Focal Resection Research Articles

Postoperative improvement of executive function and adaptive behavior in children with intractable epilepsy

IntroductionAn alteration in postoperative cognitive function varies according to the patients’ background characteristics, such as etiology, focus, and seizure duration. Accurate prediction and assessment of postoperative cognitive function is difficult in each patient. Adaptive behavior could describe the typical performance of daily activities and represents the ability to translate cognitive potential into real-world skills. We examined the relationship between alterations of executive function (EF) and adaptive behavior in school children undergoing surgery for intractable epilepsy. MethodologyWe enrolled 31 children with focal resection or corpus callosotomy for intractable epilepsy [mean age at surgery, 12.5 years; 16 boys; mean intellectual quotient, 73.3]. We surveyed answered questionnaires on attention-deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and adaptive behavior using the Vineland Adaptive Behavior Scale, 2nd edition (VABS-II), and performed continuous performance tests (CPTs) on children pre- and postoperatively. ResultADHD and ASD symptoms improved after epilepsy surgery. The omission error (OE) in the CPT variable improved after epilepsy surgery, especially in children with a shorter preoperative period. Improved ASD symptoms led to an increased score of the coping skills subdomain. The reduced OE observed after surgery also increased the score of the community skills subdomain. ConclusionImprovement in EF and ASD symptoms resulted in better adaptive behavior postoperatively. These results were important for the pre- and postoperative evaluation and re-evaluation of children with epilepsy requiring special education and related services.

Management and results of epilepsy surgery associated with acyclovir prophylaxis in four pediatric patients with drug-resistant epilepsy due to herpetic encephalitis and review of the literature.

Herpes simplex virus encephalitis (HSE) is the most common cause of sporadic viral encephalitis in children and is responsible for epilepsy in approximately half of patients. In addition to medical treatment, epilepsy surgery may be offered to drug-resistant patients but carries a high risk of relapse of herpetic encephalitis. We are reporting our series of patients operated on between 2000 and 2019 with the systematic administration of acyclovir (ACV). Four pediatric patients aged 4.5-12.8 years with drug-resistant epilepsy post-HSE underwent a tailored focal resection following invasive recordings (three patients) and a complete callosotomy (one patient). The total number of the surgical procedures for the four patients was eight, and a systematic administration of ACV as a prophylactic treatment of herpetic encephalitis relapse was done at each step. No patients had a relapse and the ACV was well-tolerated in all the cases. Following surgery two patients are seizure free, the patient who underwent callosotomy is Engel 3 and the fourth patient, in whom a large epileptic zone has contraindicated a second surgery, is Engel 4. Our series demonstrated the dramatic efficacy of systematic ACV prophylaxis during all cranial surgeries. Moreover, our results on epilepsy, together with those of the literature, encourage more consideration regarding epilepsy surgery in this specific etiology. All types of surgical procedures (curative or palliative) can be offered to the patients, but in the case of focal surgery, due to the poor anatomical limits, invasive recordings are highly recommended.

Mapping the Insula with Stereo-Electroencephalography: The Emergence of Semiology in Insula Lobe Seizures.

Insula epilepsy is rare and can be evaluated effectively by Stereotactic intracerebral EEG (SEEG). Many previous studies of insulo-opercular seizures have been unable to separate insular and opercular onset. With adequate sampling of the insula, this study shows this is possible. We analyzed intrainsular dynamics and extrainsular propagation in 12 patients with "pure" insula epilepsy (n = 9) or insular and only deepest opercular involvement (n = 3) at seizure onset. Review of semiology defined clinical groups, agglomerative cluster, and principal component analysis of semiological features were performed. Quantitative epileptogenicity, and intrainsular and extrainsular propagation were computed via time frequency analysis and epileptogenicity mapping. Seizure onset patterns were heterogeneous; the seizure onset zone was focal. Seizure onset and first ictal change within insula functional subdivision correlated with aura and reflex component. No paninsular spread occurred; contralateral insular spread was very early. While the discharge was intrainsular, clinical signs related to aura or vegetative signs. Extrainsular propagation was early and related to the emergence of the majority of clinical signs. Cluster analysis found an anterior, intermediate, and posterior insula seizure onset group. The largest principal component separated anterior insula manifestations, including early hypermotor signs, early recovery, and no aura from posterior insula features of early dystonia, early tonic motor features, and sensorimotor aura. Aura is vital to identifying seizure onset and relates to insula functional subdivision. Seizures are heterogenous; extrainsular propagation occurs early, accounting for most of the semiology. With adequate sampling, "pure" insula epilepsy can be identified and focal curative resection is possible. ANN NEUROL 2020;88:477-488.

