Hemispherotomy for Epilepsy: The Procedure Evolution and Outcome.

Hemispherectomy is a unique epilepsy surgery procedure that has undergone significant modification and evolution since Dandy's early description. This procedure is mainly indicated to treat early childhood and infancy medically intractable epilepsy. Various epileptic syndromes have been treated with this procedure, including hemimegalencephaly (HME), Rasmussen's encephalitis, Sturge-Weber syndrome (SWS), perinatal stroke, and hemispheric cortical dysplasia. In terms of seizure reduction, hemispherectomy remains one of the most successful epilepsy surgery procedures. The modification of this procedure over many years has resulted in lower mortality and morbidity rates. HME might increase morbidity and lower the success rate. Future studies should identify the predictors of outcomes based on the pathology and the type of hemispherectomy. Here, based on a literature review, we discuss the evolution of hemispherectomy techniques and their outcomes and complications.

Awake perimetry testing for occipital epilepsy surgery.

With the patient awake during surgery, the authors used a simple technique to determine which part of a patient's brain was essential for vision. This technique allows the surgeon to remove as much as the seizure-producing brain as possible by avoiding the areas that are critical for vision.

Outcome of temporal lobe epilepsy surgery evaluated with bitemporal intracranial electrode recordings.

BACKGROUND: Temporal lobe epilepsy (TLE) with unclear lateralization may require intracranial implantation of electrodes (IIE). We retrospectively assessed the association between the use of IIE and long-term outcomes in patients undergoing anterior temporal lobectomy (ATL). PARTICIPANTS AND METHODS: We retrospectively reviewed the records of 1,032 patients undergoing epilepsy surgery at our center from 1977 to 2006. Patients who underwent ATL were included. Seizure outcome was assessed through final follow-up. Those who underwent scalp and IIE (mostly evaluated with temporal subdural strip electrodes) were compared. RESULTS: From 497 patients who underwent ATL, 139 did so after IIE placement in the temporal lobes. Mean age at surgery was 32.3±12.3years and median duration of follow-up 24 months (range: 6-36). Fifty-three percent of those evaluated with IIE were seizure-free at their last available visit (vs. 68% evaluated with only scalp EEG, p=0.002). Patients with lesional TLE generally had a better outcome (65.5% seizure free) than those without lesions (56.3%, p=0.093), especially for unilateral TLE diagnosed with IIE. In a multivariate Cox regression analyses adjusted for gender, neuropsychological concordance, pathological findings, and post-operative seizures, bilateral TLE predicted seizure recurrence in IIE patients (HR=2.08, 95% CI: 1.08-4.0, p=0.029). CONCLUSIONS: More than a half of those who undergo IIE in suspected TLE are seizure free after ATL. IIE allows for the identification of surgical candidates.

Surgical techniques for the treatment of temporal lobe epilepsy.

Temporal lobe epilepsy (TLE) is the most common form of medically intractable epilepsy. Advances in electrophysiology and neuroimaging have led to a more precise localization of the epileptogenic zone within the temporal lobe. Resective surgery is the most effective treatment for TLE. Despite the variability in surgical techniques and in the extent of resection, the overall outcomes of different TLE surgeries are similar. Here, we review different surgical interventions for the management of TLE.

Seizure semiology: value in identifying seizure origin.

The diagnosis of epilepsy depends upon a number of factors, particularly detailed and accurate seizure history, or semiology. Other diagnostic data, consisting of electroencephalography, video-monitoring of the seizures, and magnetic resonance imaging, are important in any comprehensive epilepsy program, particularly with respect to lateralizing and localizing the seizure focus, if such a focus exists, and with respect to determining the type of seizure or seizure syndrome. The aim of this review is to present a survey of important semiologic characteristics of various seizures that provide the historian with observations, which help to lateralize and localize epileptic zones. Clinical semiology is the starting point of understanding a seizure disorder and making the diagnosis of epilepsy. While it may not provide unequivocal evidence of localization of the epileptic focus, nevertheless it usually directs subsequent investigations, whose concordance is necessary for the ultimate localization.

Epilepsy surgery involving the sensory-motor cortex.

