The Value of Intraoperative Ultrasound in Brain Surgery.

Favorable clinical outcomes in adult and pediatric neurosurgical oncology generally depend on the extent of tumor resection (EOR). Maximum safe resection remains the main aim of surgery in most intracranial tumors. Despite the accuracy of intraoperative magnetic resonance imaging (iMRI) in the detection of residual intraoperatively, it is not widely implemented worldwide owing to enormous cost and technical difficulties. Over the past years, intraoperative ultrasound (IOUS) has imposed itself as a valuable and reliable intraoperative tool guiding neurosurgeons to achieve gross total resection (GTR) of intracranial tumors.Being less expensive, feasible, doesn't need a high level of training, doesn't need a special workspace, and being real time with outstanding temporal and spatial resolution; all the aforementioned advantages give a superiority for IOUS in comparison to iMRI during resection of brain tumors.In this chapter, we spot the light on the technical nuances, advanced techniques, outcomes of resection, pearls, and pitfalls of the use of IOUS during the resection of brain tumors.

Postoperative shunt failure following hemispherectomy in pediatric patients with pre-existing hydrocephalus.

OBJECTIVE: The risk of hydrocephalus following hemispherectomy for drug resistant epilepsy (DRE) remains high. Patients with pre-existing hydrocephalus pose a postoperative challenge, as maintaining existing shunt patency is necessary but lacks a clearly defined strategy. This study examines the incidence and predictors of shunt failure in pediatric hemispherectomy patients with pre-existing ventricular shunts. METHODS: We performed a retrospective chart review at our center to identify pediatric patients diagnosed with DRE who were treated with ventricular shunt prior to their first hemispherectomy surgery. Demographic and perioperative data were obtained including shunt history, hydrocephalus etiology, epilepsy duration, surgical technique, and postoperative outcomes. Univariate analysis was performed using Fisher's exact test and Pearson correlation, with Bonferroni correction to a = 0.00625 and a = 0.01, respectively. RESULTS: Five of nineteen (26.3%) patients identified with ventriculoperitoneal shunting prior to hemispherectomy experienced postoperative shunt malfunction. All 5 of these patients underwent at least 1 shunt revision prior to hemispherectomy, with a significant association between pre- and post-hemispherectomy shunt revisions. There was no significant association between post-hemispherectomy shunt failure and valve type, intraoperative shunt alteration, postoperative external ventricular drain placement, hemispherectomy revision, lateralization of shunt relative to resection, postoperative complications, or postoperative aseptic meningitis. There was no significant correlation between number of post-hemispherectomy shunt revisions and age at shunt placement, age at hemispherectomy, epilepsy duration, or shunt duration prior to hemispherectomy. CONCLUSIONS: Earlier shunt revision surgery may portend a subsequent need for shunt revision following hemispherectomy. These findings may guide neurosurgeons in counseling patients with pre-existing ventricular shunts prior to hemispherectomy surgery.

MRI and pathology comparisons in Rasmussen's encephalitis: a multi-institutional examination of hemispherotomy outcomes relative to imaging and histological severity.

PURPOSE: Rasmussen encephalitis (RE) is a very rare chronic neurological disorder of unilateral inflammation of the cerebral cortex. Hemispherotomy provides the best chance at achieving seizure freedom in RE patients, but with significant risks and variable long-term outcomes. The goal of this study is to utilize our multicenter pediatric cohort to characterize if differences in pathology and/or imaging characterization of RE may provide a window into post-operative seizure outcomes, which in turn could guide decision-making for parents and healthcare providers. METHODS: This multi-institutional retrospective review of medical record, imaging, and pathology samples was approved by each individual institution's review board. Data was collected from all known pediatric cases of peri-insular functional hemispherotomy from the earliest available electronic medical records. Mean follow-up time was 4.9 years. Clinical outcomes were measured by last follow-up visit using both Engel and ILAE scoring systems. Relationships between categorical and continuous variables were analyzed with Pearson correlation values. RESULTS: Twenty-seven patients met study criteria. No statistically significant correlations existed between patient imaging and pathology data. Pathology stage, MRI brain imaging stages, and a combined assessment of pathology and imaging stages showed no statistically significant correlation to post-operative seizure freedom rates. Hemispherectomy Outcome Prediction Scale scoring demonstrated seizure freedom in only 71% of patients receiving a score of 1 and 36% of patients receiving a score of 2 which were substantially lower than predicted. CONCLUSIONS: Our analysis did not find evidence for either independent or combined analysis of imaging and pathology staging being predictive for post peri-insular hemispherotomy seizure outcomes, prompting the need for other biomarkers to be explored. Our data stands in contrast to the recently proposed Hemispherectomy Outcome Prediction Scale and does not externally validate this metric for an RE cohort.