Treating epilepsy with options other than antiepileptic medications.

Epilepsy is a common health burden worldwide. Epilepsy is linked to variety of factors, including infectious, vascular, immune, structural, genetic, and metabolic etiologies. Despite the existence of multiple antiepileptic drugs (AEDs), many patients are diagnosed with intractable epilepsy. Many nonpharmacological options are available for epilepsy. Some types of epilepsy respond to cofactors. Other patients may be candidates for a ketogenic diet. Inflammatory mediators, such as intravenous immunoglobulins (IVIgs) and steroids, are other options for epilepsy. Recently, cannabinoids have been approved for epilepsy treatment. Refractory epilepsy can be treated with surgical interventions. Focal resections, hemispherectomies, and corpus callosotomies are some common epilepsy surgery approaches. Neuromodulation techniques are another option. Thermal ablation is a minimally invasive approach for epilepsy treatment. Epilepsy outcomes are improving, and treatment modalities are expanding. Trials of nonpharmacological options for epilepsy patients are recommended. This article summarizes available nonpharmacological options other than AEDs for the treatment of epilepsy.

Analyses of risk factors for temporarily inhibited parathyroid hormone secretion of postoperative primary hyperparathyroidism

Objective: To study relative risk factors for temporarily inhibited parathyroid hormone (PTH) secretion after surgery of primary hyperparathyroidism (PHPT). Methods: Seventy-two cases with PHPT from October 2017 to March 2019 in Beijing Chaoyang Hospital were analyzed retrospectively, including 22 males and 50 females aged from 13 to 83 years old. They were reviewed and divided into a complete inhibition group (24 cases, PTH=0 pg/ml), an incomplete inhibition group (23 cases, 0<PTH<12.4 pg/ml), and a non-inhibition group (25 cases, PTH≥12.4 pg/ml) according to the PTH level on the first day after surgery of PHPT. With the Kruskal-Wallis multi-group rank sum test and the Nemenyi test, preoperative and postoperative biochemical parameters and endocrine indexes, including the preoperative serum levels of calcium, phosphorus, PTH, 25-hydroxyvitamin D, and alkaline phosphatase, as well as the levels of PTH 10 min after focal resection, calcium on the first day after surgery, and PTH on the third day after surgery, were compared among three groups to evaluate potential risk factor for postoperative temporary inhabitation of PTH secretion. The predictive values of various risk factors for postoperative temporary inhibition of PTH secretion were evaluated with ROC curve analysis. Results: Preoperative serum PTH, calcium levels, and serum calcium level on the first day after surgery in the complete inhibition group were higher than those in the non-inhibition group,respectively, with statically significant differences [256.5(141.6,585.3) pg/ml vs. 130.2(92.1,256.6) pg/ml, 2.90(2.69,3.22) mmol/L vs. 2.61(2.50,2.75) mmol/L, 2.23(2.08,2.41) mmol/L vs. 2.12(2.05,2.14) mmol/L, χ(2) were 7.17, 11.90, 8.32, respectively, all P<0.05]. When the preoperative serum calcium level was higher than 2.62 mmol/L (AUC=0.698, 95%CI: 0.57-0.83, P=0.006) or the preoperative PTH level was higher than 115.9 pg/ml (AUC=0.697, 95%CI: 0.58-0.82, P=0.007), patients tended to inhibit completely PTH secretion after operation. Conclusions: Preoperative serum calcium and PTH levels are risk factors for postoperative temporary PTH inhibition in PHPT.

