Multiple Subpial Transections Research Articles

Novel Approaches for Treatment of Epilepsy

Epilepsy is a serious neurological disorder on the juncture of psychiatry and neurology. It is characterized by recurrent and episodic seizures which are due to excessive discharge by the brain neurons. The therapeutic response failure of more than one or two antiepileptic drugs (AEDs) is the benchmark of refractory or intractable epilepsy. The aim of the study was to determine new approaches which lead towards the treatment of epilepsy. In order to treat focal mesial temporal lobe epilepsy or neocortical epilepsy in adults and any malformation of cortical development such as focal dysplasia surgical resection remains the gold standard treatment. Disconnection procedures such as corpus callosotomy and multiple subpial transections are the best alternative treatment for that patient whose seizure origin is in eloquent cortex or having generalized epilepsy syndromes. Palliative neuromodulation procedures such as Vagus nerve stimulation (VNS), Responsive neurostimulation (RNS) and Deep brain stimulation (DBS) are best approach to treat intractable epileptic patients who are not suitable candidates of surgery. As the search of better management of epilepsy continues gene therapy and optogenetics gain a momentum in neuroscience.

502 Clinical Outcomes for Treatment of Peri-Rolandic Epilepsy

INTRODUCTION: Treatment of epileptogenic foci within the eloquent peri-Rolandic region (pre- and post-central gyri) is challenging. Advances in surgical techniques and implantable neuromodulation devices have broadened the available treatment options. METHODS: We retrospectively studied all consecutive patients who underwent intracranial seizure monitoring from 2013 to 2021. We studied demographic and imaging variables, stimulation results, seizure outcomes, and neurological function at various stages of recovery. RESULTS: 22 patients encompassing 25 procedures were included in this study. 12 of the patients had non-lesional MRIs with surgical intervention involving the dominant hemisphere. 9 patients underwent peri-Rolandic resections, and 11 patients received peri-Rolandic RNS. The rest had a combination of non-peri-Rolandic resection, multiple subpial transection, and peri-Rolandic RNS. When comparing resection against RNS cohorts, more patients who elected for resection had failed prior surgical interventions. Although most resection patients had a neurological deficit at discharge (78% for resection vs 0% for RNS), those who received resection had better rates of seizure control (Engel I at last follow-up: 78% for resection vs 27% for RNS). Almost all patients with neurological deficits experienced significant functional recovery over time. CONCLUSIONS: Resection of peri-Rolandic seizure foci can lead to excellent outcomes with neurological morbidity that improves over time. Treatment selection should be tailored based on risk-benefit analysis and patient preference.

Surgical approaches to refractory central lobule epilepsy: a systematic review on the role of resection, ablation, and stimulation in the contemporary era.

Epilepsy originating from the central lobule (i.e., the primary sensorimotor cortex) is a challenging entity to treat given its involvement of eloquent cortex. The objective of this study was to review available evidence on treatment options for central lobule epilepsy. A comprehensive literature search (PubMed/Medline, EMBASE, and Scopus) was conducted for studies (1990 to date) investigating postoperative outcomes for central lobule epilepsy. The primary and secondary endpoints were seizure freedom at last follow-up and postoperative neurological deficit, respectively. The following procedures were included: open resection, multiple subpial transections (MSTs), laser and radiofrequency ablation, deep brain stimulation (DBS), responsive neurostimulation (RNS), and continuous subthreshold cortical stimulation (CSCS). A total of 52 studies and 504 patients were analyzed. Most evidence was based on open resection, yielding a total of 400 patients (24 studies), of whom 62% achieved seizure freedom at a mean follow-up of 48 months. A new or worsened motor deficit occurred in 44% (permanent in 19%). Forty-six patients underwent MSTs, of whom 16% achieved seizure freedom and 30% had a neurological deficit (permanent in 12%). There were 6 laser ablation cases (cavernomas in 50%) with seizure freedom in 4 patients and 1 patient with temporary motor deficit. There were 5 radiofrequency ablation cases, with 1 patient achieving seizure freedom, 2 patients each with Engel class III and IV outcomes, and 2 patients with motor deficit. The mean seizure frequency reduction at the last follow-up was 79% for RNS (28 patients), 90% for CSCS (15 patients), and 73% for DBS (4 patients). There were no cases of temporary or permanent neurological deficit in the CSCS or DBS group. This review highlights the safety and efficacy profile of resection, ablation, and stimulation for refractory central lobe epilepsy. Resection of localized regions of epilepsy onset zones results in good rates of seizure freedom (62%); however, nearly 20% of patients had permanent motor deficits. The authors hope that this review will be useful to providers and patients when tailoring decision-making for this intricate pathology.

