Surgery For Focal Cortical Dysplasia Research Articles

Cognitive and developmental outcomes after pediatric insular epilepsy surgery for focal cortical dysplasia.

Cognitive risk associated with insular cortex resection is not well understood. The authors reviewed cognitive and developmental outcomes in pediatric patients who underwent resection of the epileptogenic zone involving the insula. A review was conducted of 15 patients who underwent resective epilepsy surgery involving the insular cortex for focal cortical dysplasia, with a minimum follow-up of 12 months. The median age at surgery was 5.6 years (range 0.3-13.6 years). Developmental/intelligence quotient (DQ/IQ) scores were evaluated before surgery, within 4 months after surgery, and at 12 months or more after surgery. Repeated measures multivariate ANOVA was used to evaluate the effects on outcomes of the within-subject factor (time) and between-subject factors (resection side, anterior insular resection, seizure control, and antiepileptic drug [AED] reduction). The mean preoperative DQ/IQ score was 60.7 ± 22.8. Left-side resection and anterior insular resection were performed in 9 patients each. Favorable seizure control (International League Against Epilepsy class 1-3) was achieved in 8 patients. Postoperative motor deficits were observed in 9 patients (permanent in 6, transient in 3). Within-subject changes in DQ/IQ were not significantly affected by insular resection (p = 0.13). Postoperative changes in DQ/IQ were not significantly affected by surgical side, anterior insular resection, AED reduction, or seizure outcome. Only verbal function showed no significant changes before and after surgery and no significant effects of within-subject factors. Resection involving the insula in children with impaired development or intelligence can be performed without significant reduction in DQ/IQ, but carries the risk of postoperative motor deficits.

Predictors of seizure recurrence in patients with surgery for focal cortical dysplasia: pairwise and network meta-analysis and trial sequential analysis.

The aim of this study was to determine the predictors of seizure recurrence in surgery for focal cortical dysplasia (FCD) by conducting a meta-analysis. Publications that met the pre-stated inclusion criteria were selected from PubMed and CNKI databases. Two authors extracted data independently about prognostic factors, surgical outcome, and clinical characteristics of participants. A fixed-effects model was used to calculate the summary of odds ratio (OR) with 95% confidence interval (CI). Forty-eight studies were included in our meta-analysis. Three predictors of seizure recurrence (Engel class III/IV)-histological FCD type I, incomplete resection, and extratemporal location were determined; combined OR with 95% CI were 1.94 (95%CI 1.53-2.46), 12.06 (95%CI 7.32-19.88), and 1.91 (95%CI 1.06-3.44), respectively. Trial sequential analysis revealed that the outcomes had a sufficient sample size to reach firm conclusions. Furthermore, seizure location was not substantially modified by geographic region, while histological FCD type I and incomplete resection showed a significant association with seizure recurrence in different continents except Asia for incomplete resection. Sensitivity analyses restricted to studies for each variable yielded robust results. Little evidence of publication bias was observed. Meanwhile, the difference in the standard for outcome failed to influence the results for prognosis. Network meta-analysis including 13 trials comparing subtypes of FCD found the FCD IIb had the lowest seizure recurrence rate. This meta-analysis suggests that histological FCD type I, incomplete resection, and extratemporal location are recurrence factors in patients with epilepsy surgery for FCD. In addition, FCD IIb is associated with the highest rates of postoperative seizure control among the subtypes of FCD, type I and type II.

Epilepsy surgery for focal cortical dysplasia: Seizure and quality of life (QOLIE-89) outcomes.

