RESUMEN

AIMS: To investigate post-operative seizure outcomes, and predictors of surgical outcomes of the malformation of cortical development (MCD) in children with drug-resistant epilepsy (DRE) and age-specific characteristics. METHODS: We retrospectively analyzed clinical data from 428 children with MCD-related DRE who underwent curative surgical treatment. Statistical analyses were conducted to identify correlative characteristics, prognostic predictors, and differences among various age groups. RESULTS: After more than 3 years of follow-up, 81.3% of patients achieved Engel I outcomes. Prognosis was correlated with factors such as age at surgery, MRI findings, invasive EEG, pathology, acute postoperative seizures (APOS), and the number of preoperative and postoperative anti-seizure medications (AEDs). Age at surgery and the number of preoperative AEDs (p < 0.001) were significant predictors of seizure recurrence. Distinct clinical characteristics were observed among different age groups. CONCLUSION: Surgery is effective in terminating MCD-related DRE. Younger age at surgery and fewer preoperative AEDs are associated with better prognoses. Clinical characteristics vary significantly with age.

Asunto(s)

Epilepsia Refractaria , Malformaciones del Desarrollo Cortical , Humanos , Masculino , Femenino , Epilepsia Refractaria/cirugía , Niño , Estudios Retrospectivos , Preescolar , Lactante , Adolescente , Malformaciones del Desarrollo Cortical/cirugía , Malformaciones del Desarrollo Cortical/complicaciones , Malformaciones del Desarrollo Cortical/diagnóstico por imagen , Resultado del Tratamiento , Estudios de Seguimiento , Imagen por Resonancia Magnética , Electroencefalografía/tendencias , Anticonvulsivantes/uso terapéutico

RESUMEN

Hemispherotomy is an effective surgery for treating refractory epilepsy from diffuse unihemispheric lesions. To date, postsurgery neuroplastic changes supporting behavioral recovery after left or right hemispherotomy remain unclear. In the present study, we systematically investigated changes in gray matter volume (GMV) before and after surgery and further analyzed their relationships with behavioral scores in two large groups of pediatric patients with left and right hemispherotomy (29 left and 28 right). To control for the dramatic developmental effect during this stage, age-adjusted GMV within unaffected brain regions was derived voxel by voxel using a normative modeling approach with an age-matched reference cohort of 2115 healthy children. Widespread GMV increases in the contralateral cerebrum and ipsilateral cerebellum and GMV decreases in the contralateral cerebellum were consistently observed in both patient groups, but only the left hemispherotomy patients showed GMV decreases in the contralateral cingulate gyrus. Intriguingly, the GMV decrease in the contralateral cerebellum was significantly correlated with improvement in behavioral scores in the right but not the left hemispherotomy patients. Importantly, the preoperative voxelwise GMV features can be used to significantly predict postoperative behavioral scores in both patient groups. These findings indicate an important role of the contralateral cerebellum in the behavioral recovery following right hemispherotomy and highlight the predictive potential of preoperative imaging features in postoperative behavioral performance.

Asunto(s)

Epilepsia Refractaria , Sustancia Gris , Hemisferectomía , Imagen por Resonancia Magnética , Humanos , Hemisferectomía/métodos , Femenino , Masculino , Niño , Preescolar , Sustancia Gris/diagnóstico por imagen , Sustancia Gris/patología , Sustancia Gris/cirugía , Epilepsia Refractaria/cirugía , Epilepsia Refractaria/diagnóstico por imagen , Epilepsia Refractaria/patología , Adolescente , Cerebelo/diagnóstico por imagen , Cerebelo/cirugía , Cerebelo/patología , Plasticidad Neuronal/fisiología , Encéfalo/diagnóstico por imagen , Encéfalo/cirugía , Encéfalo/patología , Lateralidad Funcional/fisiología

