Reoperative Hemispherectomy for Intractable Epilepsy

Neurosurgery ◽  
2012 ◽  
Vol 71 (2) ◽  
pp. 388-393 ◽  
Author(s):  
Sumeet Vadera ◽  
Ahsan N.V. Moosa ◽  
Lara Jehi ◽  
Ajay Gupta ◽  
Prakash Kotagal ◽  
...  
Keyword(s):  
Seizure Frequency ◽  
Medical Records ◽  
Cleveland Clinic ◽  
Intractable Epilepsy ◽  
Patient Characteristics ◽  
Cortical Dysplasia ◽  
Seizure Freedom ◽  
Management Options ◽  
Functional Hemispherectomy

Abstract BACKGROUND: In patients with medically intractable epilepsy and diffuse unilateral hemispheric disease, functional or disconnective hemispherectomy is a widely accepted and successful treatment option. If recurrent seizures develop after disconnective hemispherectomy, management options become more complex and include conversion to anatomic hemispherectomy. OBJECTIVE: To present the outcomes of all patients undergoing reoperative hemispherectomy in 1 institution by 1 surgeon since 1998. METHODS: The medical records, operative reports, and imaging studies for 36 patients undergoing reoperative hemispherectomy for continuing medically intractable epilepsy from 1998 to 2011 at Cleveland Clinic were reviewed. Patient characteristics, cause of seizure, imaging findings, surgery-related complications, and long-term seizure outcomes were evaluated. RESULTS: Patients presented with a variety of seizure origins, including Rasmussen encephalitis, perinatal infarction, cortical dysplasia, and hemimegalencephaly. Overall, 19% of patients were seizure free after conversion to anatomic hemispherectomy, and 45% reported a decrease in seizure frequency by ≥ 90%. An additional 36% reported no improvement. Generalized ictal electroencephalography tended to confer a poorer prognosis, as did cortical dysplasia as the underlying diagnosis. CONCLUSION: The possibility that residual epileptogenic tissue in the operated hemisphere remains connected should be considered after failed functional hemispherectomy because our data suggest that improvement in seizure frequency is possible after reoperative hemispherectomy, although the chance of obtaining seizure freedom is relatively low. The decision to proceed with reoperative hemispherectomy should be made after proper discussion with the patient and family and informed consent is given.

scholarly journals Nine-year prospective efficacy and safety of brain-responsive neurostimulation for focal epilepsy

Neurology ◽  
2020 ◽  
Vol 95 (9) ◽  
pp. e1244-e1256 ◽  
Author(s):  
Dileep R. Nair ◽  
Kenneth D. Laxer ◽  
Peter B. Weber ◽  
Anthony M. Murro ◽  
Yong D. Park ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Seizure Frequency ◽  
Focal Epilepsy ◽  
Responder Rate ◽  
Seizure Freedom ◽  
Open Label ◽  
Cognitive Domains ◽  
Signed Rank

ObjectiveTo prospectively evaluate safety and efficacy of brain-responsive neurostimulation in adults with medically intractable focal onset seizures (FOS) over 9 years.MethodsAdults treated with brain-responsive neurostimulation in 2-year feasibility or randomized controlled trials were enrolled in a long-term prospective open label trial (LTT) to assess safety, efficacy, and quality of life (QOL) over an additional 7 years. Safety was assessed as adverse events (AEs), efficacy as median percent change in seizure frequency and responder rate, and QOL with the Quality of Life in Epilepsy (QOLIE-89) inventory.ResultsOf 256 patients treated in the initial trials, 230 participated in the LTT. At 9 years, the median percent reduction in seizure frequency was 75% (p < 0.0001, Wilcoxon signed rank), responder rate was 73%, and 35% had a ≥90% reduction in seizure frequency. We found that 18.4% (47 of 256) experienced ≥1 year of seizure freedom, with 62% (29 of 47) seizure-free at the last follow-up and an average seizure-free period of 3.2 years (range 1.04–9.6 years). Overall QOL and epilepsy-targeted and cognitive domains of QOLIE-89 remained significantly improved (p < 0.05). There were no serious AEs related to stimulation, and the sudden unexplained death in epilepsy (SUDEP) rate was significantly lower than predefined comparators (p < 0.05, 1-tailed χ2).ConclusionsAdjunctive brain-responsive neurostimulation provides significant and sustained reductions in the frequency of FOS with improved QOL. Stimulation was well tolerated; implantation-related AEs were typical of other neurostimulation devices; and SUDEP rates were low.ClinicalTrials.gov identifierNCT00572195.Classification of evidenceThis study provides Class IV evidence that brain-responsive neurostimulation significantly reduces focal seizures with acceptable safety over 9 years.

