RESUMO
To share the experiences of organizing the epilepsy surgery program in Indonesia. This study was divided into two periods based on the presurgical evaluation method: the first period (1999-2004), when interictal electroencephalogram (EEG) and magnetic resonance imaging (MRI) were used mainly for confirmation, and the second period (2005-2017), when long-term non-invasive and invasive video-EEG was involved in the evaluation. Long-term outcomes were recorded up to December 2019 based on the Engel scale. All 65 surgical recruits in the first period possessed temporal lobe epilepsy (TLE), while 524 patients were treated in the second period. In the first period, 76.8%, 16.1%, and 7.1% of patients with TLE achieved Classes I, II, and III, respectively, and in the second period, 89.4%, 5.5%, and 4.9% achieved Classes I, II, and III, respectively, alongside Class IV, at 0.3%. The overall median survival times for patients with focal impaired awareness seizures (FIAS), focal to bilateral tonic-clonic seizures and generalized tonic-clonic seizures were 9, 11 and 11 years (95% CI: 8.170-9.830, 10.170-11.830, and 7.265-14.735), respectively, with p = 0.04. The utilization of stringent and selective criteria to reserve surgeries is important for a successful epilepsy program with limited resources.
Assuntos
Lobectomia Temporal Anterior/métodos , Epilepsia do Lobo Temporal/mortalidade , Epilepsia do Lobo Temporal/cirurgia , Epilepsia Tônico-Clônica/mortalidade , Epilepsia Tônico-Clônica/cirurgia , Convulsões/mortalidade , Convulsões/cirurgia , Adulto , Países em Desenvolvimento , Eletroencefalografia/métodos , Epilepsia do Lobo Temporal/diagnóstico por imagem , Epilepsia do Lobo Temporal/epidemiologia , Epilepsia Tônico-Clônica/diagnóstico por imagem , Epilepsia Tônico-Clônica/epidemiologia , Feminino , Seguimentos , Lateralidade Funcional , Humanos , Indonésia/epidemiologia , Imageamento por Ressonância Magnética/métodos , Masculino , Convulsões/diagnóstico por imagem , Convulsões/epidemiologia , Taxa de Sobrevida , Resultado do Tratamento , Adulto JovemRESUMO
Forel-H-tomy for intractable epilepsy was introduced by Dennosuke Jinnai in the 1960s. Recently, Forel-H-tomy was renamed to "pallidothalamic tractotomy" and revived for the treatment of Parkinson's disease and dystonia. Two of our patients with movement disorders and comorbid epilepsy experienced significant seizure reduction after pallidothalamic tractotomy, demonstrating the efficacy of this method. The first was a 29-year-old woman who had temporal lobe epilepsy with focal impaired awareness seizure once every three months and an aura 10-20 times daily, even with four antiseizure medicines. For the treatment of hand dyskinesia, she underwent left pallidothalamic tractotomy and her right-hand dyskinesia significantly improved. Fourteen months later, she had experienced no focal impaired awareness seizure and the aura decreased to one to three times per month. The second case was that of a 15-year-old boy diagnosed with progressive myoclonic epilepsy, who developed generalized tonic-clonic seizure, which manifested once every month, despite treatment with five antiseizure medicines. After surgery, myoclonic movements in his right hand slightly improved. A one-year follow-up revealed that he had not experienced a generalized tonic-clonic seizure. The lesion locations in the two cases were close to the vicinity of Jinnai's Forel-H-tomy. Forel's field H deserves reconsideration as a treatment target for intractable epilepsy.