RESUMEN

OBJECTIVE: To evaluate the long-term outcomes of subtotal hemispherotomy (SH) in treating drug-resistant epilepsy caused by unilateral hemispheric lesions and try to give the prognostic factors for these outcomes. METHODS: We retrospectively reviewed the clinical data of 19 patients who underwent SH in Sanbo Brain Hospital, Capital Medical University, Beijing, China, from May 2008 to April 2021. All clinical data and factors related to surgical and functional outcomes, including motor, neuropsychiatric, and language function, were collected and analyzed. RESULTS: The surgical outcomes showed 13 (68 %) patients were seizure-free at the last follow-up (2-14 years, mean: 5.6±2.9). No changes were found in motor outcomes in 12 (63 %) patients; seven (37 %) patients had new permanent motor deficits (NPMD). Improvement in the full-scale intelligence quotient (FIQ) (p = 0.009) was observed. Univariate analysis found that patients who did not achieve seizure freedom had a significantly older age at surgery (p = 0.017) and acute post-operative seizures (APOS) (p = 0.046). Kaplan-Meier analysis also identified significant differences in seizure outcomes between the children and adult subgroups (p = 0.0017). Multivariate Cox analysis showed that older age at surgery (HR=1.055, p = 0.034) was associated with shorter time-to-seizure-recurrence. Resection of the central operculum and insula (OR= 80.433, p =0.031) and higher monthly seizure frequency (OR= 1.073, p = 0.040) were also poor prognostic factors for motor function outcomes. CONCLUSION: SH is an effective treatment procedure in treating patients with drug-resistant epilepsy caused by hemispheric lesions with satisfied seizure outcomes, limited impairment of motor function, and preserving neuropsychiatric outcomes.

Asunto(s)

Epilepsia Refractaria , Hemisferectomía , Humanos , Epilepsia Refractaria/cirugía , Masculino , Femenino , Hemisferectomía/métodos , Estudios Retrospectivos , Niño , Adolescente , Resultado del Tratamiento , Adulto , Preescolar , Adulto Joven , Estudios de Cohortes , Estudios de Seguimiento

RESUMEN

AIM OF STUDY: Glutamate decarboxylase (GAD) enzyme can be a target intracellular antigen in autoimmune focal epilepsy. GAD65 antibody is in found patients diagnosed with drug-refractory temporal lobe epilepsy (TLE). We explore the clinical features of the disease and therapeutic options. MATERIAL AND METHODS: We present the cases of four TLE patients, two of them with type 1 diabetes. All of them were drug-resistant and therefore underwent presurgical evaluation, which revealed GAD65 antibody positivity. We discuss the four GAD65 antibody positive temporal lobe epilepsy patients' electroclinical data, the treatments, and their effectiveness. RESULTS: One of them became seizure-free after right anterior temporal lobe resection, two of them did not show significant improvement with immunmodulatory agents, and the fourth patient with the shortest duration of disease had significant improvement in seizure status and normalisation of cognitive status with IVIg therapy. CONCLUSIONS AND CLINICAL IMPLICATIONS: Our cases show that the earlier a GAD65 antibody is detected, the greater the chance of achieving seizure freedom or improvements in both seizure and cognitive status with immunomodulatory agents. However, in some cases, surgery may also bring seizure freedom, but with a risk of cognitive deterioration.

Asunto(s)

Autoanticuerpos , Epilepsia del Lóbulo Temporal , Glutamato Descarboxilasa , Humanos , Glutamato Descarboxilasa/inmunología , Epilepsia del Lóbulo Temporal/cirugía , Adulto , Femenino , Masculino , Persona de Mediana Edad , Diabetes Mellitus Tipo 1/complicaciones , Enfermedades Autoinmunes , Resultado del Tratamiento , Epilepsia Refractaria/cirugía

