scholarly journals Repeat resective surgery in complex pediatric refractory epilepsy: lessons learned

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 ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Refractory Epilepsy ◽  
Intractable Epilepsy ◽  
Cortical Dysplasia ◽  
Favorable Outcome ◽  
Class I ◽  
Intracranial Eeg ◽  
Shunt Placement ◽  
Resective Surgery ◽  
Initial Surgery

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.

Seizure Outcome After Surgery for MRI-Diagnosed Focal Cortical Dysplasia: A Systematic Review and Meta-analysis

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000013066
Author(s):  
Anna Willard ◽  
Ana Antonic-Baker ◽  
Zhibin Chen ◽  
Terence John O'Brien ◽  
Patrick Kwan ◽  
...  
Keyword(s):  
Systematic Review ◽  
Focal Cortical Dysplasia ◽  
Meta Analysis ◽  
Cortical Dysplasia ◽  
Favorable Outcome ◽  
Seizure Outcome ◽  
Drug Resistant ◽  
Resective Surgery ◽  
Post Surgery ◽  
Drug Resistant Epilepsy

Objective:Focal cortical dysplasia (FCD) has been associated with poorer post-surgical seizure outcomes compared to other pathologies. FCD surgical series have been assembled on the basis of a histological diagnosis, including patients with abnormal as well as normal pre-operative MRI. However, in clinical workflow, patient selection for surgery is based on pre-operative findings, including MRI. We performed a systematic review and meta-analysis of the literature to determine the rate and predictors of favorable seizure outcome after surgery for MRI-detected FCD.Methods:We devised our study protocol in accordance with PRISMA guidelines and registered the protocol with PROSPERO. We searched MEDLINE, EMBASE, and Web of Science for studies of patients followed for ≥12 months after resective surgery for drug-resistant epilepsy with MRI-detected FCD. Random-effects meta-analysis was used to calculate the proportion of patients attaining a favorable outcome, defined as Engel Class I, ILAE Classes 1-2, or “seizure-free” status. Meta-regression was performed to investigate sources of heterogeneity.Results:Our search identified 3,745 references. Of these, 35 studies (total of 1,353 patients) were included. Most studies (89%) followed patients for ≥24 months post-surgery. The overall post-surgical favorable outcome rate was 70% (95% CI: 64-75). There was high inter-study heterogeneity. Favorable outcome was associated with complete resection of the FCD lesion [risk ratio, RR=2.42 (95% CI: 1.55-3.76), p<0.001] and location of the FCD lesion in the temporal lobe [RR=1.38 (95% CI: 1.07-1.79), p=0013], but not lesion extent, intracranial EEG use, or FCD histological type. The number of FCD histological types included in the same study accounted for 7.6% of the observed heterogeneity.Conclusions:70% of patients with drug-resistant epilepsy and MRI features of FCD attain a favorable seizure outcome following resective surgery. Our findings can be incorporated in routine pre-operative counselling and reinforce the importance of resecting completely the MRI-detected FCD where this is safe and feasible.

The Impact of Intraoperative Electrocorticography on Seizure Outcome After Resection of Pediatric Brain Tumors: A Cohort Study

Neurosurgery ◽  
2018 ◽  
Vol 85 (3) ◽  
pp. 375-383 ◽  
Author(s):  
Faith C Robertson ◽  
Nicole J Ullrich ◽  
Peter E Manley ◽  
Hasan Al-Sayegh ◽  
Clement Ma ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Focal Cortical Dysplasia ◽  
Tumor Resection ◽  
Cortical Dysplasia ◽  
Class I ◽  
Gross Total Resection ◽  
Seizure Outcome ◽  
Seizure Freedom ◽  
Total Resection ◽  
The Impact

AbstractBACKGROUNDIntraoperative electrocorticography (ECoG) has been utilized in patients with tumor-associated seizures; however, its effectiveness for seizure control remains controversial.OBJECTIVETo evaluate clinical outcomes in pediatric patients undergoing lesionectomy with or without ECoG.METHODSPatients undergoing brain tumor resection at Boston Children's Hospital were examined retrospectively (2005-2014). Inclusion criteria involved diagnosis of a supratentorial tumor, ≥2 unequivocal seizures, and ≥6 mo follow-up. Patients with isolated cortical dysplasia or posterior fossa tumors were excluded. Logistic regression models evaluated predictors of ECoG use, and the impact of ECoG, gross total resection, and focal cortical dysplasia with tumors on seizure freedom by Engel Class and anti-epileptic drug use (AED).RESULTSA total of 119 pediatric patients were included (n = 69 males, 58%; median age, 11.3 yr). Forty-one patients (34.5%) had ECoG-guided surgery. Preoperative seizure duration and number and duration of AED use were significant predictors for undergoing ECoG. There were no differences in seizure freedom (Engel Class I) or improved Engel Score (Class I-II vs III-IV) in patients who did or did not have ECoG at 30 d, 6 mo, and 1, 2, or 5 yr. Patients undergoing ECoG required a greater number of AEDs at 6 mo (P = .01), although this difference disappeared at subsequent time intervals. Gross total resection predicted seizure freedom at 30 d and 6 mo postsurgery (P = .045).CONCLUSIONThis retrospective study, one of the largest evaluating the use of ECoG during tumor resection, suggests that ECoG does not provide improved seizure freedom compared to lesionectomy alone for children.

