Hemispheric surgery in children: perisylvian technique.

Hemispheric epilepsy is quite frequent in children, compared with adults, and encompasses pathological substrates as diverse as hemimegalencephaly, Rasmussen encephalitis, Sturge-Weber syndrome, and porencephaly, among others. These patients most often become pharmacoresistant and thus require surgical management. Although anatomical hemispherectomy is a possibility, the technique that is favored by most epilepsy surgery centers worldwide is functional hemispherotomy, which results in equivalent outcomes with fewer postoperative complications. Therefore, it is essential that pediatric epilepsy neurosurgeons become familiar with these techniques. The present video describes in detail all surgical aspects of the perisylvian hemispherotomy.

Management of anhedonia after epilepsy surgery.

Anhedonia is clinically defined as difficulty or inability to feel pleasure or to be motivated to perform activities that were previously pleasurable. Anhedonia is a core feature of depressive disorders but can be present in other conditions such as substance use and anxiety disorders. Herein we report the case of a 34-year-old female who developed marked anhedonia after left cortico-amygdalohippocampectomy. Despite optimal seizure control, the person struggled with anhedonia and other depressive symptoms. After ruling out medico-neurologic complications, she was prescribed with a selective serotonin reuptake inhibitor and cognitive-behavioral therapy. Anhedonia can be a challenging neuropsychiatric presentation that requires ruling out the effects of antiseizure medications, neurosurgery, and other drugs before prescribing antidepressants.

Thermosensitive/thermochromic silicone and infrared thermography mapping in 60 consecutive cases of epilepsy surgery.

Background: Epilepsy surgery represents a therapeutic opportunity for those patients who do not respond to drug therapy. However, an important challenge is the precise identification of the epileptogenic area during surgery. Since it can be hard to delineate, it makes it necessary to use auxiliary tools as a guide during the surgical procedure. Electrocorticography (ECoG), despite having shown favorable results in terms of reducing post-surgical seizures, have certain limitations. Brain mapping using infrared thermography mapping and a new thermosensitive/thermochromic silicone (TTS) in epilepsy surgery has introduced a new resource of noninvasive and real-time devices that allow the localization of irritative zones. Methods: Sixty consecutive patients with drug-resistant epilepsy with surgical indications who decided to participate voluntarily in the study were included in the study. We measured brain temperature using two quantitative methods and a qualitative method: the TTS sheet. In all cases, we used ECoG as the gold standard to identify irritative areas, and all brain tissue samples obtained were sent to pathology for diagnosis. Results: In the subgroup in which the ECoG detected irritative areas (n = 51), adding the results in which there was a correlation with the different methods, the efficiency obtained to detect irritative areas is 94.11% (n = 48/51, P ≤ 0.0001) while the infrared thermography mapping method independently has an efficiency of 91.66% (P ≤ 0.0001). The TTS has a sensitivity of 95.71% and a specificity of 97.9% (P ≤ 0.0001) to detect hypothermic areas that correlate with the irritative zones detected by ECoG. No postoperative infections or wound dehiscence were documented, so the different methodologies used do not represent an additional risk for the surgical proceedings. Conclusion: We consider that the infrared thermography mapping using high-resolution infrared thermography cameras and the TTS are both accurate and safe methods to identify irritative areas in epilepsy surgeries.

Hemisferotomía peri-insular y Hemisferectomía funcional pediátrica para el tratamiento de la epilepsia severa refractaria al tratamiento médico: comparación de dos técnicas / Peri-insular Hemispherotomy and Pediatric Functional Hemispherectomy for the Treatment of Severe Epilepsy Refractory to Medical Treatment: Comparison of Two Techniques

Introducción. Desde que se describió por primera vez en la década de 1970, la hemisferectomía funcional ha sido una herramienta esencial en el tratamiento de la epilepsia refractaria al tratamiento médico secundaria a una enfermedad hemisférica unilateral difusa. Objetivos. Presentar nuestra experiencia con la técnica de hemisferectomía funcional (HF) y de hemisferotomía peri-insular modificada (HPI); describir además la técnica quirúrgica peri-insular, revisar los resultados después de la cirugía, y discutir las diferencias entre las técnicas en cuanto a complicaciones y resultados postoperatorios. Material y Métodos. Se realizo un estudio retrospectivo de 23 pacientes con epilepsia refractaria que fueron sometidos a hemisferectomía cerebral. Se realizó un análisis de las características clínicas, las imágenes, las técnicas quirúrgicas y los resultados postoperatorios. Analizamos tambien la técnica quirúrgica de la HPI modificada. Resultados. Entre 2000 y 2020, 23 pacientes pediátricos con convulsiones refractarias se sometieron a hemisferotomía (12 HF, 11 HPI modificada). El 91,3% de los pacientes estaban libres de crisis a los 6 meses, el 87% al año y el 78,3% en el último seguimiento. Ninguno de los 23 pacientes presentó Engel IV como resultado final. Se encontró que la HF presentó una duración quirúrgica estadísticamente más larga que la HPI (5 ± 1,5 frente a 3,83 ± 0,5 horas; p = <0,001). Como resultados generales, la esfera cognitiva mejoró en dos tercios de los pacientes (66,9%) y además demostramos una mejoría de la actividad motora en la mayoría de los pacientes, independientemente de la patología y la técnica quirúrgica. Conclusión. Cuando los pacientes se seleccionan adecuadamente, la hemisferectomía es un tratamiento eficaz para la epilepsia pediátrica resultante la marcada disfunción de un solo hemisferio cerebral, no sólo brindando al paciente una alta probabilidad de ausencia de convulsiones, sino también proporcionando una mejora en las habilidades motoras y cognitivas. En nuestro caso particular y en base al presente estudio, la HPI modificada resulta ser una técnica altamente efectiva. No solo tiene un tiempo quirúrgico más corto sino también una tasa de complicaciones muy baja