Surgery for drug resistant epilepsy (DRE) with focal cortical dysplasia (FCD) often requires multiple non-invasive as well as invasive pre-surgical evaluations and innovative surgical strategies. There is limited data regarding surgical management of people with FCD as the underlying substrate for DRE among the low and middle-income countries (LAMIC) including India. The presurgical evaluation, surgical strategy and outcome of 52 people who underwent resective surgery for DRE with FCD between January 2008 and December 2016 were analyzed. The 2011 classification proposed by Blumcke et al., was used for histo-pathological categorization. The Engel classification was used for defining the seizure outcome. The surgical outcome was correlated with the preoperative clinical presentation, video encephalogram (VEEG) recording, magnetic resonance imaging (MRI), invasive monitoring, surgical findings as well as histopathology and the quality of life in epilepsy (QOLIE)- 89 scores. Fifty-two patients underwent resective surgery for FCD (mean age at onset of seizure: 7.94 ± 6.23 years; duration of seizures prior to surgery: 12.95 ± 9.56 years; and, age at surgery: 20.88 ± 12.51 years). The following regional distribution was found; temporal-24 (language-13), frontal-15 (motor cortex- 5), parietal-5 (sensory cortex-4), occipital-1 and multilobar-7. Forty-seven percent of the cases had FCD in the right hemisphere and 53% had FCD in the left hemisphere. Invasive monitoring was performed for identification of the epileptogenic zone (EZ) as well as eloquent cortex in 7 cases and an intra-operative electro-corticography (ECoG) was used in 32 cases. Histopathology revealed the following distribution; FCD IA-4, IB- 1, IC-5, IIA-8, IIB-18, IIIA-13, IIIB -1, IIIC-1 and IIID-1. After a median follow up of 3.7 years after surgery, 84% of patients had Engel's Ia outcome. QOLIE-89 scores improved from 38.33 ± 4.7 (31.14-49.03) before surgery to 75.21 ± 8.44 (56.49-90.49) after surgery (P < 0.001). The younger age of the patient (<20 years) at surgery (P = 0.013), a lower pre-operative score (<9) on seizure severity scale (P = 0.012), focal discharges without propagation on ictal VEEG (P < 0.001), absence of acute post-operative seizures (P < 0.001) and Type II FCD (P = 0.045) were the significant predictors for a favorable seizure outcome. Surgical management of people with DRE and FCD is possible in countries with limited resources. Meticulous pre-surgical evaluation to localize the epileptogenic zone and complete resection of the focus and lesion can lead to the cure or control of epilepsy; and, improvement in the quality of life was observed along with seizure-free outcome.

Discontinuing Antiepileptic Drugs after Pediatric Epilepsy Surgery for Focal Cortical Dysplasia

Discontinuing Antiepileptic Drugs after Pediatric Epilepsy Surgery for Focal Cortical Dysplasia

131 Resective Surgery for Focal Cortical Dysplasia in Children

Purpose Seizure freedom following resection of focal cortical dysplasia (FCD) correlates with complete resection of the dysplastic cortical tissue. However, difficulty with intraoperative identification of the lesion may limit the ability to achieve the surgical objective of complete extirpation of these lesions. Intraoperative magnetic resonance imaging (iMRI) may aid in FCD resections. The objective of this study is to compare rates of postoperative seizure freedom, completeness of resection, and need for reoperation in patients undergoing iMRI-assisted FCD resection versus conventional surgical techniques.

Anti-Epileptic Drug Withdrawal after Surgery for Focal Cortical Dysplasia (P2.049)

Anti-Epileptic Drug Withdrawal after Surgery for Focal Cortical Dysplasia (P2.049)

Resective surgery for focal cortical dysplasia in children: a comparative analysis of the utility of intraoperative magnetic resonance imaging (iMRI).

Seizure freedom following resection of focal cortical dysplasia (FCD) correlates with complete resection of the dysplastic cortical tissue. However, difficulty with intraoperative identification of the lesion may limit the ability to achieve the surgical objective of complete extirpation of these lesions. Intraoperative magnetic resonance imaging (iMRI) may aid in FCD resections. The objective of this study is to compare rates of postoperative seizure freedom, completeness of resection, and need for reoperation in patients undergoing iMRI-assisted FCD resection versus conventional surgical techniques. We retrospectively reviewed the medical records of pediatric subjects who underwent surgical resection of FCD at Children's National Medical Center between March 2005 and April 2015. At the time of the last postoperative follow-up, 11 of the 12 patients (92%) in the iMRI resection group were seizure free (Engel Class I), compared to 14 of the 42 patients (33%) in the control resection group (p=0.0005). All 12 of the iMRI patients (100%) achieved complete resection, compared to 24 of 42 patients (57%) in the control group (p=0.01). One (8%) patient from the iMRI-assisted resection group has required reoperation, compared to 17 (40%) patients in the control resection group. Our results suggest that the utilization of iMRI during surgery for resection of FCD results in improved postoperative seizure freedom, completeness of lesion resection, and reduction in the need for reoperation.

Intraoperative MRI-guided resection of focal cortical dysplasia in pediatric patients: technique and outcomes.