Neurosurgery in canine epilepsy

Epilepsy surgery is functional neurosurgery applied to drug-resistant epilepsy. Although epilepsy surgery has been established and achieves fair to good outcomes in human medicine, it is still an underdeveloped area in veterinary medicine. With the spread of advanced imaging and neurosurgical modalities, intracranial surgery has become commonplace in the veterinary field, and, therefore, it is natural that expectations for epilepsy surgery increase. This review summarizes current standards of intracranial epilepsy surgery in human medicine and describes its current status and expectation in veterinary medicine. Intracranial epilepsy surgery is classified generally into resection surgery, represented by cortical resection, lobectomy, and lesionectomy, and disconnection surgery, such as corpus callosotomy and multiple subpial transection. In dogs with drug-resistant epilepsy, corpus callosotomy is available as a disconnection surgery for generalized epilepsy. However, other types of disconnection and resection surgeries for focal epilepsy are limited to experimental studies in laboratory dogs and/or anecdotal case reports of lesionectomy, such as tumor or encephalocele removal, without epileptogenic evidence. Veterinary epilepsy surgery is a new and challenging neurosurgery field; with the development of presurgical evaluations such as advanced electroencephalography and neuroimaging, it may become more readily practiced.

Imaging of Neuromodulation and Surgical Interventions for Epilepsy.

About one-third of epilepsy cases are refractory to medical therapy. During the past decades, the availability of surgical epilepsy interventions has substantially increased as therapeutic options for this group of patients. A wide range of surgical interventions and electrophysiologic neuromodulation techniques are available, including lesional resection, lobar resection, thermoablation, disconnection, multiple subpial transections, vagus nerve stimulation, responsive neurostimulation, and deep brain stimulation. The indications and imaging features of potential complications of the newer surgical interventions may not be widely appreciated, particularly if practitioners are not associated with comprehensive epilepsy centers. In this article, we review a wide range of invasive epilepsy treatment modalities with a particular focus on their postoperative imaging findings and complications. A state-of-the-art treatment algorithm provides context for imaging findings by helping the reader understand how a particular invasive treatment decision is made.

Modern Problems in the Surgical Treatment of Epilepsy

Background: The surgical treatment of epilepsy is widely recognised by neurosurgeons as the most effective method for treating patients with drug-resistant forms of the disease. Objective: To analyse the results of surgical treatments in patients with epileptic seizures, depending on the applied methods of surgery. Methods: A comprehensive clinical examination of the surgical treatments of 112 patients with various forms of drug-resistant epilepsy was carried out. Results: Hemispherectomy was performed in three patients with positive outcomes. Hippocampectomy was performed for four patients. In two patients, the seizures became medically controlled. In the other two cases, the intervals between seizures were longer and seizures tended to occur at night. Extratemporal resection of the epileptogenic focus was performed in 86 patients, 72% percent of whom became seizure-free. Six patients underwent callosotomy, five of whom were then seizure free. One patient’s seizures resumed after 8 months, this case was also drug-resistant. Thirty two patients underwent multiple subpial transection and were followed-up for approximately 5 years. Excellent results were obtained in 20 (62.5%) patients with seizures ceasing. Conclusions: The results of the study showed sufficient efficiency of the applied methods of surgical treatment for various forms of epilepsy.

