Surgical Treatment Of Epilepsy Research Articles

La qualité de vie chez l’enfant avec épilepsie : revue de la littérature

Health-related quality of life (HRQOL) is a multidimensional construct, without general agreement on the number of domains and the content of each domain. In children with epilepsy, the HRQOL evaluation includes both nonspecific aspects, such as behavioral, psychological and cognitive difficulties and the impact of a chronic pediatric illness on the child and its family and specific aspects, such as the perception of the severity of the seizures and of the undesirable effects of the antiepileptic treatments, as well as the social impact of a negative attitude toward epilepsy. The present article presents a review of the methods proposed for the assessment of HRQOL in children with epilepsy. Most methods rely on parental reports; however, there is an increasing effort to develop tools taking the child's point of view into account. HRQOL tools have often been used in clinical trials and, especially, to evaluate the surgical treatments of epilepsy. For the clinician, HRQOL tools may be a preliminary approach to the patient's problems to be interpreted in relation to the patient's medical, psychological, cognitive, social and familial context. In France, few large-scale studies on HRQOL in children with epilepsy have been conducted. We present the preliminary results of a French study based on parental reports.

Epilepsy surgery in tuberous sclerosis complex: early predictive elements and outcome

The aim of the study was to evaluate the surgical treatment of epilepsy and detection of possible early surgery predictive elements in patients with tuberous sclerosis complex (TSC). Forty-two TSC patients with epilepsy were selected and divided into two main groups: definite and fruste forms. Definite forms were divided into different groups: patients with pharmacologically controlled epilepsy, patients with pharmacoresistant epilepsy excluded from surgery after an extensive presurgical assessment, and patients with a pharmacoresistant epilepsy who underwent surgery. We compared the definite TSC groups to identify elements that predict surgical candidacy. Second, we compared all operated patients to assess surgical outcome. We found several factors that could predict a surgical intervention even if identification of patients with refractory epilepsy who can benefit from surgery is an evolving process. Also, several positive factors for good surgical outcome were identified. Patients with the fruste form had excellent surgical outcome.

Cortectomies : aspects techniques

The surgical treatment of epilepsy requires careful preparation and presents a certain number of technical specificities. The neurosurgeon must master not only the technical aspects but also the therapeutic and functional trade-off in order to modulate the procedure according to morphological and electrophysiological intraoperative data. A large number of technical variants have been developed to correspond to epileptological or functional anatomical considerations. Until this point, the choice of a particular technique does not seem to have a significant impact on the therapeutic effectiveness of surgery, and differences in results can be related to the presurgical evaluation and surgical indications. On the other hand, technical development promises to play an important role in limiting the long-term neurocognitive consequences of surgery.

Early surgical treatment for epilepsy

To review recent evidence that can assist clinicians facing the challenging question of when to offer brain surgery for epilepsy. The most robust recent evidence pertains to temporal lobe epilepsy. We focus on this syndrome to assess the main issues pertaining to early surgery, which include natural history and effectiveness of medication, risks associated with continued seizures, effectiveness and risks of surgery, and cognitive outcomes in relation to timing of surgery. The evidence for performing surgery earlier is persuasive but incomplete. Recent evidence indicates that intractability, and therefore consideration for surgery, does not develop at a uniform time in surgical candidates, and that late remissions with medical treatment are not rare. Factors that may suggest sustained intractability include a larger number of medications tried, longer duration of seizures, history of status epilepticus, mental retardation, and nonidiopathic epilepsy. Adequate prospective studies, however, need to address this important question systematically. The evidence regarding morbidity, quality of life, mortality, social and cognitive function suggests that earlier surgery may be beneficial, but prospective controlled studies with standardized interventions and outcomes will be required to derive firm conclusions.