[Influence of thromboelastography-guided hemostatic algorithm on allogeneic transfusion requirements during pediatric hemispherectomy].

Objective: To evaluate the influence of thromboelastography-guided hemostatic algorithm on allogeneic transfusion requirements during pediatric hemispherectomy. Methods: Clinical data of 38 children who underwent hemispherectomy from January 1, 2011 to October 31, 2023 at Xuanwu Hospital of Capital Medical University were retrospective collected. Patients were divided into study group (n=17) and control group (n=21) according to whether thromboelastography was employed to guide hemostatic algorithm. Demographic data and surgical data were recorded. The primary outcomes were allogeneic transfusion rates, including RBC transfusion rate, plasma transfusion rate, and platelets transfusion rate. The second outcomes were estimated blood loss, postoperative seizures during hospitalization, thromboembolic events, and length of hospital stay. Results: There were 13 boys and 4 girls with mean age of (5.7±3.3) years old in study group, and 16 boys and 5 girls with mean age of (7.4±3.4) years old in control group. The surgery duration, anesthesia duration and the proportion of prophylactic administration of tranexamic acid in study group were (424.5±98.5) min, (542.8±106.9) min, and 94.1% (16/17), which were higher than (353.1±85.3) min, (445.3±87.9) min, and 47.6% (10/21) in control group (all P<0.05). The rates of intra- and perioperative allogeneic plasma transfusion in study group were 52.9% (9/17) and 64.7% (11/17) respectively, which were lower than 90.5% (19/21) and 95.2% (20/21) in control group (all P<0.05). The ratio of fibrinogen concentrates administration in study group was 58.8% (10/17), which was higher than that in control group [4.8% (1/21), P=0.001]. There were no statistically differences in intra- and perioperative allogeneic RBC transfusion rates between the two groups (all P>0.05). No platelets were transfused in both groups. There were no statistically differences in estimated blood loss, postoperative seizures during hospitalization and the length of hospital stay between the two groups (all P>0.05). No postoperative thromboembolic events were observed. Conclusion: Thromboelastography-guided hemostatic algorithm can reduce allogeneic plasma transfusion requirements but not RBC transfusion requirements during pediatric hemispherectomy.

Predictive factors of hydrocephalus development in pediatric patients undergoing hemispherectomy for intractable epilepsy.

OBJECTIVE: Hemispherectomy surgery is an effective procedure for pediatric patients with intractable hemispheric epilepsy. Hydrocephalus is a well-documented complication of hemispherectomy contributing substantially to patient morbidity. Despite some clinical and operative factors demonstrating an association with hydrocephalus development, the true mechanism of disease is incompletely understood. The aim of this study was to investigate a range of clinical and surgical factors that may contribute to hydrocephalus to enhance understanding of the development of this complication and to aid the clinician in optimizing peri- and postoperative surgical management. METHODS: A retrospective chart review was conducted on all pediatric patients younger than 21 years who underwent hemispherectomy surgery at the Cleveland Clinic between 2002 and 2016. Data collected for each patient included general demographic information, neurological and surgical history, surgical technique, pathological analysis, presence and duration of perioperative CSF diversion, CSF laboratory values obtained while an external ventricular drain (EVD) was in place, length of hospital stay, postoperative aseptic meningitis, and in-hospital surgical complications (including perioperative stroke, hematoma formation, wound breakdown, and/or infection). Outcomes data included hemispherectomy revision and Engel grade at last follow-up (based on the Engel Epilepsy Surgery Outcome Scale). RESULTS: Data were collected for 204 pediatric patients who underwent hemispherectomy at the authors' institution. Twenty-eight patients (14%) developed hydrocephalus requiring CSF diversion. Of these 28 patients, 13 patients (46%) presented with hydrocephalus during the postoperative period (within 90 days), while the remaining 15 patients (54%) presented later (beyond 90 days after surgery). Multivariate analysis revealed postoperative aseptic meningitis (OR 7.0, p = 0.001), anatomical hemispherectomy surgical technique (OR 16.3 for functional/disconnective hemispherectomy and OR 7.6 for modified anatomical, p = 0.004), male sex (OR 4.2, p = 0.012), and surgical complications (OR 3.8, p = 0.031) were associated with an increased risk of hydrocephalus development, while seizure freedom (OR 0.3, p = 0.038) was associated with a decreased risk of hydrocephalus. CONCLUSIONS: Hydrocephalus remains a prominent complication following hemispherectomy, presenting both in the postoperative period and months to years after surgery. Aseptic meningitis, anatomical hemispherectomy surgical technique, male sex, and surgical complications show an association with an increased rate of hydrocephalus development while seizure freedom postsurgery is associated with a decreased risk of subsequent hydrocephalus. These findings speak to the multifactorial nature of hydrocephalus development and should be considered in the management of pediatric patients undergoing hemispherectomy for medically intractable epilepsy.