Seizure-free and neuropsychological outcomes after temporal lobectomy with amygdalohippocampectomy in pediatric patients with hippocampal sclerosis

2012 ◽  
Vol 10 (2) ◽  
pp. 103-107 ◽  
Author(s):  
Sumeet Vadera ◽  
Varun R. Kshettry ◽  
Patricia Klaas ◽  
William Bingaman
Keyword(s):  
Pediatric Patients ◽  
Hippocampal Sclerosis ◽  
Pediatric Population ◽  
Cleveland Clinic ◽  
Intractable Epilepsy ◽  
Cortical Dysplasia ◽  
Temporal Lobectomy ◽  
Low Grade ◽  
Neuropsychological Outcomes

Object Temporal lobe epilepsy is an uncommon clinical syndrome in the pediatric population. The most common underlying pathologies include low-grade gliomas, cortical dysplasia, and, less commonly, hippocampal sclerosis (HS). There is a paucity of data on neuropsychological and seizure-free outcomes in these patients after temporal lobectomy. In this study, the authors reviewed their seizure-free and neuropsychological outcomes after temporal lobectomy for pediatric HS. Methods The authors retrospectively reviewed the medical records of pediatric patients with HS who underwent anterior temporal lobectomy and amygdalohippocampectomy between 1998 and 2011 at the Cleveland Clinic. Results of neuropsychological assessment before and after surgery and seizure-free outcome at last follow-up were obtained. Results Forty-five patients met the inclusion criteria. Thirty-four (76%) patients had pathology of HS alone and 10 (22%) had HS and cortical dysplasia. The mean duration of follow-up was 60.2 months. Eighty-four percent of patients had postoperative Engel Class I or II outcomes. Neuropsychological outcomes remained unchanged or minimally improved postoperatively. Conclusions Seizure-free outcomes in pediatric HS are similar to historical rates in adult HS. Neuropsychological assessments remain stable after temporal lobectomy. Standard temporal lobectomy should be considered in pediatric patients with medically intractable epilepsy secondary to HS.

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 ◽  
...  
Keyword(s):  
Intractable Epilepsy ◽  
Resective Surgery ◽  
Initial Surgery

Surgical treatment of intractable epilepsy associated with focal cortical dysplasia

2008 ◽  
Vol 25 (3) ◽  
pp. E6 ◽  
Author(s):  
Roberto Jose Diaz ◽  
Elisabeth M. S. Sherman ◽  
Walter J. Hader
Keyword(s):  
Refractory Epilepsy ◽  
Functional Neuroimaging ◽  
Focal Cortical Dysplasia ◽  
Intractable Epilepsy ◽  
Cortical Dysplasia ◽  
Complete Resection ◽  
Epileptogenic Zone ◽  
Malformations Of Cortical Development ◽  
Cortical Dysplasias

Focal cortical dysplasias (FCDs) are congenital malformations of cortical development that are a frequent cause of refractory epilepsy in both children and adults. With advances in structural and functional neuroimaging, these lesions are increasingly being identified as a cause of intractable epilepsy in patients undergoing surgical management for intractable epilepsy. Comprehensive histological classification of FCDs with the establishment of uniform terminology and reproducible pathological features has aided in our understanding of FCDs as an epilepsy substrate. Complete resection of FCDs and the associated epileptogenic zone can result in a good surgical outcome in the majority of patients.