THE SURGERY OF EPILEPSY

The idea of surgical treatment for epilepsy is not new. However, widespread use and general acceptance of this treatment has only been achieved during the past three decades. A crucial step in this direction was the development of video electroencephalographic monitoring. Improvements in imaging resulted in an increased ability for preoperative identification of intracerebral and potentially epileptogenic lesions. High resolution magnetic resonance imaging plays a major role in structural and functional imaging; other functional imaging techniques (e.g., positron emission tomography and single-photon emission computed tomography) provide complementary data and, together with corresponding electroencephalographic findings, result in a hypothesis of the epileptogenic lesion, epileptogenic zone, and the functional deficit zone. The development of microneurosurgical techniques was a prerequisite for the general acceptance of elective intracranial surgery. New less invasive and safer resection techniques have been developed, and new palliative and augmentative techniques have been introduced. Today, epilepsy surgery is more effective and conveys a better seizure control rate. It has become safer and less invasive, with lower morbidity and mortality rates. This article summarizes the various developments of the past three decades and describes the present tools for presurgical evaluation and surgical strategy, as well as ideas and future perspectives for epilepsy surgery.

Surgical treatment of temporal lobe epilepsy

The surgical treatment of epilepsy is a therapeutic procedure aimed at removal of the brain tissue responsible for seizures. Neurological examinations are performed to delineate the epileptic zone, which is then removed, without causing a functional deficit. In order to fulfill these goals, it is essential to localize accurately and lateralize the epileptogenic zone and the surrounding eloquent cortex. Ninety-four adult patients were included in the study of the Epilepsy Center, National Institute of Psychiatry and Neurology, Budapest. All patients underwent a standard anterior temporal lobectomy between 1989 and 2001, whereas their preoperative evaluation consisted of detailed history of epilepsy, interictal EEG (awake and asleep), video EEG monitoring of seizures, magnetic resonance imaging, all according to the epilepsy protocol and neuropsychological investigations. The mean follow up was 6.1 years (range: 2-17 years). Seizure outcome was assessed annually, using Engel's classification. Seventy-two percents of patients were seizure-free 1 year after surgery. The percentage of seizure-free patients two, five and ten years after the surgery was 67%, 59%, and 61%, respectively. According to cost analysis, epilepsy surgery is considered to be cost effective. However, in the long run, indirect cost benefits (employment, independent living) add even more to the cost effectiveness of this method. Although the economic aspect is of great importance, especially in countries with limited financial resources, it is often neglected both by neurologists and health authorities.

Surgical Treatment of Epilepsy

Surgical Treatment of Epilepsy

The Effect of Dexmedetomidine on Electrocorticography in Patients with Temporal Lobe Epilepsy Under Sevoflurane Anesthesia

Although dexmedetomidine is often used in neuroanesthesia and neuronal critical care practice, its effect on cerebral electrical activity in those with an abnormal electroencephalogram is not known. The electrocorticogram (ECoG), a sensitive method for examining the effect of drugs on cerebral electrical activity and surgical treatment for epilepsy, is usually guided by monitoring of the ECoG. We investigated the effect of dexmedetomidine on ECoG in patients with epilepsy undergoing surgery with sevoflurane. Patients with medically intractable temporal lobe epilepsy undergoing resection of the epileptic foci (n = 11) were enrolled. Under general anesthesia with 2.5% sevoflurane and end-tidal carbon dioxide tension at 30 mm Hg, ECoG was recorded by strip electrodes with eight contacts placed on the mesial temporal lobe ipsilateral to the epilepsy foci. Dexmedetomidine was given as a computer-controlled infusion to achieve target plasma concentrations of 0.5 and 1.5 ng/mL. Each concentration was maintained for 20 min and ECoG was recorded before infusion of dexmedetomidine and between the 10th and 20th min after starting infusion. The median frequency of ECoG, spectral power density of each spectral band, and number of spikes at each concentration of dexmedetomidine were compared by Kruskal-Wallis test, followed by Student-Newman-Keuls test. The median frequency of ECoG in 88 leads from all leads from all patients was significantly decreased by 1.5 ng/mL of dexmedetomidine compared with those at baseline and 0.5 ng/mL (P = 0.003 and 0.03, respectively); however, spectral power densities in the frequency bands: delta (<4 Hz), theta (> or =4 and <8 Hz), alpha (> or =8 and <13 Hz), and beta (> or =13 Hz), were not changed. Neither the number of leads with spikes nor the number of spikes in all leads and in the lead with highest number of spikes at baseline was affected by dexmedetomidine. Dexmedetomidine at plasma concentrations of 0.48 and 1.60 ng/mL decreased the median frequency of ECoG, but did not affect spike activity in patients with temporal lobe epilepsy anesthetized with 2.5% sevoflurane.

