Clinical outcomes of pediatric hemispherectomy following unsuccessful subhemispheric resection for refractory epilepsy: a case review study

Author:

Akiyama Lisa F.12,Roberts Emma A.3,Shurtleff Hillary A.14,Barry Dwight5,Saneto Russell P.124,Novotny Edward J.124,Young Christopher C.6,Warner Molly H.14,Hauptman Jason S.478,Ojemann Jeffrey G.478,Marashly Ahmad9

Affiliation:

1. Departments of Neurology,

2. Departments of Neurology and

3. Department of Obstetrics and Gynecology, University of California San Diego School of Medicine, La Jolla, California;

4. Center for Integrated Brain Research, Seattle Children’s Hospital, Seattle, Washington;

5. Clinical Analytics, and

6. Department of Neurosurgery, Johns Hopkins University Medical Center; and

7. Neurological Surgery, Seattle Children’s Hospital, Seattle;

8. Neurological Surgery, University of Washington School of Medicine, Seattle, Washington;

9. Department of Neurology, Epilepsy Center, Johns Hopkins University Medical Center, Baltimore, Maryland

Abstract

OBJECTIVE Epilepsy surgery remains one of the most underutilized procedures in epilepsy despite its proven superiority to other available therapies. This underutilization is greater in patients in whom initial surgery fails. This case series examined the clinical characteristics, reasons for initial surgery failure, and outcomes in a cohort of patients who underwent hemispherectomy following unsuccessful smaller resections for intractable epilepsy (subhemispheric group [SHG]) and compared them to those of a cohort of patients who underwent hemispherectomy as the first surgery (hemispheric group [HG]). The objective of this paper was to determine the clinical characteristics of patients in whom a small, subhemispheric resection failed, who went on to become seizure free after undergoing a hemispherectomy. METHODS Patients who underwent hemispherectomy at Seattle Children’s Hospital between 1996 and 2020 were identified. Inclusion criteria for SHG were as follows: 1) patients ≤ 18 years of age at the time of hemispheric surgery; 2) initial subhemispheric epilepsy surgery that did not produce seizure freedom; 3) hemispherectomy or hemispherotomy after the subhemispheric surgery; and 4) follow-up for at least 12 months after hemispheric surgery. Data collected included the following: patient demographics; seizure etiology; comorbidities; prior neurosurgeries; neurophysiological studies; imaging studies; and surgical details—plus surgical, seizure, and functional outcomes. Seizure etiology was classified as follows: 1) developmental, 2) acquired, or 3) progressive. The authors compared SHG to HG in terms of demographics, seizure etiology, and seizure and neuropsychological outcomes. RESULTS There were 14 patients in the SHG and 51 patients in the HG. All patients in the SHG had Engel class IV scores after their initial resective surgery. Overall, 86% (n = 12) of the patients in the SHG had good posthemispherectomy seizure outcomes (Engel class I or II). All patients in the SHG who had progressive etiology (n = 3) had favorable seizure outcomes, with eventual hemispherectomy (1 each with Engel classes I, II, and III). Engel classifications posthemispherectomy between the groups were similar. There were no statistical differences in postsurgical Vineland Adaptive Behavior Scales Adaptive Behavior Composite scores or postsurgical full-scale IQ scores between groups when accounting for presurgical scores. CONCLUSIONS Hemispherectomy as a repeat surgery after unsuccessful subhemispheric epilepsy surgery has a favorable seizure outcome, with stable or improved intelligence and adaptive functioning. Findings in these patients are similar to those in patients who had hemispherectomy as their first surgery. This can be explained by the relatively small number of patients in the SHG and the higher likelihood of hemispheric surgeries to resect or disconnect the entire epileptogenic lesion compared to smaller resections.

Publisher

Journal of Neurosurgery Publishing Group (JNSPG)

Subject

General Medicine

Reference44 articles.

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4. Hemispherectomy for treatment of refractory epilepsy in the pediatric age group: a systematic review;Griessenauer CJ,2015

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