Patients With Refractory Epilepsy Treated Using a Modified Multiple Subpial Transection Technique

Abstract BACKGROUND: Multiple subpial transection (MST) is a potential surgical treatment for patients with epileptogenic foci located in cortical areas with higher functions. As neurosurgical teams have become more experienced with MST, the original technique has adapted. OBJECTIVE: To report our 6-year experience with a modified MST technique. METHODS: The population included 62 consecutive patients with medically refractory epilepsy treated by MST, with a follow-up period ranging from 2 to 9 years. MST was performed on gyri under neuronavigation and guided by intraoperative electrocorticography. We performed radiating MST from a single cortical entry point. The MST technique was described according to the number of transections performed and the Brodmann areas (BAs) involved. Any MST-related complications were registered and followed up. Clinical outcome was described in terms of seizure suppression or reduction according to the Engel modified classification. RESULTS: Twelve patients underwent MST alone (MSTa), and 50 had MST with another procedure. The main MST sites were BA 4 (61%) and 3, 1, 2 (58%); in 22% of cases, MST was performed in BA 44, 22, 39, and 40. Permanent neurological deficits were observed in 4 (6.4%) patients; 2 minor deficits were MST related (3.2%). A reduction in the seizure rate of at least 50% was seen in 79% of patients (MSTa group, 75%), and 42% became seizure free (MSTa group, 33%). CONCLUSION: This study demonstrates the efficacy and low morbidity of radiating MST performed under neuronavigation and intraoperative electrocorticography.

Download Full-text

Psychiatric and psychosocial morbidity 1 year after epilepsy surgery

Irish Journal of Psychological Medicine ◽

10.1017/ipm.2020.114 ◽

2020 ◽

pp. 1-8

Author(s):

S. Patel ◽

M. Clancy ◽

H. Barry ◽

N. Quigley ◽

M. Clarke ◽

...

Keyword(s):

Quality Of Life ◽

Surgical Treatment ◽

Epilepsy Surgery ◽

Refractory Epilepsy ◽

Post Surgery ◽

Axis I ◽

Patients With Epilepsy ◽

The Impact

Abstract Objectives: There is a high rate of psychiatric comorbidity in patients with epilepsy. However, the impact of surgical treatment of refractory epilepsy on psychopathology remains under investigation. We aimed to examine the impact of epilepsy surgery on psychopathology and quality of life at 1-year post-surgery in a population of patients with epilepsy refractory to medication. Methods: This study initially assessed 48 patients with refractory epilepsy using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), the Hospital Anxiety and Depression Scale (HADS) and the Quality of Life in Epilepsy Inventory 89 (QOLIE-89) on admission to an Epilepsy Monitoring Unit (EMU) as part of their pre-surgical assessment. These patients were again assessed using the SCID-I, QOLIE-89 and HADS at 1-year follow-up post-surgery. Results: There was a significant reduction in psychopathology, particularly psychosis, following surgery at 1-year follow-up (p < 0.021). There were no new cases of de novo psychosis and surgery was also associated with a significant improvement in the quality of life scores (p < 0.001). Conclusions: This study demonstrates the impact of epilepsy surgery on psychopathology and quality of life in a patient population with refractory surgery. The presence of a psychiatric illness should not be a barrier to access surgical treatment.

Download Full-text

Magnetic Resonance Thermometry-Guided Stereotactic Laser Ablation of Cavernous Malformations in Drug-Resistant Epilepsy: Imaging and Clinical Results

Operative Neurosurgery ◽

10.1227/neu.0000000000001033 ◽

2015 ◽

Vol 12 (1) ◽

pp. 39-48 ◽

Cited By ~ 40

Author(s):

D Jay McCracken ◽

Jon T Willie ◽

Brad A Fernald ◽

Amit M Saindane ◽

Daniel L Drane ◽

...