Long term outcome of functional hemispherectomy for refractory epilepsy: Experience from a single center / Resultado a largo plazo de la hemisferectomía funcional para la epilepsia refractaria: experiencia en un único centro

Background: Hemispherectomy has an established role as a treatment of last resort in patients with unilateral hemispheric lesions suffering from refractory epilepsy. Methods: Seven patients were evaluated at our Epilepsy Unit. We compared the seizure outcome at 6 months, 1, 2, 5 years post-surgery, as well as at end follow-up (mean 7.1 years) using Engel classification. Reduction of antiepileptic drugs (AEDs) was also assessed utilizing equal time frames. Results: The mean age of seizure onset was 5.4 years. Engel I was achieved in 5 patients at 6 months (71.4%). Engel at 1 year was predicted by the Engel at 6 months (p=0.013) with a similar number of patients being classified as Engel I outcome. Engel at 2 years was also predicted by Engel at 6 months and at 1 year (p=0.030). At end follow-up only 3 patients (42.9%) remained categorized as Engel I outcome. There was a trend toward a stability in Engel classification. All patients with developmental causes for their epilepsy experienced some deterioration of the surgical outcomes. Conversely, all patients with acquired causes were stable throughout follow-up. Seizure outcome at 6 months was worse in the patients who had post-op complications (p=0.044). Adult and pediatric populations did not differ significantly in any tested variable. Conclusions: Hemispherectomy is a valuable resource for seizure control in properly selected patients. Engel patient's evolution could be predicted at 6 months interval. Hemispherectomy could be considered a useful attitude in difficult cases (AU)

Antecedentes: La hemisferectomía tiene un rol establecido como último recurso de tratamiento en pacientes con lesiones hemisféricas unilaterales que padecen epilepsia refractaria. Métodos: En nuestra Unidad de Epilepsia fueron evaluados 7 pacientes. Comparamos el resultado de la crisis epiléptica a los 6 meses, 1, 2 y 5 años posteriores a la cirugía, así como durante el seguimiento final (media 7,1 años) utilizando la clasificación de Engel. También se evaluó la reducción de fármacos antiepilépticos (FAE) utilizando marcos temporales iguales. Resultados: La edad media de aparición de la crisis fue de 5,4 años. Se logró Engel I en 5 pacientes a los 6 meses (71,4%). Engel a 1año fue predicho por Engel a 6 meses (p=0,013) con un número similar de pacientes clasificados como resultado Engel I. Engel a 2 años fue también predicho por Engel a 6 meses y 1año (p=0,030). Durante el seguimiento final solo 3 pacientes (42,9%) siguieron categorizados como resultado Engel I. Se produjo una tendencia hacia la estabilidad en la clasificación Engel. Todos los pacientes con causas evolutivas para la epilepsia experimentaron cierto deterioro de los resultados quirúrgicos. Por contra, todos los pacientes con causas adquiridas permanecieron estables a lo largo del seguimiento. El resultado de las crisis a los 6 meses fue peor en los pacientes con complicaciones posquirúrgicas (p=0,044). Las poblaciones adulta y pediátrica no difirieron significativamente en ninguna de las variables probadas. Conclusiones: La hemisferectomía es un recurso válido para el control de la crisis en pacientes debidamente seleccionados. La evolución del paciente de Engel pudo predecirse a intervalos de 6 meses. La hemisferectomía podría considerarse una actitud útil en casos difíciles (AU)

Hemisferectomía funcional: seguimiento a largo plazo en una serie de cinco casos / Functional hemispherectomy: long-term follow-up in a series of five patients