Strategies for surgical treatment of epilepsies in developing countries

Epilepsy surgery has been proved to be efficacious, safe and cost-effective in developing countries. However, the success of epilepsy surgery depends on selecting suitable candidates based on the available resources and technologies. Some of the challenges to provide appropriate surgical treatment for epilepsy patients in developing countries include providing human and technological resources and developing realistic presurgical protocols. Detection of ideal candidates for epilepsy surgery is possible for well-trained epileptologists with the help of basic investigative technologies, for example, magnetic resonance imaging (MRI) and electroencephalography (EEG). Patients with potentially epileptogenic, well-circumscribed lesions on MRI and patients with mesial temporal lobe epilepsy (MTLE) are reasonable candidates for surgery. Palliative epilepsy surgeries include corpus callosotomy and other disconnections. These operations are feasible in developing countries with a knowledgeable team consisting of an epileptologist, neurosurgeon and technicians and with using MRI and EEG as basic investigative technologies.

Surgical Treatment of Epilepsy with Chronic Cerebral Granuloma Caused by Schistosoma japonicum

To study the surgical treatment of epilepsy with cerebral granuloma caused by Schistosoma japonicum. Two hundred fifty cases of epilepsy caused by cerebral schistosomiasis from 1955 to 2004 were analyzed retrospectively. There were no deaths. Follow-up of 196 cases for 4-5 years after operation demonstrated that 180 cases (92%) were seizure-free or well-controlled. Surgical treatment should be considered when drug therapy fails to control epilepsy or the lesion shows mass effect. Intraoperative electrocorticography monitoring is helpful to define the extent of the resection of the lesion.

Epilepsy Surgery in Children with Gliomatosis Cerebri

Gliomatosis cerebri (GC) is a rare neoplastic disorder that may present as intractable epilepsy during early life. We report our experience regarding the evaluation and the surgical treatment of epilepsy in this population. All children evaluated between 1990 and 2006 for surgery of epilepsy (n = 741) with pathologically proven GC were selected. We identified four male children with age at seizure onset ranging from 4 months to 11 years. Two had hemiparesis and one child with infantile spasms was developmentally delayed. Seizures occurred daily (n = 3) or monthly (n = 1). Ictal semiology was consistent with psychomotor seizures (n = 1), partial motor seizures (n = 2), and asymmetric epileptic spasms (n = 1). Surgery was symptomatic and aimed at debulking and controlling the epilepsy. Procedure was individually tailored based on the presurgical evaluation. Brain MRI revealed widespread hemispheric involvement (n = 3) or infiltration of the temporal lobe and basal ganglia (n = 1). Two patients were initially misdiagnosed as hemispheric cortical dysplasia and hemimegalencephaly. Scalp EEG was nonlocalizing in two cases, showed a right temporal focus in one case, and was not performed in one case. Interictal SPECT in one patient revealed widespread hemispheric hypoperfusion. Three cases were resected under ECoG guidance after a mean delay of 11 months after seizure onset. Following functional hemispherectomy (n = 1) or focal cortical resection (n = 2), all children were alive and seizure free with a mean follow-up of 48 months (2-5 years). No unexpected complication was reported. One nonoperated case was alive but still seizing after 15 months follow-up. Chemotherapy was associated in three cases. GC is a rare cause of medically resistant epilepsy that may present in early life. The lack of a discrete lesion may lead to diagnostic uncertainty, especially in infancy. Epilepsy surgery is an effective therapy that can improve quality of life.