A Novel Surgical Technique for Placenta Accreta Spectrum: Comparisons of Intra- and Post-operative Outcomes [01N

INTRODUCTION: A novel surgical technique to reduce blood loss during cesarean hysterectomy (Chyst) for placenta accreta spectrum disorder (PAS) was previously described (LC-VSS: hysterotomy using linear cutter and dissection of the bladder using vessel sealing system before clamping uterine arteries). We hypothesized that LC-VSS reduces intra- and post-operative complications. METHODS: After IRB approval, PAS cases from 2014 to 2019 were reviewed. Gravid hysterectomy, interval hysterectomy and focal resection were excluded. Data collected includes patient demographics, estimated blood loss (EBL), number of intra-operative blood products, massive transfusion, organ injuries and post-operative complications (intensive care unit (ICU) admission, re-laparotomy, hospital stay). Chyst without using LC-VSS was marked as control. Impact of LC-VSS was analyzed using univariate analysis. Predictors for transfusion of more than 4 packed red blood cells (PRBCs) were assessed using regression analysis including pathology (accreta-increta vs percreta), surgical technique and urgency. RESULTS: Of 59 cases, LC-VSS was used in 39 cases (66%). EBL was significantly lower in LC-VSS cases compared to controls (1200 vs 3330 ml, P=.0001) as well as the number of PRBCs and fresh frozen plasma transfused (0 vs. 4, P&lt;.0001, and 0 vs 2, P=.0007, respectively). The number of massive transfusions was lower in LC-VSS cases (1 vs. 7, P=.002). Need for re-laparotomy was lower in LC-VSS patients (0 vs. 20%, P=.01). Median hospital stay was similar between groups. LC-VSS was the only predictor of blood transfusion less than 4 units of PRBCs (P=.004). CONCLUSION: Use of this novel surgical technique (LC-VSS) during Chyst for PAS improves intra- and post-operative outcomes.

Long-term outcomes after surgery for catastrophic epilepsy in infants: institutional experience and review of the literature.

Uncontrolled epilepsy is associated with serious deleterious effects on the neurological development of infants and has been described as "catastrophic epilepsy." Recently, there has been increased emphasis on early surgical interventions to preserve or rescue neurodevelopmental outcomes in infants with early intractable epilepsy. The enthusiasm for early treatments is often tempered by concerns regarding the morbidity of neurosurgical procedures in very young patients. Here, the authors report outcomes following the surgical management of infants (younger than 1 year). The authors performed a retrospective review of patients younger than 1 year of age who underwent surgery for epilepsy at Miami (Nicklaus) Children's Hospital and Jackson Memorial Hospital between 1994 and 2018. Patient demographics, including the type of interventions, were recorded. Seizure outcomes (at last follow-up and at 1 year postoperatively) as well as complications are reported. Thirty-eight infants (median age 5.9 months) underwent a spectrum of surgical interventions, including hemispherectomy (n = 17), focal resection (n = 13), and multilobe resections (n = 8), with a mean follow-up duration of 9.1 years. Hemimegalencephaly and cortical dysplasia were the most commonly encountered pathologies. Surgery for catastrophic epilepsy resulted in complete resolution of seizures in 68% (n = 26) of patients, and 76% (n = 29) had a greater than 90% reduction in seizure frequency. Overall mortality and morbidity were 0% and 10%, respectively. The latter included infections (n = 2), infarct (n = 1), and immediate reoperation for seizures (n = 1). Surgical intervention for catastrophic epilepsy in infants remains safe, efficacious, and durable. The authors' work provides the longest follow-up of such a series on infants to date and compares favorably with previously published series.

Butterfly technique in mitral valve repair.

