficits. At the most recent follow-up (mean 43.8 months), 9 (69%) children were seizure free and 1 had greater than 90% seizure reduction. CONCLUSIONS Primary insular seizure origin should be considered in children with treatment-resistant focal seizures that are believed to arise within the perisylvian region based on semiology, widespread electrical field on scalp EEG, or insular abnormality on anatomical/functional neuroimaging. There is a reasonable chance of seizure freedom in this group of patients, and the surgical risks are low.


2020 ◽  
Vol 133 (5) ◽  
pp. 1576-1581 ◽  
Author(s):  
Yutaro Takayama ◽  
Naoki Ikegaya ◽  
Keiya Iijima ◽  
Yuiko Kimura ◽  
Norihiro Muraoka ◽  
...  

OBJECTIVEIntractable epilepsy patients with ulegyria could be candidates for resective surgery. Complete resection of ulegyria in the epileptogenic hemisphere is associated with favorable seizure outcome, although the risk of postoperative functional deficits is higher. The authors evaluated the extent of resection and postsurgical outcomes in epilepsy patients with ulegyria who underwent intracranial electroencephalography (iEEG) monitoring prior to resection to clarify the efficacy of iEEG-guided partial resection of ulegyria.METHODSTen consecutive epilepsy patients with ulegyria (7 males and 3 females, age range at surgery 7–34 years) underwent iEEG prior to resective surgery between 2011 and 2017 with a minimum follow-up of 12 months (range 12–72 months). The diagnosis of ulegyria was based on the typical pattern of cortical atrophy especially at the bottom of the sulcus on MRI. An iEEG study was indicated after comprehensive preoperative evaluations, including high-field MRI, long-term video-EEG, magnetoencephalography, and FDG-PET. The resection planning was based on iEEG analysis. Total lesionectomy was not always performed, as preservation of cortical function was prioritized.RESULTSUlegyria was seen in the occipital and/or parietal lobe in 9 patients and bilaterally in 5 patients. Ictal EEG onset involved the temporal neocortex in 6 patients. Intracranial electrodes were implanted unilaterally in all except 1 patient with bilateral lesions. The extent of MRI lesion was covered by the electrodes. Seizure onset zones (SOZs) and irritative zones (IZs) were identified in all patients. SOZs and IZs were completely resected in 8 patients but were only partially removed in the remaining 2 patients because the eloquent cortices and the epileptogenic zones overlapped. Ulegyria of the epileptogenic side was totally resected in 1 patient. Seizure freedom was achieved in 4 patients, including 3 after partial lesionectomy. Extended resection of the temporal neocortex was performed in 4 patients, although postoperative seizure freedom was achieved only in 1 of these patients. Visual field deficit was seen in 4 patients. Three of 5 patients with bilateral lesions achieved seizure freedom after unilateral resective surgery.CONCLUSIONSIntracranial EEG–guided partial lesionectomy provides a reasonable chance of postoperative seizure freedom with a lower risk of functional deficits. Patients with bilateral ulegyria should not be excluded from consideration as surgical candidates.


1995 ◽  
Vol 83 (1) ◽  
pp. 60-66 ◽  
Author(s):  
Itzhak Fried ◽  
Dennis D. Spencer ◽  
Susan S. Spencer

✓ An aura is generally understood to be the beginning of a seizure. Yet, following successful surgery for intractable epilepsy, patients may have persistent auras even though they are otherwise seizure free. Ninety patients with intractable seizures and auras underwent resective surgery. Forty-three patients had hippocampal sclerosis and 47 had temporal or extratemporal lesions such as glial tumors or vascular malformations. The semiology of the auras was found to have value in localization but not lateralization of the pathology. Epigastric auras as well as gustatory and olfactory auras were significantly more frequent in patients with hippocampal sclerosis than in those with temporal or extratemporal lesions. Auras of vertigo or dizziness were most frequent in patients with extratemporal pathology. There was a significant difference between the pathology groups in the efficacy of resection in eliminating the auras. Of the patients with hippocampal sclerosis who were rendered seizure free, 18.9% had persistent auras, whereas only one (2.6%) of the patients with temporal or extratemporal lesions who were rendered seizure free had persistent auras. These findings suggest that for patients with hippocampal sclerosis an anatomical dissociation between seizure and aura may occur, whereas this dissociation is not present in patients with lesions. Patients suspected of having hippocampal sclerosis should be counseled preoperatively as to the significant likelihood of persistent auras even if seizures are successfully abolished.


2013 ◽  
Vol 2013 ◽  
pp. 1-12 ◽  
Author(s):  
Iordanis Georgiadis ◽  
Effie Z. Kapsalaki ◽  
Kostas N. Fountas

Object. It is widely accepted that temporal resective surgery represents an efficacious treatment option for patients with epilepsy of temporal origin. The meticulous knowledge of the potential complications, associated with temporal resective procedures, is of paramount importance. In our current study, we attempt to review the pertinent literature for summating the complications of temporal resective procedures for epilepsy. Method. A PubMed search was performed with the following terms: “behavioral,” “cognitive,” “complication,” “deficit,” “disorder,” “epilepsy,” “hemianopia,” “hemianopsia,” “hemorrhage,” “lobectomy,” “medial,” “memory,” “mesial,” “neurobehavioral,” “neurocognitive,” “neuropsychological,” “psychological,” “psychiatric,” “quadranopia,” “quadranopsia,” “resective,” “side effect,” “surgery,” “temporal,” “temporal lobe,” and “visual field.” Results. There were six pediatric, three mixed-population, and eleven adult surgical series examining the incidence rates of procedure-related complications. The reported mortality rates varied between 0% and 3.5%, although the vast majority of the published series reported no mortality. The cumulative morbidity rates ranged between 3.2% and 88%. Conclusions. Temporal resective surgery for epilepsy is a safe treatment modality. The reported morbidity rates demonstrate a wide variation. Accurate detection and frank reporting of any surgical, neurological, cognitive, and/or psychological complications are of paramount importance for maximizing the safety and improving the patients’ overall outcome.


2012 ◽  
Vol 2012 ◽  
pp. 1-5
Author(s):  
George M. Ibrahim ◽  
Aria Fallah ◽  
O. Carter Snead ◽  
James T. Rutka

Introduction. Tuberous sclerosis (TS) is the leading cause of genetic epilepsy worldwide. Here, we evaluate changes in seizure outcomes following resective epilepsy surgery in children with TS over time. Methods. A systematic review of the literature was performed to identify studies reporting seizure outcomes following resective epilepsy surgery in children with TS. Using an individual participant meta-analysis approach, seizure outcomes and associated covariates were combined. Multivariate logistic regression was used to determine significant associations between seizure outcomes and time of surgery. Results. Twenty studies from 1966 to present, yielding 186 participants, met the inclusion criteria for the study. On univariate analysis, there was a significant improvement in seizure outcomes in children who underwent resective epilepsy surgery within the last 15 years compared to older cohorts (chi-square 4.1; P=0.043). On multivariate analysis, adjusting for length of followup, this trend was not significant (OR 0.52; 95% CI 0.23–1.17; P=0.11). In the last 15 years, a greater proportion of younger children also underwent resective surgery compared to older cohorts (OR 0.93; 95% CI 0.89–0.97; P<0.01). Conclusions. A trend towards improved seizure outcomes following resective surgery for TS was observed from 1966 to present on multivariate analysis.


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