Assuntos
Transtornos dos Movimentos/cirurgia , Palidotomia , Convulsões/terapia , Subtálamo/cirurgia , Adolescente , Adulto , Distonia/cirurgia , Epilepsia do Lobo Temporal/cirurgia , Epilepsia Tônico-Clônica/cirurgia , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Procedimento de Encéfalo Dividido , Técnicas Estereotáxicas , Adulto JovemRESUMO
OBJECTIVE: Laser interstitial thermal therapy (LITT) for mesial temporal lobe epilepsy (mTLE) has reported seizure freedom rates between 36% and 78% with at least 1 year of follow-up. Unfortunately, the lack of robust methods capable of incorporating the inherent variability of patient anatomy, the variability of the ablated volumes, and clinical outcomes have limited three-dimensional quantitative analysis of surgical targeting and its impact on seizure outcomes. We therefore aimed to leverage a novel image-based methodology for normalizing surgical therapies across a large multicenter cohort to quantify the effects of surgical targeting on seizure outcomes in LITT for mTLE. METHODS: This multicenter, retrospective cohort study included 234 patients from 11 centers who underwent LITT for mTLE. To investigate therapy location, all ablation cavities were manually traced on postoperative magnetic resonance imaging (MRI), which were subsequently nonlinearly normalized to a common atlas space. The association of clinical variables and ablation location to seizure outcome was calculated using multivariate regression and Bayesian models, respectively. RESULTS: Ablations including more anterior, medial, and inferior temporal lobe structures, which involved greater amygdalar volume, were more likely to be associated with Engel class I outcomes. At both 1 and 2 years after LITT, 58.0% achieved Engel I outcomes. A history of bilateral tonic-clonic seizures decreased chances of Engel I outcome. Radiographic hippocampal sclerosis was not associated with seizure outcome. SIGNIFICANCE: LITT is a viable treatment for mTLE in patients who have been properly evaluated at a comprehensive epilepsy center. Consideration of surgical factors is imperative to the complete assessment of LITT. Based on our model, ablations must prioritize the amygdala and also include the hippocampal head, parahippocampal gyrus, and rhinal cortices to maximize chances of seizure freedom. Extending the ablation posteriorly has diminishing returns. Further work is necessary to refine this analysis and define the minimal zone of ablation necessary for seizure control.
Assuntos
Epilepsia do Lobo Temporal/cirurgia , Terapia a Laser/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Tonsila do Cerebelo/diagnóstico por imagem , Criança , Estudos de Coortes , Epilepsia do Lobo Temporal/diagnóstico por imagem , Epilepsia Tônico-Clônica/diagnóstico por imagem , Epilepsia Tônico-Clônica/cirurgia , Feminino , Humanos , Terapia a Laser/efeitos adversos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Convulsões/cirurgia , Resultado do Tratamento , Adulto JovemRESUMO
We describe the unique case of a 6-year old boy who presented with recalcitrant generalized tonic-clonic seizures and clinicoradiological features of congenital Cirsoid aneurysm. The lesion was supplied by occipital arteries and a large right parietal parasagittal intracranial feeding artery in a Yokouchi type C pattern. The venous drainage was communicating with the posterior part of the superior sagittal sinus. Six months after successful ligation of the feeding arteries and complete surgical excision of the lesion, the patient remains seizure free.
Assuntos
Aneurisma/cirurgia , Malformações Arteriovenosas/cirurgia , Couro Cabeludo/irrigação sanguínea , Artérias Cerebrais/cirurgia , Criança , Cavidades Cranianas , Epilepsia Tônico-Clônica/etiologia , Epilepsia Tônico-Clônica/cirurgia , Humanos , Ligadura/métodos , Masculino , Lobo Occipital/irrigação sanguínea , Artérias Temporais/cirurgiaRESUMO
OBJECT: The intention of our study was to identify predictive characteristics for long-term seizure control and running down phenomenon after surgical treatment of pharmacoresistant mesiotemporal lobe epilepsy (mTLE) with and without associated cortical dysplasia. MATERIALS AND METHODS: Our study comprises a consecutive series of 458 patients who underwent surgical treatment for intractable mTLE at the Epilepsy Center Freiburg. Data evaluated included semiology, duration and frequency of seizures, results of presurgical diagnostics including video-EEG monitoring, MRI, PET and SPECT as well as postoperative seizure outcome. Results were evaluated forming two groups: Group A consisted of isolated mesiotemporal lesions. Group B comprised patients with mTLE and additional focal cortical dysplasia (FCD). Statistical evaluation was based on the Kaplan Meier survival analysis, using log-rank-tests and a multivariate regression model. Postoperative running down phenomenon was defined as seizure freedom after a period of gradual reduction of postoperative seizure frequency. This was compared to patients with ongoing epilepsy. RESULTS: Complete seizure freedom was achieved in 65.0% of investigated patients at 1year and in 56.5% at long-term follow-up of ≥5 years after surgery. Corresponding results were 64.2% and 56.8% at 1 and ≥5 years, respectively in group A and 66.4% and 56.0%, respectively in group B. Predictive for favorable postoperative outcome in the total group were younger age at surgery, shorter duration of epilepsy, absence of secondarily generalized tonic-clonic seizures (SGTCS), presence of strictly ipsilateral temporal interictal epileptiform discharges (IEDs), complete resection of the lesion as well as absence of postoperative epileptiform activity and of early postoperative seizures. In subgroup analyses, patients of group A demonstrated longer postoperative seizure-free intervals with adolescent age at surgery, short duration of epilepsy before surgery and absence of SGTCS, whereas in patients of group B ipsilateral temporal seizure onset and strictly unilateral IEDs in EEG as well as complete resection were predictors for favorable seizure outcome. Furthermore, absence of early postoperative seizures and of spikes in EEG were predictive factors for long-term seizure-freedom in both subgroups. The running down phenomenon was found in 33 (7.2%) patients. None of the parameters evaluated demonstrated significant predictive power. Only late seizure onset and neoplastic lesions showed a trend for postoperative gradual seizure reduction in multivariate analyses. CONCLUSION: Depending on the presence or absence of focal cortical dysplasia in addition to mesiotemporal structural alterations, predictors of long-term seizure control differed regarding the relevant clinical and electrophysiological features. This is important for specific patient counseling in respective groups.