Degenerative mitral regurgitation due to posterior leaflet prolapse is often associated with tissue redundancy in the leaflet height and free margin of the prolapsing segment. The butterfly technique has been introduced for focal resection to precisely control the leaflet height without annular plication. This technique is indicated for a high prolapsing leaflet, greater than 20 mm. With intraoperative measurement of leaflet heights and ink dot marking as a depth indicator, the butterfly technique can be safely performed in most high posterior leaflet prolapse cases, without increasing the risk of systolic anterior motion.

Clinical Outcomes in Patients with Renal Cell Carcinoma Metastases to the Choroid Plexus

Intraventricular metastatic brain tumors account for a small, but challenging, fraction of metastatic brain tumors (0.9%-4.5%). Metastases from renal cell carcinoma (RCC) account for a large portion of these intraventricular tumors. Although patient outcomes have been assumed to be poor, these have not been reported in a modern series with a multimodality treatment paradigm of radiotherapy (RT), resection, and cerebrospinal fluid (CSF) diversion. We have presented the first case series of patients with intraventricular metastatic tumors from RCC. We performed a single-institution retrospective review of patients with intraventricular RCC metastases treated from January 2003 to January 2019. Volumetric analysis was used to delineate the tumor size and the Kaplan-Meier method to evaluate the survival data. A total of 22 intraventricular RCC metastases were identified in 19 patients with 61.3 patient-years of follow-up. The median patient age was 64 years, and the median tumor volume was 2.2 cm3. Overall, 19 metastases had been treated initially with RT. Of these, 16 had received stereotactic body RT and 3 had received whole brain RT. Three tumors were surgically excised and had received adjuvant stereotactic body RT in the upfront setting. Although 5 patients had presented with obstructive hydrocephalus, none had required CSF diversion. After treatment, 5 metastases had progressed, resulting in 1- and 3-year progression-free survival rates of 81.6% and 68%, respectively. The median overall survival was 2.8 years, with 1- and 5-year overall survival rates of 76.7% and 28.3%, respectively. Leptomeningeal carcinomatosis was not observed. Despite the relatively limited overall survival for this population with metastatic cancer, comparable to contemporary parenchymal brain metastasis cohorts, reasonable local central nervous system control was achieved in most patients using a paradigm of focal RT and resection, where indicated. Finally, CSF diversion wasnot required even in patients presenting with hydrocephalus.

Surgical Prognostic Value of Epileptic Aura Based on History and Electrical Stimulation.

Background and PurposeWe attempted to evaluate the surgical prognostic value of various types of aura in conjunction with the results of other presurgical evaluations in patients with an intracranial ictal onset zone confirmed by invasive studies and focal resection. We also attempted to determine how often the habitual auras could be elicited and to demonstrate the prognostic value of these stimulation-induced auras (SIAs).MethodsWe reviewed retrospectively the records of patients who had undergone intracranial electroencephalography evaluation and focal resective surgery for intractable partial epilepsy between 1995 and 2009. We identified the localizing value and prognostic value of the patients’ auras. We correlated the resection of the area with SIA and surgical outcome.ResultsAura was reported in 225 out of 300 patients. Patients with medial temporal lobe epilepsy (TLE) or occipital lobe epilepsy had a higher chance of having aura. The presence of aura, medial TLE, hippocampal sclerosis on pathology, focal lesions on magnetic resonance imaging (MRI), and ipsilateral abnormality on fluorodeoxyglucose-positron emission tomography were significantly correlated with seizure-free outcome. The presence of auditory aura, parietal lobe epilepsy, multifocal epilepsy, and dual pathology was associated with poor outcomes. Multivariate analysis revealed that auditory aura, multifocal epilepsy, hippocampal sclerosis, and lesion on MRI were prognostic factors for intractable partial epilepsy. SIA was observed in 29 out of the 134 patients who had habitual aura on history. The degree of complete resection of the area with SIA was not related to seizure-free outcome.ConclusionsThe presence of aura favors good surgical outcome and certain types of aura, such as auditory aura, have poor prognostic value. SIA, which was encountered in 21.6% of patients, was not related to seizure-free outcome.

