Article

Extratemporal, nonlesional epilepsy in children: Postsurgical clinical and neurocognitive outcomes

Pediatric Epilepsy Center, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri 63110-1002, USA.
Journal of Neurosurgery Pediatrics (Impact Factor: 1.48). 02/2011; 7(2):179-88. DOI: 10.3171/2010.11.PEDS10265
Source: PubMed

ABSTRACT

Patients undergoing epilepsy surgery without evidence of a lesion on MR imaging and without a temporal source for seizure onset generally have less favorable outcomes than patients with structural lesions or temporal onset. However, many of these patients are viable candidates for invasive monitoring and subsequent resection or multiple subpial transections (MSTs). The purpose of this study was to evaluate the surgical treatment of pediatric patients with extratemporal, nonlesional epilepsy in order to better understand the clinical and neuropsychological outcomes expected in this patient group.
Forty-three pediatric patients with negative results on MR imaging and lateralized, extratemporal findings on electroencephalography underwent invasive monitoring with grid and/or strip electrodes. Thirty-three subsequently had resection of an epileptogenic focus and/or MSTs.
Outcome was classified as Engel class I or II in 54.5% of the patients who underwent resection/MSTs and Engel class III or IV in 45.5%. Use of MSTs was associated with poor outcome. Neuropsychological evaluation showed significant improvement in immediate auditory attention following surgery and revealed several significant results on subgroup analysis. Complications occurred in 14% of patients (a 7% rate per procedure). Ten patients (23%) underwent invasive monitoring without proceeding to therapeutic surgery because no epileptogenic region was amenable to resection. Neuropsychological outcomes were generally stable.
Patients with extratemporal, nonlesional seizures are viable candidates for invasive monitoring with grid/strip electrodes, and good outcomes can be obtained with resective surgery. The use of MSTs may correlate with worse outcome. This study also provides additional data to assist in counseling patients on the risks of negative invasive monitoring, deficits resulting from resection/MSTs, and possible operative complications.