RESUMEN

Objective.For medically-refractory epilepsy patients, stereoelectroencephalography (sEEG) is a surgical method using intracranial electrode recordings to identify brain networks participating in early seizure organization and propagation (i.e. the epileptogenic zone, EZ). If identified, surgical EZ treatment via resection, ablation or neuromodulation can lead to seizure-freedom. To date, quantification of sEEG data, including its visualization and interpretation, remains a clinical and computational challenge. Given elusiveness of physical laws or governing equations modelling complex brain dynamics, data science offers unique insight into identifying unknown patterns within high-dimensional sEEG data. We apply here an unsupervised data-driven algorithm, dynamic mode decomposition (DMD), to sEEG recordings from five focal epilepsy patients (three with temporal lobe, and two with cingulate epilepsy), who underwent subsequent resective or ablative surgery and became seizure free.Approach.DMD obtains a linear approximation of nonlinear data dynamics, generating coherent structures ('modes') defining important signal features, used to extract frequencies, growth rates and spatial structures. DMD was adapted to produce dynamic modal maps (DMMs) across frequency sub-bands, capturing onset and evolution of epileptiform dynamics in sEEG data. Additionally, we developed a static estimate of EZ-localized electrode contacts, termed the higher-frequency mode-based norm index (MNI). DMM and MNI maps for representative patient seizures were validated against clinical sEEG results and seizure-free outcomes following surgery.Main results.DMD was most informative at higher frequencies, i.e. gamma (including high-gamma) and beta range, successfully identifying EZ contacts. Combined interpretation of DMM/MNI plots best identified spatiotemporal evolution of mode-specific network changes, with strong concordance to sEEG results and outcomes across all five patients. The method identified network attenuation in other contacts not implicated in the EZ.Significance.This is the first application of DMD to sEEG data analysis, supporting integration of neuroengineering, mathematical and machine learning methods into traditional workflows for sEEG review and epilepsy surgical decision-making.

Asunto(s)

Electrocorticografía , Humanos , Masculino , Femenino , Adulto , Electrocorticografía/métodos , Electroencefalografía/métodos , Algoritmos , Electrodos Implantados , Red Nerviosa/fisiopatología , Epilepsia Refractaria/cirugía , Epilepsia Refractaria/fisiopatología , Epilepsia/fisiopatología , Epilepsia/cirugía , Epilepsia/diagnóstico , Técnicas Estereotáxicas , Adulto Joven

RESUMEN

Focal cortical dysplasia type I (FCD I) is the most common cause of pharmaco-resistant epilepsy with the poorest prognosis. To understand the epileptogenic mechanisms of FCD I, we obtained tissue resected from patients with FCD I epilepsy, and from tumor patients as control. Using whole-cell patch clamp in acute human brain slices, we investigated the cellular properties of fast-spiking interneurons (FSINs) and pyramidal neurons (PNs) within the ictal onset zone. In FCD I epilepsy, FSINs exhibited lower firing rates from slower repolarization and action potential broadening, while PNs had increased firing. Importantly, excitatory synaptic drive of FSINs increased progressively with the scale of cortical activation as a general property across species, but this relationship was inverted towards net inhibition in FCD I epilepsy. Further comparison with intracranial electroencephalography (iEEG) from the same patients revealed that the spatial extent of pathological high-frequency oscillations (pHFO) was associated with synaptic events at FSINs.

Asunto(s)

Potenciales de Acción , Epilepsia , Interneuronas , Células Piramidales , Humanos , Interneuronas/fisiología , Femenino , Masculino , Células Piramidales/fisiología , Potenciales de Acción/fisiología , Epilepsia/fisiopatología , Adulto , Malformaciones del Desarrollo Cortical/fisiopatología , Adolescente , Adulto Joven , Niño , Técnicas de Placa-Clamp , Sinapsis/fisiología , Preescolar , Epilepsia Refractaria/fisiopatología , Epilepsia Refractaria/cirugía , Electrocorticografía

RESUMEN

In patients with drug-resistant epilepsy, difficulties in identifying the epileptogenic zone are well known to correlate with poorer clinical outcomes post-surgery. The integration of PET and MRI in the presurgical assessment of pediatric patients likely improves diagnostic precision by confirming or widening treatment targets. PET and MRI together offer superior insights compared to either modality alone. For instance, PET highlights abnormal glucose metabolism, while MRI precisely localizes structural anomalies, providing a comprehensive understanding of the epileptogenic zone. Furthermore, both methodologies, whether utilized through simultaneous PET/MRI scanning or the co-registration of separately acquired PET and MRI data, present unique advantages, having complementary roles in lesional and non-lesional cases. Simultaneous FDG-PET/MRI provides precise co-registration of functional (PET) and structural (MR) imaging in a convenient one-stop-shop approach, which minimizes sedation time and reduces radiation exposure in children. Commercially available fusion software that allows retrospective co-registration of separately acquired PET and MRI images is a commonly used alternative. This review provides an overview and illustrative cases that highlight the role of combining 18F-FDG-PET and MRI imaging and shares the authors' decade-long experience utilizing simultaneous PET/MRI in the presurgical evaluation of pediatric epilepsy.