Cortical high-frequency oscillation loops initiate spasm seizures

Some epileptic spasms are classified into focal-onset seizures. However, the cortical network underlying this kind of spasm seizure is not yet clear. Four patients with epileptic spasms who underwent intracranial electrode implantation and focal resection surgery were studied. All the patients had good outcomes, and three of them with intellectual disability showed improved intelligence after surgery. The power spectra characteristics of electrocorticography and the dynamic functional network changes of epileptic spasms were investigated. Electrocorticography power in the resected zone peaked 0.5 seconds before the clinical seizure onset and was especially prominent in the γ and ripple bands. The functional network analysis showed particular dynamic patterns of high-frequency activity among the resected zone, sensorimotor cortex, and the other region. In the gamma band, during the interictal segment, the information flow from the resected zone and the other region to the sensorimotor cortex was prominent. During the preictal segment, the information flow from the resected zone and sensorimotor cortex to the other region became stronger. In the ripple band, during the interictal segment, the information flow from the resected zone to the sensorimotor cortex and the other region was high. During the preictal segment, the information flow between the resected zone and sensorimotor cortex became stronger. Our results suggest that the sensorimotor cortex is a requisite for spasm seizure initiation, and the ripple activity loop between the resected zone and sensorimotor cortex may give rise to the seizure onset with the help of the gamma activity loop between the sensorimotor cortex and the other region for activation spreading.

Corpus callosotomy for treatment of drug-resistant epilepsy: a review of 16 pediatric cases in northern Vietnam.

The aim of this study was to evaluate postoperative seizure outcome in children with drug-resistant epilepsy not eligible for focal resection who underwent corpus callosotomy. The study included 16 patients undergoing corpus callosotomy between September 2015 and May 2018. Seizure semiology and frequency, psychomotor status, and video electroencephalography and imaging findings were evaluated for all patients. Of the 16 patients who underwent callosotomy during the study period, 11 underwent complete callosotomy and 5 underwent anterior only. Seizure improvement greater than 75% was achieved in 37.5% of patients, and another 50% of patients had seizure improvement of 50%-75%. No sustained neurological deficits were observed in these patients. There were no significant complications. Duration of postoperative follow-up ranged from 12 to 44 months. Corpus callosotomy is an effective treatment for selected patients with drug-resistant epilepsy not eligible for focal resection in resource-limited settings. Fostering and developing international epilepsy surgery centers should remain a high priority for the neurosurgical community at large.

Measure thrice, cut twice: On the benefit of reoperation for failed pediatric epilepsy surgery

ObjectiveTo determine whether clinical outcomes are improved after repeat surgery for medically refractory epilepsy in children. MethodsThis is a single-center retrospective cohort analysis of all patients who received repeat resective surgery for ongoing seizures from 2000-2017. From a total of 251 consecutive individual epilepsy surgical patients for focal resection, 53 patients met study inclusion criteria and had adequate follow-up documented. ResultsMedian age of seizure-onset was 2.0-years-old (IQR 0.3–5.5 years). The median age at first epilepsy surgery was 6.3-years-old (IQR 2.9–9.2 years) and at second epilepsy surgery was 8.4-years-old (IQR 4.7–12.6 years). Overall, 53 % (n = 28) of this series achieved Engel Class I (seizure freedom); with improved seizure control (Engel Class I-II) in 83 % (n = 44) of the cohort. 64 % (n = 34) had one reoperation; 26 % (n = 14) had two; and 9% (n = 5) had three. Pathology: 58 % (n = 31) had focal cortical dysplasia; 13 % (n = 10) tumor; 9% (n = 5) encephalitis; 6% (n = 3) gliosis; 4% (n = 2) mesial temporal sclerosis; and 2% (n = 1) hemimegalencephaly. Tumor pathology was associated with increased chance (p = 0.01) for seizure freedom (90 % of tumor patients had Engel Class I outcome). MTS had worse outcome with both patients having ongoing seizures (Engel II-IV). There were 6 patients who developed post-operative hemiparesis; one was unplanned but resolved. SignificanceReoperation for pediatric epilepsy surgery can lead to seizure freedom in many cases and improved seizure control in most cases. Reoperation for brain tumor pathology is associated with a high rate of seizure freedom.