Assuntos
Epilepsia Resistente a Medicamentos/complicações , Epilepsia Resistente a Medicamentos/cirurgia , Epilepsia do Lobo Temporal/complicações , Epilepsia do Lobo Temporal/cirurgia , Malformações do Desenvolvimento Cortical/complicações , Malformações do Desenvolvimento Cortical/cirurgia , Adolescente , Adulto , Fatores Etários , Idoso , Criança , Pré-Escolar , Epilepsia Resistente a Medicamentos/fisiopatologia , Epilepsia do Lobo Temporal/fisiopatologia , Epilepsia Tônico-Clônica/complicações , Epilepsia Tônico-Clônica/fisiopatologia , Epilepsia Tônico-Clônica/cirurgia , Feminino , Seguimentos , Lateralidade Funcional , Humanos , Estimativa de Kaplan-Meier , Masculino , Malformações do Desenvolvimento Cortical/fisiopatologia , Pessoa de Meia-Idade , Estudos Retrospectivos , Convulsões/complicações , Convulsões/fisiopatologia , Convulsões/cirurgia , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE AND BACKGROUND: To report symptomatic seizures of a patient with an old type II odontoid fracture with atlantoaxial dislocation. The type II odontoid fracture is a dangerous disease and presents as neurological deficits. Because of the compression of upper cervical cord, without timely diagnosis and treatment, a type II odontoid fracture may result in sudden death. Although it has been shown that epileptic seizures may lead to type II odontoid fracture, there is no report of symptomatic seizures in patients with odontoid fracture. METHODS: A 16-year-old adolescent boy with neurological deficits, especially grand mal seizures for duration of 5 years, was diagnosed as an old type II odontoid fracture with atlantoaxial dislocation and treated in our hospital. A 1-year follow-up was performed. RESULTS: Systematic analyses of the clinical history, manifestations, physical examination, and radiologic results of the patient revealed an old type II odontoid fracture. Magnetic resonance imaging showed spinal cord compression and degeneration. The patient received posterior atlantoaxial fixation and fusion procedure following successful closed reduction. The frequency of seizures was reduced to once a month and there was a thorough recovery in other neurological functions 1 year after the operation. CONCLUSIONS: Old type II odontoid fracture might present as symptomatic seizures in addition to other neurological deficits. Posterior atlantoaxial screw-plate fixation and fusion is an effective treatment for old type II odontoid fracture.
Assuntos
Articulação Atlantoaxial/lesões , Articulação Atlantoaxial/cirurgia , Epilepsia Tônico-Clônica/etiologia , Epilepsia Tônico-Clônica/cirurgia , Luxações Articulares/complicações , Luxações Articulares/cirurgia , Processo Odontoide/lesões , Processo Odontoide/cirurgia , Convulsões/etiologia , Fraturas da Coluna Vertebral/complicações , Fraturas da Coluna Vertebral/cirurgia , Adolescente , Articulação Atlantoaxial/anormalidades , Anormalidades Congênitas , Seguimentos , Humanos , Luxações Articulares/diagnóstico , Imageamento por Ressonância Magnética , Masculino , Compressão da Medula Espinal/diagnóstico , Compressão da Medula Espinal/etiologia , Compressão da Medula Espinal/cirurgia , Fraturas da Coluna Vertebral/diagnósticoRESUMO
BACKGROUND: Blister-like aneurysms (BLAs) are challenging lesions that require unique microsurgical strategies. BLAs are predominantly found along the internal carotid artery; however, BLAs of the basilar artery are a rare subset that requires a modified treatment strategy. OBJECTIVE: To discuss the microsurgical management and review the long-term outcomes of patients with BLAs of the basilar artery. METHODS: We retrospectively reviewed the surgical technique, postoperative results, and long-term outcomes of all patients with basilar artery BLAs treated at our institution from 2005 to 2011. RESULTS: Four patients with basilar artery BLAs were identified over this 6-year interval. All 4 patients were treated by direct microsurgical clipping. A thin layer of cotton reinforcement was used beneath the clip tines to minimize the risk of clip slippage in 2 of 4 patients; 1 patient required adjunctive endovascular stent placement for residual aneurysm after clipping. Complete obliteration of all aneurysms was achieved, and there has been no recurrence at mean clinical follow-up of 72 months (median, 74.5; range, 37-103) and imaging follow-up of 48 months (median, 54; range 12-72). CONCLUSION: Direct clipping with or without cotton reinforcement can obliterate basilar BLAs with excellent long-term outcomes. Clip wrapping is not an option for these lesions given the proximity to perforating branches. Endovascular techniques provide a useful adjunctive strategy; however, risks with antiplatelet therapy in the acute subarachnoid hemorrhage period must be considered.