Functional magnetic resonance imaging based on Chinese tasks to protect language function in epileptics.

ObjectiveTo evaluate the efficacy of functional magnetic resonance imaging (fMRI) based on Chinese tasks to protect the language function in epileptics.Materials and MethodsA total of 34 native Chinese patients with epilepsy were enrolled and examined with BOLD‐fMRI scan based on six Chinese tasks. The epileptics were randomly divided into the control group (n = 15) and the experimental group (n = 19). The control group underwent the hollowing and multiple subpial transection operation only based on intraoperative EEG, while the experimental group was under notification of task‐state fMRI results in addition. Whereafter, the language ability of patients was evaluated by ABC assessment.ResultsThe brain regions related to Chinese function activated by different tasks were remarkably distinct and mainly concentrated in the temporal lobe and frontal lobe. In ontoanalysis, the activation signals of the fusiform gyrus, parahippocampal gyrus, hippocampus, and precentral gyrus were generally low or even could not be detected. Unlike ontoanalysis, group analysis showed that the main effect regions of AN and PN task were in right superior temporal gyrus. The main effect regions of FF and VFC task were in right middle temporal gyrus. The main effect region of SF task was in left superior temporal gyrus. The main effect region of VFL task was in right middle frontal gyrus. The ABC assessment score of the control group 6 months after surgery was significantly lower than that 1 week before surgery (p < .05), while there was no significant difference in the experimental group, and the score of the experimental group was higher than that of the control group.ConclusionIn the surgical treatment of epilepsy, a personalized surgical plan, based on task‐state fMRI and intraoperative EEG, can be developed according to the difference of activation areas to protect the language function and improve the quality of life in postoperative patients.

Multifocal resection in therapy of pediatric progredient epilepsy

Objective. To analyze the long-term results after surgical treatment of multifocal cortical epilepsy in children and determine prognostic factors. The use of multilobar resections in the surgical treatment of pediatric multi-focal epilepsy remains an pressing problem of current neurology and neurosurgery. Materials and methods . A retrospective analysis of the multifocal resections data in 47 children with drug-resistant single-hemispheric multifocal epilepsy was performed by monitoring patients between age of 8 months up to 17 years old, who were operated from 1994 to 2014, additionally examined for prognostic factors affecting short- and long-term treatment outcomes after surgery. Results. According to the MRI data, structural changes in the brain were found in 63.8% subjects, whereas in 36.2% cases no pathology was detected. The following types of surgical interventions were performed: fronto-temporal resection - 44.68% cases; temporal resection combined with subpial removal of the frontal and parietal cortex in 21.28% patients; resection of the temporal lobe and cortical foci of the parietal lobe - 19.15%; removal of the temporal, parietal and occipital lobes - 2 cases; resection of the temporal and occipital - 2 cases; resection of the temporal lobe in combination with multifocal resection of the cortical epileptic foci of the frontal, parietal and occipital lobes - 1 cases; fronto-central-parietal combined with multiple subpial transection of the cortex - 1 case, fronto-parieto-occipital - 1 case. Immediately in postoperative period and up to 12 months post-surgery, seizures disappeared in 42.9% cases, whereas in long-term period results remained stable with Engel I outcome in 41.7% after 3 years, 41.2% - after 5 years and 40.6% - after 10 years post-surgery. Conclusion: Multilobar resections performed in multifocal epilepsy allow to provide a favorable result in the short-term and long-term period with fully abrogated seizures in 48% and 41% cases, respectively. Positive prognostic factors were found to be duration of epilepsy less than 7 years, onset of the disease at school age, lack of generalized seizures and epileptic status in history, as well as the vastness of surgery.

Multiple Subpial Transections in Eloquent Cortex for Refractory Epilepsy: 2-Dimensional Operative Video.