Background. Since it was first described in the 1970s, functional hemispherotomy has been an essential tool in treating disabling, medically refractory epilepsy resulting from diffuse unilateral hemispheric disease. Objectives. To report our experience with 23 patients who underwent hemispherotomy, both using the functional hemispherotomy (FH) as well as a modified peri-insular hemispherotomy (PIH) technique; to present the surgical technique, review outcomes following disconnection surgery and discuss the differences between the techniques when it comes to complications and postoperative results. Methods. A retrospective study of 23 patients with refractory seizures who underwent cerebral hemispherectomy. A thorough analysis of the clinical, imaging, surgical features and postoperative results was performed. We also review the surgical technique for the modified PIH technique. Results. Between 2000 and 2020, 23 pediatric patients with refractory seizures underwent hemispherotomy (12 FHs, 11 modified PIHs). 91.3% of patients were seizure free at 6 months, 87% at 1 year, and 78.3% at last follow-up. None of the 23 patients presented Engel IV outcome. FH was found to have statistically longer surgical duration (5 ± 1.5 vs 3.83 ± 0.5 hours; p = <0.001). Neurocognition was improved in two thirds of the patients (66.9%). Our study also shows improvement of motor activity in most of the patients, regardless of the pathology and surgical technique. Conclusion. When patients are wisely selected, the hemispherotomy procedure should be considered as a most attractive and curative treatment for children with refractory seizures, not only giving the patient a high chance of seizure freedom but also providing an improvement in motor and cognitive skills. In our case and based on the present study, the modified PIH proves to be a highly effective technique. It not only has a shorter surgical time but also a very low complication rate

Bilateral ictal EEG is associated with better memory outcome after hippocampal sclerosis surgery.

OBJECTIVE: To compare memory outcomes after surgery for unilateral hippocampal sclerosis (HS)-associated epilepsy in patients with unilateral and bilateral ictal electrographic involvement. METHODS: We prospectively evaluated HS patients, aged 18-55 years and IQ ≥70. Left (L) and right (R) surgical groups underwent noninvasive video-EEG monitoring and Wada test. We classified patients as Ipsilateral if ictal EEG was restricted to the HS side, or Bilateral, if at least one seizure onset occurred contralaterally to the HS, or if ictal discharge evolved to the opposite temporal region. Patients who declined surgery served as controls. Memory was evaluated on two occasions with Rey Auditory-Verbal Learning Test and Rey Visual-Design Learning Test. Baseline neuropsychological test scores were compared between groups. Pre- and postoperative scores were compared within each group. Reliable change index Z-scores (RCI) were obtained using controls as references, and compared between surgical groups. RESULTS: We evaluated 64 patients. Patients were classified as: L-Ipsilateral (9), L-Bilateral (15), L-Control (9), R-Ipsilateral (10), R-Bilateral (9), and R-Control (12). On preoperative evaluation, memory performance did not differ among surgical groups. Right HS patients did not present postoperative memory decline. L-Ipsilateral group presented postoperative decline on immediate (P = 0.036) and delayed verbal recall (P = 0.011), while L-Bilateral did not decline. L-Ipsilateral had lower RCI Z-scores, indicating delayed verbal memory decline compared to L-Bilateral (P = 0.012). SIGNIFICANCE: Dominant HS patients with bilateral ictal involvement presented less pronounced postoperative verbal memory decline compared to patients with exclusive ipsilateral ictal activity. Surgery was indicated in these patients regardless of memory impairment on neuropsychological testing, since resection of the left sclerotic hippocampus could result in cessation of contralateral epileptiform activity, and, therefore, improved memory function.

Clinical and Surgical Approach for Cerebral Cortical Dysplasia.