Assuntos
Aneurisma Intracraniano/cirurgia , Microcirurgia/métodos , Procedimentos Neurocirúrgicos/métodos , Adulto , Idoso , Aneurisma Roto/epidemiologia , Aneurisma Roto/cirurgia , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/métodos , Epilepsia Tônico-Clônica/etiologia , Epilepsia Tônico-Clônica/cirurgia , Feminino , Seguimentos , Humanos , Aneurisma Intracraniano/complicações , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/efeitos adversos , Inibidores da Agregação Plaquetária/uso terapêutico , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Stents , Instrumentos Cirúrgicos , Resultado do TratamentoRESUMO
OBJECTIVE: Some patients with Sturge-Weber syndrome (SWS) need epilepsy surgery for adequate seizure control and prevention of psychomotor deterioration. The majority of patients with SWS have leptomeningeal angioma located over the temporal, parietal, and occipital lobes. We applied posterior quadrant disconnection surgery for this type of SWS with intractable seizure. We evaluated the efficacy of this procedure in seizure control and psychomotor development. METHODS: Ten patients who were surgically treated using the posterior quadrantectomy (PQT) were enrolled in this study. Surgical outcome was analyzed as seizure-free or not at 2 years after surgery. Psychomotor development was evaluated by the scores of mental developmental index (MDI) and psychomotor developmental index (PDI) in the Bayley Scales of Infant Development II preoperatively, and at 6 and 12 months after the PQT. RESULTS: Eight of 10 patients were seizure-free. Patients without complete elimination of the angiomatous areas had residual seizures. Average MDI and PDI scores before the surgery were 64.8 and 71.6, respectively. Scores of MDI at 6 and 12 months after the PQT in seizure-free patients were 80.5 and 84.5, respectively (p < 0.01). PDI scores at these postoperative intervals were 87.3 and 86.4, respectively (p < 0.05). Patients with residual seizures did not improve in either MDI or PDI. SIGNIFICANCE: The PQT achieved good seizure control and improved psychomotor development in patients with SWS. The complete deafferentation of angiomatous areas is required for seizure-free results and psychomotor developmental improvement.
Assuntos
Craniotomia/métodos , Epilepsia Tônico-Clônica/cirurgia , Vias Neurais/cirurgia , Neuronavegação/métodos , Lobo Occipital/cirurgia , Lobo Parietal/cirurgia , Síndrome de Sturge-Weber/cirurgia , Lobo Temporal/cirurgia , Corpo Caloso/cirurgia , Epilepsia Tônico-Clônica/diagnóstico , Hemangioma/diagnóstico , Hemangioma/cirurgia , Humanos , Aumento da Imagem , Imageamento por Ressonância Magnética , Neoplasias Meníngeas/cirurgia , Transtornos Psicomotores/diagnóstico , Transtornos Psicomotores/cirurgia , Síndrome de Sturge-Weber/diagnósticoRESUMO
OBJECT: Functional hemispherectomy is a well-recognized surgical option for the treatment of unihemispheric medically intractable epilepsy. While the resultant motor deficits are a well-known and expected consequence of the procedure, the impact on other cortical functions has been less well defined. As the cortical control of swallowing would appear to be threatened after hemispherectomy, the authors retrospectively studied a pediatric population that underwent functional hemispherectomy for medically intractable epilepsy to characterize the incidence and severity of dysphagia after surgery. METHODS: A retrospective cohort (n = 39) of pediatric patients who underwent hemispherectomy at a single institution was identified, and available clinical records were reviewed. Additionally, the authors examined available MR images for integrity of the thalamus and basal ganglia before and after hemispherectomy. Clinical and video fluoroscopic assessments of speech pathology were reviewed, and the presence, type, and duration of pre- and postoperative dysphagia were recorded. RESULTS: New-onset, transient dysphagia occurred in 26% of patients after hemispherectomy along with worsening of preexisting dysphagia noted in an additional 15%. Clinical symptoms lasted a median of 19 days. Increased duration of symptoms was seen with late (> 14 days postoperative) pharyngeal swallow dysfunction when compared with oral dysphagia alone. Neonatal stroke as a cause for seizures decreased the likelihood of postoperative dysphagia. There was no association with seizure freedom or postoperative hydrocephalus. CONCLUSIONS: New-onset dysphagia is a frequent and clinically significant consequence of hemispherectomy for intractable epilepsy in pediatric patients. This dysphagia was always self-limited except in those patients in whom preexisting dysphagia was noted.