Introducción. La hemisferectomía funcional es una de las técnicas quirúrgicas con intención paliativa que se pueden realizar en pacientes con epilepsia farmacorresistente y síndromes hemisféricos. Se basa en la desconexión neuronal del hemisferio afectado preservando el árbol vascular. Objetivo. Analizar el pronóstico y la seguridad a largo plazo de las hemisferectomías realizadas en nuestro centro. Pacientes y métodos. Revisión retrospectiva de los casos intervenidos, recogiendo las siguientes variables clínicas: edad, sexo, edad de inicio de la epilepsia, tipo de crisis, etiología de la epilepsia, edad de intervención, pronóstico posquirúrgico y posibles complicaciones. El seguimiento mínimo fue de cinco años. Resultados. Cinco pacientes (60% mujeres) fueron intervenidos entre 1999 y 2010. La edad de inicio de la epilepsia fue de 36 meses, y el tiempo de evolución hasta la cirugía, de 7 años. El tipo de crisis más habitual fueron las crisis parciales simples motoras con generalización secundaria (n = 5). Tres pacientes permanecieron libres de crisis tras la cirugía, y otro paciente mejoró más de un 90%. El tiempo medio de seguimiento fue de 13 años. Como complicaciones, una paciente sufrió una meningitis bacteriana sin secuelas posteriores. A los seis años de la cirugía, un paciente presentó una hidrocefalia que requirió la implantación de una válvula de derivación ventriculoperitoneal. Conclusiones. La hemisferectomía funcional constituye un procedimiento quirúrgico eficaz para el tratamiento de pacientes con epilepsia farmacorresistente, patología hemisférica extensa y crisis limitadas a ese hemisferio. Hay complicaciones que pueden aparecer tardíamente, por lo que se aconseja un seguimiento a largo plazo de estos pacientes (AU)

Introduction. Functional hemispherectomy consists in palliative epilepsy surgical procedure usually performed in patients with pharmaco-resistant epilepsy and hemispheric syndromes. It is based on the neural disconnection of the affected hemisphere with preservation of the vascular supply. Aim. To analyze long-term prognosis and safety of the hemispherectomies performed in our institution. Patients and methods. Retrospective analysis collecting the following variables: age, gender, age of epilepsy onset, type of seizures, etiology, age of epilepsy surgery, prognosis and potential surgical complications. All patients had a minimum of five years of follow up. Results. Five patients (60% females) underwent hemispherotomy between 1999 and 2010. Age of epilepsy onset was 36 months and time of evolution until surgery was 7 years. The most frequent type of seizures were simple motor seizures with secondary generalization (n = 5). Three patients remained seizure free persistently after surgery and another patient had a more than 90% improvement. Time of follow up was 13 years. One patient suffered a bacterial meningitis without sequelae. Six years after surgery a patient suffered hydrocephalous requiring ventriculoperitoneal shunt. Conclusions. Functional hemispherectomy constitutes an effective method to treat patients with pharmaco-resistant epilepsy, extensive unihemispheric pathology and seizures limited to that hemisphere. Late complications may occur thus long-term follow-up is needed (AU)

Hemispherectomy in treatment of seizures: current perspectives of the indications, techniques and complications: literature review

Introducción: A hemisferectomía es un procedimiento valioso en el tratamiento de trastornos convulsivos causados por desordenes hemisféricos unilaterales. El hemisferectomía anatómica se ha utilizado para este fin desde 1938, sin embargo, se abandonó este procedimiento después de informes de complicaciones postoperatorias causadas por hemosiderosis superficial, ependimitis e hidrocefalia obstructiva. Así que, se ha mostrado en la literatura modificaciones en las indicaciones y técnicas de hemisferectomía anatómica cuya finalidad es la de reducir la incidencia de esta complicación sin dejar de lograr control de las convulsiones. Sobre la base de la literatura, la hemisferectomía mejora la calidad de vida de los pacientes que tiene la indicación para realizar este procedimiento, ya que permite reducir la frecuencia de las convulsiones, si tónica o átona, tónico-clónicas Objetivo: El objetivo de esta revisión de la literatura es discutir los detalles técnicos, modalidades, riesgos, complicaciones, resultados y de pronóstico de hemisferectomía basado en la revisión crítica de la literatura. Casuística y Métodos: Se realizó la consulta bibliográfica, utilizando la base de datos MEDLINE, LILACS, SciELO, que utiliza el lenguaje como criterios de selección, la elección de los artículos recientes preferiblemente en portugués, español o inglés. Conclusión: Según las referencias, hemisferectomía es un procedimiento con buen resultado para las personas con convulsiones derivadas cuando está indicado para casos seleccionados y la tasa de éxito no es proporcional a la extensión de la resección del tejido neuronal. A mayor resección puede o no reducir la frecuencia de las crisis, sin embargo, la incidencia de la morbilidad puede ser mayor.