The present article describes pathophysiological and clinical aspects of congenital malformations of the cerebral tissue (cortex and white matter) that cause epilepsy and very frequently require surgical treatment. A particular emphasis is given to focal cortical dysplasias, the most common pathology among these epilepsy-related malformations. Specific radiological and surgical features are also highlighted, so a thorough overview of cortical dysplasias is provided.

Long-term seizure outcome and mobility after surgical treatment for Rasmussen encephalitis in children: A single-center experience.

OBJECTIVE: Rasmussen Encephalitis (RE) is a rare inflammatory neurodegenerative disease associated with refractory seizures, hemiparesis, and cognitive deterioration, due to lateralized cortical atrophy. Hemispheric surgery (hemispherotomy) is the mainstay of treatment, but its unavoidable motor deficits and lack of long-term data regarding seizure outcomes can make patients and families apprehensive to undergo this procedure. The present study aimed at analyzing the results of surgical treatment for RE from a motor and epilepsy standpoint, and mitigate such concerns. METHODS: Clinical and operative data were retrospectively collected from medical records of pharmacoresistant patients treated with functional hemispherectomy at a tertiary reference center for epilepsy surgery, during a 24-year period (1996-2020). Variables such as age of epilepsy onset, seizure semiology, seizure frequency, immunomodulatory therapy, age at surgery, duration of epilepsy, surgical procedures and complications, number of medications used preoperatively and postoperatively were described and statistically analyzed. RESULTS: Forty-three (43) patients were included in this study. Mean age of epilepsy onset was 6.14 years, the average interval between epilepsy onset and hemispherotomy was 2.21 years. and the mean age at surgery was 8.28 years. Thirty patients (69.7%) were Engel I at their last follow-up, of whom 23 (56.4%) were Engel Ia, within a mean follow-up of 11.3 years. Duration of epilepsy, seizure frequency, and age at surgery, among others, did not correlate with seizure outcome, except the use of immunotherapy which led to worse outcomes (p < .05). Also, after surgery, motor functionality was significantly recovered (i.e., most patients returned to their previous status) with time. SIGNIFICANCE: This study tackled some issues regarding the surgical treatment of this disease, particularly showing that hemispherotomy is safe and leads to potentially recoverable disability of motor functions while providing high rates of effective and long-lasting seizure control; therefore, early surgical indication should be warranted once medical refractoriness has been established.

Case report: Successful anterior temporal lobectomy in drug-resistant temporal lobe epilepsy associated with Sotos syndrome.

The Sotos syndrome is an autosomal dominant disorder characterized by haploinsufficiency of NSD1 gene, with some individuals affected by epilepsy and, rarely, drug-resistant seizures. A 47-years-old female patient with Sotos syndrome was diagnosed with focal-onset seizures in left temporal lobe, left-side hippocampal atrophy, and neuropsychological testing with decreased performance in several cognitive domains. Patient was treated with left-side temporal lobe resection and developed complete awake seizure control in 3-years of follow-up, with marked improvement in quality-of-life. In selected, clinically concordant patients, resective surgeries may play a significant role in improving patient's quality of life and seizure control.

Reduction in anti-seizure medications use in pediatric patients with pharmacoresistant epilepsy submitted to surgical treatment.

PURPOSE: We aimed to analyze the potential for postoperative (PO) medication suspension and reduction, emphasizing passive withdrawal. METHODS: Retrospective study of patients under 18 years old submitted to surgical treatment for pharmacoresistant epilepsy and classified as Engel I during the first year of PO follow-up. Therapeutic management was evaluated through discontinuation or reduction of medications, both in terms of the number of ASM prescribed and in daily maintenance dosages in mg/kg. RESULTS: ASM withdrawal started in the first year PO and occurred in 1.2% of cases, with a significant yearly reduction in the number of ASM during follow-up (p < 0.001). A comparison of the most commonly used ASM in daily mg/kg between the preoperative period (preop) and PO showed a reduction of ASM maintenance dosages during PO. Even though recurrence of seizures was observed 5 years after surgery, 125 patients (85%) were still classified as Engel I, albeit a higher number of ASM per patient was observed. Most patients showed no changes in cognitive and adaptive behavior evaluation between preop and PO, even in those who were able to reduce ASM. CONCLUSION: Significant reduction observed both in the number and daily maintenance dosages of ASM following each year of PO may be an indirect measure of the effectiveness of epilepsy surgery.

