The periinsular functional hemispherotomy

2012 ◽  
Vol 32 (3) ◽  
pp. E7 ◽  
Author(s):  
Leonardo Rangel-Castilla ◽  
Steven W. Hwang ◽  
George Al-Shamy ◽  
Andrew Jea ◽  
Daniel J. Curry
Keyword(s):  
Surgical Treatment ◽  
Operative Technique ◽  
Seizure Control ◽  
Refractory Epilepsy ◽  
Internal Capsule ◽  
Lateral Approach ◽  
Complication Rates ◽  
Central Sulcus ◽  
Functional Hemispherectomy ◽  
Good Seizure Control

The surgical treatment of refractory epilepsy has evolved as new innovations have been created. Disconnective procedures such as hemispherectomy have evolved. Presently, hemispherotomy has replaced hemispherectomy to reduce complication rates while maintaining good seizure control. Several disconnective techniques have been described including the Rasmussen, vertical, and lateral approaches. The lateral approach, or periinsular hemispherectomy, was derived from modifications on the functional hemispherectomy and involves removal of the temporal lobe mesial structures, exposure of the atrium via the circular sulcus, internal capsule transection under the central sulcus, intraventricular callosotomy, and frontobasal disconnection. The purpose of this article is to describe and illustrate in detail the anatomy and operative technique for periinsular hemispherotomy, as well as to discuss the nuances and issues involved with this procedure.

Hemispherotomy and other disconnective techniques

2008 ◽  
Vol 25 (3) ◽  
pp. E14 ◽  
Author(s):  
Sandrine De Ribaupierre ◽  
Olivier Delalande
Keyword(s):  
Surgical Treatment ◽  
Seizure Control ◽  
Intractable Epilepsy ◽  
Historical Background ◽  
Epileptogenic Zone ◽  
Complication Rates ◽  
Hypothalamic Hamartomas ◽  
Posterior Quadrant ◽  
Technical Innovations ◽  
Good Seizure Control

The surgical treatment of intractable epilepsy has evolved as new technical innovations have been made. Hemispherotomy techniques have been developed to replace hemispherectomy in order to reduce the complication rates while maintaining good seizure control. Disconnective procedures are based on the interruption of the epileptic network rather than the removal of the epileptogenic zone. They can be applied to hemispheric pathologies, leading to hemispherotomy, but they can also be applied to posterior quadrant epilepsies, or hypothalamic hamartomas. In this paper, the authors review the literature, present an overview of the historical background, and discuss the different techniques along with their outcomes and complications.

Operculoinsular cortectomy for refractory epilepsy. Part 1: Is it effective?

2020 ◽  
Vol 133 (4) ◽  
pp. 950-959
Author(s):  
Alain Bouthillier ◽  
Alexander G. Weil ◽  
Laurence Martineau ◽  
Laurent Létourneau-Guillon ◽  
Dang Khoa Nguyen
Keyword(s):  
Surgical Treatment ◽  
Frontal Lobe ◽  
Seizure Control ◽  
Refractory Epilepsy ◽  
Seizure Outcome ◽  
Seizure Freedom ◽  
Invasive Monitoring ◽  
Seizure Semiology ◽  
Intracranial Electrodes