Expression and cellular distribution of multidrug resistance-related proteins in patients with focal cortical dysplasia

Recent arouse of interest indicated that drug resistant proteins are markedly over-expressed in the epileptogenic tissue and they may be responsible for the one-third of the epileptic patients who were refractory to anti-epileptic drugs (AEDs). Since several AEDs may act as substrates for these drug resistant proteins, the enhanced function of such proteins may increase drug extrusion, resulting in inadequate response to drug therapy in patients with epilepsy. We studied expression of the multidrug resistance protein 1 (MDR1) and multidrug resistance-associated protein 1 (MRP1) in the epileptic tissues resected surgically in 28 patients with focal cortical dysplasia (FCD) by immunohistochemistry. The results were compared with 10 normal necropsy brain tissues. Normal brain showed no MDR1 expression in neurons and astrocytes, while MRP1 expression was very weak, which were encountered in a few samples. MDR1 expression was mainly localized on the vascular endothelial cells. In contrast to normal brain, we found intense MDR1 and MRP1 expression in both neurons and reactive astrocytes in the vast majority of dysplastic tissues. The majority of the dysplastic neurons demonstrated moderate to strong MRP1 immunoreactivity. Endothelial cells showed both MDR1 and MRP1 expression in the majority of the specimens studied. Multidrug transporters are over-expressed in the epileptogenic zone in patients with FCD. These results are concordant with previous studies, in which over-expression of multidrug proteins were shown in epileptogenic brain tissue in patients with FCD, that the over-expression of drug transport proteins in tissue from patients with refractory epilepsy may explain one possible mechanism for drug resistant in these pathologies.

Focal cortical dysplasia: long term seizure outcome after surgical treatment

Background: Studies of long term outcome after epilepsy surgery for cortical malformations are rare. In this study, we report our experience with surgical treatment and year to year long term...

Medical and surgical treatment of epilepsy

Medical and surgical treatment of epilepsy

Surgical treatment of epilepsy in Sturge–Weber syndrome in children

The authors sought to analyze the success rate of surgery in the management of medically intractable epilepsy in children with Sturge-Weber syndrome and to determine whether the extent and timing of surgery affected seizure and developmental outcomes. The authors performed a retrospective review of 27 children who underwent surgery at their institution for medically resistant epilepsy, and they examined the outcomes with regard to epilepsy control and neuropsychological development. Seventeen children (63%) experienced onset of their epilepsy when they were younger than 1 year of age. These patients were significantly more likely to have hemiparesis (p < or =0.001) and status epilepticus (p < or = 0.001) and be developmentally delayed (p < or = 0.025) than children whose epilepsy started later in life. Eight patients underwent a hemispherectomy (either anatomical or functional), and complete resolution of epilepsy was noted in all. Of the 19 patients in whom a focal resection was performed, 11 (58%) became seizure free. The 10 children in whom there was residual disease were more likely to have continuing epilepsy than the nine whose lesions were completely excised (p< or = 0.05). Seventeen children exhibited improvement in their developmental status following surgery. This improvement was significantly affected by completeness of resection (p< or = 0.05) and age at surgery (p< or = 0.009). Seizure freedom per se was not affected by the timing of surgery. Medically intractable epilepsy in children can be treated effectively by surgery. The degree of resection or disconnection of diseased tissue, but not patient age at the time of surgery, is an important factor in achieving epilepsy control. Early surgery is more likely to improve developmental outcome.

Visuelle Objektbenennungsstörungen in der neuropsychologischen Diagnostik und chirurgischen Therapie bei Temporallappenepilepsie