Tratamiento quirúrgico en estado epiléptico super refractario relacionado con malformación arterio venosa

Introducción: Las malformaciones arteriovenosas cerebrales (MAV) son un conjunto anormal de arterias y venas dilatadas del cerebro y caracterizadas por la pérdida de la organización vascular con una derivación arteriovenosa anormal. La probabilidad de ruptura de una MAV es baja, pudiendo causar déficit hasta en el 45% de los pacientes. La epilepsia puede asociarse con MAV siendo raro el estado epiléptico. La evolución a estado epiléptico refractario o estado epiléptico super refractario (EESR) es excepcional. Se presenta paciente con epilepsia asociada a MAV, con embolización y posterior complicación que evoluciona a EESR, donde se logró una resolución favorable con cirugía. Caso clínico: Paciente masculino de 70 años, con MAV temporal derecha no rota y epilepsia, libre de crisis desde el diagnóstico de ambas condiciones. Se realizó embolización logrando exclusión, pero con evolución a EESR. Tras estudio se realiza resección de MAV y resección parcial de zona de inicio de actividad epileptógena parieto-temporal. Además, se realizó una desconexión de región fronto-parietal central donde había evidencia de propagación de la actividad epiléptica. Paciente logra salir de estado crítico, con recuperación de conciencia y normalización de electroencefalogramas posquirúrgicos. A los 2 años evoluciona con epilepsia controlada (Engel IIa). Discusión y conclusiones: El abordaje quirúrgico es una opción en EESR y debe plantearse en un tiempo precoz de evolución (1-2 semanas). La cirugía se realizó para controlar EESR y fue una intervención exitosa. Esta estrategia puede lograr un cambio dramático en el pronóstico. La cirugía resectiva está indicada cuando hay evidencia etiológica en imágenes y focalidad eléctrica consistente en los estudios.

Introduction: Brain Arteriovenous Malformations (AVM) are an abnormal set of dilated arteries and veins within the brain and are characterized by loss of vascular organization with an abnormal arteriovenous shunt. The probability of AVM rupture is low, but it can cause deficits in up to 45% ofpatients. Epilepsy could be associated with AVM, and status epilepticus is rare. The evolution to refractory status epilepticus or super refractory status epilepticus (SRSE) is very rare. The objective is to present a patient with epilepsy associated with non-ruptured AVM, treated with embolization and a subsequent complication that evolves into SRSE, in which a favorable resolution was achieved after surgery Clinical case: 70-year-old male, with a diagnosis of non-ruptured right temporal AVM and epilepsy, who has been seizure free since the diagnosis, is reported. Embolization of the AVM was performed, achieving total exclusion, after the procedure presented seizures that evolved into SRSE. After investigation, an AVM resection and partial resection of the ictal onset zone on the right parieto-temporal region was performed, including a disconnection of the central fronto-parietal region, where there was evidence of propagation of ictal activity. Patient recovered from the critical condition after surgery, and also presented electrographic normalization. After 2 years, the epilepsy is well controlled (Engel IIa). Discussion and conclusions: The surgical approach is an option in SRSE, and it should be proposed early on, within a reasonable time of evolution (1-2 weeks). The active approach in this case, where the surgery was done for SRSE control, was a successful intervention. Especially when the features are consistent -there is etiological evidence in imaging and electrical focality in studies- there can be a dramatic change in the prognosis.

Impacto psicosocial del desarrollo científico-técnico en el estudio de la epilepsia

Introducción: Se ha planteado que no existe otra enfermedad asociada a tantos problemas sociales como lo es la epilepsia. Objetivo: Describir el impacto social del desarrollo científico-técnico en el estudio de la epilepsia. Método: Se realizó una revisión narrativa a partir del estudio documental de varias fuentes bibliográficas encontradas en base de datos electrónicas. Los principales criterios de búsqueda fueron: artículos publicados en los últimos 10 años sobre impacto psicosocial del desarrollo científico-técnico en el estudio de la epilepsia. Desarrollo: El efecto sobrenatural atribuido a la epilepsia, con su consecuente repercusión social, es resultado de especulaciones provocadas por siglos de falsas creencias sobre esta enfermedad. El impacto social de la enfermedad es negativo, genera problemas financieros, de aislamiento, de exclusión social y discriminación. Se plantea que la epilepsia tiene gran influencia en todos los niveles de calidad de vida. Las anomalías detectadas por las novedosas técnicas de estudio por neuroimagen en la epilepsia se han relacionado con el deterioro cognitivo, refractariedad de la enfermedad y otros hallazgos que pueden estar relacionados indirectamente con las alteraciones psicosociales de los pacientes. Consideraciones finales: La epilepsia, además del daño orgánico, genera consecuencias psicosociales negativas que limitan el desempeño saludable de los enfermos. En los últimos años los adelantos científico-técnicos han limitado de forma parcial los efectos sociales negativos de la enfermedad con la incorporación de novedosas tecnologías para su estudio y tratamiento.