Keyword(s):

Laser Ablation ◽

Magnetic Resonance ◽

Minimally Invasive ◽

Real Time ◽

Refractory Epilepsy ◽

Acute Hemorrhage ◽

Cavernous Malformations ◽

Remote Imaging ◽

Medically Refractory Epilepsy

Abstract BACKGROUND Surgery is indicated for cerebral cavernous malformations (CCMs) that cause medically refractory epilepsy. Real-time magnetic resonance thermography (MRT)-guided stereotactic laser ablation (SLA) is a minimally invasive approach to treating focal brain lesions. SLA of CCM has not previously been described. OBJECTIVE To describe MRT-guided SLA, a novel approach to treating CCM-related epilepsy, with respect to feasibility, safety, imaging, and seizure control in 5 consecutive patients. METHODS Five patients with medically refractory epilepsy undergoing standard presurgical evaluation were found to have corresponding lesions fulfilling imaging characteristics of CCM and were prospectively enrolled. Each underwent stereotactic placement of a saline-cooled cannula containing an optical fiber to deliver 980-nm diode laser energy via twist drill craniostomy. MR anatomic imaging was used to evaluate targeting before ablation. MR imaging provided evaluation of targeting and near real-time feedback regarding the extent of tissue thermocoagulation. Patients maintained seizure diaries, and remote imaging (6-21 months postablation) was obtained in all patients. RESULTS Imaging revealed no evidence of acute hemorrhage following fiber placement within presumed CCM. MRT during treatment and immediate postprocedure imaging confirmed the desired extent of ablation. We identified no adverse events or neurological deficits. Four of 5 (80%) patients achieved freedom from disabling seizures after SLA alone (Engel class 1 outcome), with follow-up ranging 12 to 28 months. Reimaging of all subjects (6-21 months) indicated lesion diminution with surrounding liquefactive necrosis, consistent with the surgical goal of extended lesionotomy. CONCLUSION Minimally invasive MRT-guided SLA of epileptogenic CCM is a potentially safe and effective alternative to open resection. Additional experience and longer follow-up are needed.

Download Full-text

Clinical Outcome of Hypertensive Uveitis

Journal of Ophthalmology ◽

10.1155/2015/974870 ◽

2015 ◽

Vol 2015 ◽

pp. 1-6 ◽

Cited By ~ 6

Author(s):

Deborah Lewkowicz ◽

François Willermain ◽

Lia Judice Relvas ◽

Dorine Makhoul ◽

Sarah Janssens ◽

...

Keyword(s):

Intraocular Pressure ◽

Surgical Treatment ◽

Clinical Outcome ◽

Topical Corticosteroid ◽

Retrospective Review ◽

Corticosteroid Treatment ◽

First Episode ◽

Elevated Intraocular Pressure ◽

Unilateral Disease

Purpose. To review the clinical outcome of patients with hypertensive uveitis.Methods. Retrospective review of uveitis patients with elevated intraocular pressure (IOP) > 25 mmHg and >1-year follow-up. Data are uveitis type, etiology, viral (VU) and nonviral uveitis (NVU), IOP, and medical and/or surgical treatment.Results. In 61 patients, IOP values are first 32.9 mmHg (SD: 9.0), highest 36.6 mmHg (SD: 9.9), 3 months after the first episode 19.54 mmHg (SD: 9.16), and end of follow-up 15.5 mmHg (SD: 6.24). Patients with VU (n=25) were older (50.6 y/35.7 y,p=0.014) and had more unilateral disease (100%/72.22% p=0.004) than those with NVU (n=36). Thirty patients (49.2%) had an elevated IOP before topical corticosteroid treatment. Patients with viral uveitis might have higher first elevated IOP (36.0/27.5 mmHg,p=0,008) and maximal IOP (40.28/34.06 mmHg,p=0.0148) but this was not significant when limited to the measurements before the use of topical corticosteroids (p=0.260and 0.160). Glaucoma occurred in 15 patients (24.59%) and was suspected in 11 (18.03%) without difference in viral and nonviral groups (p=0.774).Conclusion. Patients with VU were older and had more unilateral hypertensive uveitis. Glaucoma frequently complicates hypertensive uveitis. Half of the patients had an elevated IOP before topical corticosteroid treatment.