Assuntos
Transtornos de Deglutição/etiologia , Epilepsia Tônico-Clônica/cirurgia , Hemisferectomia/efeitos adversos , Adolescente , Criança , Pré-Escolar , Feminino , Hemisferectomia/métodos , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Estudos RetrospectivosRESUMO
Atlanto Axial Rotatory Dislocations (AARDs) are a heterogeneous group of post-traumatic pathologies typical of the pediatric age, and rare in adults. We describe the case of a 34-year-old woman, developing Atlanto Axial Rotatory Fixation (AARF) after a generalized tonic-clonic epileptic seizure, an extremely rare traumatic cause never described in literature. AARF was detected only 1 month after the accident and nonsurgical treatment was attempted at the beginning. The patient underwent surgery only 2 months after the accident. The best treatment should be conservative reduction within 1 month; when it is not possible, it is advisable to perform surgery as soon as possible. C1-C2 fixation with Harm's technique is the gold standard for fixed luxations. Delay of treatment makes intraoperative reduction more difficult and increase the establishment of the chronic permanent change of neck muscles and ligaments.
Assuntos
Articulação Atlantoaxial , Erros de Diagnóstico , Epilepsia Tônico-Clônica/complicações , Luxações Articulares/etiologia , Adulto , Lobectomia Temporal Anterior , Anticonvulsivantes/uso terapêutico , Articulação Atlantoaxial/diagnóstico por imagem , Articulação Atlantoaxial/cirurgia , Parafusos Ósseos , Colchicina/análogos & derivados , Colchicina/uso terapêutico , Terapia Combinada , Diagnóstico Tardio , Resistência a Medicamentos , Epilepsia Tônico-Clônica/tratamento farmacológico , Epilepsia Tônico-Clônica/cirurgia , Feminino , Humanos , Luxações Articulares/diagnóstico , Luxações Articulares/diagnóstico por imagem , Luxações Articulares/cirurgia , Luxações Articulares/terapia , Ligamentos/patologia , Imageamento por Ressonância Magnética , Cervicalgia/etiologia , Aparelhos Ortopédicos , Rotação , Tomografia Computadorizada por Raios X , Torcicolo/diagnóstico , TraçãoRESUMO
BACKGROUND: Medically intractable epilepsy involving drop attacks can be difficult to manage and negatively affect quality of life. Most studies investigating the effect of corpus callosotomy (CC) on seizures have been limited, focusing on the pediatric population or drop seizures alone, with little attention to other factors influencing seizure outcome. OBJECTIVE: To assess seizure outcomes after CC in adults and children. METHODS: Retrospective analysis was performed on all patients who underwent CC (anterior two thirds, 1- or 2-stage complete) at our institution between 1990 and 2011. Change in frequency after CC was assessed for drop seizures and other seizure types. Multiple factors were evaluated for impact on seizure outcome. RESULTS: Fifty patients met inclusion criteria. The median age was 1.5 years at seizure onset and 17 years at time of surgery. Anterior two-thirds CC was performed in 28 patients, 1-stage complete in 17, and 2-stage complete in 5. All 3 groups experienced a significant decrease in drop seizures (P < .001, P < .001, and P = .020, respectively), with 40% experiencing complete resolution, and 64% dropping at least 1 frequency category. Other seizure types significantly decreased in anterior two-thirds CC and 1-stage complete (P = .0035, P = .001, respectively). Younger age at surgery correlated with better seizure outcomes (P = .043). CONCLUSION: CC for medically refractory generalizing epilepsy is effective for both drop seizures and other seizure types. CC should be considered soon after a patient has been deemed medically refractory because earlier age at surgery results in lower risk and better outcome.
