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1.
PLoS One ; 15(9): e0238389, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32898166

RESUMO

Mapping brain functions is crucial for neurosurgical planning in patients with drug-resistant seizures. However, presurgical language mapping using either functional or structural networks can be challenging, especially in children. In fact, most of the evidence on this topic derives from cross-sectional or retrospective studies in adults submitted to anterior temporal lobectomy. In this prospective study, we used fMRI and DTI to explore patterns of language representation, their predictors and impact on cognitive performances in 29 children and young adults (mean age at surgery: 14.6 ± 4.5 years) with focal lesional epilepsy. In 20 of them, we also assessed the influence of epilepsy surgery on language lateralization. All patients were consecutively enrolled at a single epilepsy surgery center between 2009 and 2015 and assessed with preoperative structural and functional 3T brain MRI during three language tasks: Word Generation (WG), Rhyme Generation (RG) and a comprehension task. We also acquired DTI data on arcuate fasciculus in 24 patients. We first assessed patterns of language representation (relationship of activations with the epileptogenic lesion and Laterality Index (LI)) and then hypothesized a causal model to test whether selected clinical variables would influence the patterns of language representation and the ensuing impact of the latter on cognitive performances. Twenty out of 29 patients also underwent postoperative language fMRI. We analyzed possible changes of fMRI and DTI LIs and their clinical predictors. Preoperatively, we found atypical language lateralization in four patients during WG task, in one patient during RG task and in seven patients during the comprehension task. Diffuse interictal EEG abnormalities predicted a more atypical language representation on fMRI (p = 0.012), which in turn correlated with lower attention (p = 0.036) and IQ/GDQ scores (p = 0.014). Postoperative language reorganization implied shifting towards atypical language representation. Abnormal postoperative EEG (p = 0.003) and surgical failures (p = 0.015) were associated with more atypical language lateralization, in turn correlating with worsened fluency. Neither preoperative asymmetry nor postoperative DTI LI changes in the arcuate fasciculus were observed. Focal lesional epilepsy associated with diffuse EEG abnormalities may favor atypical language lateralization and worse cognitive performances, which are potentially reversible after successful surgery.


Assuntos
Mapeamento Encefálico , Epilepsias Parciais/diagnóstico por imagem , Epilepsias Parciais/psicologia , Transtornos da Linguagem/diagnóstico por imagem , Transtornos da Linguagem/psicologia , Adolescente , Criança , Cognição , Compreensão , Imagem de Tensor de Difusão , Epilepsia Resistente a Medicamentos/diagnóstico por imagem , Epilepsia Resistente a Medicamentos/psicologia , Epilepsia Resistente a Medicamentos/cirurgia , Epilepsias Parciais/cirurgia , Feminino , Lateralidade Funcional , Neuroimagem Funcional , Humanos , Imagem por Ressonância Magnética , Masculino , Estudos Prospectivos , Adulto Jovem
3.
Lancet Neurol ; 19(9): 748-757, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32822635

RESUMO

BACKGROUND: Surgery is a widely accepted treatment option for drug-resistant focal epilepsy. A detailed analysis of longitudinal postoperative seizure outcomes and use of antiepileptic drugs for different brain lesions causing epilepsy is not available. We aimed to analyse the association between histopathology and seizure outcome and drug freedom up to 5 years after epilepsy surgery, to improve presurgical decision making and counselling. METHODS: In this retrospective, multicentre, longitudinal, cohort study, patients who had epilepsy surgery between Jan 1, 2000, and Dec 31, 2012, at 37 collaborating tertiary referral centres across 18 European countries of the European Epilepsy Brain Bank consortium were assessed. We included patients of all ages with histopathology available after epilepsy surgery. Histopathological diagnoses and a minimal dataset of clinical variables were collected from existing local databases and patient records. The primary outcomes were freedom from disabling seizures (Engel class 1) and drug freedom at 1, 2, and 5 years after surgery. Proportions of individuals who were Engel class 1 and drug-free were reported for the 11 main categories of histopathological diagnosis. We analysed the association between histopathology, duration of epilepsy, and age at surgery, and the primary outcomes using random effects multivariable logistic regression to control for confounding. FINDINGS: 9147 patients were included, of whom seizure outcomes were available for 8191 (89·5%) participants at 2 years, and for 5577 (61·0%) at 5 years. The diagnoses of low-grade epilepsy associated neuroepithelial tumour (LEAT), vascular malformation, and hippocampal sclerosis had the best seizure outcome at 2 years after surgery, with 77·5% (1027 of 1325) of patients free from disabling seizures for LEAT, 74·0% (328 of 443) for vascular malformation, and 71·5% (2108 of 2948) for hippocampal sclerosis. The worst seizure outcomes at 2 years were seen for patients with focal cortical dysplasia type I or mild malformation of cortical development (50·0%, 213 of 426 free from disabling seizures), those with malformation of cortical development-other (52·3%, 212 of 405 free from disabling seizures), and for those with no histopathological lesion (53·5%, 396 of 740 free from disabling seizures). The proportion of patients being both Engel class 1 and drug-free was 0-14% at 1 year and increased to 14-51% at 5 years. Children were more often drug-free; temporal lobe surgeries had the best seizure outcomes; and a longer duration of epilepsy was associated with reduced chance of favourable seizure outcomes and drug freedom. This effect of duration was evident for all lesions, except for hippocampal sclerosis. INTERPRETATION: Histopathological diagnosis, age at surgery, and duration of epilepsy are important prognostic factors for outcomes of epilepsy surgery. In every patient with refractory focal epilepsy presumed to be lesional, evaluation for surgery should be considered. FUNDING: None.