OBJECTIVEPatients with refractory epilepsy of operculoinsular origin are often denied potentially effective surgical treatment with operculoinsular cortectomy (also termed operculoinsulectomy) because of feared complications and the paucity of surgical series with a significant number of cases documenting seizure control outcome. The goal of this study was to document seizure control outcome after operculoinsular cortectomy in a group of patients investigated and treated by an epilepsy team with 20 years of experience with this specific technique.METHODSClinical, imaging, surgical, and seizure control outcome data of all patients who underwent surgery for refractory epilepsy requiring an operculoinsular cortectomy were retrospectively reviewed. Tumors and progressive encephalitis cases were excluded. Descriptive and uni- and multivariate analyses were done to determine seizure control outcome and predictors.RESULTSForty-three patients with 44 operculoinsular cortectomies were studied. Kaplan-Meier estimates of complete seizure freedom (first seizure recurrence excluding auras) for years 0.5, 1, 2, and 5 were 70.2%, 70.2%, 65.0%, and 65.0%, respectively. With patients with more than 1 year of follow-up, seizure control outcome Engel class I was achieved in 76.9% (mean follow-up duration 5.8 years; range 1.25–20 years). With multivariate analysis, unfavorable seizure outcome predictors were frontal lobe–like seizure semiology, shorter duration of epilepsy, and the use of intracranial electrodes for invasive monitoring. Suspected causes of recurrent seizures were sparing of the language cortex part of the focus, subtotal resection of cortical dysplasia/polymicrogyria, bilateral epilepsy, and residual epileptic cortex with normal preoperative MRI studies (insula, frontal lobe, posterior parieto-temporal, orbitofrontal).CONCLUSIONSThe surgical treatment of operculoinsular refractory epilepsy is as effective as epilepsy surgeries in other brain areas. These patients should be referred to centers with appropriate experience. A frontal lobe–like seizure semiology should command more sampling with invasive monitoring. Recordings with intracranial electrodes are not always required if the noninvasive investigation is conclusive. The complete resection of the epileptic zone is crucial to achieve good seizure control outcome.

scholarly journals Tailored suprainsular partial hemispherotomy: a new functional disconnection technique for stroke-induced refractory epilepsy

2018 ◽  
Vol 22 (6) ◽  
pp. 601-609 ◽  
Author(s):  
Didier Scavarda ◽  
Tiago Cavalcante ◽  
Agnès Trébuchon ◽  
Anne Lépine ◽  
Nathalie Villeneuve ◽  
...  
Keyword(s):  
Motor Cortex ◽  
Seizure Control ◽  
Refractory Epilepsy ◽  
Favorable Outcome ◽  
Functional Consequences ◽  
Severe Epilepsy ◽  
Ischemic Events ◽  
Good Seizure Control ◽  
Surgical Option

OBJECTIVEHemispherotomy is currently the most frequently performed surgical option for refractory epilepsy associated with large perinatal or childhood ischemic events. Such an approach may lead to good seizure control, but it has inherent functional consequences linked to the disconnection of functional cortices. The authors report on 6 consecutive patients who presented with severe epilepsy associated with hemiplegia due to stroke and who benefitted from a new, stereoelectroencephalography-guided partial disconnection technique.METHODSThe authors developed a new disconnection technique termed “tailored suprainsular partial hemispherotomy” (TSIPH). Disconnection always included premotor and motor cortex with variable anterior and posterior extent.RESULTSAt a mean follow-up of 28 months, there were no deaths and no patient had hydrocephalus. Motor degradation was observed in all patients in the 2 weeks after surgery, but all patients completely recovered. The 6 patients were seizure free (Engel class IA) at the last follow-up. No neuropsychological aggravation was observed.CONCLUSIONSTSIPH appears to be a conservative alternative to classic hemispherotomy, leading to favorable outcome in this series.

scholarly journals D.06 Insular involvement in intractable epilepsy: results of invasive EEG data

2016 ◽  
Vol 43 (S2) ◽  
pp. S14-S14
Author(s):  
M Ranjan ◽  
Y Starreveld ◽  
L Bello-Espinosa ◽  
S Wiebe ◽  
S Singh ◽  
...  
Keyword(s):  
Seizure Control ◽  
Refractory Epilepsy ◽  
Intractable Epilepsy ◽  
Insular Cortex ◽  
Electrode Placement ◽  
Secondary Spread ◽  
Depth Electrode ◽  
Eeg Data ◽  
Effective Adjunct ◽  
Good Seizure Control

Background: Exploration of the insular cortex is now commonly considered in patients with refractory epilepsy requiring invasive EEG investigations. The safety and yield of routine insular exploration is uncertain. Methods: All patients (pediatric and adult) who had invasive EEG (iEEG) with insular depth electrode placement, either through SEEG or open implantation, were reviewed. Ictal insular involvement was characterized as primary, secondary or not involved. Results of insular resections were recorded. Results: A total of 173 patients had iEEG of which 26 included insular electrodes (SEEG-18, Open - 8). No complications of placement were identified. Insular involvement was seen in 20 (76%) patients. Primary ictal involvement was identified in 9 (33 %) patients, while secondary spread was noted in 11 (42 %) patients. Six patients went on to have resections including the insular cortex of which 5 patients achieved good seizure control (Engle class I/II). Conclusions: Insular depth electrode placement is a safe and effective adjunct to invasive EEG investigations. Ictal involvement of the insular cortex was commonly identified in our series leading to inclusion of the insula in cortical resections with good seizure control, which may not have been considered without iEEG evidence.