Background: The hemispherectomy is a valuable procedure in the management of seizure disorders caused by unilateral hemispheric disease. The anatomical hemispherectomy has been used for this purpose since 1938, however, it was abandoned after reports of postoperative complications caused by superficial hemosiderosis, ependymitis and obstructive hydrocephalus. So that, it has been showed modifications in the techniques of hemispherectomy whose the purpose is reduce the incidence of this complications while still achieving seizure control. Based on literature, the hemispherectomy improves the quality of life of patients that has the indication to perform this procedure because it allows reducing the frequency of seizures, whether tonic or atonic, tonic-clonic. Aim: The aim of this literature review is discuss the indications, technical details, modalities, risks, complications, results as well de prognosis of callosotomy based on critical literature review and the authors experience. Casuistry and Methods: It was performed bibliographical consultation, using the databases MEDLINE, LILACS, SciELO, utilizing language as selection criteria, choosing preferably recent articles in Portuguese, Spanish or English. Conclusion: According to references, the functional hemispherectomy has a good outocome for those with seizures arisin when indicated to selected cases and the success rate is not proportional to the extent of neuronal tissue resection. So that, a greater resection cannot necessarily reduce the seizure frequency, however the morbidity may also be larger.

Seizure Outcome after Anterior versus Complete Corpus Callosotomy in Children: A Systematic Review with Meta-Analysis / Controle das crises epilépticas após calosotomia anterior versus completa em crianças: uma revisão sistemática com metanálise

Introduction Refractory epilepsy is a debilitating and challenging condition to manage. Corpus callosotomy (CC) seems to be an effective treatment option for patients with seizures not amenable to focal resection. The aim of the present study is to compare seizure outcome of pediatric patients following anterior CC, compared with complete CC. Method The authors performed a systematic review and meta-analysis of the English literature involving comparative studies. Results The present investigation includes four retrospective case-controlled studies and authors perform a pooled analysis of the surgical results. Seizure outcome presented favorable results in patients who underwent complete CC (Odds Ratio, M-H, Fixed, 95% CI: 3.02 [1.43, 6.387], p-value: 0.005). Clinical and neurological complications occurred independently when a complete or anterior CC was performed. Conclusion Complete CC seems to be the most effective treatment option to control intractable seizure in children not amenable to focal resection.

Introdução Epilepsia refratária é uma condição debilitante e desaadora para lidar. Calosotomia parece ser uma opção de tratamento ecaz para pacientes com convulsões não passíveis de ressecção focal. O objetivo do presente estudo é comparar o resultado de convulsões em pacientes pediátricos de acordo com calosotomia anterior e completa. Métodos Uma revisão sistemática e metanálise da literatura médica em inglês envolvendo estudos comparativos. Resultados Quatro casos retrospectivos foram incluídos na presente investigação e uma análise dos resultados cirúrgicos foi realizada. Convulsões decorrentes tiveram resultados favoráveis em pacientes submetidos a calosotomia complete (odds ratio, M-H, xo, 95% IC: 3,02 [1,43; 6,387], valor de p: 0,005). Complicações clínicas e neurológicas ocorreram independentemente de se calosotomia complete ou anterior. Conclusão Calosotomia completa parece ser a opção de tratamento mais ecaz para controlar convulsões não rastreáveis e não passíveis de ressecção focal em crianças.

Long-Term Outcomes of Hemispheric Disconnection in Pediatric Patients with Intractable Epilepsy

BACKGROUND AND PURPOSE: Hemispherectomy reportedly produces remarkable results in terms of seizure outcome and quality of life for medically intractable hemispheric epilepsy in children. We reviewed the neuroradiologic findings, pathologic findings, epilepsy characteristics, and clinical long-term outcomes in pediatric patients following a hemispheric disconnection. METHODS: We retrospectively studied 12 children (8 males) who underwent a hemispherectomy at Asan Medical Center between 1997 and 2005. Clinical, EEG, neuroradiological, and surgical data were collected. Long-term outcomes for seizure, motor functions, and cognitive functions were evaluated at a mean follow-up of 12.7 years (range, 7.6-16.2 years) after surgery. RESULTS: The mean age at epilepsy onset was 3.0 years (range, 0-7.6 years). The following epilepsy syndromes were identified in our cohort: focal symptomatic epilepsy (n=8), West syndrome (n=3), and Rasmussen's syndrome (n=1). Postoperative histopathology of our study patients revealed malformation of cortical development (n=7), encephalomalacia as a sequela of infarction or trauma (n=3), Sturge-Weber syndrome (n=1), and Rasmussen's encephalitis (n=1). The mean age at surgery was 6.5 years (range, 0.8-12.3 years). Anatomical or functional hemispherectomy was performed in 8 patients, and hemispherotomy was performed in 4 patients. Eight of our 12 children (66.7%) were seizure-free, but 3 patients with perioperative complications showed persistent seizure. Although all patients had preoperative hemiparesis and developmental delay, none had additional motor or cognitive deficits after surgery, and most achieved independent walking and improvement in daily activities. CONCLUSIONS: The long-term clinical outcomes of hemispherectomy in children with intractable hemispheric epilepsy are good when careful patient selection and skilled surgical approaches are applied.