Assuntos
Anticonvulsivantes/uso terapêutico , Epilepsia Resistente a Medicamentos/tratamento farmacológico , Epilepsia Resistente a Medicamentos/cirurgia , Convulsões/tratamento farmacológico , Convulsões/prevenção & controle , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Estudos de Coortes , Epilepsia Resistente a Medicamentos/patologia , Feminino , Humanos , Lactente , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Convulsões/patologia , Resultado do Tratamento , Adulto Jovem
4.
World Neurosurg ; 139: 762-774, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32689697

RESUMO

Though frequently effective in the management of medically refractory seizures, epilepsy surgery presents numerous challenges. Selection of the appropriate candidate patients who are likely to benefit from surgery is critical to achieving seizure freedom and avoiding neurocognitive morbidity. Identifying the seizure focus and mapping epileptogenic networks involves an interdisciplinary team dedicated to formulating a safe and effective surgical plan. Various strategies can be employed either to eliminate the epileptic focus or to modulate network activity, including resection of the focus with open surgery or laser interstitial thermal therapy; modulation of epileptogenic firing patterns with responsive neurostimulation, deep brain stimulation, or vagus nerve stimulation; or non-invasive disconnection of epileptic circuits with focused ultrasound, which is also discussed in greater detail in the subsequent chapter in our series. We review several challenges of epilepsy surgery that must be thoughtfully addressed in order to ensure its success.


Assuntos
Epilepsia Resistente a Medicamentos/cirurgia , Procedimentos Neurocirúrgicos/métodos , Seleção de Pacientes , Fatores Etários , Epilepsia Resistente a Medicamentos/diagnóstico , Epilepsia Resistente a Medicamentos/terapia , Eletroencefalografia , Encefalite/cirurgia , Técnicas de Ablação Endometrial , Lateralidade Funcional , Neuroimagem Funcional , Humanos , Neuroestimuladores Implantáveis , Imagem por Ressonância Magnética , Magnetoencefalografia , Testes Neuropsicológicos , Tomografia por Emissão de Pósitrons , Implantação de Prótese , Encaminhamento e Consulta , Tomografia Computadorizada de Emissão de Fóton Único , Falha de Tratamento , Esclerose Tuberosa/cirurgia
5.
World Neurosurg ; 139: 750-761, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32689696

RESUMO

The diagnostic and surgical management of epilepsy has made enormous strides over the past 3 decades, concomitant with advances in technology and electrophysiologic understanding of neuronal connectivity. Distinct zones have been identified within this network that each communicate and play a role in the genesis of seizures. Invasive and noninvasive modalities for defining the epileptogenic lesion or region have been able to more accurately determine which patients are optimal candidates for treatment when their seizures are refractory to conventional conservative management. Ablative, palliative, and disconnecting procedures have been developed as alternatives for traditional open resection techniques, and in recent studies, they have shown excellent seizure control and mitigation of complications. In this review, we discuss the evolution of these advancements in the management of epilepsy and provide an overview of current and future neurosurgical therapeutic modalities.


Assuntos
Epilepsia Resistente a Medicamentos/cirurgia , Procedimentos Neurocirúrgicos/métodos , Implantação de Prótese , Técnicas de Ablação , Lobectomia Temporal Anterior , Estimulação Encefálica Profunda , Epilepsia Resistente a Medicamentos/diagnóstico , Epilepsia Resistente a Medicamentos/terapia , Eletrocorticografia , Eletroencefalografia , Neuroimagem Funcional , Ablação por Ultrassom Focalizado de Alta Intensidade , Humanos , Neuroestimuladores Implantáveis , Terapia a Laser , Imagem por Ressonância Magnética , Magnetoencefalografia , Tomografia por Emissão de Pósitrons , Radiocirurgia , Procedimento de Encéfalo Dividido , Tomografia Computadorizada de Emissão de Fóton Único , Estimulação do Nervo Vago
6.
World Neurosurg ; 139: 775-788, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32689698

RESUMO

Technical limitations and clinical challenges have historically limited the diagnostic tools and treatment methods available for surgical approaches to the management of epilepsy. By contrast, recent technological innovations in several areas hold significant promise in improving outcomes and decreasing morbidity. We review innovations in the neurosurgical management of epilepsy in several areas, including wireless recording and stimulation systems (particularly responsive neurostimulation [NeuroPace]), conformal electrodes for high-resolution electrocorticography, robot-assisted stereotactic surgery, optogenetics and optical imaging methods, novel positron emission tomography ligands, and new applications of focused ultrasonography. Investigation into genetic causes of and susceptibilities to epilepsy has introduced a new era of precision medicine, enabling the understanding of cell signaling mechanisms underlying epileptic activity as well as patient-specific molecularly targeted treatment options. We discuss the emerging path to individualized treatment plans, predicted outcomes, and improved selection of effective interventions, on the basis of these developments.