Patterns of anti-seizure medication (ASM) use in pediatric patients with surgically managed epilepsy: A retrospective review of data from Boston Children’s Hospital

ObjectUp to 30 % of patients with epilepsy are medically intractable, defined as persistent seizures despite 2 or more appropriate anti-seizure medications (ASMs) at therapeutic doses. Such patients require non-pharmacologic management that often includes epilepsy surgery. This paper aims to assess the pre-operative ASM use patterns of patients who were surgically managed. MethodsRetrospective review of children who underwent surgery for epilepsy at Boston Children’s Hospital between January 2010 and December 2014 were performed. Patient demographics, covariates, etiology, surgery type and ASM use patterns were assessed. Patient characteristics were displayed using descriptive statistics, correlation between ASM use and patient covariates were calculated with the Spearman coefficient, and univariate analysis was performed with Cox regression analysis. Results141 consecutive records of children were reviewed. All underwent one of four surgical procedures: focal resection, hemispherectomy, corpus callosotomy, or magnetic resonance-guided laser interstitial thermal therapy (MRgLITT). In this cohort, at the time of surgical evaluation the average number of pre-operative ASMs trialed was 5.2 and the average number of current ASMs was 2.6. The mean age of seizure onset was 4.4 years, the mean age at the time of surgery was 11.1 years, and the average time from seizure onset to surgery was 6.7 years. The number of total pre-operative ASMs was significantly related to longer time to surgery. Focal resection was associated with decreased ASM use and corpus callosotomy was associated with increased ASM use. Patients with radiographic findings that confer better surgical candidacy did not use fewer pre-operative ASMs or undergo earlier surgical referral. ConclusionsDespite guidelines that encourage early surgical referral and evaluation for drug-resistant epilepsy, a delay in surgical referral was seen in clinical practice, as evidenced by an average trial of 5.2 ASMs prior to referral, and an average lag of 6.7 years between time of seizure onset and surgery. Increased medication trials was directly correlated with increased time to definitive surgery. Improved education amongst neurologists for earlier surgical referral is required, especially for pathologies associated with good surgical outcome.

Tau deposition in young adults with drug-resistant focal epilepsy.

ObjectiveTo evaluate the presence of tau deposition and pathologic features of chronic traumatic encephalopathy (CTE) in young adult patients treated with focal cortical resections for drug‐resistant epilepsy.MethodsSixty consecutive patients who had undergone surgical treatment for drug‐resistant focal epilepsy between 18 and 45 years of age were identified (2010‐2017). Medical records were reviewed to determine clinical factors, including history of head trauma, age at seizure onset, age at surgical resection, seizure type(s) and frequency, imaging findings, and surgical outcome. All formalin‐fixed, paraffin‐embedded blocks from the surgical specimens from each subject were sectioned and stained with hematoxylin and eosin and antibodies to tau (Thermo Fisher Scientific Clone AT8), and examined blindly for tau pathology, including lesions characteristic of CTE.ResultsThe median age at resection was 29.5 years (range = 19‐45). A history of head trauma was reported in 19 patients. Although none of the patients had pathological findings characteristic of CTE, 23 patients (38%) demonstrated tau‐immunoreactive lesions, including neurites, neurofibrillary pretangles, neurofibrillary tangles, subpial tau, and/or glial tau. In 4 of the 23 patients (7% of the cohort; 17% of those with tau pathology), substantial tau burden was identified. Three of these 4 patients had no significant history of head trauma; 1 patient had multiple sports‐related concussions. No specific clinical factors correlated with the presence of tau pathology.SignificanceTau‐immunoreactive lesions were found in 38% of 60 patients who underwent a focal cortical resection for drug‐resistant focal epilepsy. Diagnostic features of CTE were not detected in any patient; however, the pathological evaluation for CTE was limited to a surgical specimen. The prominent and excessive tau deposition in 23 patients (38%) is abnormal in this age group and warrants further investigation.