Although the epilepsy refractory to medical therapy can potentially be cured by the resection of epileptogenic tissue, many patients do not qualify for surgery, because epileptogenic tissue can arise from eloquent areas of the brain, where surgical resection would result in severe neurological deficits. Palliative surgical treatments currently used in these situations include deep brain stimulation, responsive neurostimulation, and vagal nerve stimulation.1 A previously developed technique, multiple subpial transections (MSTs), although used infrequently, is another effective tool.2 Our patient, a 34-yr-old man, had epilepsy that was refractory to medical management. His preoperative work-up demonstrated a potential seizure focus in the left pars opercularis and left superior temporal gyrus, which was verified using invasive stereoelectroencephalography. Functional magnetic resonance imaging demonstrated a significant verbal and motor function in this region. After informed consent was obtained, the patient underwent a left-sided craniotomy. The central portion of the seizure focus was resected using the subpial technique. The surrounding presumed epileptogenic cortex, which was considered functionally eloquent, was then horizontally disconnected with MSTs. For each transection, a small puncture incision was made in the pia, and a vertical cut was completed using Morrell dissectors.2 MSTs were performed circumferentially around the entire resection cavity in 5-mm increments. All hemostasis was achieved with irrigation instead of electrocautery, although noncauterizing hemostatic agents are also acceptable. The patient was neurologically intact after the operation and was discharged home on postoperative day 2. He was free of seizures at 11-month follow-up. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Aggressive cytoreduction and multiple subpial cortical transections may obtain good surgical outcomes in refractory epilepsy with multiple epileptic foci

BackgroundsEpilepsy surgery is the most efficacious therapeutic modality for patients with medical refractory epilepsy, especially resective surgery. However, the variable etiologies and multiple epileptic foci are usually associated with the outcomes. The aim of this study was to demonstrate that combination of different intervention procedures might be an alternative option for patients of refractory epilepsy. MethodsWe retrospectively analyzed pre-operative and post-surgical outcomes in 30 patients who received epilepsy surgery between January 1, 2010 and December 31, 2014 at Chang Gung Memorial Hospital (CGMH), Linkou, according to Engel's classification. ResultsTwenty-six of the 30 patients (86.7%) had good outcomes, sum of class I and class II after epilepsy surgery. The good outcome rate of our complicated group was 80.0% (12/15), compared to 93.3% (14/15) in the simple group, but no significant differences between the two groups (p = 0.569). Four patients whose epileptic foci involved eloquent area and received multiple subpial cortical transection, and good outcome rate was 75% (3/4). At last, six patients had previously failed epilepsy surgery and received a reoperation, with a good outcome rate of 83.3% (5/6). ConclusionAfter complete pre-surgical evaluation and combined interventional procedures, the patients with refractory epilepsy had satisfactory outcomes and few neurological complications. Moreover, re-operation can improve the outcome in some patients who previously failed epilepsy surgery.

Transecciones radiales múltiples para tratamiento de la epilepsia refractaria

Objetivo: Las transecciones subpiales múltiples (MST) representan una opción técnica de tratamiento quirúrgico para pacientes con focos epileptogénicos ubicados en áreas corticales elocuentes. Podrían realizarse además de otras técnicas quirúrgicas o solo. Presentamos los resultados clínicos de 20 pacientes que recibieron una cirugía MST única con un seguimiento mínimo de 5 años. Métodos: Los autores estudiaron a todos los pacientes que se sometieron a una intervención quirúrgica entre 2007 y 2019 para la epilepsia refractaria. Entre ellos, 20 tenían MST radiante (rMST) como el único tratamiento quirúrgico con un seguimiento de al menos 5 años. Resultados: A los 5 años de seguimiento, el 80% de nuestros pacientes eran Engel clase I, el 20% eran Engel clase II, ninguno era Engel clase III y ninguno era Engel clase IV. En el último seguimiento, 12 pacientes (60%) no sufrieron convulsiones, quatro (20%) tuvieron una disminución de más del 75% y quatro (20%) no mejoraron después del procedimiento. Ninguno de los pacientes con Engel I tuvo recurrencia de ataques, y los que pertenecían a una clase intermedia mejoraron durante el seguimiento, en algunos casos en asociación con una modificación farmacológica antiepiléptica. Cuatro (20%) tuvieron una complicación transitoria menor, y cuatro pacientes (20%) tuvieron una complicación permanente menor. Conclusiones: La MST realizada sola da un resultado favorable en el 80% de los pacientes (16) con un seguimiento mínimo de 5 años con pocas complicaciones menores. Este procedimiento parece ser efectivo incluso con un seguimiento prolongado en la epilepsia refractaria con los focos epileptogénicos ubicados en áreas elocuentes.