Introduction: Views has been expressed that there is no disease more linked with social problems than epilepsy. Objective: To describe the social impact of scientific and technological development on the study of epilepsy. Method: A narrative review was carried out supported on the documentary research of several bibliographic sources found in electronic databases. The main search criteria were as follow: articles published in the last 10 years, which had relation with aspects concerning the psychosocial impact of scientific and technological development on the study of epilepsy. Development: The supernatural effect attributes to epilepsy, including its social repercussions, is the result of centuries of speculative theories and false beliefs about this disease. Epilepsy has negative impact on social well-being, causing serious economic problems, isolation, social exclusion and discrimination. Epilepsy is described as a disease with a great influence on all levels of quality of life. The abnormalities detected using novel neuroimaging techniques referred to the presence of cognitive impairment, refractory period and other aspects which may be indirectly related to psychosocial alterations in patients. Final considerations: Epilepsy, in addition to its traumatic effects, has negative psychosocial consequences that affect the healthy performance of patients. In recent years, the scientific and technological advancements have partially limited the negative social effects causes by this disease with the use of new technologies for its study and treatment.

Introdução: Tem sido sugerido que não há outra doença associada a tantos problemas sociais quanto a epilepsia. Objetivo: Descrever o impacto social do desenvolvimento científico-técnico no estudo da epilepsia. Método: Realizou-se revisão narrativa a partir do estudo documental de diversas fontes bibliográficas encontradas em bases de dados eletrônicas. Os principais critérios de busca foram: artigos publicados nos últimos 10 anos sobre o impacto psicossocial do desenvolvimento científico-técnico no estudo da epilepsia. Desenvolvimento: O efeito sobrenatural atribuído à epilepsia, com sua consequente repercussão social, é fruto de especulações causadas por séculos de falsas crenças sobre essa doença. O impacto social da doença é negativo, gera problemas financeiros, isolamento, exclusão social e discriminação. Sugere-se que a epilepsia tenha grande influência em todos os níveis da qualidade de vida. As anormalidades detectadas pelas novas técnicas de estudo de neuroimagem na epilepsia têm sido relacionadas à deterioração cognitiva, refratariedade da doença e outros achados que podem estar indiretamente relacionados às alterações psicossociais dos pacientes. Considerações finais: A epilepsia, além dos danos orgânicos, gera consequências psicossociais negativas que limitam o desempenho saudável dos pacientes. Nos últimos anos, os avanços técnico-científicos limitaram parcialmente os efeitos sociais negativos da doença com a incorporação de novas tecnologias para seu estudo e tratamento.

Evolución clínica, cognitiva y calidad de vida posquirúrgica en un caso con síndrome de Lennox Gastaut / Clinical and Cognitive Evolution and Postoperative Quality of Life in a Case with Lennox Gastaut Syndrome

Introducción: El síndrome de Lennox Gastaut se considera una encefalopatía epiléptica. Las anomalías epileptiformes en este síndrome contribuyen a la discapacidad intelectual gradual, a las comorbilidades psiquiátricas y alteraciones conductuales. En la práctica clínica aparecen atipicidades del síndrome, con focalización funcional cuyo tratamiento constituye un desafío. Objetivo: Describir la evolución clínica, cognitiva y calidad de vida en un caso con síndrome de Lennox Gastaut antes, y después del tratamiento quirúrgico. Presentación del caso: Paciente masculino de 16 años con síndrome de Lennox Gastaut. Se revisó la historia clínica y se tomaron en consideración, los resultados del video-electroencefalograma, de la resonancia magnética nuclear y de la tomografía computarizada por emisión de fotón único. Se evaluó, además, el proceder quirúrgico, la evaluación clínica y neuropsicológica. Se realizó una descripción cualitativa de la evolución del paciente a los 6 meses y al año de la intervención quirúrgica. Conclusiones: el paciente con síndrome de Lennox Gastaut presentó una evolución favorable después del tratamiento quirúrgico, lo cual se reflejó en una disminución en la frecuencia de las crisis. mejoría cognitiva, conductual y mejor calidad de vida(AU)

Introduction: Lennox Gastaut syndrome is considered an epileptic encephalopathy. Epileptiform abnormalities in this syndrome contribute to gradual intellectual disability, psychiatric comorbidities and behavioral disturbances. In clinical practice, atypicalities of the syndrome appear with functional focalization whose treatment constitutes a challenge. Objective: To describe the clinical and cognitive evolution and quality of life in a case with Lennox Gastaut syndrome before and after surgical treatment. Case presentation: A 16-year-old male patient with Lennox Gastaut syndrome. The clinical history was reviewed and the results of the video-electroencephalogram, nuclear magnetic resonance and single photon emission computed tomography were taken into consideration. The surgical procedure, clinical and neuropsychological evaluation were also evaluated. A qualitative description of the patient's evolution past 6 months and one year after surgery was prepared. Conclusions: the patient with Lennox Gastaut syndrome has a favorable evolution after surgical treatment, which is reflected in a decrease in seizure frequency, cognitive and behavioral improvement and better quality of life(AU)

Retos en el diagnóstico y tratamiento de la Encefalitis de Rasmussen de inicio tardío: Reporte de tres casos / Challenges in diagnosis and treatment of late-onset Rasmussen encephalitis: Report of three cases

RESUMEN La encefalitis de Rasmussen es una entidad clínica poco frecuente caracterizada por epilepsia focal farmacorresistente, creciente déficit neurológico y hemiatrofia cerebral progresiva. Los abordajes diagnóstico y terapéutico son complejos, más aún en pacientes con inicio tardío de la enfermedad (adolescencia y adultez), en los cuales el cuadro clínico podría ser atípico cuando comparado con su presentación en niños. Se reporta una serie de tres casos clínicos de encefalitis de Rasmussen de inicio tardío, confirmados con evaluaciones histopatológicas e inmunohistoquímicas y en los cuales se obtuvo mejoría clínica tras ser intervenidos quirúrgicamente. Se efectúa también una revisión de la literatura sobre la evolución clínica y alternativas terapéuticas para el manejo de este tipo de presentación.