Resection of early esophageal neoplasms: The pendulum swings from surgical to endoscopic management.

Esophageal cancer is a highly lethal disease and is the sixth leading cause of cancer related mortality in the world. The standard treatment is esophagectomy which is associated with significant morbidity and mortality. This led to development of minimally invasive, organ sparing endoscopic therapies which have comparable outcomes to esophagectomy in early cancer. These include endoscopic mucosal resection and endoscopic submucosal dissection. In early squamous cell cancer, endoscopic submucosal dissection is preferred as it is associated with cause specific 5-year survival rates of 100% for M1 and M2 tumors and 85% for M3 and SM1 tumors and low recurrence rates. In early adenocarcinoma, endoscopic resection of visible abnormalities is followed by ablation of the remaining flat Barrett’s mucosa to prevent recurrences. Radiofrequency ablation is the most widely used ablation modality with others being cryotherapy and argon plasma coagulation. Focal endoscopic mucosal resection followed by radiofrequency ablation leads to eradication of neoplasia in 93.4% of patients and eradication of intestinal metaplasia in 73.1% of patients. Innovative techniques such as submucosal tunneling with endoscopic resection are developed for management of submucosal tumors of the esophagus. This review includes a discussion of various endoscopic techniques and their clinical outcomes in early squamous cell cancer, adenocarcinoma and submucosal tumors. An overview of comparison between esophagectomy and endoscopic therapy are also presented.

Epilepsy surgery – the role for earlier intervention and when to wean AEDS

In well-selected children with focal lesional epilepsy, surgery is the most effective – and only curative – treatment option. If the epileptogenic source is well-localized and outside eloquent brain areas, a focal resection or disconnection is considered. Children with hemispheric pathology and existing neurological deficits may undergo hemispherotomy. The overall chance of seizure-freedom in children is 70-80% at 2 years and 60-70% at 5 years following surgery. A recent randomized trial has confirmed the unequivocal benefits of surgery over continued medical treatment. The number of referrals and surgeries steadily increases in children. Surgical indications have broadened over the past decades, now including generalized epileptic encephalopathies in the context of unilateral structural pathology. An increasing number of MRI-negative children – with presumed focal cortical dysplasia – is evaluated for surgery, using improved functional and structural imaging and invasive monitoring. It has been convincingly demonstrated that postoperative seizure-outcome improves with shorter duration of epilepsy. Epilepsy surgery can improve developmental capacities of children with refractory epilepsy, and shorter epilepsy duration predicts better postoperative cognitive outcome and more cognitive improvement. Finally, AED withdrawal – which can be safely considered early after surgery in many children – is an independent predictor of eventual IQ and of IQ increase after surgery. Given the low risks of epilepsy surgery, the small chance of spontaneous “cure” in focal epilepsy, and the high success-rate of surgery, all children with focal lesional epilepsy should be referred for presurgical evaluation early after diagnosis, even when seizures are well-controlled with one or two AEDs. Epilepsy surgery is an early treatment option rather than a last resort.

Effects of computer aided design and manufacture for reconstruction of mandibular defect with vascularied iliac crest flap graft

Objective To evaluate the clinical application and effect of computerized digital surgical assisted design and manufacture for reconstruction of mandibular defect with vascularied iliac crest flap graft. Methods CT was used to scan the craniofacial and maxillofacial region of mandibular ameloblastoma patient, and then the 3D model of the maxillofacial skeleton was reconstructed using the computerized digital surgical aid design to simulate the focal resection and the mandibular defect reconstruction with the iliac crest flap. Surgical guides were prepared by 3D printing to assist focal resection and bone reshaping. Postoperatively, clinical and CT examinations were performed to observe the restoration of the patient＇s facial appearance and occlusal relationship, as well as wound healing and graft survival. Results Postoperative review results showed that the bone graft survived well, and the anastomosed bone was formed. The wound in the surgery area healed. No recurrence of the tumor was found after clinical and CT examination. The maxillofacial appearance was well restored, and the residual occlusal relationship recovered well. Conclusions The use of computerized digital surgical aided design combined with 3D printing technology can effectively simplify the mandibular segmental defect repair and reconstruction and optimize the postoperative repair effect. Key words: Image processing; Computer-aided design and manufacture; Ilium; Myocutaneous flap; Mandibular defect