Our aim was to assess the outcome with regard to seizures and neurological function in unselected patients undergoing resective surgery involving the perirolandic area, with or without multiple subpial transections (MSTs). All patients who underwent perirolandic cortical resection or MSTs from 1979 to 2003 at the London Health Sciences Centre were identified. Patients were included if they had seizures originating in the perirolandic area, recorded with subdural electrodes, or if they had scalp recorded seizures and a congruent discrete epileptogenic lesion on MRI in the perirolandic area. Most patients had electrocorticography (ECoG) at the time of surgery. Data collected include pre-operative and post-operative neurological deficits, MRI findings, interictal and ictal scalp EEG, interictal and ictal subdural data, ECoG findings, type and extent of surgery, neuropathologic diagnoses, and seizure outcomes. We studied 52 patients (22 females). The average age at the time of surgery was 33 years, and the average post-operative follow-up was 4.2 years. The most frequent aetiologies were neoplastic in 26 patients (50%), vascular in eight (15%), malformations of cortical development in six (12%), Rasmussen's encephalitis in three (6%) and other aetiologies in nine (17%). Surgery involved the pre-central gyrus in 17 patients, pre- and post-central gyrus in 13, the inferior central region in 11, the post-central gyrus in 7, and the pre-central gyrus and mesial frontal area in 2. At last follow-up 16 patients were in Engel class I (31%), 8 (15%) in class II, 14 (27%) in class III and 14 (27%) in class IV. Residual neurological deficits were present in 26 patients (50%), occurred more frequently in patients > or =25 years old (P < 0.05) and were mild in 14 (54%) patients. In univariate analyses, better seizure outcomes (P < 0.05) occurred in patients whose ECoG showed infrequent post-resectional spikes and no spikes distant to the resection margin, and in resections involving the pre-central and inferior rolandic cortex. In unselected patients with intractable perirolandic epilepsy, many of whom have large, complex epileptogenic lesions, various levels of seizure improvement can be achieved in almost 75% through well-planned surgical resections. New, severe post-operative neurological deficits can occur in 23% of these patients and appear to be more frequent in older patients. Whereas scalp EEG provided limited information to guide surgery, findings on interictal ECoG predicted seizure outcome.

Functional hemispherectomy for the treatment of intractable seizures.

Hemispherectomy is the most successful operation for the control of seizures in a very select group of patients with infantile hemiplegia and intractable epilepsy. The efficacy of anatomical hemispherectomy has been offset to some degree by the fact that up to one third of those operated upon will subsequently develop obstructive hydrocephalus, and the so-called superficial subpial cerebral hemosiderosis, with potentially fatal complications. This review article details the operative technique of a modified `functional` hemispherectomy. In essence, the technique consists of removing the central (Rolandic) cortex and the temporal lobe of the affected hemisphere and leaving the remainder of the hemisphere intact, but neurogenically disconnected from the remaining brain.

Febrile seizures. Update and controversies.

Febrile seizures are the most common seizure disorder in children younger than 5 years of age. Most febrile seizures are brief, do not require any specific treatment or workup, and have benign prognoses. Generalists and pediatricians are frequently faced with anxious parents and are required to make rational decisions regarding the need to investigate and treat such a child. They subsequently need to provide further prognostic information and counseling to the families. The aim of this article is to provide an updated overview of febrile seizures and review the most recent diagnostic and therapeutic recommendations. Despite the progress in the understanding of this benign syndrome, a wide variation in physician evaluation and management persists. However, there is recent evidence that pediatricians are becoming more selective in admitting and investigating children with febrile seizures. Admitted children frequently had complex seizures, status epilepticus, or were ill looking. Considering the full scope of febrile seizures, the yield of investigations that might alter management remains low and does not justify extensive work-up or prolonged hospitalization.

A longitudinal study of the effects of seizure symptoms on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) clinical interpretation.

This study investigated whether the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) items reflecting seizure symptoms spuriously inflate MMPI-2 scores in persons with epilepsy. In a repeated measures prospective design, patients with epilepsy completed the MMPI-2 prior to epilepsy surgery and again two years later when they were either seizure-free or not seizure-free. Compared to baseline scores, only seizure-free patients showed a decline in endorsement of seizure items, and only on one scale, Hypochondriasis (Hs). Clinical profiles were not meaningfully different when readministered when seizures were no longer present. Moreover, profiles generated by individuals with and without seizures were not significantly different. We conclude the MMPI-2 is a valid test in an epilepsy population, as seizure content did not alter its clinical interpretation. In using the MMPI-2 in patients with epilepsy, a modest correction on the Hs and Schizophrenia (Sc) scales is warranted in selected cases. In MMPI-2 research, assessing both statistical and clinical significance is recommended.

Surgery for complex partial seizures.

Dr. Girvin discusses the technique of surgery for complex partial seizures, some of the questions and controversies related to this technique and the probability of a successful outcome.

The communication of neurological bad news to parents.

Communicating disappointing or unexpected neurological news to parents is often both difficult and emotionally unwelcome. At the same time, it is important that transfer of such information is done well and, indeed, if done well, can be a very rewarding experience. Limited references are available for physicians regarding the proper communication of neurological bad news to parents. This paper attempts to provide general guidelines regarding this process. The review is based on the available medical literature, detailed discussions with many senior physicians from different medical systems and the authors personal experience. The manner in which neurological bad news is conveyed to parents can significantly influence their emotions, their beliefs and their attitudes towards the child, the medical staff, and the future. This review of the literature, combined with clinical experience, attests to the fact that most families describe emotional shock, upset, and subsequent depression after the breaking of news of a bad neurological disorder. However, the majority find the attitude of the news giver, combined with the clarity of the message and the news giver's knowledge to answer questions as the most important aspects of giving bad news.