Multiple Subpial Transection (MST) Technique in the Treatment of Epilepsy

Multiple Subpial Transection (MST) Technique in the Treatment of Epilepsy

Clinical Outcome of Radiating Multiple Subpial Transections Alone for Drug Resistant Epilepsy After More Than 5 Years Follow-Up

Multiple subpial transection (MST) is a possible surgical treatment for patients with epileptogenic foci located in eloquent cortical areas. Commonly, it is performed in addition to other surgical techniques. In some cases, however, it is performed alone. We report the clinical results of 12 patients who received solely radiating MST with a minimal follow-up of 5 years. All patients who underwent a surgical intervention between 2003 and 2012 for refractory epilepsy were studied. Among them, 12 had radiating MST (rMST) as the only surgical treatment with a follow-up of at least 5 years. At 5-year follow-up, 50% of the patients were Engel class I, 25% were Engel class II, 0% were Engel class III, and 25% were Engel class IV. At last follow-up, 8 patients (67%) were free of seizures, 1 patient (8%) had an over 75% decrease, and 3 patients (25%) did not improve after the procedure. None of the Engel I patients had seizure recurrence, and those belonging to an intermediate class improved during follow-up, in some cases in association with an antiepileptic drug modification. Two patients (17%) had a minor transient complication, and 1 patient (8%) had a minor permanent complication. rMST performed alone gives a favorable outcome in 75% of the patients at a minimum 5-year follow-up with few minor complications. This procedure appears to be effective even with a prolonged follow-up in drug resistant epilepsy with the epileptogenic foci located in eloquent areas.

Multiple Subpial Transections for Medically Refractory Epilepsy: A Disaggregated Review of Patient-Level Data.

Multiple subpial transections (MST) are a treatment for seizure foci in nonresectable eloquent areas. To systematically review patient-level data regarding MST. Studies describing patient-level data for MST procedures were extracted from the Medline and PubMed databases, yielding a synthetic cohort of 212 patients from 34 studies. Data regarding seizure outcome, patient demographics, seizure type, surgery type, and complications were extracted and analyzed. Seizure freedom was achieved in 55.2% of patients undergoing MST combined with resection, and 23.9% of patients undergoing MST alone. Significant predictors for seizure freedom were a temporal lobe focus (odds ratio 4.9; 95% confidence interval 1.71, 14.3) and resection of portions of the focus, when feasible (odds ratio 3.88; 95% confidence interval 2.02, 7.45). Complications were frequent, with transient mono- or hemiparesis affecting 19.8% of patients, transient dysphasia 12.3%, and permanent paresis or dysphasia in 6.6% and 1.9% of patients, respectively. MST is an effective treatment for refractory epilepsy in eloquent cortex, with greater chances of seizure freedom when portions of the focus are resected in tandem with MST. The reported rates of seizure freedom with MST are higher than those of existing neuromodulatory therapies, such as vagus nerve stimulation, deep brain stimulation, and responsive neurostimulation, though these latter therapies are supported by randomized-controlled trials, while MST is not. The reported complication rate of MST is higher than that of resection and neuromodulatory therapies. MST remains a viable option for the treatment of eloquent foci, provided a careful risk-benefit analysis is conducted.