Assuntos
Epilepsia Resistente a Medicamentos/cirurgia , Invenções , Procedimentos Neurocirúrgicos , Epilepsia Resistente a Medicamentos/diagnóstico , Epilepsia Resistente a Medicamentos/terapia , Eletrocorticografia , Ablação por Ultrassom Focalizado de Alta Intensidade , Humanos , Neuroestimuladores Implantáveis , Imagem Óptica , Optogenética , Tomografia por Emissão de Pósitrons , Medicina de Precisão , Implantação de Prótese , Procedimentos Cirúrgicos Robóticos , Técnicas Estereotáxicas , Tecnologia sem Fio
7.
Neurology ; 95(10): e1404-e1416, 2020 09 08.
Artigo em Inglês | MEDLINE | ID: mdl-32641528

RESUMO

OBJECTIVE: Surgery is an effective but costly treatment for many patients with drug-resistant temporal lobe epilepsy (DR-TLE). We aim to evaluate whether, in the United States, surgery is cost-effective compared to medical management for patients deemed surgical candidates and whether surgical evaluation is cost-effective for patients with DR-TLE in general. METHODS: We use a semi-Markov model to assess the cost-effectiveness of surgery and surgical evaluation over a lifetime horizon. We use second-order Monte Carlo simulations to conduct probabilistic sensitivity analyses to estimate variation in model output. We adopt both health care and societal perspectives, including direct health care costs (e.g., surgery, antiepileptic drugs) and indirect costs (e.g., lost earnings by patients and care providers.) We compare the incremental cost-effectiveness ratio to societal willingness to pay (∼$100,000 per quality-adjusted life-year [QALY]) to determine whether surgery is cost-effective. RESULTS: Epilepsy surgery is cost-effective compared to medical management in surgically eligible patients by virtue of being cost-saving ($328,000 vs $423,000) and more effective (16.6 vs 13.6 QALY) than medical management in the long run. Surgical evaluation is cost-effective in patients with DR-TLE even if the probability of being deemed a surgical candidate is only 5%. From a societal perspective, surgery becomes cost-effective within 3 years, and 89% of simulations favor surgery over the lifetime horizon. CONCLUSION: For surgically eligible patients with DR-TLE, surgery is cost-effective. For patients with DR-TLE in general, referral for surgical evaluation (and possible subsequent surgery) is cost-effective. Patients with DR-TLE should be referred for surgical evaluation without hesitation on cost-effectiveness grounds.


Assuntos
Análise Custo-Benefício , Epilepsia Resistente a Medicamentos/cirurgia , Epilepsia do Lobo Temporal/cirurgia , Procedimentos Neurocirúrgicos/economia , Epilepsia Resistente a Medicamentos/economia , Epilepsia do Lobo Temporal/economia , Humanos , Estados Unidos
8.
World Neurosurg ; 139: e78-e87, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32229300

RESUMO

OBJECTIVE: To analyze the relationship between cognitive performance and white matter integrity in patients with temporal lobe epilepsy (TLE) to establish radiologic criteria to help with patient selection for surgery. METHODS: The study included 19 adults with temporal lobe epilepsy. A tractography analysis of fractional anisotropy and mean diffusivity (MD) of the following fascicles was performed: arcuate fascicle, cingulum, fornix, inferior fronto-occipital fascicle, inferior longitudinal fascicle, parahippocampal fibers of the cingulum, and uncinate fascicle. The Wechsler Memory Scale-Third Edition neuropsychological test was performed to evaluate short- and long-term verbal (Logical Memory I and II subtests) and nonverbal (Visual Reproduction I and II subtests) memory. Relationships between memory scores and diffusion were calculated. RESULTS: Lower Logical Memory I subtest scores were correlated with lower MD of the right inferior fronto-occipital fascicle, while lower Logical Memory II subtest scores were related to higher values of fractional anisotropy in bilateral cingulum, right uncinate, and right parahippocampal fibers of the cingulum and lower MD in left cingulum fascicle. Finally, lower values in Visual Reproduction I subtest scores were associated with lower values in MD in right cingulum and inferior fronto-occipital fascicles. CONCLUSIONS: Structural changes of some white matter tracts were associated with deterioration of both short- and long-term memory. These alterations were more associated with verbal memory than with nonverbal memory. These changes mainly consist of an increase in fractional anisotropy and a decrease in MD, which could be interpreted as reorganization phenomena. Diffusion tensor imaging could be a useful tool for cognitive assessment in surgical candidates with temporal lobe epilepsy who are not suitable for neuropsychological testing or in whom their results do not lead to definitive conclusions.