Monitorización con espectrograma del sistema de monitorización BIS VISTA(TM) en una hemisferectomía funcional / Density spectral array of BIS VISTA(TM) monitoring system in a functional hemispherectom

Presentamos el caso de una paciente adulta con epilepsia farmacorresistente secundaria a una inflamación extensa del hemisferio cerebral derecho, que fue programada para realizársele una hemisferectomía funcional. Se trata de una cirugía habitual en pediatría, pero con pocas publicaciones en pacientes adultos. Durante el intraoperatorio se utilizó el espectrograma perteneciente al sistema de monitorización VISTATM del índice biespectral bilateral (BIS). Se objetivó un aumento de potencia en las bandas de baja frecuencia (0,1-4Hz) y en las bandas alfa (8-12Hz) del hemisferio cerebral derecho, donde se encontraba el foco epileptógeno. Durante la desconexión del lóbulo frontal se observó una marcada disminución de potencia en dichas bandas, sin objetivarse cambios durante la desconexión de las otras áreas cerebrales. Pensamos que se necesitan más estudios para saber si el espectrograma puede ser una herramienta útil para monitorizar la efectividad de la hemisferectomía funcional

We present the case of an adult patient with drug-resistant epilepsy caused by extensive inflammation in the right cerebral hemisphere. She was scheduled to undergo right functional hemispherectomy, which is common in pediatric surgery, but about which few studies have been published with respect to adult patients. During the intraoperative period, the density spectral array of the bilateral bispectral index (BIS) VISTATM monitoring system was used. We observed a power increase in low frequency (0.1-4Hz) and alpha bands (8-12Hz) in the right hemisphere, where the epileptogenic focus was. During disconnection from the frontal lobe, there was a marked decrease of power in low frequency and alpha bands on the right side, with no changes during disconnection from other areas of the brain. We think that further studies are needed to determine whether the density spectral array can be a useful tool for monitoring the effectiveness of functional hemispherectomy

Experiencia en el uso del video-electroencefalograma en el servicio de neurofisiología clínica / Differential leukocyte count in cerebrospinal fluid and time of infection progression in children with aseptic meningitis

Objetivo: mostrar los resultados de la introducción del video-electroencefalograma en la evaluación de los eventos paroxísticos neurológicos de naturaleza no precisada y/o en la epilepsia de difícil control en pacientes pediátricos. Métodos: se estudiaron 121 niños (edad 5,90 ± 4,34 años), divididos en 4 grupos atendiendo a la finalidad del estudio de video-electroencefalograma: I. Determinar la naturaleza (epiléptica o no) del evento paroxístico; II. Confirmar el síndrome epiléptico; III. Cuantificar las crisis epilépticas y IV. Estudiar candidatos para cirugía de la epilepsia.Resultados: la eficacia diagnóstica fue de un 86,77 por ciento, y provocó modificaciones en el diagnóstico y/o el tratamiento inicial en un 32,38 por ciento. Las modificaciones en el diagnóstico en el grupo I fueron en 16/43 pacientes (2 epilepsias, 7 trastornos del movimiento, 4 trastornos del sueño y 3 crisis psicógenas). En el grupo II se clasificaron 47 síndromes epilépticos (11 epilepsias focales, 31 epilepsias generalizadas y 5 indeterminadas). Para el grupo III el número de crisis registradas fue 7,31 ± 4,21, y el tiempo de registro del video-electroencefalograma fue de 3,86 ± 1,10 horas. En el grupo IV se estudiaron 2 pacientes, y se confirmaron como candidatos para hemisferectomía funcional. Conclusiones: el monitoreo por video-electroencefalograma ratificó ser una herramienta de gran valor y utilidad en el diagnóstico de los eventos paroxísticos neurológicos en niños, lo que incide en establecer una adecuada conducta terapéutica y contribuye a disminuir ciertas limitaciones en la aplicación de los criterios de la Liga Internacional contra la Epilepsia(AU)