SUMMARY Rasmussen's encephalitis is an unusual clinical entity characterized by drug-resistant focal epilepsy, neurological deficit and progressive cerebral hemiatrophy. The diagnostic and therapeutic approach is complex, even more so in patients with Rasmussen's encephalitis of late onset (in adolescence and adulthood) whose clinical picture could be atypical when compared with its occurrence in children. We report a series of three clinical cases of late-onset Rasmussen's encephalitis confirmed by histopathology and immunohistochemistry evaluations and in which clinical improvement was achieved after surgical interventions. Literature reviews on the clinical evolution and therapeutic alternatives for this type of presentation are included.

Extended resection for seizure control of pure motor strip focal cortical dysplasia during awake craniotomy: illustrative case.

BACKGROUND: Focal cortical dysplasias (FCD) represent highly intrinsically epileptogenic lesions that require complete resection for seizure control. Resection of pure motor strip FCD can be challenging. Effective control of postoperative seizures is crucial and extending the boundaries of resection in an eloquent zone remains controversial. OBSERVATIONS: The authors report a 52-year-old right-handed male with refractory epilepsy. The seizure phenotype was a focal crisis with preserved awareness and a clonic motor onset of right-hemibody. Epilepsy surgery protocol demonstrated a left pure motor strip FCD and a full-awake resective procedure with motor brain mapping was performed. Further resection of surgical boundaries monitoring function along intraoperative motor tasks with no direct electrical stimulation corroborated by intraoperative-neuromonitorization was completed as the final part of the surgery. In the follow-up period of 3-years, the patient has an Engel-IB seizure-control with mild distal lower limb palsy and no gate compromise. LESSONS: This report represents one of the few cases with pure motor strip FCD resection. In a scenario similar to this case, the authors consider that this variation can be useful to improve seizure control and the quality of life of these patients by extending the resection of a more extensive epileptogenic zone minimizing functional damage.

Epilepsia del lóbulo temporal farmacorresistente como resultado de un programa quirúrgico / Drug-resistant temporal lobe epilepsy as a result of a surgical program

Introducción: La epilepsia del lóbulo temporal es la forma más común de epilepsia focal en el adulto y la que mejor responde al tratamiento quirúrgico. Objetivo: Identificar la asociación entre variables prequirúrgicas, transquirúrgicas y posquirúrgicas y la evolución en pacientes con epilepsia temporal farmacorresistente sometidos a cirugía de epilepsia. Métodos: Se estudiaron para la cirugía 24 pacientes con epilepsia temporal farmacorresistente, en el Instituto de Neurología y Neurocirugía, entre el año 2012 y 2020. Se utilizó el test de Fisher para identificar la asociación entre variables. Se evaluó la escala de Engel al año de la cirugía y en el último seguimiento. Resultados: Se alcanzó libertad de crisis (Engel I) en el 66,7 por ciento de los casos, según último seguimiento, con un período ente 1 a 8 años. La resección completa de la zona epileptogénica y la ausencia de crisis en los primeros 6 meses de la cirugía estuvieron relacionadas con Engel I al año y al último seguimiento. De igual forma las estadísticas estuvieron relacionadas: la ausencia de crisis posoperatorias agudas con Engel I al año y menos de 10 crisis al mes previo a la cirugía, la desaparición luego de la resección, del patrón epileptiforme encontrado en la electrocorticografía preresección, con Engel I al último seguimiento. Conclusiones: La mayoría de los pacientes operados de epilepsia del lóbulo temporal farmacorresistente quedaron libres de crisis en el último seguimiento. La resección completa de la zona epileptogénica y la ausencia de crisis en los primeros 6 meses de la cirugía estuvo asociada a las estadísticas de los resultados posquirúrgicos(AU)