Download Full-text

Presurgical evaluation and surgical treatment of medically refractory epilepsy

Neurosurgical Review ◽

10.1007/s10143-003-0306-5 ◽

2004 ◽

Vol 27 (1) ◽

pp. 19-19

Author(s):

Helmut Bertalanffy

Keyword(s):

Surgical Treatment ◽

Refractory Epilepsy ◽

Presurgical Evaluation ◽

Medically Refractory Epilepsy

Download Full-text

The Effectiveness of Medical and Surgical Treatment for Children With Refractory Epilepsy

Neurosurgery ◽

10.1093/neuros/nyz310_136 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Melissa LoPresti ◽

Iwen Pan ◽

Dave Clarke ◽

Sandi Lam

Keyword(s):

Surgical Treatment ◽

Healthcare Utilization ◽

Epilepsy Surgery ◽

Refractory Epilepsy ◽

Survival Rates ◽

Treated Group ◽

Pediatric Epilepsy ◽

Ed Visits ◽

The Impact

Abstract INTRODUCTION Pediatric refractory epilepsy affects quality of life, clinical disability, and healthcare costs for patients and families. We aimed to show the impact of surgical treatment for pediatric epilepsy on healthcare utilization compared to medically treated pediatric epilepsy over 5 yr. METHODS The Pediatric Health Information System database was used to study hospitalized children with epilepsy using five published algorithms. Refractory epilepsy (RE) patients treated with either antiepileptic medications (AEDs) only or AEDs plus epilepsy surgery (ES) between 1/1/2008 and 12/31/2014 were included. Patients with a history of ES before 1/1/2008 or a vagus nerve stimulation implantation surgery were excluded. ICD-9-CM codes were used to identify ES. Healthcare utilization following the index date at 2- and 5-yr including inpatient, emergency department (ED), and all epilepsy-related visits were evaluated. The propensity scores (PS) method was used to match surgically and medically treated patients. Covariates associated with the probability of receiving surgical treatment were chosen in the logistic regression model for calculating PS. SAS 9.4 and Stata 14.0 were used for data management and statistical analysis. RESULTS A total of 2106 (17.1%) and 10186 (82.9%) were surgically and medically treated, respectively. A total of 4050 matched cases, 2025 per each treated group, were included. Overall survival rates of matched cases were 98.07% and 99.58% at 2-yr and 96.66% and 98.99% at 5-yr for medically and surgically treated patients, respectively. Within 5-yr follow-up, seizure-associated healthcare utilization was lower for the surgically treated group: number of inpatient visits were 3.9 vs 2.5 and ED visits were 3.2 vs 1.7 for medically and surgically treated patients, respectively. The number of AEDs at 1-yr follow-up was significantly lower for the surgically treated group (3.22 decreased to 2.59: surgical group, 3.24 decreased to 3.06: medical group). CONCLUSION We found a significant decrease in inpatient and ED visits and number of antiepileptic drug prescriptions, as well as higher survival rates, at 2- and 5-yr follow-up in the surgically treated group compared to the medically treated group for pediatric patients with refractory epilepsy. Pediatric epilepsy surgery can provide beneficial outcomes, favorable long-term effectiveness, and reduced healthcare utilization compared to medical management.

Download Full-text

Periinsular anterior quadrantotomy: technical note

Journal of Neurosurgery Pediatrics ◽

10.3171/2017.8.peds17339 ◽

2018 ◽

Vol 21 (2) ◽

pp. 124-132 ◽

Cited By ~ 3

Author(s):

Giulia Cossu ◽

Sebastien Lebon ◽

Margitta Seeck ◽

Etienne Pralong ◽

Mahmoud Messerer ◽

...

Keyword(s):