Die visuelle Objektbenennung ist ein konstruktiver Verarbeitungsprozess im Gehirn, bei dem externe Informationen sowie intern gespeichertes Wissen uber Form- und Bedeutungsmerkmale von Objekten zusammengefuhrt werden. Klinische und kognitionspsychologische Studien zeigen eine spezifische Beteiligung des linken Temporallappens an der zielgerichteten sprachlichen Klassifikation von Objekten. Es wird vermutet, dass Benennstorungen bei linkstemporalen Schadigungen durch Fehlfunktionen in der wissensgesteuerten, semantischen Verarbeitung komplexer visueller Objektreprasentationen resultieren. Storungen der Objektbenennung stellen ein wichtiges Begleitsymptom bei Epilepsien im linken Temporallappen (LTE) dar. Neben praoperativen Defiziten, die primar mit der Lokalisation des epileptischen Fokus in der sprachdominanten Hemisphare zusammenhangen, resultieren funktionelle Verschlechterungen vor allem durch linkstemporale epilepsiechirurgische Eingriffe. Risiken betreffen jedoch nicht alle Patienten gleichermasen, sondern werden in besonderer Weise durch epilepsiespezifische Faktoren bestimmt.

Evaluation of quality of life and clinical status of children operated on for intractable epilepsy

The aim of the study was evaluation of surgical treatment of epilepsy measured by changes in quality of life (QOL) and in seizure frequency and severity. Examined group consists of 24 boys and 9 girls. We performed corpus callosotomy, lesionectomy, vagal nerve stimulation, temporal lobectomy and multiple subpial transections. Age at surgery ranged from 5 months to 19 years, with mean follow-up of 11.9 months. QOL was evaluated on the basis of the questionnaire created by us, in which parents were asked to assess the following variables before and after the surgical procedure: communication, socialization, daily living skills, movement abilities and behavioural problems. The seizure frequency was assessed with the Engel's scale, the modified Engel's scale and the Seizure Scoring System. Clinical state of all the patients was evaluated as well. There were no patients with stable and worsening QOL status. In the whole group treated with callosotomy, the considerable improvement in QOL concerned 36.4% of cases. In more than 95% of cases, the reduction in seizures frequency is greater than 75%. In more than 43% of patients, there are no seizures after surgery. Surgical treatment of intractable epilepsy is an effective method in terms of both seizure control and QOL improvement. Our results indicate the improvement in QOL of all operated patients. The improvement in QOL was accompanied by decrease in frequency and 'positive' changes in morphology of seizures. Improvement in QOL, as equivalent to seizure reduction rate, may influence further differentiation of qualification methods and surgical procedures of epilepsy.

Pre-surgical evaluation and surgical treatment in children with extratemporal epilepsy

This review summarizes some patterns of pre-surgical evaluation and surgical treatment of extratemporal epilepsy in pediatric patients with medically refractory seizures, whose ictal behavior is variable. The most effective treatment for intractable partial epilepsy is a focal cortical resection with excision of the epileptogenic zone (the area of ictal onset and initial seizure propagation). This might be risky, though, in the case of a widespread lesion, sometimes encroaching one or more lobes, given the risk to the functional cerebral cortex. An anterior temporal lobectomy might prove more effective then in preventing seizures with fewer potential complications. If partial extratemporal epilepsy is associated with pharmaco-resistant seizures, the preoperative evaluation and operative strategy are determined according to the epileptogenic zone and to the relationship between a substrate-directed disorder and eloquent areas. The pediatric treatment of extratemporal epilepsy is aimed at controlling the seizures, avoiding morbidity, and improving the patient's quality of life through psychosocial integration. Since the immature brain is more plastic than when mature, the recovery of functions after surgery is greater in children than in adults. Early surgery is recommended for children with intractable epilepsy, and is now accepted as an important therapeutic modality also for children with chronic epilepsy. Technological advances in the last two decades, mainly in neuroimaging, have led many medical centers to consider surgical treatment of epilepsy, accuracy being granted by MRI-based neuronavigation systems-an interface between the lesion seen in the preoperative magnetic resonance imaging (MRI) and the operative field, often invisible to the surgeon.