Introduction: Temporal lobe epilepsy is the most common form of focal epilepsy in adults and the one that best responds to surgical treatment. Objective: to identify the association between pre-surgical, intra-surgical and post-surgical variables and evolution in patients with drug-resistant temporal epilepsy undergoing epilepsy surgery. Methods: Twenty four (24) patients with drug-resistant temporal epilepsy were studied for surgery at the Institute of Neurology and Neurosurgery, from 2012 to 2020. Fisher's test was used to identify the association between variables. The Engel scale was evaluated one year after surgery and at the last follow-up. Results: Seizure freedom (Engel I) was achieved in 66.7 percent of the cases, according to the last follow-up, with a period between 1 and 8 years. The complete resection of the epileptogenic zone and the absence of seizures in the first 6 months after surgery were related to Engel I at one year and at the last follow-up. In the same way, the statistics were related the absence of acute postoperative crises with Engel I a year and less than 10 crises a month prior to surgery, the disappearance, after resection, of the epileptiform pattern found in the pre-resection electrocorticography, with Engel I at last follow-up. Conclusions: The majority of patients operated on for drug-resistant temporal lobe epilepsy were seizure-free at the last follow-up. The complete resection of the epileptogenic zone and the absence of crises in the first 6 months after surgery were associated with the statistics of the postoperative results(AU)

Long-Term Outcome of Temporal Lobe Epilepsy Surgery in 621 Patients With Hippocampal Sclerosis: Clinical and Surgical Prognostic Factors.

Temporal lobe epilepsy (TLE) is the most common type of focal epilepsy and is frequently drug-resistant (DR) to antiseizure medication (ASM), corresponding to approximately one-third of the cases. When left inadequately treated, it can worsen the quality of life, cognitive deficits, and risk of death. The standard treatment for drug-resistant TLE is the surgical removal of the structures involved, with good long-term outcome rates of 60-70 % and a low rate of adverse effects. The goal of successful treatment is sustained seizure freedom. In our study, we evaluated sustained long-term (up to 23 years) surgical outcomes in 621 patients with DR-TLE associated with hippocampal sclerosis, who underwent a temporal lobectomy. We analyzed the main predictive factors that influence the surgical outcome related to seizure control, through a longitudinal and retrospective study, using a multivariable regression model. We found that 73.6% of the patients were free from disabling seizures (Engel Class I), maintained over time in 65% of patients followed up to 23 years after surgery. We found that four independent variables predicted seizure outcomes. The presence of dysmnesic and olfactory aura predicted a less favorable outcome. The history of febrile seizure and the surgical technique predicted a good outcome. Regarding the type of surgical technique, the standard anteromesial temporal lobectomy (ATL) led to significantly better outcomes (78.6% Engel Class I) when compared to the selective amygdalohippocampectomy via subtemporal approach (67.2% Engel Class I; p = 0.002), suggesting that the neuronal networks involved in the epileptogenic zone may be beyond mesial temporal structures. The multivariable regression model with the above-mentioned predictor variables revealed an ExpB = 3.627 (N = 621, p < 0.001), indicating that the model was able to distinguish between patients with a seizure-free. We conclude that epilepsy surgery is a safe procedure, with low rates of postoperative complications and good long-term results.

Inteligencia artificial en la evaluación y manejo de pacientes con epilepsia / Artificial intelligence in the evaluation and management of patients with epilepsy

RESUMEN La epilepsia es una enfermedad que frecuentemente conlleva significativos niveles de morbi-mortalidad, afecta seriamente la calidad de vida y, en cerca de un tercio de los pacientes, es refractaria a diversos tratamientos. La inteligencia artificial (IA) ha beneficiado el estudio, tratamiento y pronóstico de los pacientes con epilepsia a través de los años. Estos logros abarcan diagnóstico, predicción de crisis automatizada, monitoreo avanzado de crisis epilépticas y electroencefalograma, uso de recursos genéticos en manejo y diagnóstico, algoritmos en imagen y tratamiento, neuromodulación y cirugía robótica. La presente revisión explica de forma práctica los avances actuales y futuros de la inteligencia artificial, rama de la ciencia que ha mostrado resultados prometedores en el diagnóstico y tratamiento de pacientes con epilepsia.

SUMMARY Epilepsy is a condition that frequently coexists with significant morbi-mortality levels, seriously affects the quality of life and, in up to one third of patients, is refractory to a variety of treatment approaches. Artificial intelligence (AI) has largely benefitted the study, treatment, and prognosis of patients with epilepsy through the course of recent years. These achievements applied the fields of diagnosis, automated seizure prediction, advanced seizure monitoring and electroencephalogram, use of genetics in diagnosis and management, imaging algorithms in the treatment, neuromodulation, and robotic surgery. This review conveys the actual and future directions of AI. a branch of science that has shown promising results in the treatment and diagnosis of patients with epilepsy.

Localization of irritative zones in epilepsy with thermochromic silicone.