Dysphagia after pediatric functional hemispherectomy

2014 ◽  
Vol 13 (1) ◽  
pp. 95-100 ◽  
Author(s):  
Robert T. Buckley ◽  
Tiffany Morgan ◽  
Russell P. Saneto ◽  
Jason Barber ◽  
Richard G. Ellenbogen ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Clinical Symptoms ◽  
Intractable Epilepsy ◽  
Seizure Freedom ◽  
Postoperative Dysphagia ◽  
Duration Of Symptoms ◽  
Functional Hemispherectomy ◽  
Clinical Records ◽  
The Impact ◽  
New Onset

Object Functional hemispherectomy is a well-recognized surgical option for the treatment of unihemispheric medically intractable epilepsy. While the resultant motor deficits are a well-known and expected consequence of the procedure, the impact on other cortical functions has been less well defined. As the cortical control of swallowing would appear to be threatened after hemispherectomy, the authors retrospectively studied a pediatric population that underwent functional hemispherectomy for medically intractable epilepsy to characterize the incidence and severity of dysphagia after surgery. Methods A retrospective cohort (n = 39) of pediatric patients who underwent hemispherectomy at a single institution was identified, and available clinical records were reviewed. Additionally, the authors examined available MR images for integrity of the thalamus and basal ganglia before and after hemispherectomy. Clinical and video fluoroscopic assessments of speech pathology were reviewed, and the presence, type, and duration of pre- and postoperative dysphagia were recorded. Results New-onset, transient dysphagia occurred in 26% of patients after hemispherectomy along with worsening of preexisting dysphagia noted in an additional 15%. Clinical symptoms lasted a median of 19 days. Increased duration of symptoms was seen with late (> 14 days postoperative) pharyngeal swallow dysfunction when compared with oral dysphagia alone. Neonatal stroke as a cause for seizures decreased the likelihood of postoperative dysphagia. There was no association with seizure freedom or postoperative hydrocephalus. Conclusions New-onset dysphagia is a frequent and clinically significant consequence of hemispherectomy for intractable epilepsy in pediatric patients. This dysphagia was always self-limited except in those patients in whom preexisting dysphagia was noted.

scholarly journals Rates and Predictors of Seizure Freedom With Vagus Nerve Stimulation for Intractable Epilepsy

Neurosurgery ◽  
2015 ◽  
Vol 79 (3) ◽  
pp. 345-353 ◽  
Author(s):  
Dario J. Englot ◽  
John D. Rolston ◽  
Clinton W. Wright ◽  
Kevin H. Hassnain ◽  
Edward F. Chang
Keyword(s):  
Vagus Nerve ◽  
Seizure Frequency ◽  
Nerve Stimulation ◽  
Vagus Nerve Stimulation ◽  
Intractable Epilepsy ◽  
Progressive Increase ◽  
Seizure Type ◽  
Seizure Freedom ◽  
Outcome Registry ◽  
Over Time