Asunto(s)

Epilepsia , Fluorodesoxiglucosa F18 , Imagen por Resonancia Magnética , Tomografía de Emisión de Positrones , Cuidados Preoperatorios , Radiofármacos , Humanos , Imagen por Resonancia Magnética/métodos , Tomografía de Emisión de Positrones/métodos , Niño , Cuidados Preoperatorios/métodos , Epilepsia/diagnóstico por imagen , Epilepsia/cirugía , Imagen Multimodal/métodos , Preescolar , Adolescente , Femenino , Masculino , Epilepsia Refractaria/diagnóstico por imagen , Epilepsia Refractaria/cirugía

RESUMEN

Ninety percent of tuberous sclerosis complex (TSC) patients have seizures, with ∼50 % developing drug refractory epilepsy. Surgical intervention aims to remove the seizure onset zone (SOZ). This retrospective study investigated the relationship of SOZ size, ictal pattern, and extent of resection with surgical outcomes. TSC patients undergoing resective/ablative surgery with >1-year follow-up and adequate imaging were included. Preoperative iEEG data were reviewed to determine ictal pattern and SOZ location. For outcomes, an ILAE score of 1-3 was defined as good and 4-6 as poor. Forty-four patients were included (age 117.4 ± 110.8 months). Of these, 59.1 % achieved a good outcome, while 40.9 % had a poor outcome. Size of SOZ was a significant factor (p = 0.009), with the poor outcome group having a larger SOZ (11.9 ± 6.7 electrode contacts) than the good outcome group (7.3 ± 7.2). SOZ number was significant (p = 0.020); >1 SOZ was associated with poor outcome. These results demonstrate extent of SOZ as a predictor of seizure freedom following epilepsy surgery in a mostly pediatric TSC cohort. We hypothesize that these features represent biomarkers of focality of the epileptogenic zone and can be used to sharpen prognosis for epilepsy surgery outcomes in this cohort.

Asunto(s)

Electrocorticografía , Convulsiones , Esclerosis Tuberosa , Humanos , Esclerosis Tuberosa/cirugía , Esclerosis Tuberosa/complicaciones , Esclerosis Tuberosa/fisiopatología , Masculino , Femenino , Niño , Estudios Retrospectivos , Convulsiones/cirugía , Convulsiones/fisiopatología , Preescolar , Resultado del Tratamiento , Electrocorticografía/métodos , Adolescente , Electroencefalografía/métodos , Epilepsia Refractaria/cirugía , Epilepsia Refractaria/fisiopatología , Lactante , Epilepsia/cirugía , Epilepsia/fisiopatología , Procedimientos Neuroquirúrgicos/métodos , Adulto Joven , Encéfalo/cirugía , Encéfalo/fisiopatología , Estudios de Seguimiento