Seizures following surgery for supratentorial extratemporal low-grade tumors in children: a multicenter retrospective study

2020 ◽  
Vol 26 (1) ◽  
pp. 27-33
Author(s):  
Jonathan Roth ◽  
Or Bercovich ◽  
Ashton Roach ◽  
Francesco T. Mangano ◽  
Arvind C. Mohan ◽  
...  
Keyword(s):  
Retrospective Study ◽  
Brain Tumors ◽  
Seizure Control ◽  
Seizure Activity ◽  
Refractory Epilepsy ◽  
Low Grade ◽  
Refractory Seizures ◽  
Low Rate ◽  
Over Time ◽  
New Onset

OBJECTIVEResection of brain tumors may lead to new-onset seizures but may also reduce seizure rates in patients presenting with seizures. Seizures are seen at presentation in about 24% of patients with brain tumors. For lesional epilepsy in general, early resection is associated with improved seizure control. However, the literature is limited regarding the occurrence of new-onset postoperative seizures, or rates of seizure control in those presenting with seizures, following resections of extratemporal low-grade gliomas (LGGs) in children.METHODSData were collected retrospectively from 4 large tertiary centers for children (< 18 years of age) who underwent resection of a supratentorial extratemporal (STET) LGG. The patients were divided into 4 groups based on preoperative seizure history: no seizures, up to 2 seizures, more than 2 seizures, and uncontrolled or refractory epilepsy. The authors analyzed the postoperative occurrence of seizures and the need for antiepileptic drugs (AEDs) over time for the various subgroups.RESULTSThe study included 98 children. Thirty patients had no preoperative seizures, 18 had up to 2, 16 had more than 2, and 34 had refractory or uncontrolled epilepsy. The risk for future seizures was higher if the patient had seizures within 1 month of surgery. The risk for new-onset seizures among patients with no seizures prior to surgery was low. The rate of seizures decreased over time for children with uncontrolled or refractory seizures. The need for AEDs was higher in the more active preoperative seizure groups; however, it decreased with time.CONCLUSIONSThe resection of STET LGGs in children is associated with a low rate of postoperative new-onset epilepsy. For children with preoperative seizures, even with uncontrolled epilepsy, most have a significant improvement in the seizure activity, and many may be weaned off their AEDs.

Psychiatric and psychosocial morbidity 1 year after epilepsy surgery

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.

scholarly journals Lateral Ankle Instability Surgical Treatment

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0003
Author(s):  
Bahman Sahranavard ◽  
Cesar de Cesar Netto ◽  
Ashish Shah ◽  
Parke Hudson ◽  
Ibukunoluwa Araoye ◽  
...  
Keyword(s):  
Surgical Treatment ◽  
Revision Surgery ◽  
Surgical Repair ◽  
Ankle Instability ◽  
Primary Repair ◽  
P Value ◽  
Complication Rates ◽  
Suture Anchors ◽  
Lateral Ankle ◽  
Lateral Ankle Instability