OBJECTIVE Previous meta-analysis has demonstrated that the most important factor in seizure freedom following surgery for focal cortical dysplasia (FCD) is completeness of resection. However, intraoperative detection of epileptogenic dysplastic cortical tissue remains a challenge, potentially leading to a partial resection and the need for reoperation. The objective of this study was to determine the role of intraoperative MRI (iMRI) in the intraoperative detection and localization of FCD as well as its impact on surgical decision making, completeness of resection, and seizure control outcomes. METHODS The authors retrospectively reviewed the medical records of pediatric patients who underwent iMRI-assisted resection of FCD at the Children's National Health System between January 2014 and April 2015. Data reviewed included demographics, length of surgery, details of iMRI acquisition, postoperative seizure freedom, and complications. Postsurgical seizure outcome was assessed utilizing the Engel Epilepsy Surgery Outcome Scale. RESULTS Twelve consecutive pediatric patients (8 females and 4 males) underwent iMRI-guided resection of FCD lesions. The mean age at the time of surgery was 8.8 years ± 1.6 years (range 0.7 to 18.8 years), and the mean duration of follow up was 3.5 months ± 1.0 month. The mean age at seizure onset was 2.8 years ± 1.0 year (range birth to 9.0 years). Two patients had Type 1 FCD, 5 patients had Type 2A FCD, 2 patients had Type 2B FCD, and 3 patients had FCD of undetermined classification. iMRI findings impacted intraoperative surgical decision making in 5 (42%) of the 12 patients, who then underwent further exploration of the resection cavity. At the time of the last postoperative follow-up, 11 (92%) of the 12 patients were seizure free (Engel Class I). No patients underwent reoperation following iMRI-guided surgery. CONCLUSIONS iMRI-guided resection of FCD in pediatric patients precluded the need for repeat surgery. Furthermore, it resulted in the achievement of complete resection in all the patients, leading to a high rate of postoperative seizure freedom.

Surgery for focal cortical dysplasia in children using intraoperative mapping.

Children with malformation of cortical development represent a significant proportion of pediatric epilepsy surgery candidates. Here, we describe a single-center experience with pediatric patients who underwent surgery for intractable epilepsy due to focal cortical dysplasia (FCD). Clinical data of 78 patients under 18years of age with diagnosis of intractable epilepsy due to FCD who underwent surgery from January 1996 to January 2012 were reviewed comparing data of patients submitted to electrocorticography (ECoG) with those without ECoG. Patients' mean age at surgery was 8.52 ± 4.99years; mean age at epilepsy onset was 2.55 ± 3.01years. Almost 80% of the patients underwent ECoG register that was essential for delimitation of surgical resection in 66 out of 78 patients. ECoG was performed in all patients with extratemporal lesions, and the most common FCD found was type II. Seizure outcome was similar in groups with or without ECoG. Tailored resection of FCD lesions for intractable epilepsy can be safely performed in children with a good seizure outcome and low complication rate. Epilepsy surgery should be considered for all patients with FCD and refractory epilepsy.

Applications of Intraoperative Ultrasound in Epilepsy Surgery for Focal Cortical Dysplasia

The definite margins of focal cortical dysplasias (FCDs) are usually not clear, and all epileptic surgeons have tried to identify them by advanced navigation, fusing magnetic resonance imaging and positron emission tomography, intraoperative magnetic resonance imaging, and intraoperative mapping in past decades. In this report, we present a convenient tool to define the boundary of FCD and improve the surgical outcome. The safe and effective method of image guidance by intraoperative ultrasound was demonstrated, and is time-saving and of a high resolution. In the future, intraoperative ultrasound will be useful in defining subtle epileptogenic lesions, especially when the surgeons encounter FCDs.

Subdural electrode analysis in focal cortical dysplasia

Patients undergoing epilepsy surgery for focal cortical dysplasia (FCD) guided by subdural EEG generally have a poor surgical outcome. Our objective was to identify predictors of postoperative seizure recurrence in this patient cohort. We retrospectively reviewed 48 consecutive surgeries guided by subdural electrode recordings between 1990 and 2004 in patients with a pathologic diagnosis of isolated FCD. Using survival analysis, we analyzed results of the noninvasive evaluation, MRI, subdural interictal and ictal EEG patterns, extent of resection, proximity to eloquent cortex, and postoperative EEG. After a median follow-up of 2.7 years, 45% of patients were completely seizure-free. Most seizures recurred in the first 6 months or between years 2 and 3 after surgery. On univariate analysis, seizure recurrence was associated with bilateral EEG abnormalities, multiple semiologic seizure types, and incomplete resection of the ictal onset zone. The absence of an MRI lesion did not affect outcome, nor did proximity to eloquent cortex. Interictal paroxysmal fast and runs of repetitive spikes correlated with the ictal onset zone, whereas isolated spikes did not. The 6-month EEG predicted ultimate surgical failure in patients seizure-free at that stage. An ictal spread pattern from the edge of the subdural grids was an independent predictor of seizure recurrence on multivariate analysis. We have identified specific predictive factors that may guide the surgical evaluation of patients with focal cortical dysplasia and intractable epilepsy requiring subdural EEG monitoring. Successful surgical results can be obtained utilizing subdural EEG in carefully selected patients.