Multiple subpial transections and magnetic resonance imaging

IntroductionMultiple subpial transection (MST) has been applied to the treatment of refractory epilepsy when epileptogenic zone involves eloquent areas since 1989. However, there is a lack of data evaluating the effect of this surgical technique on the cortex as measured by Magnetic Resonance Imaging (MRI). Patients and methodsTen consecutive patients (3F/7M, average age: 18.5 years) were operated on using radiating MST (average: 39; min: 19, max: 61) alone (n=3) or associated with another technique (n=7). Seven patients underwent a post-operative 3.0T MRI while 3 had a 1.5T MRI. Three patients had an early post-operative MRI and 7 a late MRI, among which 3 previously had an intraoperative MRI. ResultsThe MR sequences that allowed the best assessment of MST-induced changes were T2 and T2*. The traces of MST are more visible on late MRI. These discrete non-complicated stigmas of MST were observed in all 10 studied patients: on the intraoperative MRI they are seen as micro-hemorrhagic spots (hypo-T2), on the early postoperative MRI as a discreet and limited cortical edema whether associated or not with micro-hemorrhagic spots and on the late MRI as liquid micro-cavities (hyper-T2) surrounded with a fine border of hemosiderin. ConclusionsMST-induced cerebral lesions are best visualized in T2-sequences, mainly on the late postoperatively MRIs. On all the MRI examinations in this study, the MST are only associated with limited modifications of the treated cortical regions.

Current Treatment Options for Early-Onset Pediatric Epileptic Encephalopathies.

The management of early-onset, genetically determined epilepsies is often challenging. First-line anti-epileptic drugs (AEDs) often include phenobarbital, phenytoin, oxcarbazepine, carbamazepine, clonazepam, levetiracetam, and valproic acid. Combinations of medications are used in these patients with often intractable seizures, and they include topiramate, clobazam, felbamate, lacosamide, lamotrigine, rufinamide, vigabatrin, ACTH, oral steroids, and the ketogenic diet. Vagus nerve stimulator therapy offers some relief in selected patients. Surgical procedures, such as multiple subpial transections (MSTs), hemispherectomy, focal epilepsy surgery, or corpus callosotomy, may also be performed in selected patients. Careful monitoring of drug levels, if available, is highly recommended, as well as liver function tests, complete blood count, and electrolyte levels. AEDs often interact with each other, and the physician must be knowledgeable about such drug interactions, when selecting a new medication. In this article, the various encephalopathies are reviewed and presented according to age of onset of symptoms. Different treatment options are also summarized.

Not all that glitters is gold: A guide to surgical trials in epilepsy.

SummaryEpilepsy surgery is often the only effective treatment in appropriately selected patients with drug‐resistant epilepsy, a disease affecting about 30% of those with epilepsy. We review the evidence supporting the use of epilepsy surgery, with a focus on randomized controlled trials (RCTs). Second, we identify gaps in knowledge about the benefits of epilepsy surgery for certain populations, the challenges of individualizing the choice of surgery, and our lack of understanding of the mechanisms of surgical outcomes. We conducted a search (MEDLINE, Embase, Cochrane, Clinicaltrials.gov) on March 2, 2016, to identify epilepsy surgery RCTs, systematic reviews, or health technology assessments (HTAs). s were screened to identify resective, palliative (e.g., corpus callosotomy, multiple subpial transection [MST]), ablative (e.g., Laser interstitial thermal therapy [LITT], gamma knife radiosurgery [RS]), and neuromodulation (e.g., cerebellar stimulation [CS], hippocampal stimulation [HS], repetitive transcranial magnetic stimulation [rTMS], responsive neurostimulation [RNS], thalamic stimulation [TS], trigeminal nerve stimulation [TNS], and vagal nerve stimulation [VNS]) RCTs. Study characteristics and outcomes were extracted. Knowledge gaps were identified. Of 1,205 abstracts, 20 RCTs were identified (resective surgery including corpus callosotomy [n = 7], MST [n = 0], RS [n = 1, 3 papers], LITT [n = 0], CS [n = 1], HS [n = 2], RNS [n = 1], rTMS [n = 1], TNS [n = 1], TS [n = 1], and VNS [n = 5]). Most studies targeted patients with temporal lobe epilepsy (TLE) and none examined the effectiveness of resective surgical therapies in patients with extra‐TLE (ETLE) or with specific lesions aside from mesial temporal lobe sclerosis. No pediatric surgical RCTs were identified except for VNS. Few RCTs address the effectiveness of surgery in epilepsy and most are of limited generalizability. Future studies are needed to compare the effectiveness of different surgical strategies, better understand the mechanisms of surgical outcomes, and define the ideal surgical approaches, particularly for patients with high or very low cognitive function, normal imaging, or ETLE.