BACKGROUND: During epilepsy surgery, the gold standard to identify irritative zones (IZ) is electrocorticography (ECoG); however, new techniques are being developed to detect IZ in epilepsy surgery and in neurosurgery in general, such as infrared thermography mapping (ITM), and the use of thermosensitive/thermochromic materials. METHODS: In a cohort study of consecutive patients with focal drug-resistant epilepsy of the temporal lobe treated with surgery, we evaluated possible adverse effects to the transient placement of a thermochromic/thermosensitive silicone (TTS) on the cerebral cortex and their postoperative evolution. Furthermore, we compared the precision of TTS for detecting cortical IZ against the gold standard ECoG and with ITM, as proof of concept. RESULTS: We included 10 consecutive patients, 6 women (60%) and 4 men (40%). Age ranges from 15 to 56 years, mean 33.2 years. All were treated with unilateral temporal functional lobectomy. The mean hospital stay was 4 days. There were no immediate or late complications associated with the use of any of the modalities described. In the 10 patients, we obtained consistency in locating the IZ with ECoG, ITM, and the TTS. CONCLUSION: The TTS demonstrated biosecurity in this series. The accuracy of the TTS to locate IZ was similar to that of ECoG and ITM in this study. More extensive studies are required to determine its sensitivity and specificity.

Can We Anticipate and Prevent the Occurrence of Iatrogenic Psychiatric Events Caused by Anti-seizure Medications and Epilepsy Surgery?

Psychiatric disorders and behavioral manifestations in patients with epilepsy have complex and multifactorial etiologies. The psychotropic properties of anti-seizure medications (ASMs) and psychiatric effects of epilepsy surgery can result in iatrogenic psychiatric symptoms or episodes or can yield a therapeutic effect of underlying psychiatric disorders and have a significant impact on the patients' quality of life. The aims of this chapter are to review the available evidence of psychotropic properties of ASMs, which may be responsible for iatrogenic psychiatric symptoms and/or disorders. Moreover, the several aspects associated with the impact of epilepsy surgery on the possible improvement/development of psychiatric disorders were addressed.

Rehabilitación neuropsicológica en pacientes pre y posquirúrgicos de lobectomía temporal por epilepsia fármaco resistente / Neuropsychological rehabilitation in pre- and post-surgical temporal lobectomy patients for drug-resistant epilepsy

Introducción. La epilepsia del lóbulo temporal suele producir déficits mnésicos, atencionales y del lenguaje. En la mayoría de los casos, se trata con fármacos an-tiepilépticos, pero falla en un tercio de ellos. Por tal razón, una opción terapéutica es la lobectomía temporal, que contribuye a menguar las crisis. Sin embargo, los procedimientos quirúrgicos pueden conllevar secuelas, entre ellas consecuencias a nivel cognitivo. Para contrarrestar dichos efectos, se acostumbra llevar a cabo una rehabilitación neuropsicológica que va en pro de recuperar, fortalecer y sostener en el tiempo habilidades que ya venían afectándose desde antes de la cirugía. Objetivo. Brindar una reflexión en torno a la intervención neuropsicológica de la epilepsia en el lóbulo temporal. Método. La reflexión sobre el tema parte de un interés clínico y posteriormente se fue ampliando a partir de la revisión de la literatura en diferentes bases de datos como PubMed, Medline y Scopus entre los años 2000 y 2021. Reflexión. Son amplias las opciones terapéuticas a nivel neuropsicológico y pueden contribuir de manera positiva en la recuperación del paciente, por lo cual los profe-sionales requieren conocer las posibilidades de ello para poder utilizar las estrategias más adecuadas según cada caso y brindar opciones que beneficien la calidad de vida, teniendo en cuenta que ninguna es más efectiva que otra. Conclusión. Como resultado, se presenta un panorama general de la rehabilitación neuropsicológica en pacientes pre y posquirúrgicos con lobectomía, haciendo énfasis en la rehabilitación neuropsicológica tradicional y la rehabilitación basada en inteli-gencia artificial, realidad virtual y computación

Introduction. Temporal lobe epilepsy usually produces mnestic, attentional, and language deficits. In most cases, it is treated with antiepileptic drugs, but one third of them fail, so one therapeutic option is temporal lobectomy, which helps to reduce seizures. However, surgical procedures can have sequelae, including cognitive con-sequences. To counteract these effects, neuropsychological rehabilitation is usually carried out in order to recover, strengthen, and sustain in time skills that were already affected before the surgery. Objective. To provide a reflection on the neuropsychological intervention of tem-poral lobe epilepsy. Method. The reflection on the subject starts from a clinical interest and was sub-sequently expanded from the review of the literature in different databases such as PubMed, Medline, and Scopus between 2000 and 2021. Reflection. There are many therapeutic options at the neuropsychological level and they can contribute positively to the patient's recovery, so professionals need to know the possibilities in order to use the most appropriate strategies according to each case and provide options that benefit the quality of life, taking into account that none is more effective than the other one.Conclusion. As a result, an overview of neuropsychological rehabilitation in pre- and post-surgical patients with lobectomy is presented, with emphasis on traditional neuropsychological rehabilitation and rehabilitation based on artificial intelligence, virtual reality, and computation