Assuntos
Epilepsia Resistente a Medicamentos/cirurgia , Epilepsia do Lobo Temporal/cirurgia , Transtornos da Memória/diagnóstico por imagem , Procedimentos Neurocirúrgicos/métodos , Substância Branca/diagnóstico por imagem , Adulto , Anisotropia , Imagem de Tensor de Difusão , Epilepsia do Lobo Temporal/fisiopatologia , Feminino , Lateralidade Funcional , Humanos , Masculino , Transtornos da Memória/complicações , Pessoa de Meia-Idade , Seleção de Pacientes
9.
J Clin Neurosci ; 76: 67-73, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32305273

RESUMO

Corpus callosotomy is a palliative surgical option for patients with refractory epilepsy and frequent drop attacks, decreasing seizure frequency and severity by disconnecting the cerebral hemispheres. Though often successful, open surgery is not without risk. Corpus callosotomy by MRI-guided laser interstitial thermal therapy (MRgLITT) is a minimally invasive alternative to the standard open procedure. This report aims to present an illustrative case and systematically review the current literature on the surgical technique. A systematic review of the English literature through January 2019 was performed. Articles were searched by title utilizing the following key word combinations: "laser" and "callosotomy", "callosotomy" and "ablation", "laser" and "corpus", "callosotomy" and "thermal", and "stereotactic" and callosotomy". The articles recovered were then classified by level of evidence and summarized. Fifteen papers were reviewed, of which 6 met inclusion and exclusion criteria. All included studies were classified as level IV evidence. There was a total of 13 patients ranging from 13 months to 44 years old (mean 23.5 years old). The number of laser fibers utilized ranged from 1 to 3. Engel class I was achieved in 5 patients, II in 4, III in 2, IV in 1. Reported patient follow up was 4-39.7 months (mean 15.43). Corpus callosotomy utilizing MRI-guided laser interstitial thermal therapy results in improvement in seizure frequency and severity with minimal complications. Prospective trials are needed to compare its seizure control and long-term outcomes to that of standard open callosotomy.


Assuntos
Corpo Caloso/cirurgia , Epilepsia Resistente a Medicamentos/cirurgia , Hemisferectomia/métodos , Terapia a Laser/métodos , Radiografia Intervencionista/métodos , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Imagem por Ressonância Magnética/métodos , Masculino , Estudos Prospectivos , Resultado do Tratamento , Adulto Jovem
11.
Zh Vopr Neirokhir Im N N Burdenko ; 84(1): 109-117, 2020.
Artigo em Russo | MEDLINE | ID: mdl-32207750

RESUMO

PURPOSE: To conduct a systematic assessment of scientific publications devoted to pre-surgical examination of patients with intactable epilepsy. MATERIAL AND METHODS: We found, using PubMed and available Internet search tools, and analyzed 1.414 articles on pre-surgical diagnostics in patients with intractable epilepsy. RESULTS: Epilepsy is a chronic disorder caused by brain injury, which manifests as repeated epileptic seizures and is accompanied by a variety of personality changes. Mortality risks in the population of patients with uncontrolled intractable epilepsy significantly exceed those in the general population. Early onset of comprehensive treatment prevents pathological personality changes and reduces the risks of mortality. However, complete seizure control is not achieved in 30% of patients, and they develop pharmacoresistance later, which is the reason for considering these patients as candidates for surgical treatment. In the literature, many approaches to pre-surgical examination are described as each clinic has its own concept of pre-surgical diagnostics and its own approaches to surgical management. Based on the conducted analysis, we tried to summarize the received information and describe current ideas about pre-surgical examination of patients with intactable epilepsy. CONCLUSION: On the basis of analyzed literature, we performed a systematic assessment and the evaluated effectiveness of various approaches in the pre-surgical diagnostics of patients with intactable epilepsy.


