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Occult hemispherectomy: an unusual finding at autopsy

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... The specimen is linked to autopsy number 217/1970 and is part of the non-public section of the forensic specimen collection of the Institute of Legal Medicine and Forensic Sciences in Berlin. Previous papers have described other interesting specimens held in this collection [1,2]. ...
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To study the outcome after hemispherectomy (HP) in a homogeneous adult patient population with refractory hemispheric epilepsy. Fourteen adult patients submitted to HP were studied. Patients had to be at least 18 years old, and have refractory epilepsy, clearly focal lateralized seizures and unilateral porencephalus consistent with early middle cerebral artery infarct on magnetic resonance imaging (MRI). All patients were submitted to functional hemispherectomy. We analyzed age of seizure onset, age by the time of surgery, gender, seizure type and frequency, interictal and ictal electroencephalography (EEG) findings, MRI and IQ scores preoperatively; seizure frequency, drug regimen, and IQ outcome were studied postoperatively. Mean follow-up was 64 months. All patients had frequent daily seizures preoperatively. All patients had unilateral simple partial motor seizures (SPS); 11 patients had secondarily generalized tonic-clonic (GTC) seizures and five patients had complex partial seizures (CPS), preoperatively. All patients had hemiplegia and hemianopsia. Twelve patients had unilateral EEG findings, and in two epileptic discharges were seen exclusively over the apparently normal hemisphere. Twelve patients were seizure-free after surgery and two patients had at least 90% improvement in seizure frequency. Pre- and postoperative mean general IQ was 84 and 88, respectively. Five of the twelve Engel I patients were receiving no drugs at last follow-up. There was no mortality or major morbidity. Our results suggest that well-selected adult patients might also get good results after HP. Although good results were obtained in our adult series, the same procedure yielded a much more striking result if performed earlier in life.
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Anatomical hemispherectomy is frequently employed in the surgical management of pediatric patients with medically refractory epilepsy. In this chapter, we review the historical evolution of this surgical procedure, outline the indications and the criteria for selecting surgical candidates and describe the important pre-operative evaluation of the surgical candidates. We provide a detailed description of our surgical technique, anesthesiological considerations, and post-operative care plan. Ultimately we analyze the most common complications associated with this procedure. Anatomical hemispherectomy performed in carefully selected pediatric patients with medically intractable epilepsy can be a safe and efficacious surgical procedure.
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Hemispherectomy for intractable unihemispheric epilepsy (IUE) has long been established in pediatric patients. This study reports the first series examining hemispherectomy exclusively in adult patients (>18 years old). Nine adults with IUE underwent hemispherectomy at the University of Minnesota. All patients had unilateral hemiplegia and visual field loss. Seven patients (77.8%) were Engel class I/II at last follow-up. Five (83.3%) of the six patients with >30 years of follow-up were seizure free. No surgery-related mortality, hydrocephalus, or superficial cerebral hemosiderosis occurred. Hemispherectomy is an effective procedure in appropriately selected adult patients, resulting in excellent long-term seizure control and no mortality.
Fig. 3 Oblique intracranial view of specimen 172 CBF demonstrating the location were surgery took place. The falx cerebri, and the areas were the right cerebral hemisphere was disconnected during surgery, are visible 124
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Leestma JE. Forensic neuropathology. New York: Raven Press; 1988. Fig. 3 Oblique intracranial view of specimen 172 CBF demonstrating the location were surgery took place. The falx cerebri, and the areas were the right cerebral hemisphere was disconnected during surgery, are visible 124 Forensic Sci Med Pathol (2013) 9:122–124 123
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R. Gapert (&) Á M. Tsokos Institute of Legal Medicine and Forensic Sciences, Charité – University Medicine Berlin, Berlin, Germany e-mail: rene.gapert@ucd.ie R. Gapert Human Anatomy Laboratory, UCD School of Medicine and Medical Science, University College Dublin, Dublin, Ireland N. Widulin Berlin Museum of Medical History, Charité – University Medicine Berlin, Berlin, Germany References
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