Optimizing the Detection of Subtle Insular Lesions on MRI When Insular Epilepsy Is Suspected.

Insular epilepsy is underdiagnosed and accounts for a number of failed operations. Identifying insular target lesions on MR imaging can help guide intracranial electroencephalography and improve the outcome of surgery. In this study, we present a novel method of exploring the insular region for subtle lesions on 3D MR imaging by MPR postprocessing of slices in oblique reference planes. Using this method, we retrospectively reviewed presurgical MRIs that were initially considered to have normal findings in 7 pediatric patients with intractable insular epilepsy. Insular epilepsy was confirmed in these patients on stereo-electroencephalography and histopathology. The MPR postprocessing method we describe helped detect subtle insular lesions in all 7 patients.

Outcome of surgery in children with focal cortical dysplasia younger than 5 years explored by stereo-electroencephalography.

PURPOSE: Focal cortical dysplasia (FCD) is the most frequent etiology for drug-resistant epilepsy in young children. Complete removal of the lesion is mandatory to cure the epilepsy. Stereo-EEG (SEEG) is an excellent method to delimitate the zone to be resected in older children and adults. We studied its feasibility in younger children. METHODS: We retrospectively studied 19 children under 5 years of age who underwent SEEG between January 2009 and December 2012 and were subsequently operated on. FCD was diagnosed in all. We reviewed magnetic resonance imaging (MRI), electrophysiological and clinical data, as well as postoperative seizure outcome. We also included fluoro-deoxyglucose positron emission tomography (FDG-PET) studies, which had been systematically performed before invasive recording in 16 of the 19 children. RESULTS: The mean patient's age at the time of SEEG was 38.6 months, and the mean age at seizure onset was 8 months. Three patients had normal MRI. No SEEG-associated complications occurred. We were able to delineate the epileptogenic zone in all children, and electrode stimulation localized the motor area when necessary (12 patients). Hypometabolic areas on FDG-PET included the epileptogenic zone in 13 of the 16 children, with a lobar concordance in 9 (56 %) and the same anatomical extent in 6 (38 %). Twelve children subsequently underwent focal or sublobar resection, six had multilobar resection, and one had hemispherotomy. The etiology was FCD type 2 in 15 and FCD type 1 or type 3 in three children. Eighty-four percent of our population have remained seizure-free at a mean follow-up of 29 months (12-48 months). CONCLUSION: Although children with FCD can successfully undergo resective surgery without invasive EEG, poor seizure semiology at this age inclines to perform SEEG when the dysplastic lesion is ill-defined and/or the electroclinical correlation is unclear. In cases with normal imaging as well as with suspected huge malformations, as was the case in 52 % of our patients, we consider it to be indispensable.

Insular and insulo-opercular epilepsy in childhood: an SEEG study.

PURPOSE: In recent years, there have been series analysing the electro-clinical correlations of insular epilepsy in adult populations. In contrast, the ictal semiology in children with insular epilepsy is poorly described. Considering that early and successful surgery may greatly improve the cognitive outcome and quality of life, it is worthwhile to deepen our knowledge of insular epilepsy in children. METHODS: We retrospectively evaluated ten children with drug-resistant focal insular epilepsy who had been consecutively explored with stereoelectroencephalography (SEEG), followed by individually tailored resective surgery that included part of the insula in all cases. A detailed anatomo-electro-clinical analysis of non-invasive EEG and SEEG data was performed. At least one of the electrodes explored the insular cortex. SEEG analysis confirmed that the insular cortex was included in the ictal onset zone. RESULTS: Epilepsy onset was mostly during the first year of life, characterized by subtle seizures as well as spasms and myoclonic seizures. Later on, neurovegetative signs and asymmetric tonic and hypermotor seizures (HMS) dominated the ictal semiology. The epileptogenic zone was frequently wider than insular with frontal and central predominance. In eight patients, the tailored resection included a lesion. In seven patients, an Engel class 1 outcome as well as neuropsychological and behavioural improvement was obtained. CONCLUSIONS: SEEG is feasible and useful in children with drug-resistant insular epilepsy which is often characterized by autonomic symptoms as the initial symptoms and should be suspected in cases with HMS, asymmetric tonic seizures and even asymmetric spasms. Early propagation is mostly frontal and central. Analysis of a larger population is required to refine these findings.

[Retrospective study of the long-term results of selective peripheral neurotomy for the treatment of spastic upper limb]. / Etude rétrospective du résultat à long terme des neurotomies sélectives périphériques dans le traitement du membre supérieur spastique.

BACKGROUND/OBJECTIVE: Peripheral selective neurotomy is commonly used to treat the equinus spastic foot (tibial nerve), but is less frequently used in treating upper limb spasticity, because of the complexity of the articular deformities and the complex innervations of the different muscles. We present our experience and the long-term results of this surgery based on a retrospective series of 22 patients with a disabling spasticity of the upper limb. METHODS: Between 2003 and 2006, neurotomies were performed in 22 patients with disabling spasticity of the upper limb despite optimal medical treatment. Patients were evaluated before and after the surgical procedure. Twelve clinical parameters were studied for describing deformity (resting position and amplitude of each joint), spasticity (Ashworth and Tardieu scores), and the functional impacts of the spasticity. RESULTS: At long-term follow-up, all parameters were improved from the surgery, both in terms of spastic symptoms (highly significantly decreased in Ashworth and Tardieu scores) and the deformity of the upper limb (e.g., 60 degrees increase in the extension of the elbow). Pain, active amplitude, and functional impact scores were also statistically significantly improved after surgery. The mean satisfaction index was 7/10 (+/-1.6). CONCLUSIONS: Selective neurotomy is an effective treatment for patients with a disabling and excessive spasticity in the upper limb. It provides a long-term, objective improvement based on analytical and functional parameters. We emphasize the importance of accurate clinical evaluation and surgical planning. Finally, excessive time to treatment seems to be an important factor for recurrence or incomplete efficiency of the procedure.