Frontal Lobe ◽

Refractory Epilepsy ◽

Focal Cortical Dysplasia ◽

Seizure Outcome ◽

Illustrative Case ◽

Neural Pathways ◽

Functional Neuroanatomy ◽

The Right ◽

Epileptogenic Foci

Refractory frontal lobe epilepsy has been traditionally treated through a frontal lobectomy. A disconnective technique may allow similar seizure outcomes while avoiding the complications associated with large brain resections. The aim of this study was to describe a new technique of selective disconnection of the frontal lobe that can be performed in cases of refractory epilepsy due to epileptogenic foci involving 1 frontal lobe (anterior to the motor cortex), with preservation of motor function. In addition to the description of the technique, an illustrative case is also presented.This disconnective procedure is divided into 4 steps: the suprainsular window, the anterior callosotomy, the intrafrontal disconnection, and the frontobasal disconnection. The functional neuroanatomy is analyzed in detail for each step of the surgery. It is important to perform cortical and subcortical electrophysiological mapping to guide this disconnective procedure and identify eloquent cortices and intact neural pathways.The authors describe the case of a 9-year-old boy who presented with refractory epilepsy due to epileptogenic foci localized to the right frontal lobe. MRI confirmed the presence of a focal cortical dysplasia of the right frontal lobe. A periinsular anterior quadrant disconnection (quadrantotomy) was performed. The postoperative period was uneventful, and the patient was in Engel seizure outcome Class I at the 3-year follow-up. A significant cognitive gain was observed during follow-up.Periinsular anterior quadrantotomy may thus represent a safe technique to efficiently treat refractory epilepsy when epileptogenic foci are localized to 1 frontal lobe while preserving residual motor functions.

Download Full-text

Safe Resection of Arteriovenous Malformations in Eloquent Motor Areas Aided by Functional Imaging and Intraoperative Monitoring

Operative Neurosurgery ◽

10.1227/neu.0b013e318237aac5 ◽

2011 ◽

Vol 70 (suppl_2) ◽

pp. ons276-ons289 ◽

Cited By ~ 5

Author(s):

Guilherme Lepski ◽

Jürgen Honegger ◽

Marina Liebsch ◽

Marília Grando Sória ◽

Porn Narischat ◽

...

Keyword(s):

Surgical Treatment ◽

Functional Imaging ◽

Arteriovenous Malformations ◽

Motor Evoked Potentials ◽

Neurological Deficits ◽

Functional Improvement ◽

Cortical Areas ◽

Electrophysiological Monitoring ◽

Motor Cortical ◽

Motor Areas

ABSTRACT BACKGROUND: Arteriovenous malformations (AVMs) proximal to motor cortical areas or motor projection systems are challenging to manage because of the risk of severe sensory and motor impairment. Surgical indication in these cases therefore remains controversial. OBJECTIVE: To propose a standardized approach for centrally situated AVMs based on functional imaging and intraoperative electrophysiological evaluation. METHODS: We conducted a retrospective analysis of 15 patients who underwent surgical treatment for AVMs in motor cortical areas or proximal to motor projections. Preoperative assessment included functional magnetic resonance and 3-dimensional tractography. Operations were performed under continuous electrophysiological monitoring aided by direct brain stimulation. We identified critical bloody supply to the motor areas by temporary occluding the feeding vessels under electrophysiological monitoring. Clinical outcome was evaluated with the modified Rankin Scale. RESULTS: Total resection was achieved in 12 cases, whereas electrophysiology limited total extirpation in 3 cases. A significant reduction of motor evoked potentials by up to 15% of the initial values was associated with good recovery of motor function; in contrast, the disappearance of potentials correlated with long-term impairment. The mean follow-up time was 13 months, and clinical assessments revealed overall functional improvement (P < .05). After surgery, 11 patients were asymptomatic or presented with only minor neurological deficits. CONCLUSION: Surgical resection of AVMs in eloquent motor areas can be considered a safe option for selected cases when performed in conjunction with a detailed functional assessment. Possible selection criteria for surgical treatment are discussed in light of the presented clinical data.

Download Full-text

Endovascular and Surgical Treatment of Internal Carotid Bifurcation Aneurysms

Neurosurgery ◽

10.1227/neu.0000000000000672 ◽

2015 ◽

Vol 76 (5) ◽

pp. 540-551 ◽

Cited By ~ 28

Author(s):

Juergen Konczalla ◽

Johannes Platz ◽

Nina Brawanski ◽

Erdem Güresir ◽

Stephanie Lescher ◽

...