Editorial on “Surgical treatment of epilepsy in children”

The diagnosis and the treatment of epilepsy represent one of the most rapidly evolving fields of neurosciences. Electroencephalographic video monitoring, more sophisticated neurophysiological investigations, more accurate neurocognitive tests, and advances in structural, functional, and metabolic neuroimaging have changed the way how epilepsy is approached over the last decade. New antiepileptic drugs have increased the number of subjects whose seizure disorder is controlled in comparison with the success rates recorded with the classical pharmacological agents. However, in spite of this broader availability of effective antiepileptic drugs, the surgical treatment of epilepsy is progressively more utilized in difficult cases. The phenomenon depends on a variety of factors: more reliable indications for the surgical candidacy better planned operative approaches, advanced surgical technology, improved intraand postoperative anesthesiological care, and gathering evidence that early surgical intervention may lessen the associated cognitive, behavioral, and psychological problems while favoring social integration. All these factors have contributed to deeply modify the previous attitude to consider the surgical treatment as the last therapeutic resort after having exhausted all available pharmacological agents. Nowadays, the surgical treatment of epilepsy is well established based on several surgical options with an obvious trend from the older to the younger ages and from resective to disconnective procedures. Vagus nerve stimulator, which was approved nearly 10 years age, is currently regarded as an effective option for some children with intractable epilepsy. Radiosurgical management is a further option, the utilization of which is going to increase as far as well-documented reports on large clinical series, with sufficiently long follow-up observation, appear in the literature and more clinical centers delivering such a treatment become available. This annual issue of Child’s Nervous System, which the Executive Committee of the International Society for Pediatric Neurosurgery decided to devote to the surgical treatment of epilepsy, is a further expression of the hope the neurosurgical community gives to the surgical therapy for improving the quality of life for a wide number of children with a variety of drug-resistant epilepsies. The Editors would like to thank all the contributors whose cooperation has allowed the publication of the issue, the Publisher and Mrs. G. Schroeder for their kind acceptation to increment the number of pages allotted, and Mrs. H. Haala for the great and continuous assistance in processing the manuscripts. Childs Nerv Syst (2006) 22:743 DOI 10.1007/s00381-006-0152-1

NO TITLE AVAILABLE

INTRODUÇÃO: Artigo de revisão baseado em analise crítica da literatura atual sobre o tratamento cirúrgico da epilepsia na infância. OBJETIVOS: Realizar revisão bibliográfica e atualização sobre a cirurgia de epilepsia na infância. RESULTADOS: A cirurgia da epilepsia tem como objetivo o controle das crises e a melhora da qualidade de vida do paciente sem determinar seqüelas inaceitáveis. Uma vez constatada a refratariedade das crises ao tratamento medicamentoso, o paciente deverá ser investigado para a correta localização da área responsável pelas crises, utilizando-se o vídeo-EEG para registro das crises, a avaliação neuropsicológica e os exames funcionais e anatômicos de neuro-imagem. Em relação ao momento da cirurgia, sabemos que: (1) os pacientes mais jovens apresentam melhores resultados quanto aos aspectos psicossociais; (2) a maior incidência de tumores ocultos nas epilepsias parciais refratárias na criança favorecem uma intervenção precoce; (3) a longa espera entre o início da epilepsia e a cirurgia pode predispor a um controle mais pobre das crises; e (4) a neuroplasticidade é um importante aliado nas crianças podendo reduzir o risco de déficit pós-operatório. O maior objetivo da cirurgia da epilepsia é o controle absoluto das crises. É importante também considerar o seguimento global do paciente, incluindo a satisfação dos pais, a melhora no desenvolvimento neuropsicomotor e social, as atividades da vida diária, as modificações comportamentais e no rendimento escolar. Nas séries pediátricas, 60-100% dos pacientes tem uma boa evolução pós-operatória. Os pacientes com epilepsia temporal têm uma maior taxa de ausência de crises quando comparados com o grupo extratemporal. CONCLUSÕES: A cirurgia da epilepsia em crianças tornou-se uma opção realística para casos selecionados e tende a se expandir num futuro próximo. Devemos reconhecer as formas de epilepsia que tem um curso catastrófico, evitando tentativas demoradas de controle com fármacos antiepilépticos que não mudarão a evolução da doença e que retardando o tratamento cirúrgico podem piorar o prognóstico. A terapêutica cirúrgica só deve ser indicada se houver uma boa oportunidade de melhorar a qualidade de vida do paciente.