AbstractBACKGROUND:Neuromodulation-based treatments have become increasingly important in epilepsy treatment. Most patients with epilepsy treated with neuromodulation do not achieve complete seizure freedom, and, therefore, previous studies of vagus nerve stimulation (VNS) therapy have focused instead on reduction of seizure frequency as a measure of treatment response.OBJECTIVE:To elucidate rates and predictors of seizure freedom with VNS.METHODS:We examined 5554 patients from the VNS therapy Patient Outcome Registry, and also performed a systematic review of the literature including 2869 patients across 78 studies.RESULTS:Registry data revealed a progressive increase over time in seizure freedom after VNS therapy. Overall, 49% of patients responded to VNS therapy 0 to 4 months after implantation (≥50% reduction seizure frequency), with 5.1% of patients becoming seizure-free, while 63% of patients were responders at 24 to 48 months, with 8.2% achieving seizure freedom. On multivariate analysis, seizure freedom was predicted by age of epilepsy onset &gt;12 years (odds ratio “OR”, 1.89; 95% confidence interval “CI”, 1.38-2.58), and predominantly generalized seizure type (OR, 1.36; 95% CI, 1.01-1.82), while overall response to VNS was predicted by nonlesional epilepsy (OR, 1.38; 95% CI, 1.06-1.81). Systematic literature review results were consistent with the registry analysis: At 0 to 4 months, 40.0% of patients had responded to VNS, with 2.6% becoming seizure-free, while at last follow-up, 60.1% of individuals were responders, with 8.0% achieving seizure freedom.CONCLUSION:Response and seizure freedom rates increase over time with VNS therapy, although complete seizure freedom is achieved in a small percentage of patients.

scholarly journals Resective Epilepsy Surgery for Tuberous Sclerosis in Children

Neurosurgery ◽  
2015 ◽  
Vol 77 (4) ◽  
pp. 517-524 ◽  
Author(s):  
Aria Fallah ◽  
Shaun D. Rodgers ◽  
Alexander G. Weil ◽  
Sumeet Vadera ◽  
Alireza Mansouri ◽  
...  
Keyword(s):  
Tuberous Sclerosis ◽  
Epilepsy Surgery ◽  
Medical Center ◽  
Cleveland Clinic ◽  
Intractable Epilepsy ◽  
Seizure Outcome ◽  
Seizure Freedom ◽  
Epileptogenic Zone ◽  
Children's Hospital ◽  
Children’S Hospital

Abstract BACKGROUND: There are no established variables that predict the success of curative resective epilepsy surgery in children with tuberous sclerosis complex (TSC). OBJECTIVE: We performed a multicenter observational study to identify preoperative factors associated with seizure outcome in children with TSC undergoing resective epilepsy surgery. METHODS: A retrospective chart review was performed in eligible children at New York Medical Center, Miami Children's Hospital, Cleveland Clinic Foundation, BC Children's Hospital, Hospital for Sick Children, and Sainte-Justine Hospital between January 2005 and December 2013. A time-to-event analysis was performed. The “event” was defined as seizures after resective epilepsy surgery. RESULTS: Seventy-four patients (41 male) were included. The median age of the patients at the time of surgery was 120 months (range, 3-216 months). The median time to seizure recurrence was 24.0 ± 12.7 months. Engel Class I outcome was achieved in 48 (65%) and 37 (50%) patients at 1- and 2-year follow-up, respectively. On univariate analyses, younger age at seizure onset (hazard ratio [HR]: 2.03, 95% confidence interval [CI]: 1.03-4.00, P = .04), larger size of predominant tuber (HR: 1.03, 95% CI: 0.99-1.06, P = .12), and resection larger than a tuberectomy (HR: 1.86, 95% CI: 0.92-3.74, P = .084) were associated with a longer duration of seizure freedom. In multivariate analyses, resection larger than a tuberectomy (HR: 2.90, 95% CI: 1.17-7.18, P = .022) was independently associated with a longer duration of seizure freedom. CONCLUSION: In this large consecutive cohort of children with TSC and medically intractable epilepsy, a greater extent of resection (more than just the tuber) is associated with a greater probability of seizure freedom. This suggests that the epileptogenic zone may include the cortex surrounding the presumed offending tuber.

scholarly journals Long-Term Outcome of Functional Hemispherectomy in Two Cases of Diffuse Cortical Dysplasia of One Hemisphere