S4-3. Recording ingenuity for intracranial EEG monitoring in pediatric patients with intractable epilepsy

2019 ◽  
Vol 130 (10) ◽  
pp. e190-e191
Author(s):  
Koji Iida ◽  
Kota Kagawa ◽  
Masaya Katagiri ◽  
Go Seyama ◽  
Akira Hashizume ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Intractable Epilepsy ◽  
Eeg Monitoring ◽  
Intracranial Eeg

Reoperation for Refractory Epilepsy in Childhood

Neurosurgery ◽  
2013 ◽  
Vol 73 (4) ◽  
pp. 695-704 ◽  
Author(s):  
Georgia Ramantani ◽  
Karl Strobl ◽  
Angeliki Stathi ◽  
Armin Brandt ◽  
Susanne Schubert-Bast ◽  
...  
Keyword(s):  
Refractory Epilepsy ◽  
Cortical Dysplasia ◽  
Glioneuronal Tumor ◽  
Pediatric Epilepsy ◽  
Seizure Freedom ◽  
Epileptogenic Zone ◽  
Rasmussen Encephalitis ◽  
Initial Surgery ◽  
Pediatric Epilepsy Surgery ◽  
Catastrophic Epilepsy

Abstract BACKGROUND: Reoperations account for &gt;10% in pediatric epilepsy surgery cohorts, and they are especially relevant in young children with catastrophic epilepsy. OBJECTIVE: To determine surgical outcomes and their predictive factors in reoperations for refractory epilepsy in childhood. METHODS: We retrospectively analyzed presurgical findings, resections, and outcomes of 23 consecutive children who underwent reoperations from 2000 to 2011. RESULTS: Etiology included cortical dysplasia with/without glioneuronal tumor in 19 patients (83%), sole glioneuronal tumor in 2, and tuberous sclerosis and Rasmussen encephalitis in 1 each. The reasons for the failure of the initial surgery were functional considerations in 8 (35%), incorrect delineation of the epileptogenic zone in 8 (35%), and resection not performed as initially planned in 7 (30%) cases. Final procedures included 8 (35%) intralobar, 8 (35%) multilobar resections, and 7 (30%) hemispherotomies. Following reoperations, 14 (61%) patients were seizure free, 6 (26%) showed significant or worthwhile improvement, and 3 (13%) did not respond to surgery. Six of 8 patients who underwent the first resection before the age of 3 years, 6 of 8 whose first resection was limited by functional considerations, and all 7 with hemispherotomy as the final resection achieved seizure freedom after reoperation. CONCLUSION: Reoperation is particularly beneficial for selected children with refractory epilepsy associated with cortical dysplasia that did not respond to an initial limited and/or early resection but achieved seizure freedom after extensive procedures. When indicated, reoperation should be performed at the youngest possible age to profit from higher functional plasticity in compensating for neurological deficit.

scholarly journals Hemispherectomy for the Control of Intractable Epilepsy in Childhood: Comparison of 2 Surgical Techniques in a Single Institution

2010 ◽  
Vol 67 (suppl_2) ◽  
pp. ons429-ons436 ◽  
Author(s):  
Allison Kwan ◽  
Wai Hoe Ng ◽  
Hiroshi Otsubo ◽  
Ayako Ochi ◽  
O. Carter Snead ◽  
...  
Keyword(s):  
Surgical Techniques ◽  
Intractable Epilepsy ◽  
Class I ◽  
Clinical Criteria ◽  
Patient Demographics ◽  
Initial Surgery ◽  
Age At Surgery ◽  
Second Procedure ◽  
Catastrophic Epilepsy

ABSTRACT BACKGROUND: Hemispherectomy is an established neurosurgical procedure for catastrophic epilepsy in childhood. However, the technique used to achieve an optimum outcome remains to be determined. OBJECTIVE: We examined the influence of hemidecortication (HD) vs peri-insular hemispherotomy (PIH) on patient outcome. METHODS: The medical records of 41 children undergoing hemispherectomy were reviewed for patient demographics, clinical criteria, and surgical outcomes. RESULTS: HD and PIH were performed in 21 and 20 children, respectively. The mean age at surgery for HD was 54 months and 61 months for PIH. The median durations of surgery for HD and PIH were 5 hours and 7 hours, respectively (P &lt; .001). For HD, 6 patients required a second surgery and 3 required a third. One PIH patient required a second procedure. Postoperative shunting was required in 5 HD patients, but only 1 PIH patient. All patients had increased hemiparesis after surgery. The overall mean follow-up time was 72 months. Engel class I or II outcomes after initial surgery were better after PIH (85%) compared with HD (48%) (P &lt; .02). After subsequent surgeries for seizure control, 4 HD patients and 1 PIH patient improved to Engel class I or II. CONCLUSION: Hemispherectomy is an effective surgical procedure for childhood intractable catastrophic epilepsy. In patients with diffuse hemispheric disorder, PIH tends to have fewer major complications, more favorable seizure outcomes, and a decreased need for subsequent surgical procedures, including shunting for hydrocephalus, compared with HD.

Functional hemispherotomy for refractory epilepsy in pediatric patients: the right person at the right time

2010 ◽  
Vol 41 (02) ◽  
Author(s):  
G Ramantani ◽  
T Bast ◽  
T Gerstner ◽  
G Wiegand ◽  
K Strobl ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Refractory Epilepsy ◽  
The Right
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