Assuntos
Corpo Caloso/cirurgia , Epilepsia Tônico-Clônica/cirurgia , Hemisferectomia , Convulsões/cirurgia , Síncope/etiologia , Síncope/cirurgia , Adolescente , Adulto , Idade de Início , Criança , Pré-Escolar , Epilepsia Tônico-Clônica/complicações , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Convulsões/etiologia , Resultado do Tratamento , Adulto JovemRESUMO
Cranioplasty is often undertaken as a joint neurosurgical and maxillofacial procedure. The principal aims remain to improve cosmesis and to protect the underlying brain. We report two cases of cranioplasty with subsequent improvement in neurological function and discuss the possible therapeutic role of cranioplasty.
Assuntos
Craniotomia/reabilitação , Procedimentos de Cirurgia Plástica/métodos , Crânio/cirurgia , Idoso , Benzofenonas , Materiais Biocompatíveis/química , Substitutos Ósseos/química , Transplante Ósseo/patologia , Epilepsia Tônico-Clônica/cirurgia , Feminino , Osso Frontal/cirurgia , Escala de Coma de Glasgow , Humanos , Cetonas/química , Masculino , Meningioma/cirurgia , Pessoa de Meia-Idade , Osso Parietal/cirurgia , Polietilenoglicóis/química , Polímeros , Implantação de Prótese/métodos , Convulsões/cirurgia , Infecção da Ferida Cirúrgica/reabilitação , Infecção da Ferida Cirúrgica/cirurgiaRESUMO
Extensive multilobar cortical dysplasias occasionally occur in children and can induce seizure onset in early infancy, causing severe epileptic encephalopathy. Surgical interventions in early infancy, such as disconnection of large parts of the brain, are challenging because of the degree of invasiveness and carry greater risks in infants compared with older children. Here we report the successful treatment of intractable epilepsy with multilobar cortical dysplasias in the posterior cortex by posterior disconnection in three infants (age 3 months). The patients showed good postoperative recovery and exhibited excellent seizure control at follow-up evaluation within a year after surgery. Developmental catch-up was also achieved and no early complications have been detected to date. Use of the posterior disconnection technique for early-stage extensive multilobar cortical dysplasias can result in good seizure control and developmental progress with little perioperative morbidity. However, the efficacy of this surgical technique needs to be verified with long-term follow up after surgery.
Assuntos
Lobectomia Temporal Anterior/métodos , Epilepsia Tônico-Clônica/cirurgia , Malformações do Desenvolvimento Cortical/cirurgia , Espasmos Infantis/cirurgia , Córtex Cerebral/patologia , Eletroencefalografia , Feminino , Seguimentos , Humanos , Interpretação de Imagem Assistida por Computador , Imageamento Tridimensional , Lactente , Imageamento por Ressonância Magnética , Masculino , Malformações do Desenvolvimento Cortical/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Reoperação , Espasmos Infantis/diagnóstico , Técnica de Subtração , Tomografia Computadorizada de Emissão de Fóton ÚnicoRESUMO
An encephalocele is a protrusion of the cranial contents beyond the normal confines of the skull. It is a rare cause of seizure in adults. A 38-year-old woman presented with a first-onset seizure. Brain CT was interpreted as right frontal sinus opacification suggestive of sinusitis. The patient was discharged home with an amoxicillin prescription. A few days later, she was re-admitted with another seizure. Careful evaluation of the brain CT and MRI revealed a right frontal sinus posterior wall defect and possible brain encephalocele. The patient had complained of chronic nasal discharge for years and had also noticed a watery discharge from her right nostril. We suspected cerebrospinal fluid rhinorrhea. A bifrontal craniotomy was performed, the encephalocele was resected and cranialisation of the frontal sinus was completed. The patient remained free of seizures at the last follow-up.