Seizure outcomes in nonresective epilepsy surgery: an update.

In approximately 30% of patients with epilepsy, seizures are refractory to medical therapy, leading to significant morbidity and increased mortality. Substantial evidence has demonstrated the benefit of surgical resection in patients with drug-resistant focal epilepsy, and in the present journal, we recently reviewed seizure outcomes in resective epilepsy surgery. However, not all patients are candidates for or amenable to open surgical resection for epilepsy. Fortunately, several nonresective surgical options are now available at various epilepsy centers, including novel therapies which have been pioneered in recent years. Ablative procedures such as stereotactic laser ablation and stereotactic radiosurgery offer minimally invasive alternatives to open surgery with relatively favorable seizure outcomes, particularly in patients with mesial temporal lobe epilepsy. For certain individuals who are not candidates for ablation or resection, palliative neuromodulation procedures such as vagus nerve stimulation, deep brain stimulation, or responsive neurostimulation may result in a significant decrease in seizure frequency and improved quality of life. Finally, disconnection procedures such as multiple subpial transections and corpus callosotomy continue to play a role in select patients with an eloquent epileptogenic zone or intractable atonic seizures, respectively. Overall, open surgical resection remains the gold standard treatment for drug-resistant epilepsy, although it is significantly underutilized. While nonresective epilepsy procedures have not replaced the need for resection, there is hope that these additional surgical options will increase the number of patients who receive treatment for this devastating disorder-particularly individuals who are not candidates for or who have failed resection.

Current and Emerging Surgical Therapies for Severe Pediatric Epilepsies

The use of epilepsy surgery in various medically resistant epilepsies is well established. For patients with intractable pediatric epilepsy, the role of intracranial electrodes, resective surgery, hemispherectomy, corpus callosotomy, neurostimulation, and multiple subpial transections continues to be very effective in select cases. Newer treatment and diagnostic methods include laser thermal ablation, minimally invasive surgeries, stereo electroencephalography, electrocorticography, and other emerging techniques. This article will review the established and emerging surgical therapies for severe pediatric epilepsies, their respective indications and overall efficacy.

Psychiatric and Behavioural Disorders in Children with Epilepsy (ILAE Task Force Report): Behavioural effects of epilepsy surgery.

There are relatively few studies of the behavioural outcome of epilepsy surgery in children that have used standardised behavioural measures before and after the procedure. Those investigations that have used such measures are often on mixed groups with mixed pathology, implying that the numbers, when stratified, are very small. They are also often retrospective. Furthermore, because placebo surgery is generally not an option, the studies have been open and they are usually uncontrolled. The few available data suggest that, although individual children may benefit or deteriorate, there is little overall group effect of temporal or extratemporal surgery on behavioural/psychiatric outcome. Hemispherectomy has traditionally been associated with the expectation of marked behavioural improvement but firm data are lacking. Multiple subpial transection performed for electrical status epilepticus of slow-wave sleep in the Landau-Kleffner syndrome can result in marked improvements in cognition and behaviour. Vagus nerve stimulation appears to improve quality of life and mood/behaviour but again the quality of the data has been questioned. There is a need for large, prospective, multicentre, collaborative studies using standardised cognitive and behavioural measures before and after surgery to provide an adequate database on the outcome of various categories of procedures, pathologies and patients.