Objective: to show the results of the use of video electroencephalogram in the evaluation of undetermined neurological paroxysmal events and/or difficult epilepsy in pediatric patients. Methods: one hundred and 21 children (aged 5.90 ± 4.34 years), divided into 4 groups according to the objective of the video-EEG based study, were researched on. This study was aimed at 1) determining the nature of the paroxysmal event -either epileptic or not-; 2) confirming the epileptic syndrome; 3) quantifying the epileptic attacks; and 4) studying candidates for epilepsy surgery. Results: the diagnostic efficacy was 86.77 percent and caused changes in diagnosis and/or in the initial treatment in 32.38 percent of cases. Changes in diagnosis of group I occurred in 16 out of 43 patients (2 epilepsies, 7 movement disorders, 4 sleeping disorders and 3 psychogenic crises). Forty seven epileptic syndromes were classified in the second group (11 focal epilepsy, 31 generalized epilepsy and 5 undetermined). The number of recorded crises was 7.31 ± 4.21 in the third group and the video-EEG recording time was 3.6±1.10 hours. Two patients in the fifth group were studied and confirmed as candidates for functional hemispherectomy. Conclusions: video-electroencephalogram monitoring ratified that it is a very useful tool in the diagnosis of neurological paroxysmal events in children, which influences in setting a proper therapeutic behaviour and in assisting in the reduction of certain restrictions for the application of the International League against Epilepsy criteria(AU)

Pathologic features of ulegyria in refractory epilepsy by modified anatomic hemispherectomy: a clinicopathologic study of 39 cases / 中华病理学杂志

<p><b>OBJECTIVE</b>To investigate the clinicopathologic features of the brain tissue diagnosed as ulegyria from modified anatomic hemispherectomy for refractory epilepsy.</p><p><b>METHODS</b>The clinical and pathologic findings were reviewed in 39 patients who underwent modified anatomic hemispherectomy and diagnosed as ulegyria in the Epilepsy Center of Tsinghua University Yuquan Hospital from 2007 to 2011.</p><p><b>RESULTS</b>All patients including 30 males and 9 females had medically intractable seizures, and the mean age of seizure onset and disease duration were 4.0 years and 7.3 years respectively. Significant history included febrile seizure in 14 patients (35.9%), cerebral hemorrhage in 8 patients (20.5%), fetal distress and surgical trauma each in 6 patients (15.4%), vascular malformation and cerebral hemorrhage in 1 patient (2.6%), and unclear history in 4 patients (10.2%). Histologically, all cases were characterized by cortical destruction, with neuronal loss and gliosis. All cases were accompanied by varying degree of cortical dysplasia, which were diagnosed as focal cortical dysplasia IIId. Hippocampus sclerosis was identified in 2 cases. Seizure outcome after surgery revealed 37 patients (94.9%) had an Engel grade I, two patients (5.1%) had an Engel grade II.</p><p><b>CONCLUSIONS</b>Febrile seizure, cerebral hemorrhage, fetal distress and surgical trauma in childhood can lead to refractory epilepsy. Histopathological change in the brain is ulegyria accompanied by focal cortical dysplasia IIId. Modified anatomic hemispherectomy is an effective therapy to treat those patients with extensive changes of one hemisphere.</p>

The usefulness of neuronavigation in functional hemispherectomy / Aplicabilidade da neuronavegação em hemisferectomia funcional

Catastrophic epileptic encephalopathies in children comprise devastating conditions that features cerebral dysfunction in association with refractory epileptic seizures. The diagnosis is based on the clinical findings, on magnetic resonance imaging (MRI) of the brain and on electroencephalographic findings. For these conditions, surgery remains essential for attaining seizure control. We report two cases of 5-year-old girls. The first one had a diagnosis of Rasmussen’s syndrome. The second one had a large porencephalic cyst secondary to perinatal cerebral ischemia. Despite trials of anticonvulsants, both patients deteriorated, and a functional hemispherectomy guided by neuronavigation was indicated and performed, with low morbidity and excellent seizure control. The neuronavigation proved to be a valuable guidance tool in performing the functional hemispherectomy, making the disconnections more accurate, and thus decreasing the surgical time and blood loss.

Aplicabilidade da neuronavegação em hemisferectomia funcional As encefalopatias epilépticas catastróficas da infância compreendem condições graves que associam disfunção cerebral e crises epilépticas refratárias. Seu diagnóstico é firmado com base nos dados clínicos e nos achados de ressonância magnética e eletrencefalográficos. Para algumas destas condições o tratamento cirúrgico continua sendo essencial para o controle das crises. Relatamos dois casos de pacientes de 5 anos. A primeira teve diagnóstico de síndrome de Rasmussen. A segunda tinha antecedentes de encefalopatia hipóxico-isquêmica perinatal. Ambas apresentaram epilepsia parcial refratária em associação com rápida deterioração neurológica, e foram submetidas à hemisferectomia funcional com auxílio da neuronavegação, com baixa morbidade e excelente controle das crises. A neuronavegação se mostrou como uma valiosa ferramenta na realização da hemisferectomia funcional, possibilitando desconexões mais precisas, menor tempo de cirurgia e menor perda sanguínea.