Establishment of low cost epilepsy surgery centers in resource poor setting

PurposeTo prospectively assess the feasibility of establishing low cost epilepsy surgery programs in resource poor settings. MethodWe started epilepsy surgery centers in Tier 2 and Tier 3 cities in India in private hospitals. This model is based on the identifying and operating ideal epilepsy surgery candidates on the basis of clinical history, interictal and ictal video-EEG data, and 1.5 T MRI without other investigations and without regular involvement of other specialists. Trained epileptologists formed the fulcrum of this program who identified ideal candidates, offered them counseling, and read video-EEG and MRI. We also spread epilepsy awareness among locals and physicians and established focused epilepsy clinics. The expenses were subsidized for deserving patients and policies were devised to keep video-EEG duration and staff requirement to minimum. Difficult epilepsy surgery cases were referred to established centers. Initial surgeries were performed by invited epilepsy surgeons and subsequently by local neurosurgeons. ResultsA total of 125 epilepsy surgeries were performed at three centers since 2012. This included 81(64.8%) temporal lobe resections, 26 (20.8%) extratemporal focal resections, and 13 (10.4%) hemispherotomies. Of the 93 patients with more than 1 year of postoperative followup, 86 (92.5%) had Engel class IA outcome. There were minor complications in 5% patients. Average cost of presurgical evaluation and surgery was Rs. 92,707 (USD 1,324). ConclusionsIt is possible to establish successful epilepsy surgery programs in resource poor setting with reasonable costs. This low cost model can be replicated in other parts of world to reduce the surgical treatment gap.

Focal Cortical Dysplasia and Refractory Epilepsy: Role of Multimodality Imaging and Outcome of Surgery.

Focal cortical dysplasia (FCD) is one of the most common causes of drug resistant epilepsy. Our aim was to evaluate the role of presurgical noninvasive multimodality imaging techniques in selecting patients with refractory epilepsy and focal cortical dysplasia for epilepsy surgery and the influence of the imaging modalities on long-term seizure freedom. We performed a retrospective analysis of data of 188 consecutive patients with FCD and refractory epilepsy with at least 2 years of postsurgery follow-up. Predictors of seizure freedom and the sensitivity of neuroimaging modalities were analyzed. MR imaging showed clear-cut FCD in 136 (72.3%) patients. Interictal FDG-PET showed focal hypo-/hypermetabolism in 144 (76.6%); in 110 patients in whom ictal SPECT was performed, focal hyperperfusion was noted in 77 (70.3%). Focal resection was the most common surgery performed in 112 (59.6%). Histopathology revealed FCD type I in 102 (54.3%) patients. At last follow-up, 124 (66.0%) were seizure-free. Complete resection of FCD and type II FCD were predictors of seizure freedom. Localization of FCD on either MR imaging or PET or ictal SPECT had the highest sensitivity for seizure freedom at 97.5%. Among individual modalities, FDG-PET had the highest sensitivity (78.2%), followed by MR imaging (75.8%) and ictal SPECT (71.8%). The sensitivity of MR imaging to localize type I FCD (60.8%) was significantly lower than that for type II FCD (84.8%, P < .001). Among 37 patients with subtle MR imaging findings and a focal FDG-PET pattern, 30 patients had type I FCD. During presurgical multimodality evaluation, localization of the extent of the epileptogenic zone in at least 2 imaging modalities helps achieve seizure freedom in about two-thirds of patients with refractory epilepsy due to FCD. FDG-PET is the most sensitive imaging modality for seizure freedom, especially in patients with type I FCD.