Assuntos
Epilepsia Resistente a Medicamentos/cirurgia , Epilepsia/diagnóstico , Humanos , Convulsões , Resultado do Tratamento
12.
World Neurosurg ; 138: 141-144, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32169621

RESUMO

BACKGROUND: Neuromodulation is recommended for patients with refractory tuberous sclerosis related epilepsy (TRE) who are unable to localize epileptogenic nodules after comprehensive preoperative evaluation or for patients and families who do not agree to resection. CASE DESCRIPTION: We report a patient with refractory TRE who received deep brain stimulation of anterior thalamic nucleus (ANT-DBS) and achieved a satisfactory response. To our knowledge, this is the first case of TRE being treated with ANT-DBS. A 22-year-old male was admitted to the hospital for refractory TRE seeking surgical treatment. Seizures were mainly manifested by deep temporal and frontal lobe epilepsy and suspected to originate in the limbic system. Magnetic resonance imaging revealed extensive potentially epileptogenic nodules in the brain lacking significant nodules. Scalp electroencephalogram showed a comprehensive, bilateral synchronous low-voltage rapid rhythm, unable to localize seizure origin. We performed bilateral ANT-DBS according to the preoperative evaluation, and the frequency and intensity of seizures were significantly reduced after the 15-month follow-up (P <0.05, Student's t-test). Our case extends the therapeutic indications of ANT-DBS to a certain extent, providing a neuromodulation alternative to vagus nerve stimulation for patients with TRE who are unsuitable candidates or refuse resection.


Assuntos
Núcleos Anteriores do Tálamo/cirurgia , Estimulação Encefálica Profunda/métodos , Epilepsia Resistente a Medicamentos/etiologia , Epilepsia Resistente a Medicamentos/cirurgia , Procedimentos Neurocirúrgicos/métodos , Esclerose Tuberosa/complicações , Esclerose Tuberosa/cirurgia , Eletrodos Implantados , Eletroencefalografia , Humanos , Imagem por Ressonância Magnética , Masculino , Exame Neurológico , Convulsões/etiologia , Convulsões/cirurgia , Resultado do Tratamento , Adulto Jovem
13.
Epilepsia ; 61(3): 539-548, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32108938

RESUMO

OBJECTIVE: Humans use a complex system of protective cognitive biases or "positive illusions" that foster emotional well-being and subjective quality of life. This study examined the role of positive illusions in patient adjustment to drug-resistant epilepsy and its surgical treatment. METHODS: One hundred fifty people participated, including 93 focal epilepsy patients being evaluated for surgery and 57 sociodemographically matched healthy controls. We purpose-built computer software, "Living With Epilepsy," to assess the impact of positive illusions on patient perceptions of their current life, and administered well-validated questionnaires of depression (Neurological Disorders Depression Inventory for Epilepsy), anxiety (Patient Health Questionnaire for Generalized Anxiety Disorder-7 items), and health-related quality of life (HRQOL; Epilepsy Surgery Inventory-55) before and at 3 and 12 months after surgery. RESULTS: We identified two patient groups: those with "high positive illusions" (53%) about their epilepsy and those with "low positive illusions" (47%), with no differences between sociodemographic or epilepsy variables (all P > .05). Before epilepsy surgery, patients with high positive illusions exhibited fewer symptoms of depression (P < .001) and anxiety (P = .002) and higher HRQOL (P ≥ .002 ≤ 0.046) than those with low positive illusions. A subset of patients proceeded with surgery (n = 34 at 3 months; n = 26 at 12 months). They showed that the beneficial impact of having high positive illusions re-emerged 12 months postsurgery, with patients reporting lower depression and anxiety (P = .006) and elevated HRQOL (P = .036) compared to low positive illusions patients, independent of seizure outcome (P > .05). SIGNIFICANCE: These findings point to an active psychological process in drug-resistant patients, where approximately half generate strong positive illusions about their life with epilepsy, maintaining their mood and subjective well-being. Those who use this psychological mechanism show better adjustment 12 months postsurgery independent of seizure outcome, providing a potential new target for psychological treatment in patients with epilepsy.


Assuntos
Ansiedade/psicologia , Cognição , Depressão/psicologia , Epilepsia Resistente a Medicamentos/psicologia , Ajustamento Emocional , Epilepsias Parciais/psicologia , Otimismo/psicologia , Qualidade de Vida/psicologia , Adulto , Idoso , Estudos de Coortes , Epilepsia Resistente a Medicamentos/cirurgia , Epilepsias Parciais/cirurgia , Feminino , Humanos , Ilusões , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos , Estudos Prospectivos , Software
14.
Epilepsia ; 61(3): 465-478, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32108946

RESUMO

OBJECTIVE: To analyze longitudinal seizure outcomes following epilepsy surgery, including reoperations, in patients with intractable focal epilepsy. METHODS: Clinicoradiological characteristics of patients who underwent epilepsy surgery from 1995 to 2016 with follow-up of ≥1 year were reviewed. In patients undergoing reoperations, the latest resection was considered the index surgery. The primary outcome was complete seizure freedom (Engel I) at last follow-up. Potentially significant outcome variables were first identified using univariate analyses and then fit in multivariate Cox proportional hazards models. RESULTS: Of 898 patients fulfilling study criteria, 110 had reoperations; 92 had one resection prior to the index surgery and 18 patients had two or more prior resective surgeries. Two years after the index surgery, 69% of patients with no prior surgeries had an Engel score of I, as opposed to only 42% of those with one prior surgery, and 33% of those with two or more prior resections (P < .001). Among surgical outcome predictors, the number of prior epilepsy surgeries, female sex, lesional initial magnetic resonance imaging, no prior history of generalization, and pathology correlated with better seizure outcomes on univariate analysis. However, only sex (P = .011), history of generalization (P = .016), and number of prior surgeries (P = .002) remained statistically significant in the multivariate model. SIGNIFICANCE: Although long-term seizure control is possible in patients with failed prior epilepsy surgery, the chances of success diminish with every subsequent resection. Outcome is additionally determined by inherent biological markers (sex and secondary generalization tendency), rather than traditional outcome predictors, supporting a hypothesis of "surgical refractoriness."