Epilepsia ◽  
1998 ◽  
Vol 39 (S5) ◽  
pp. 62-62
Author(s):  
Toshisaburo Nagai ◽  
Hiroshi Arai ◽  
Michiko Sakamoto ◽  
Tosiyuki Mano ◽  
Taro Matuoka ◽  
...  
Keyword(s):  
Cortical Dysplasia ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Functional Hemispherectomy

Long-term Seizure Outcome in Reoperation after Failure of Epilepsy Surgery

Neurosurgery ◽  
2007 ◽  
Vol 60 (5) ◽  
pp. 873-880 ◽  
Author(s):  
Jorge A. González-Martínez ◽  
Teeradej Srikijvilaikul ◽  
Dileep Nair ◽  
William E. Bingaman
Keyword(s):  
Epilepsy Surgery ◽  
Intractable Epilepsy ◽  
Cortical Dysplasia ◽  
Categorical Variables ◽  
Seizure Outcome ◽  
Mesial Temporal Sclerosis ◽  
Long Term Outcome ◽  
The Relationship

Abstract OBJECTIVE Treatment of patients who fail epilepsy surgery is problematic. Selected patients may be candidates for further surgery, potentially leading to a significant decrease in the frequency and severity of seizures. We present our long-term outcome series of highly investigated patients who failed resective epilepsy surgery and subsequently underwent reoperative resective procedures. METHODS We performed a retrospective consecutive analysis of patients who underwent reoperative procedures because of medically intractable epilepsy at our institution from 1990 to 2001. Seventy patients underwent reoperative epilepsy surgery, with 57 patients having a minimum follow-up period of 2 years. We assessed the relationship between seizure outcome and categorical variables using χ2 and Fisher's exact tests, and the relationship between outcome and continuous variables using a Wilcoxon rank-sum test. Statistical significance was set at a P value of 0.05. RESULTS Of the 57 patients (29 male and 28 female patients), the age of seizure onset ranged from 3 months to 39 years (mean, 10.7 ± 10.3 yr; median, 7 yr). The mean age at reoperation was 24.7 ± 12 years (range, 4–50 yr). The interval between first and second resection was 7 days to 16 years. The follow-up period ranged from 24 to 228 months (mean, 128 mo; mode, 132 mo). Seizure outcome was classified according to Engel's classification. Fifty-two percent of the patients had a favorable outcome (38.6% were Class I and 14.0% were Class II). Patients with tumors as their initial pathology had better outcome compared with patients with focal cortical dysplasia and mesial temporal sclerosis (P &lt; 0.05). CONCLUSION Reoperation should be considered in selected patients failing epilepsy resective surgery because approximately 50% of patients may have benefit. Patients with cortical dysplasia and mesial temporal sclerosis are less likely to improve after reoperation.

Appropriateness of Acid Suppression Therapy

2016 ◽  
Vol 51 (2) ◽  
pp. 125-134 ◽  
Author(s):  
Thomas De Rijdt ◽  
Isabel Spriet ◽  
Ludo Willems ◽  
Marianne Blanckaert ◽  
Martin Hiele ◽  
...  
Keyword(s):  
Medical Records ◽  
Total Population ◽  
Patient Characteristics ◽  
Suppressive Therapy ◽  
Payer Perspective ◽  
Acid Suppression Therapy ◽  
Broad Variety ◽  
Care Payer ◽  
Medical Disciplines

Background: The inappropriate startup of long-term acid suppressive therapy (AST) can have clinical and pharmacoeconomic impacts on ambulatory care. Objective: To assess the proportion of patients with appropriate initiation of long-term AST in non–critically ill patients. To describe possible risk factors for nonappropriate AST. To calculate the potential savings when eliminating the nonappropriate startup of AST. Method: This observational, retrospective study evaluated the appropriateness of startup of long-term AST in medical records using a broad variety of international criteria and guidelines and using a validated screening instrument. Results: A sample of 597 patients was included in the analysis. In 57% of them, AST was appropriately initiated. No specific risk profile could be defined. There was some indication that the availability of a clinical pharmacist and the use of standing orders were correlated to the outcome. Extrapolation to the total population (ie, 2836 patients) led to a total cost of €8880 during hospital stay plus an extra €40 391 per month after discharge. Avoiding inappropriate initiation of AST could lead to a saving of €3805 plus €17 441 per month. Conclusion: In all, 43% of initiation of long-term AST in the hospital was inappropriate. The potential savings from avoiding this could be substantial from a health care payer perspective. No patient characteristics that could predict for inappropriate initiation of AST were identified. A correlation between inappropriate initiation and medical disciplines using standing orders that include AST was seen.