Keyword(s):

Surgical Treatment ◽

Internal Carotid ◽

Treatment Options ◽

Carotid Bifurcation ◽

Neurological Deficits ◽

Bleeding Complications ◽

Treatment Rate ◽

Surgical Clipping ◽

Aneurysm Neck

Abstract BACKGROUND: Aneurysms of the internal carotid artery (ICA) bifurcation are rare, and no studies have compared patient outcomes after endovascular vs surgical treatment. OBJECTIVE: To report the safety, efficacy, and follow-up outcome of these 2 treatment options for patients with ICA bifurcation aneurysms. METHODS: Patient and aneurysm characteristics, treatment results, and follow-up outcomes (at 30 months) were analyzed from patient records and review of imaging findings. RESULTS: A total of 58 patients with ICA bifurcation aneurysms were treated. By interdisciplinary consensus, 30 aneurysms were assigned for coiling and 28 for clipping. Patients who underwent surgical clipping were younger and had larger aneurysms. More patients were assigned to coiling if their aneurysms originated only from the ICA bifurcation or projected superiorly. For the combined angiographic endpoint, complete and nearly complete occlusion (Raymond-Roy I + II), similar rates of 96% (coiling) or 100% (clipping) could be achieved. Raymond-Roy I occlusion occurred more often after clipping (79% vs 41% coiling). Follow-up of the endovascular group showed minor recanalization of the aneurysm neck (Raymond-Roy II) in 42%. One patient (4%) showed a major recanalization (Raymond-Roy III) and needed re-treatment. For incidental findings, no bleeding complications or new persistent neurological deficits occurred during follow-up. CONCLUSION: Treatment of ICA bifurcation aneurysms after interdisciplinary assignment to clipping or coiling is effective and safe. Despite significantly more minor recanalizations after coiling, the re-treatment rate was very low, and no bleeding was observed during follow-up. Multivariate analysis revealed that origin only from the ICA bifurcation was an independent predictor of aneurysm recanalization after endovascular treatment.

Download Full-text

Long-term outcomes of resective epilepsy surgery after invasive presurgical evaluation in children with tuberous sclerosis complex and bilateral multiple lesions

Journal of Neurosurgery Pediatrics ◽

10.3171/2014.10.peds14107 ◽

2015 ◽

Vol 15 (1) ◽

pp. 26-33 ◽

Cited By ~ 32

Author(s):

Ravindra Arya ◽

Jeffrey R. Tenney ◽

Paul S. Horn ◽

Hansel M. Greiner ◽

Katherine D. Holland ◽

...

Keyword(s):

Tuberous Sclerosis ◽

Epilepsy Surgery ◽

Tuberous Sclerosis Complex ◽

Refractory Epilepsy ◽

Full Scale ◽

Secondary Outcome ◽

Resective Surgery ◽

Class 1 ◽

Medically Refractory Epilepsy

OBJECT Tuberous sclerosis complex (TSC) with medically refractory epilepsy is characterized by multifocal brain abnormalities, traditionally indicating poor surgical candidacy. This single-center, retrospective study appraised seizurerelated, neuropsychological, and other outcomes of resective surgery in TSC patients with medically refractory epilepsy, and analyzed predictors for these outcomes. METHODS Patients with multilesional TSC who underwent epilepsy surgery between 2007 and 2012 were identified from an electronic database. All patients underwent multimodality noninvasive and subsequent invasive evaluation. Seizure outcomes were classified using the International League Against Epilepsy (ILAE) scale. The primary outcome measure was complete seizure remission (ILAE Class 1). Secondary outcome measures included 50% responder rate, change in full-scale IQ, electroencephalography improvement, and reduction in antiepileptic drug (AED) burden. RESULTS A total of 37 patients with TSC underwent resective surgery during the study period. After a mean follow-up of 5.68 ± 3.67 years, 56.8% achieved complete seizure freedom (ILAE Class 1) and 86.5% had ILAE Class 4 outcomes or better. The full-scale IQ on follow-up was significantly higher in patients with ILAE Class 1 outcome (66.70 ± 12.36) compared with those with ILAE Class 2 or worse outcomes (56.00 ± 1.41, p = 0.025). In 62.5% of the patients with ILAE Class 2 or worse outcomes, the number of AEDs were found to be significantly reduced (p = 0.004). CONCLUSIONS This study substantiates the evidence for efficacy of resective epilepsy surgery in patients with bilateral multilesional TSC. More than half of the patients were completely seizure free. Additionally, a high proportion achieved clinically meaningful reduction in seizure burden and the number of AEDs.

Download Full-text