Assuntos
Epilepsia Resistente a Medicamentos/cirurgia , Epilepsias Parciais/cirurgia , Procedimentos Neurocirúrgicos , Reoperação , Adolescente , Adulto , Criança , Epilepsia Resistente a Medicamentos/diagnóstico por imagem , Epilepsia Resistente a Medicamentos/fisiopatologia , Epilepsias Parciais/diagnóstico por imagem , Epilepsias Parciais/fisiopatologia , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Tomografia por Emissão de Pósitrons , Prognóstico , Modelos de Riscos Proporcionais , Fatores Sexuais , Resultado do Tratamento , Adulto Jovem
15.
World Neurosurg ; 137: 357-361, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32059966

RESUMO

BACKGROUND: Hemispherectomy has been shown to be successful in treating medically intractable epilepsy, with favorable seizure-free outcomes. However, the procedure is technically challenging with high rates of in-hospital complications. We present a unique case of functional hemispherectomy complicated by diffuse cerebral vasospasm and subsequent death in a patient with COL4A1 gene mutation. CASE DESCRIPTION: A 17-year-old boy presented with right hemispheric epilepsy and a previously diagnosed autosomal dominant heterozygous COL4A1 gene mutation (c.4380T>G;p.Cys1460Trp). Functional hemispherectomy was performed without complications. On postoperative day 8, he developed an acute decline in neurologic status requiring urgent intubation for airway protection. Magnetic resonance imaging revealed areas of restricted diffusion throughout bilateral hemispheres that was explained by severe vasospasm and minimal cerebral blood flow seen on cerebral angiography. Intra-arterial calcium channel blocker infusion and balloon angioplasty were attempted without improvement in perfusion. With a worsening clinical picture, he was transitioned to comfort care and died. CONCLUSIONS: This is the first report in the literature describing global vasospasm and delayed cerebral ischemia following hemispherectomy in a patient carrying COL4A1 gene mutation. We postulate that his COL4A1 gene mutation might have resulted in this exaggerated vasospasm despite minimal residual postoperative subarachnoid hemorrhage burden. This hypothesis needs to be studied in animal models of this genetic disorder.


Assuntos
Isquemia Encefálica/diagnóstico por imagem , Colágeno Tipo IV/genética , Epilepsia Resistente a Medicamentos/cirurgia , Epilepsias Parciais/cirurgia , Hemisferectomia , Porencefalia/genética , Complicações Pós-Operatórias/diagnóstico por imagem , Vasoespasmo Intracraniano/diagnóstico por imagem , Adolescente , Angiografia Digital , Isquemia Encefálica/fisiopatologia , Isquemia Encefálica/terapia , Angiografia Cerebral , Deficiências do Desenvolvimento/complicações , Epilepsia Resistente a Medicamentos/complicações , Epilepsia Resistente a Medicamentos/diagnóstico por imagem , Epilepsia Resistente a Medicamentos/fisiopatologia , Epilepsias Parciais/complicações , Epilepsias Parciais/diagnóstico por imagem , Epilepsias Parciais/fisiopatologia , Evolução Fatal , Hemianopsia/complicações , Hemiplegia/complicações , Humanos , Masculino , Porencefalia/complicações , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/terapia , Vasoespasmo Intracraniano/fisiopatologia , Vasoespasmo Intracraniano/terapia
16.
Clin Neurophysiol ; 131(3): 734-743, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32007920

RESUMO

OBJECTIVE: To localize the seizure onset zone (SOZ) and irritative zone (IZ) using electric source imaging (ESI) on intracranial EEG (iEEG) and assess their clinical value in predicting epilepsy surgery outcome in children with focal cortical dysplasia (FCD). METHODS: We analyzed iEEG data from 25 children with FCD-associated medically refractory epilepsy (MRE) who underwent surgery. We performed ESI on ictal onset to localize SOZ (ESI-SOZ) and on interictal discharges to localize IZ (ESI-IZ). We tested whether resection of ESI-SOZ and ESI-IZ predicted good surgical outcome (Engel 1). We further compared the prediction performance of ESI-SOZ and ESI-IZ to those of SOZ and IZ defined using conventional methods, i.e. by identifying iEEG-contacts showing ictal onsets (conventional-SOZ) or being the most interictally active (conventional-IZ). RESULTS: The proximity of ESI-SOZ (p = 0.043, odds-ratio = 3.9) and ESI-IZ (p = 0.011, odds-ratio = 7.04) to resection has higher effect on patients' outcome than proximity of conventional-SOZ (p = 0.17, odds-ratio = 1.7) and conventional-IZ (p = 0.038, odds-ratio = 2.6). Resection of ESI-SOZ and ESI-IZ presented higher discriminative power in predicting outcome (68% and 60%) than conventional-SOZ and conventional-IZ (48% and 53%). CONCLUSIONS: Localizing SOZ and IZ via ESI on iEEG offers higher predictive value compared to conventional-iEEG interpretation. SIGNIFICANCE: iEEG-ESI may help surgical planning and facilitate prognostic assessment of children with FCD-associated MRE.