Surgery: All Ages

Surgery: All Ages

Surgery for focal cortical dysplasia

Three decades since its comprehensive and elegant description (Taylor et al ., 1971), focal cortical dysplasia (FCD) remains an enigmatic condition. Its true incidence is not well known, as even high-resolution MRI studies may not enable its detection. In surgical series, which are inevitably pre-selected, FCD is the most common developmental pathology identified. Undoubtedly, FCD may cause severe refractory epilepsy including epilepsia partialis continua or generalized status epilepticus that can be directly life-threatening. Despite the attention focused on FCD because of this not infrequent malign presentation, much of its biology remains obscure, from its molecular pathology to its natural history. For example, we do not know why paediatric and adult presentations may differ; we do not know if the newly comprehended cellular dynamics of the postnatal human brain, including neoneurogenesis, constitute an important component of FCD biology; and fundamentally we do not know why FCD causes epilepsy or looks so bizarre under the microscope. When antiepileptic drugs fail to bring about complete seizure freedom in FCD, surgical resection of the FCD may hold the prospect of at least some relief for some patients. Practising epileptologists will all have seen individual patients who, following focal resection of the FCD, have done well or even become seizure free, and whose quality of life has improved even if seizure freedom has not been achieved. A previous review found that in comparison with the benchmark of patients having therapeutic resective surgery for epilepsy caused by hippocampal sclerosis, post-surgical outcome for FCD is less good, with ∼45% of reported patients becoming seizure free overall (Sisodiya, 2000); nevertheless, this figure is likely to be considerably …

Surgery for focal cortical dysplasia.

Focal cortical dysplasia (FCD) frequently is associated with medically intractable epilepsy.1–3⇓⇓ The advent of powerful neuroimaging technology has revolutionized the identification and management of this difficult group of disorders. Despite increasing awareness, surgery historically yields less-promising results than other well-recognized epilepsy syndromes.2–6⇓⇓⇓⇓ No universally accepted classification scheme exists. Cortical dysplasia, cortical malformation, neuronal migration disorder, and cortical dysgenesis all are appropriate terms in the correct setting. FCD, described by Taylor et al.1 in 1971, implies a pathologic diagnosis of disordered cerebral cortex with abnormal neurons (balloon cells). Neuronal migration disorder refers to a disturbance in cortical development resulting during the migration of neurons to their predestined cortical location. Other terms are less specific and imply abnormalities in cortical development occurring anytime during the differentiation, migration, and maturation of the cerebral cortex. The reader is referred to several excellent reviews of cortical development for more detailed information.3,7,8⇓⇓ Grading of cortical malformations based on histopathology and neuroimaging may be clinically relevant as a predictor of epileptogenicity and surgical outcome.6,9⇓ In addition, individual malformations may have different EEG signatures, ultimately requiring different surgical approaches. This may revolve around the presence or absence of balloon cells. Clinical investigations studying mechanisms of epileptogenicity in different subtypes of dysplasia are ongoing. The true incidence of FCD remains unclear. Before the availability of modern neuroimaging techniques, diagnosis depended solely on histopathology from surgical specimens of patients with epilepsy.10–12⇓⇓ A recent autopsy series of 7,374 brains found a 1.7% incidence of FCD in normal brains.13 The incidence was significantly higher (46.5%) in patients with epilepsy. Other centers report a 2 to 36% incidence in surgically treated epilepsy series.4,14⇓ In pediatric patients with intractable epilepsy, the incidence was 25% …

Surgery for focal cortical dysplasia

Interest in surgery for focal cortical dysplasia has grown with the enhanced ability to detect these lesions preoperatively with modern imaging techniques. This article focuses on the surgical management of epilepsy associated with focal cortical dysplasia. The authors highlight the approaches practiced at Yale University, review their recent series of operative cases, and discuss a representative case example to illustrate important aspects of surgical strategy.