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Available from: Jeffrey B. Titus, Jun 13, 2014
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    • "D'autres e ´ tudes ré trospectives rapportent mê me des taux de liberté de crises compris entre 50 et 75 % [113] [114] [115] [116] [117]. Pour la chirurgie extratemporale exclusivement non lé sionnelle, les ré sultats sont logiquement moins flatteurs avec 54,5 % des enfants classé s Engel I ou II, mais sans dé gradation du bilan neuropsychologique postopé ratoire [118]. E ´ galement, en postopé ratoire, il n'a pas e ´ té montré de modification des fonctions cognitives ou psychopathologies pré existantes, ces derniè res touchant 52 % des enfants opé ré s [119] [120]. "
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    ABSTRACT: The aim of this article was to review and evaluate the published literature related to the outcome of epilepsy surgery, while placing it in an historical perspective, and to describe the future prospects in this field.
    Full-text · Article · Dec 2014 · Revue Neurologique
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    • "D'autres e ´ tudes ré trospectives rapportent mê me des taux de liberté de crises compris entre 50 et 75 % [113] [114] [115] [116] [117]. Pour la chirurgie extratemporale exclusivement non lé sionnelle, les ré sultats sont logiquement moins flatteurs avec 54,5 % des enfants classé s Engel I ou II, mais sans dé gradation du bilan neuropsychologique postopé ratoire [118]. E ´ galement, en postopé ratoire, il n'a pas e ´ té montré de modification des fonctions cognitives ou psychopathologies pré existantes, ces derniè res touchant 52 % des enfants opé ré s [119] [120]. "
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    ABSTRACT: The aim of this article was to review and evaluate the published literature related to the outcome of epilepsy surgery, while placing it in an historical perspective, and to describe the future prospects in this field. Temporal lobe surgery achieves seizure freedom in about 70% of cases. Seizure outcome is similar in the pediatric population. Extratemporal resections impart good results to 40% to 60% of patients, with a better prognosis in the case of frontal lobe surgery. Pediatric hemispherotomy leads to seizure control in about 80% of children. Radiosurgery used as a treatment for temporal mesial epilepsy has an outcome quite similar to that obtained with surgical resection, but provides a neuropsychological advantage. Radiosurgery is also effective in 60% of children treated for seizures related to hypothalamic hamartoma. Regarding palliative surgery, callosotomy and multiple subpial transections show satisfactory outcomes in over 60% of cases. Neuromodulation techniques (vagus nerve stimulation and bilateral stimulation of the anterior nucleus of the thalamus) allow a 50% reduction of seizures in half of patients. Transcranial magnetic stimulation combined with electroencephalography seems a promising technique because of its diagnostic, prognostic and therapeutic applications. Transcranial ultrasound stimulation, which can reversibly control neuronal activity, is also under consideration. Concerning neuromodulation, trigeminal nerve stimulation may become an alternative to vagus nerve stimulation; while other targets of deep brain stimulation are being evaluated. Also, the possibility of coupling SEEG seizure focus detection with concomitant laser or radiofrequency focus destruction is under development. Constant evolution of epilepsy surgery has improved patient outcomes over time. Current research and development axes suggest the continuation of this trend and a reduction of the invasiveness of surgical procedures.
    Full-text · Article · Dec 2014 · Revue Neurologique
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    ABSTRACT: Ganglioglioma is the most common neoplasm causing focal epilepsy, accounting for approximately 40% of all epileptogenic tumors and for 1-4% of all pediatric CNS tumors. The optimal surgical treatment for pediatric epileptogenic ganglioglioma has not been fully established. The authors present their experience in the surgical management of these lesions. The authors retrospectively analyzed seizure outcome and surgical results of pediatric patients with ganglioglioma treated with resection. The patients' charts were reviewed for demographic data, clinical presentation, surgical therapy, and follow-up. The 30 patients (17 boys, 13 girls) had a history of medically intractable epilepsy. Total resection of tumor was achieved with or without adjacent epileptogenic tissue resection in all patients except 1, who underwent cyst fenestration and biopsy. Intraoperative electrocorticography (ECoG) was used in 21 patients. If an active spike focus or profound attenuation was observed in adjacent tissues, resection of those tissues was performed in addition to complete tumor resection (lesionectomy). The interval between onset of seizures and surgery ranged from 1 month to 9 years (mean 1.6 years). Patient age at the time of surgery ranged from 9 months to 16.3 years (mean 8.6 years). Twenty-five patients (83.3%) had complex partial seizures and 5 (16.7%) had simple partial seizures. Eighteen tumors (60%) were temporal (14 temporomesial, 4 temporolateral), and 12 (40%) were extratemporal. The mean follow-up period was 3.4 years (range 1 month-8.16 years). In 2 cases (6.7%), tumor recurrence was observed. Outcome was Engel Class I in 27 cases (90.0%; 14 temporomesial, 4 temporolateral, 9 extratemporal) and Engel Class II in 3 (10.0%; all extratemporal). Tumor resection allowed good seizure control, especially in the 18 cases of temporal ganglioglioma (all Engel Class I postoperatively). Eleven patients underwent removal of extratumoral epileptogenic tissue (anterior temporal neocortex resection in 10, anterior temporal neocortex resection with anterior hippocampectomy in 1) in addition to lesionectomy using intraoperative ECoG. Lesionectomy with adjacent temporal neocortex resection using intraoperative ECoG provided good seizure control of pediatric temporal ganglioglioma. For extratemporal ganglioglioma, lesionectomy alone can provide fairly good seizure control. Considering the memory function of the hippocampus, lesionectomy with adjacent temporal neocortical resection can be a safe, feasible, and effective treatment option for epileptogenic gangliogliomas in pediatric patients.
    Preview · Article · Mar 2010 · Journal of Neurosurgery Pediatrics
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