Assuntos
Encéfalo/fisiopatologia , Epilepsia Resistente a Medicamentos/fisiopatologia , Epilepsia/fisiopatologia , Malformações do Desenvolvimento Cortical do Grupo I/fisiopatologia , Adolescente , Encéfalo/diagnóstico por imagem , Encéfalo/cirurgia , Mapeamento Encefálico , Criança , Pré-Escolar , Epilepsia Resistente a Medicamentos/diagnóstico por imagem , Epilepsia Resistente a Medicamentos/cirurgia , Eletroencefalografia , Epilepsia/diagnóstico por imagem , Epilepsia/cirurgia , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Malformações do Desenvolvimento Cortical do Grupo I/diagnóstico por imagem , Malformações do Desenvolvimento Cortical do Grupo I/cirurgia , Período Pré-Operatório , Prognóstico , Estudos Retrospectivos , Resultado do Tratamento
17.
Epilepsia ; 61(3): 408-420, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32072621

RESUMO

OBJECTIVE: To describe seizure outcomes in patients with medically refractory epilepsy who had evidence of bilateral mesial temporal lobe (MTL) seizure onsets and underwent MTL resection based on chronic ambulatory intracranial EEG (ICEEG) data from a direct brain-responsive neurostimulator (RNS) system. METHODS: We retrospectively identified all patients at 17 epilepsy centers with MTL epilepsy who were treated with the RNS System using bilateral MTL leads, and in whom an MTL resection was subsequently performed. Presumed lateralization based on routine presurgical approaches was compared to lateralization determined by RNS System chronic ambulatory ICEEG recordings. The primary outcome was frequency of disabling seizures at last 3-month follow-up after MTL resection compared to seizure frequency 3 months before MTL resection. RESULTS: We identified 157 patients treated with the RNS System with bilateral MTL leads due to presumed bitemporal epilepsy. Twenty-five patients (16%) subsequently had an MTL resection informed by chronic ambulatory ICEEG (mean = 42 months ICEEG); follow-up was available for 24 patients. After MTL resection, the median reduction in disabling seizures at last follow-up was 100% (mean: 94%; range: 50%-100%). Nine patients (38%) had exclusively unilateral electrographic seizures recorded by chronic ambulatory ICEEG and all were seizure-free at last follow-up after MTL resection; eight of nine continued RNS System treatment. Fifteen patients (62%) had bilateral MTL electrographic seizures, had an MTL resection on the more active side, continued RNS System treatment, and achieved a median clinical seizure reduction of 100% (mean: 90%; range: 50%-100%) at last follow-up, with eight of fifteen seizure-free. For those with more than 1 year of follow-up (N = 21), 15 patients (71%) were seizure-free during the most recent year, including all eight patients with unilateral onsets and 7 of 13 patients (54%) with bilateral onsets. SIGNIFICANCE: Chronic ambulatory ICEEG data provide information about lateralization of MTL seizures and can identify additional patients who may benefit from MTL resection.


Assuntos
Lobectomia Temporal Anterior/métodos , Epilepsia Resistente a Medicamentos/cirurgia , Epilepsia do Lobo Temporal/cirurgia , Lobo Temporal/cirurgia , Adulto , Idoso , Epilepsia Resistente a Medicamentos/fisiopatologia , Terapia por Estimulação Elétrica , Eletrocorticografia , Epilepsia do Lobo Temporal/fisiopatologia , Feminino , Humanos , Neuroestimuladores Implantáveis , Masculino , Pessoa de Meia-Idade , Monitorização Ambulatorial , Procedimentos Neurocirúrgicos , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
18.
Neurosurgery ; 86(4): E366-E382, 2020 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-31980831