RESUMEN

OBJECTIVE: We retrospectively explored patients with drug-resistant epilepsy (DRE) who previously underwent presurgical evaluation to identify correlations between surgical outcomes and pathogenic variants in epilepsy genes. METHODS: Through an international collaboration, we evaluated adult DRE patients who were screened for surgical candidacy. Patients with pathogenic (P) or likely pathogenic (LP) germline variants in genes relevant to their epilepsy were included, regardless of whether the genetic diagnosis was made before or after the presurgical evaluation. Patients were divided into two groups: resective surgery (RS) and non-resective surgery candidates (NRSC), with the latter group further divided into: palliative surgery (vagus nerve stimulation, deep brain stimulation, responsive neurostimulation or corpus callosotomy) and no surgery. We compared surgical candidacy evaluations and postsurgical outcomes in patients with different genetic abnormalities. RESULTS: We identified 142 patients with P/LP variants. After presurgical evaluation, 36 patients underwent RS, while 106 patients were NRSC. Patients with variants in ion channel and synaptic transmission genes were more common in the NRSC group (48 %), compared with the RS group (14 %) (p<0.001). Most patients in the RS group had tuberous sclerosis complex. Almost half (17/36, 47 %) in the RS group had Engel class I or II outcomes. Patients with channelopathies were less likely to undergo a surgical procedure than patients with mTORopathies, but when deemed suitable for resection had better surgical outcomes (71 % versus 41 % with Engel I/II). Within the NRSC group, 40 underwent palliative surgery, with 26/40 (65 %) having ≥50 % seizure reduction after mean follow-up of 11 years. Favourable palliative surgery outcomes were observed across a diverse range of genetic epilepsies. SIGNIFICANCE: Genomic findings, including a channelopathy diagnosis, should not preclude presurgical evaluation or epilepsy surgery, and appropriately selected cases may have good surgical outcomes. Prospective registries of patients with monogenic epilepsies who undergo epilepsy surgery can provide additional insights on outcomes.

Asunto(s)

Epilepsia Refractaria , Humanos , Epilepsia Refractaria/genética , Epilepsia Refractaria/cirugía , Femenino , Masculino , Adulto , Estudios Retrospectivos , Resultado del Tratamiento , Adulto Joven , Persona de Mediana Edad , Mutación de Línea Germinal/genética , Procedimientos Neuroquirúrgicos/métodos , Variación Genética/genética , Adolescente

RESUMEN

AIM: Paediatric patients with drug-resistant focal epilepsy (DRFE) who have no clear focal lesion identified on conventional structural magnetic resonance imaging (MRI) are a particularly challenging cohort to treat and form an increasing part of epilepsy surgery programs. A recently developed deep-learning-based MRI lesion detection algorithm, the Multicentre Lesion Detection (MELD) algorithm, has been shown to aid detection of focal cortical dysplasia (FCD). We applied this algorithm retrospectively to a cohort of MRI-negative children with refractory focal epilepsy who underwent stereoelectroencephalography (SEEG) to determine its accuracy in identifying unseen epileptic lesions, seizure onset zones and clinical outcomes. METHODS: We retrospectively applied the MELD algorithm to a consecutive series of MRI-negative patients who underwent SEEG at our tertiary Paediatric Epilepsy Surgery centre. We assessed the extent to which the identified MELD cluster or lesion area corresponded with the clinical seizure hypothesis, the epileptic network, and the positron emission tomography (PET) focal hypometabolic area. In those who underwent resective surgery, we analysed whether the region of MELD abnormality corresponded with the surgical target and to what extent this was associated with seizure freedom. RESULTS: We identified 37 SEEG studies in 28 MRI-negative children in whom we could run the MELD algorithm. Of these, 14 (50 %) children had clusters identified on MELD. Nine (32 %) children had clusters concordant with seizure hypothesis, 6 (21 %) had clusters concordant with PET imaging, and 5 (18 %) children had at least one cluster concordant with SEEG electrode placement. Overall, 4 MELD clusters in 4 separate children correctly predicted either seizure onset zone or irritative zone based on SEEG stimulation data. Sixteen children (57 %) went on to have resective or lesional surgery. Of these, only one patient (4 %) had a MELD cluster which co-localised with the resection cavity and this child had an Engel 1 A outcome. CONCLUSIONS: In our paediatric cohort of MRI-negative patients with drug-resistant focal epilepsy, the MELD algorithm identified abnormal clusters or lesions in half of cases, and identified one radiologically occult focal cortical dysplasia. Machine-learning-based lesion detection is a promising area of research with the potential to improve seizure outcomes in this challenging cohort of radiologically occult FCD cases. However, its application should be approached with caution, especially with regards to its specificity in detecting FCD lesions, and there is still work to be done before it adds to diagnostic utility.