Category: Ankle, Sports Introduction/Purpose: Lateral ankle instability is a common cause of disability in the active population. Although the majority of patients can be treated conservatively, surgical repair of the ligaments, with or without reinforcement, represents an excellent option for refractory cases. Failed primary surgical repair, recurrence of the ankle instability and need for revision surgery can rarely happen and is probably affected by multiple variables. That includes patient’s characteristics such as BMI and comorbidities and surgical aspects such as the use of suture anchors and soft-tissue reinforcement. The purpose of this study was to compare patient’s characteristics and complication rates of primary repair and revision procedures. Methods: We retrospectively reviewed 231 patients (160 Female, 71 Male) who underwent surgical treatment for lateral ankle instability between 2010-2016. Thirty-two were revision cases (14.2%), including 24 females and 8 males, and 199 were primary direct repairs (85.8%). The mean age at the time of the surgery was 39 (19-65)years, and average follow-up was 9 (2-55) months. The procedures were performed by four different surgeons. All cases were reviewed based on age, gender, BMI, procedure type and number of incisions, comorbidities, and complications. Data found was compared between the two groups (primary repair and revision surgery) by T-test. A p-value <0.05 was considered significant. Results: The Brostrom-Gould procedure was used in 69.5% of the primary repairs and 63.6% of the revision cases. The use of suture anchors was also similar in both groups (51%). Repair of the calcaneofibular ligament was performed in 68% of primary repairs and 81.8% of the revisions. We didn’t find significant differences regarding comorbidities between two groups: smoking (23.4% x 27.2%, p-value 0.371); diabetes (6.8% x 6%, p-value 0.951) and body mass index above 30 (28.5% x 24.2%, p-value 0.347). We found significant difference in the complication rate of the procedures, with a higher incidence in the revision group (48.4%) when compared to the primary repair group (24%). That included: sural neuritis (15.1% x 3.4%), superficial peroneal neuritis (12.1% x 4.5%), skin problems (9% x 7.4%). Conclusion: Our study of 231 patients that underwent surgical treatment for lateral ankle instability found significant higher incidence of complications in patients who had revision procedures when compared to primary repair. No differences regarding smoking status, diabetes and BMI were found.

scholarly journals Keto-Sleuths – An Unusual Cause of Loss of Ketosis?

2021 ◽  
Vol 8 ◽  
pp. 2329048X2110297
Author(s):  
Christine M. Foley ◽  
Christopher Ryan ◽  
Stacey Tarrant ◽  
Ann M. Bergin
Keyword(s):  
Effective Treatment ◽  
Seizure Control ◽  
Refractory Epilepsy ◽  
Clinical Scenario ◽  
Diet Restriction ◽  
Ketogenic Diets ◽  
Control And Prevention

Ketogenic diets provide a non-pharmaceutical alternative for treatment of refractory epilepsy. When successful in reducing or eliminating seizures, medication numbers or doses may be reduced. Unexpected loss of ketosis is a common problem in management of patients on ketogenic diets and, especially when the diet is an effective treatment, loss of ketosis may be associated with an exacerbation in seizures. Identification of the cause of loss of ketosis is critical to allow rapid resumption of seizure control, and prevention of unnecessarily increased diet restriction or increased medication doses. Here an unusual environmental cause of loss of ketosis is described (contamination with starch-containing drywall dust), illustrating the extent of investigation sometimes necessary to understand the clinical scenario.

scholarly journals First, do no harm: the risks of overtreating children with epilepsy

2007 ◽  
Vol 65 (1) ◽  
pp. 1-4 ◽  
Author(s):  
Eunice Chuang ◽  
Marilisa M. Guerreiro ◽  
Sara Y. Tsuchie ◽  
Angelica Santucci ◽  
Carlos A. M. Guerreiro ◽  
...  
Keyword(s):  
Adverse Events ◽  
Prospective Study ◽  
Antiepileptic Drug ◽  
Antiepileptic Drugs ◽  
Seizure Frequency ◽  
Seizure Control ◽  
Control Method ◽  
Refractory Epilepsy ◽  
Do No Harm ◽  
A Prospective Study

BACKGROUND: Although overtreatment with antiepileptic drugs contributes to the morbidity associated with epilepsy, many children still are overtreated. OBJECTIVE: To evaluate if the withdrawal of at least one antiepileptic drug (AED) in children with refractory epilepsy using polytherapy enable a better seizure control. METHOD: This was a prospective study. Children with refractory epilepsy using at least two AEDs were included. Once the patient, or guardian, agreed to participate in the study, one or more AED were slowly tapered off. The remaining AEDs dosages could be adjusted as needed, but a new AED could not be introduced. RESULTS: Fifteen patients were evaluated, three girls; ages ranging from 3 to 18 (mean=8.7 years). After at least one AED withdrawal, two (13.5%) patients became seizure free, seizures improved >50% in 5 (33.5%) patients, did not change in 5 (33.5%), and seizure frequency became worse in 3 (20%). Adverse events improved in 12 patients (80%). CONCLUSION: The withdrawal of at least one AED is a valuable option in the treatment of selected children with refractory epilepsy.

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