RESUMO

BACKGROUND: For patients with focal drug-resistant epilepsy (DRE), surgical resection of the epileptogenic zone (EZ) may offer seizure freedom and benefits for quality of life. Yet, concerns remain regarding invasiveness, morbidity, and neurocognitive side effects. Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) has emerged as a less invasive option for stereotactic ablation rather than resection of the EZ. OBJECTIVE: To provide an introduction to MRgLITT for epilepsy, including historical development, surgical technique, and role in therapy. METHODS: The development of MRgLITT is briefly recounted. A systematic review identified reported techniques and indication-specific outcomes of MRgLITT for DRE in human studies regardless of sample size or follow-up duration. Potential advantages and disadvantages compared to available alternatives for each indication are assessed in an unstructured review. RESULTS: Techniques and outcomes are reported for mesial temporal lobe epilepsy, hypothalamic hamartoma, focal cortical dysplasia, nonlesional epilepsy, tuberous sclerosis, periventricular nodular heterotopia, cerebral cavernous malformations, poststroke epilepsy, temporal encephalocele, and corpus callosotomy. CONCLUSION: MRgLITT offers access to foci virtually anywhere in the brain with minimal disruption of the overlying cortex and white matter, promising fewer neurological side effects and less surgical morbidity and pain. Compared to other ablative techniques, MRgLITT offers immediate, discrete lesions with real-time monitoring of temperature beyond the fiber tip for damage estimates and off-target injury prevention. Applications of MRgLITT for epilepsy are growing rapidly and, although more evidence of safety and efficacy is needed, there are potential advantages for some patients.


Assuntos
Epilepsia Resistente a Medicamentos/cirurgia , Terapia a Laser/métodos , Imagem por Ressonância Magnética/métodos , Cirurgia Assistida por Computador/métodos , Feminino , Humanos , Hipertermia Induzida/métodos , Masculino , Resultado do Tratamento
19.
Eur J Paediatr Neurol ; 24: 40-42, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31917082

RESUMO

Epilepsy surgery is the most effective treatment option for children with refractory focal lesional epilepsy, with seizure-freedom rates exceeding 70% two years after surgery. Although numbers of procedures in children are increasing over time, epilepsy surgery remains underutilized. Particularly in young children with developmental delay, arrest, or even regression, surgery can improve cognitive outcome. Many factors determine eventual developmental abilities, of which epilepsy duration is the most important modifiable predictor. Earlier surgery is not only associated with higher seizure-freedom rates, it also improves postoperative developmental outcomes. Every child with focal lesional epilepsy should therefore be referred early, to evaluate the possibilities of epilepsy surgery.


Assuntos
Deficiências do Desenvolvimento/cirurgia , Epilepsia Resistente a Medicamentos/cirurgia , Epilepsias Parciais/cirurgia , Criança , Deficiências do Desenvolvimento/complicações , Epilepsia Resistente a Medicamentos/complicações , Epilepsias Parciais/complicações , Humanos , Resultado do Tratamento
20.
Brain ; 143(2): 570-581, 2020 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-31953931

RESUMO

At least 50% of patients with tuberous sclerosis complex present with intractable epilepsy; for these patients, resective surgery is a treatment option. Here, we report a nationwide multicentre retrospective study and analyse the long-term seizure and neuropsychological outcomes of epilepsy surgery in patients with tuberous sclerosis complex. There were 364 patients who underwent epilepsy surgery in the study. Patients' clinical data, postoperative seizure outcomes at 1-, 4-, and 10-year follow-ups, preoperative and postoperative intelligence quotients, and quality of life at 1-year follow-up were collected. The patients' ages at surgery were 10.35 ± 7.70 years (range: 0.5-47). The percentage of postoperative seizure freedom was 71% (258/364) at 1-year, 60% (118/196) at 4-year, and 51% (36/71) at 10-year follow-up. Influence factors of postoperative seizure freedom were the total removal of epileptogenic tubers and the presence of outstanding tuber on MRI at 1- and 4-year follow-ups. Furthermore, monthly seizure (versus daily seizure) was also a positive influence factor for postoperative seizure freedom at 1-year follow-up. The presence of an outstanding tuber on MRI was the only factor influencing seizure freedom at 10-year follow-up. Postoperative quality of life and intelligence quotient improvements were found in 43% (112/262) and 28% (67/242) of patients, respectively. Influence factors of postoperative quality of life and intelligence quotient improvement were postoperative seizure freedom and preoperative low intelligence quotient. The percentage of seizure freedom in the tuberectomy group was significantly lower compared to the tuberectomy plus and lobectomy groups at 1- and 4-year follow-ups. In conclusion, this study, the largest nationwide multi-centre study on resective epilepsy surgery, resulted in improved seizure outcomes and quality of life and intelligence quotient improvements in patients with tuberous sclerosis complex. Seizure freedom was often achieved in patients with an outstanding tuber on MRI, total removal of epileptogenic tubers, and tuberectomy plus. Quality of life and intelligence quotient improvements were frequently observed in patients with postoperative seizure freedom and preoperative low intelligence quotient.


Assuntos
Epilepsia Resistente a Medicamentos/cirurgia , Epilepsia/cirurgia , Convulsões/cirurgia , Esclerose Tuberosa/cirurgia , Adolescente , Adulto , Criança , Pré-Escolar , China , Eletroencefalografia/métodos , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
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