Assuntos
Encefalocele/diagnóstico , Epilepsia Tônico-Clônica/etiologia , Sinusite Frontal/diagnóstico , Adulto , Rinorreia de Líquido Cefalorraquidiano/diagnóstico , Rinorreia de Líquido Cefalorraquidiano/cirurgia , Craniotomia , Diagnóstico Diferencial , Encefalocele/cirurgia , Epilepsia Tônico-Clônica/cirurgia , Feminino , Seio Frontal/patologia , Seio Frontal/cirurgia , Sinusite Frontal/cirurgia , Humanos , Imageamento por Ressonância Magnética , Tomografia Computadorizada por Raios XRESUMO
OBJECT: Intractable epilepsy is a significant burden on families and on the cognitive development and quality of life (QOL) of patients. Periinsular hemispherotomy (PIH) for medically intractable epilepsy can benefit patients who qualify for this procedure. The ideal hemispherotomy candidate has ipsilateral ictal and interictal epileptiform activity, unilateral MR imaging abnormalities, contralateral hemiplegia, and a normal contralateral hemisphere. However, certain patients present with a mixed picture of bilateral electroencephalography (EEG) findings and severe intractable epilepsy, prompting consideration of a more aggressive treatment approach. This report introduces the possibility of surgery for patients who normally would not meet criteria for this treatment modality. METHODS: In this retrospective chart review, the authors report on 7 patients with bilateral seizure onset noted on routine or video-EEG monitoring. A QOL phone questionnaire, based on the Quality of Life in Childhood Epilepsy tool, was administered to a parent. The authors reviewed each patient's chart for surgical complications, changes in examination, QOL, limited neuropsychological outcomes, and seizure outcomes. They also investigated each chart for MR imaging and EEG findings as well as the patient's epilepsy clinic notes for seizure semiology and frequency. RESULTS: All patients enjoyed a decrease in seizure frequency and a subjective increase in QOL after PIH. Five patients (71%) achieved Engel Class I or II seizure control. The mean follow-up was 3.64 years (2-5.3 years). One patient is now off all antiseizure medication. No patient had a decrement in Full Scale IQ on postsurgical testing, and 2 (28.5%) of 7 individuals had increased adaptive and social functioning. Postsurgical examination changes included hemiplegia and homonymous hemianopia. CONCLUSIONS: Hemispherotomy in patients with intractable epilepsy is generally reserved for individuals with unilateral epileptiform abnormalities or lesions on MR imaging. Seven patients in this study benefited from surgery despite bilateral seizure onset with improvement in seizure control and overall QOL. Thus, bilateral ictal onset does not necessarily preclude consideration for hemispherotomy in selected patients with severe medically refractory epilepsy.
Assuntos
Encéfalo/cirurgia , Epilepsia Tônico-Clônica/cirurgia , Hemisferectomia , Cuidados Paliativos/métodos , Qualidade de Vida , Convulsões/cirurgia , Encéfalo/patologia , Encéfalo/fisiopatologia , Criança , Cognição , Eletroencefalografia , Epilepsia Tônico-Clônica/fisiopatologia , Epilepsia Tônico-Clônica/psicologia , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Testes Neuropsicológicos , Pais , Estudos Retrospectivos , Convulsões/fisiopatologia , Convulsões/psicologia , Inquéritos e Questionários , Resultado do TratamentoAssuntos
Transtornos da Consciência/etiologia , Discalculia/diagnóstico , Dor de Orelha/etiologia , Abscesso Epidural/diagnóstico , Abscesso Epidural/cirurgia , Epilepsia Tônico-Clônica/etiologia , Férias e Feriados , Mastoidite/diagnóstico , Mastoidite/cirurgia , Complicações Pós-Operatórias/diagnóstico , Estações do Ano , Adulto , Transtornos da Consciência/cirurgia , Diagnóstico Diferencial , Dislexia Adquirida/diagnóstico , Dor de Orelha/cirurgia , Epilepsia Tônico-Clônica/cirurgia , Seguimentos , Humanos , Imageamento por Ressonância Magnética , Masculino , Ventilação da Orelha Média , Exame Neurológico , Tomografia Computadorizada por Raios XAssuntos
Neoplasias Encefálicas/patologia , Epilepsia Tônico-Clônica/patologia , Fórnice/patologia , Glioma/patologia , Processamento de Imagem Assistida por Computador , Imageamento por Ressonância Magnética , Lobo Temporal/patologia , Tomografia Computadorizada por Raios X , Biomarcadores Tumorais/análise , Neoplasias Encefálicas/cirurgia , Proliferação de Células , Meios de Contraste/administração & dosagem , Diagnóstico Diferencial , Imagem de Difusão por Ressonância Magnética , Dominância Cerebral/fisiologia , Epilepsia Tônico-Clônica/cirurgia , Fórnice/cirurgia , Gadolínio , Glioma/cirurgia , Humanos , Imuno-Histoquímica , Invasividade Neoplásica , Lobo Occipital/patologia , Lobo Occipital/cirurgia , Giro Para-Hipocampal/patologia , Giro Para-Hipocampal/cirurgia , Lobo Temporal/cirurgia , Tálamo/patologia , Tálamo/cirurgiaRESUMO