Cerebral Paragonimiasis and Bo Sung Sim's Hemispherectomy in Korea in 1950s-1960s / 의사학

This paper deals with cerebral paragonimiasis and cerebral hemispherectomy conducted as a treatment of cerebral paragonimiasis by Bo Sung Sim in Korea in 1950s-1960s. He demonstrated that cerebral hemispherectomy could be used for unilateral diffuse cerebral paragonimiasis. Sim learned cerebral hemispherectomy from Dr. L. A. French. at the University of Minnesota from 1955 to 1957 in America. The authors argues that Bo Sung Sim's introduction of cerebral hemispherectomy to Korea was not a simple application of an advanced medical technology, but a complicated and active process in that Sim used the technique to intervene intractable complications from cerebral paragonimiasis such as generalized convulsions, spastic hemiplegia and mental deterioration. Bo Sung Sim, one of the neurosurgeons of the first generation in Korea, was trained in neurology, neuropathology, neuroradiology and animal experiments as well as in neurosurgery at the University of Minnesota. After returning to Korea, Sim faced parasitic diseases, one of the most serious public health problems at that time, which were far different from what he learned in America. As a neurosurgeon, Sim tackled with parasitic diseases of the central nervous system with various diagnostics and therapeutics. In 1950s, more than one million populations suffered from pulmonary paragonimiasis acquired by eating raw crabs or by feeding juice of crushed crayfish for the treatment of measles in Korea. About 26.6 percent of people with paragonimiasis had cerebral paragonimiasis. Before bithionol therapy was introduced in 1962, neurosurgery was the only available treatment to control increased intracranial pressures, intractable epilepsy, paralysis and mental deterioration. Between 1958 to 1962, Bo Sung Sim operated on 24 patients of cerebral paragonimiasis. In two of them, he performed cerebral hemispherectomy to control intractable convulsions when he found diffuse cerebral paragonimiasis and cerebral atrophy at the operating table. The two patients were recovered dramatically after the operation. The first patient became a part of medical campus for 20 years after hemispherectomy, doing chores at the hospital and helping Bo Sung Sim for his teaching neuroanatomy. The presence of the hemispherectomized patient in the classroom impressed the students deeply. Furthermore, the hemispherectomized patient stimulated Sim and his school to perform research upon the neuroanatomy and neurophysiology of the brain with hemispherectomized animals.

Motor evoked potential of both upper extremities long term after anatomical hemispherectomy / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the function and motor pathway of remained cerebral hemisphere by studying motor evoked potential of both upper extremities on patients long term after anatomical hemispherectomy.</p><p><b>METHODS</b>Five patients after anatomical hemispherectomy, who were marked 5 dispersive sites on head to perform transcranial magnetic stimulation. Recording motor evoked potential of target muscles (brachioradialis muscle and abductor pollicis brevis) of both upper extremities respectively when muscle resting and contracting.</p><p><b>RESULTS</b>Only affected abductor pollicis brevis of case 2 and only affected brachioradialis muscle of case 4 and 5 recorded motor evoked potential when muscle resting. Motor evoked potential of some cases can be recorded simultaneously in homonymous muscles of both sides when muscle resting or contracting.</p><p><b>CONCLUSIONS</b>There exists motor cortex that controls movement of ipsilateral limbs and also ipsilateral motor pathway of corticospinal connection at patients after anatomical hemispherectomy. It also means that the motor function of affected limbs has potency to recover well after hemispherectomy. The mirror movement after hemispherectomy is possible relate to overlap of both limbs' motor cortex.</p>

Upper limbs motor maps in cortex and plasticity after the anatomical hemispherectomy / 中华外科杂志

<p><b>OBJECTIVE</b>To locate motor functional area of patients who undergone modified anatomical hemispherectomy in order to analysis the plasticity of upper limbs motor.</p><p><b>METHODS</b>The patients who undergone modified anatomical hemispherectomy were performed BOLD sequences, to locate functional cortical areas in their residual brain.</p><p><b>RESULTS</b>6 patients have performed examination of BOLD sequences by 3.0-T MRI.5 of them obtained contralateral upper limb motor areas in their residual brain, and 3 of them obtained ipsilateral and contralateral upper limb motor area map in cortex. The ipsilateral upper limb motor areas in the M1, SMA and posterior parietal cortex.</p><p><b>CONCLUSIONS</b>The patients who undergone modified anatomical hemispherectomy is an excellent model to investigate mechanism of plasticity in the developing brain. Functional magnetic resonance (fMRI) provided fine spatial detail of brain responses, would describe the motor functional area of cortical maps. These patients exist ipsilateral motor areas in their residual mono hemisphere. The study indicated there maybe have somewhat extent of correlation between the surgical procedure and the outcome of neuroplasticity.</p>