Surgical management of cortical dysplasia in infancy and early childhood.

PURPOSE: To describe operative procedures, seizure control and complications of surgery for cortical dysplasia (CD) causing intractable epilepsy in infancy and early childhood. METHODS: Fifty-six consecutive children (less than 6years old) underwent resective epilepsy surgery for CD from December 2000 to August 2011. Age at surgery ranged from 2 to 69months (mean 23months) and the follow-up was from 1 to 11years (mean 4years 4months). RESULTS: Half of the children underwent surgery during infancy at an age less than 10months, and the majority (80%) of these infants needed extensive surgical procedures, such as hemispherotomy and multi-lobar disconnection. Seizure free (ILAE class 1) outcome was obtained in 66% of the cases (class 1a; 55%): 85% with focal resection (n=13), 50% with lobar resection (n=18), 71% with multilobar disconnection (n=7) and 67% with hemispherotomy (n=18). Peri-ventricular and insular structures were resected in 23% of focal and 61% of lobar resections. Repeated surgery was performed in 9 children and 5 (56%) became seizure free. Histological subtypes included hemimegalencephaly (16 patients), polymicrogyria (5 patients), and FCD type I (6 patients), type IIA (19 patients), type IIB (10 patients). Polymicrogyria had the worst seizure outcome compared to other pathologies. Surgical complications included 1 post-operative hydrocephalus, 1 chronic subdural hematoma, 2 intracranial cysts, and 1 case of meningitis. No mortality or severe morbidities occurred. CONCLUSIONS: Early surgical intervention in children with CD and intractable seizures in infancy and early childhood can yield favorable seizure outcome without mortality or severe morbidities although younger children often need extensive surgical procedures.

Titanium alloys as fixation device material for cranioplasty and its safety in electroconvulsive therapy.

Here, we report the case of a patient successfully treated by a series of electroconvulsive therapy (ECT) who had implanted skull fixation devices made of titanium alloy. The patient was a 57-year-old man with bipolar I disorder. He was hospitalized for the treatment of manic symptoms of bipolar I disorder with pharmacotherapy and ECT. He sustained a fall and hit his head hard on the ground. Acute subdural hematoma developed, and emergent surgery to remove the hematoma was carried out. Cranioplasty was performed using fixation devices made of titanium alloy (Ti 6Al-4V). In order to control his manic symptoms, a series of ECT was readministered from 1 week after surgery. No adverse effects occurred. Devices must be investigated and chosen very carefully for permanent implantation, especially in patients during a course of ECT.

Rapid antidepressant effect of ketamine anesthesia during electroconvulsive therapy of treatment-resistant depression: comparing ketamine and propofol anesthesia.

BACKGROUND: Reports of the superiority of the antidepressant effect of ketamine during the conduct of electroconvulsive therapy (ECT) have been limited. We conducted an open-label trial of ketamine to determine whether ketamine as the anesthetic during ECT would provide a greater antidepressant effect than the antidepressant effect obtained with propofol. METHODS: Between April 2006 and April 2007, 31 inpatients with treatment-resistant depression gave written consent for ECT and to participate in this study. An anesthesiologist who was unaware of the mental symptoms of the subjects assigned them to receive propofol or ketamine anesthetic according to the preferences of the patients, and the patients underwent 8 ECT sessions for 4 weeks. The Hamilton Depression Rating Scale (HDRS) was valuated before ECT and after the completion of the second, fourth, sixth, and eighth ECT sessions. RESULTS: The HDRS scores improved earlier in the ketamine group, with decreases in HDRS scores that were significantly greater in the ketamine group. CONCLUSIONS: The results suggested that it is possible to improve symptoms of depression earlier by using ketamine anesthesia.

[Bispectral index monitoring during anesthesia with propofol for electroconvulsive therapy].

We studied the changes in the bispectral index (BIS) of 22 patients during electroconvulsive therapy (ECT) under propofol and succinylcholine anesthesia. BIS values (mean+/-SD) were 94+/-4 before anesthesia, 51+/-15 before ECT, 49+/-20 after ECT, and 60+/-17 at complete re-awakening. The BIS values at re-awakening were significantly different from those before anesthesia (P<0.05). In conclusion, our study suggests that the BIS values following ECT might not reliably correlate with the patients' clinical level of consciousness.

Does sex difference influence the neuromuscular blocking potencies of vecuronium?

One hundred and fifty patients of ASA class I-II undergoing elective surgery were given vecuronium 0.1 mg·kg-1 under fentanyl- (NLA), halothane, enflurane, isoflurane, or sevoflurane anesthesia, and the spontaneous recovery was monitored to study the sex differences as to onset time, duration [(T1, train of four (TOF)], and recovery index (T1, TOF). The onset time was significantly shorter in women than in men under isoflurane and sevoflurane anesthesia. No significant differences were seen between the sexes in terms of duration and recovery index of both T1 and TOF. We suggest that the results regarding onset time were due to the differences in distribution volume and extracellular fluid volume influenced by the proportions of lean body mass, fat tissue, and the occasional menstruation in women. It remains unclear, however, whether or not the effects of volatile gases to the sensitivity of receptors may contribute to the observed sex difference. Similar durations and recovery indexes in any anesthetic method indicate that the drug's rate of elimination is similar between the sexes. In conclusion, female patients favor the rapid onset of vecuronium when used under isoflurane or sevoflurane, but the recovery from the paralysis seems to be the same between the sexes regardless of the type of general anesthesia used.