Long-term Seizure Control Outcomes After Resection of Gangliogliomas

Neurosurgery ◽  
2012 ◽  
Vol 70 (6) ◽  
pp. 1406-1414 ◽  
Author(s):  
Derek G. Southwell ◽  
Paul A. Garcia ◽  
Mitchel S. Berger ◽  
Nicholas M. Barbaro ◽  
Edward F. Chang
Keyword(s):  
Tumor Progression ◽  
Seizure Control ◽  
Intractable Epilepsy ◽  
Gross Total Resection ◽  
Subtotal Resection ◽  
Seizure Outcome ◽  
Seizure Freedom ◽  
Total Resection ◽  
History Of

Abstract BACKGROUND: Gangliogliomas are rare glioneuronal tumors that typically cause refractory seizures during the first 3 decades of life. OBJECTIVE: To determine the prognosticators of seizure outcome after surgery for ganglioglioma. METHODS: We reviewed the cases of 66 patients who underwent resection of gangliogliomas at the University of California, San Francisco. Demographic, seizure history, and operative data were examined for statistical association with postoperative seizure outcomes. RESULTS: Of the 66 patients who underwent surgical resection of ganglioglioma, 49 patients (74%) presented with a history of seizures. Of those 49 patients, 50% presented with intractable epilepsy. Temporal lobe gangliogliomas were present in 76% of the patients who presented with a history of seizures. Electrocorticography was performed on 35% of the patients, and of those patients, 82% underwent extended lesionectomy to remove abnormally epileptogenic extralesional tissue. The median follow-up duration was 6.9 years, during which tumor progression occurred in 38% of patients who underwent subtotal resection and in 8% of patients who underwent gross total resection (P = .02). Overall, 85% of patients were seizure free (International League Against Epilepsy class I or II) 5 years after surgery. Subtotal resection was associated with poor seizure outcomes 1 year after resection (odds ratio = 14.6; 95% confidence interval = 2.4-87.7): rates of seizure freedom were 54% after subtotal resection, 96% after gross total resection, and 93% after gross total resection with intraoperative electrocorticography-guided extended lesionectomy. CONCLUSION: We report excellent long-term seizure control outcomes after surgery for gangliogliomas. Intraoperative electrocorticography may be a useful adjunct for guiding extended resection in certain pharmacoresistant epilepsy patients with gangliogliomas. Subtotal resection is associated with higher rates of tumor progression and nonoptimal seizure outcomes.

Transmantle sign in focal cortical dysplasia: a unique radiological entity with excellent prognosis for seizure control

2013 ◽  
Vol 118 (2) ◽  
pp. 337-344 ◽  
Author(s):  
Doris D. Wang ◽  
Abby E. Deans ◽  
A. James Barkovich ◽  
Tarik Tihan ◽  
Nicholas M. Barbaro ◽  
...  
Keyword(s):  
Seizure Control ◽  
Focal Cortical Dysplasia ◽  
Prognostic Significance ◽  
Intractable Epilepsy ◽  
Cortical Dysplasia ◽  
Seizure Freedom ◽  
Mri Findings ◽  
Patient Demographics ◽  
Vagus Nerve Stimulator ◽  
Common Causes