PURPOSE: We analyzed clinical and electroencephalography (EEG) outcomes of 13 patients with pharmacoresistant encephalopathy with electrical status epilepticus during sleep (ESES) following epilepsy surgery. METHODS: All patients had symptomatic etiology of ESES and preoperative neuropsychological deterioration. Ten patients had daily atypical absences. Clinical outcome was assessed at 6 months and at 2 years after surgery. Clinical and EEG data were reviewed retrospectively. The spike propagation pattern and area and source strength in source montage were analyzed from preoperative and postoperative EEG studies. KEY FINDINGS: Preoperative sleep EEG showed electrical status epilepticus during sleep (SES) with one-way interhemispheric propagation in nine patients and with two-way interhemispheric propagation in four. The age of the patients at the time of surgery ranged from 3.6-9.9 years. Focal resection (two patients) or hemispherotomy (one patient with postoperative EEG) either terminated SES or restricted the discharge to one region. Either reduced SES propagation area or source strength was found in four of eight callosotomy patients with postoperative EEG. Of patients who had seizures preoperatively, Engel class I-II seizure outcome was observed in two of three children after focal resection or hemispherotomy and in two of eight children after callosotomy. None of these patients with Engel class I-II outcome had SES with two-way interhemispheric propagation on preoperative EEG. Cognitive deterioration was halted postoperatively in all except one patient. Cognitive catch-up of more than 10 IQ points was seen in three patients, all of whom had shown a first measured IQ of >75. SIGNIFICANCE: Patients with pharmacoresistant ESES based on symptomatic etiology may benefit from resective surgery or corpus callosotomy regarding both seizure outcome and cognitive prognosis.
Assuntos
Corpo Caloso/cirurgia , Eletroencefalografia , Epilepsia Tipo Ausência/cirurgia , Epilepsia Tônico-Clônica/cirurgia , Hemisferectomia , Processamento de Sinais Assistido por Computador , Transtornos do Sono-Vigília/fisiopatologia , Transtornos do Sono-Vigília/cirurgia , Estado Epiléptico/fisiopatologia , Estado Epiléptico/cirurgia , Anticonvulsivantes/uso terapêutico , Córtex Cerebral/fisiopatologia , Córtex Cerebral/cirurgia , Criança , Pré-Escolar , Corpo Caloso/fisiopatologia , Dominância Cerebral/fisiologia , Resistência a Medicamentos , Epilepsia Tipo Ausência/fisiopatologia , Epilepsia Tônico-Clônica/fisiopatologia , Potenciais Evocados/fisiologia , Feminino , Seguimentos , Humanos , Deficiência Intelectual/fisiopatologia , Deficiência Intelectual/cirurgia , Síndrome de Lennox-Gastaut , Magnetoencefalografia , Masculino , Testes Neuropsicológicos , Polissonografia , Estudos Retrospectivos , Espasmos Infantis/fisiopatologia , Espasmos Infantis/cirurgiaRESUMO
BACKGROUND: Awake craniotomy and electrophysiologic mapping (EPM) is an established technique to facilitate the resection of near eloquent cortex. Intraoperative magnetic resonance imaging (iMRI) is increasingly used to aid in the resection of intracranial lesions. Standard draping protocols in high-field iMRI units make awake craniotomies challenging, and only two groups have previously reported combined EPM and high-field iMRI. METHODS: We present an illustrative case describing a simple technique for combining awake craniotomy and EPM with high-field iMRI. A movable platter is used to transfer the patient from the operating table to a transport trolley and into the adjacent MRI and still maintaining the patient's surgical position. This system allows excess drapes to be removed, facilitating awake craniotomy. RESULTS: A 57-year-old right-handed man presented with new onset seizures. Magnetic resonance imaging demonstrated a large left temporal mass. The patient underwent an awake, left frontotemporal craniotomy. The EPM demonstrated a single critical area for speech in his inferior frontal gyrus. After an initial tumor debulking, the scalp flap was loosely approximated, the wound was covered with additional drapes, and the excess surrounding drapes were trimmed. An iMRI was obtained. The image-guidance system was re-registered and the patient was redraped. Additional resection was performed, allowing extensive removal of what proved to be an anaplastic astrocytoma. The patient tolerated this well without any new neurological deficits. CONCLUSIONS: Standard protocols for positioning and draping in high-field iMRI units make awake craniotomies problematic. This straightforward technique for combined awake EPM and iMRI may facilitate safe removal of large lesions in eloquent cortex.