Object Focal cortical dysplasia (FCD) represents a spectrum of developmental cortical abnormalities and is one of the most common causes of intractable epilepsy in children and young adults. Outcomes after surgery for FCD are highly variable, and prognosticators of seizure freedom are unclear. In a subset of FCDs, a transmantle sign is observed on imaging that focally spans the entire cerebral mantle from the ventricle to the cortical surface. The aim of this study was to characterize seizure control outcomes and prognostic significance of the transmantle sign in FCD epilepsy. Methods Fourteen patients with the transmantle sign underwent epilepsy surgery for medically refractory epilepsy. Thirteen patients underwent resective surgery and 1 underwent multiple subpial transections with vagus nerve stimulator placement. Patient demographics, MRI, electroencephalography, intraoperative electrocorticography (ECoG), and pathology were reviewed. The results of this series were compared with those of 114 previously reported patients with FCD without the transmantle sign. Results All patients were found to have childhood seizure onset and concordant MRI and ECoG findings. The primary MRI findings associated with transmantle sign included gray-white junction blurring, appearance of cortical thickening, T2 or FLAIR abnormality, and bottom-of-the-sulcus dysplasia. The transmantle sign was usually a focal finding, typically confined to 1 or several gyri with well-circumscribed epileptic tissue. Correlation of the transmantle sign with FCD histopathological subtypes was highly variable. Patients who underwent complete resection of MRI and ECoG abnormalities (12 of 13 patients) became seizure free. When compared with 114 FCD patients without the transmantle sign, patients with the transmantle sign showed significantly improved seizure-free outcomes after complete resections (p = 0.04). Conclusions The presence of the transmantle sign in patients with medically refractory partial epilepsy is associated with highly favorable seizure control outcomes after surgical treatment.

scholarly journals Seizure control after radiosurgery for cerebral arteriovenous malformations: a 25-year experience

2019 ◽  
Vol 131 (6) ◽  
pp. 1763-1772
Author(s):  
Ajay Niranjan ◽  
Ahmed Kashkoush ◽  
Hideyuki Kano ◽  
Edward A. Monaco ◽  
John C. Flickinger ◽  
...  
Keyword(s):  
Seizure Frequency ◽  
Arteriovenous Malformations ◽  
Seizure Control ◽  
Venous Drainage ◽  
Seizure Outcome ◽  
Seizure Freedom ◽  
Impaired Awareness ◽  
Free Status

OBJECTIVESeizures are the second-most common presenting symptom in patients with lobar arteriovenous malformations (AVMs). However, few studies have assessed the long-term effect of stereotactic radiosurgery (SRS) on seizure control. The authors of this study assess the outcome of SRS for these patients to identify prognostic factors associated with seizure control.METHODSPatients with AVM who presented with a history of seizure and underwent SRS at the authors’ institution between 1987 and 2012 were retrospectively assessed. The total cohort included 155 patients with a mean follow-up of 86 months (range 6–295 months). Primary outcomes assessed were seizure frequency, antiepileptic drug regimen, and seizure freedom for 6 months prior to last follow-up.RESULTSSeizure-free status was achieved in 108 patients (70%), with an additional 23 patients (15%) reporting improved seizure frequency as compared to their pre-SRS status. The median time to seizure-free status was estimated to be 12 months (95% CI 0–27 months) as evaluated via Kaplan-Meier survival analysis. The mean seizure frequency prior to SRS was 14.2 (95% CI 5.4–23.1) episodes per year. Although not all patients tried, the proportion of patients successfully weaned off all antiepileptic drugs was 18% (28/155 patients). On multivariate logistic regression, focal impaired awareness seizure type (also known as complex partial seizures) and superficial venous drainage were significantly associated with a decreased odds ratio for seizure-free status at last follow-up (OR 0.37 [95% CI 0.15–0.92] for focal impaired awareness seizures; OR 0.36 [95% CI 0.16–0.81] for superficial venous drainage). The effects of superficial venous drainage on seizure outcome were nonsignificant when excluding patients with < 2 years of follow-up. AVM obliteration did not correlate with long-term seizure freedom (p = 0.202, chi-square test).CONCLUSIONSThis study suggests that SRS improves long-term seizure control and increases the likelihood of being medication free, independently of AVM obliteration. Patients with focal impaired awareness seizures were less likely to obtain long-term seizure relief.

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