Asunto(s)

Algoritmos , Epilepsia Refractaria , Electroencefalografía , Imagen por Resonancia Magnética , Humanos , Niño , Imagen por Resonancia Magnética/métodos , Masculino , Femenino , Estudios Retrospectivos , Electroencefalografía/métodos , Adolescente , Epilepsia Refractaria/cirugía , Epilepsia Refractaria/diagnóstico por imagen , Preescolar , Convulsiones/diagnóstico por imagen , Convulsiones/cirugía , Epilepsias Parciales/diagnóstico por imagen , Epilepsias Parciales/cirugía , Tomografía de Emisión de Positrones/métodos , Encéfalo/diagnóstico por imagen

RESUMEN

MR-guided Laser Interstitial Thermal Therapy (MRgLITT) is a minimally invasive neurosurgical technique increasingly used for the treatment of drug-resistant epilepsy and brain tumors. Utilizing near-infrared light energy delivery guided by real-time MRI thermometry, MRgLITT enables precise ablation of targeted brain tissues, resulting in limited corridor-related morbidity and expedited postoperative recovery. Since receiving CE marking in 2018, the adoption of MRgLITT has expanded to more than 40 neurosurgical centers across Europe. In epilepsy treatment, MRgLITT can be applied to various types of focal lesional epilepsy, including mesial temporal lobe epilepsy, hypothalamic hamartoma, focal cortical dysplasias, periventricular heterotopias, cavernous malformations, dysembryoplastic neuroepithelial tumors (DNET), low-grade gliomas, tuberous sclerosis, and in disconnective surgeries. In neuro-oncology, MRgLITT is used for treating newly diagnosed and recurrent primary brain tumors, brain metastases, and radiation necrosis. This comprehensive review presents an overview of the current evidence and technical considerations for the use of MRgLITT in treating various pathologies associated with drug-resistant epilepsy and brain tumors.

Asunto(s)

Neoplasias Encefálicas , Terapia por Láser , Humanos , Neoplasias Encefálicas/cirugía , Neoplasias Encefálicas/diagnóstico por imagen , Terapia por Láser/métodos , Epilepsia/cirugía , Epilepsia/etiología , Imagen por Resonancia Magnética/métodos , Epilepsia Refractaria/cirugía , Epilepsia Refractaria/diagnóstico por imagen , Procedimientos Neuroquirúrgicos/métodos , Cirugía Asistida por Computador/métodos

RESUMEN

OBJECTIVE: To summarize the surgical outcomes of genetically refractory epilepsy and identify prognostic factors for these outcomes. METHODS: A literature search of the PubMed, Web of Science, and Embase databases for relevant studies, published between January 1, 2002 and December 31, 2023, was performed using specific search terms. All studies addressing surgical outcomes and follow-up of genetically refractory epilepsy were included. All statistical analyses were performed using STATA software (StataCorp LLC, College Station, TX, USA). This review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, 2020 (i.e., "PRISMA") reporting guidelines. RESULTS: Of the 3833 studies retrieved, 55 fulfilled the inclusion criteria. Eight studies were eligible for meta-analysis at the study level. Pooled outcomes revealed that 74 % of patients who underwent resective surgery (95 % confidence interval [CI] 0.55-0.89; z = 9.47, p < 0.05) achieved Engel I status at the last follow-up. In the study level analysis, pooled outcomes revealed that 9 % of patients who underwent vagus nerve stimulation achieved seizure-free status (95 % CI 0.00-0.31; z = 1.74, p < 0.05), and 61 % (95 % CI 0.55-0.89; z = 11.96, p < 0.05) achieved a 50 % reduction in seizure frequency at the last follow-up. Fifty-three studies comprising 249 patients were included in an individual-level analysis. Among patients who underwent lesion resection or lobectomy/multilobar resection, 65 % (100/153) achieved Engel I status at the last follow-up. Univariate analysis indicated that female sex, somatic mutations, and presenting with focal seizure symptoms were associated with better prognosis (p < 0.05). Additionally, 75 % (21/28) of patients who underwent hemispherectomy/hemispherotomy achieved Engel I status at the last follow-up. In the individual-level analysis, among patients treated with vagus nerve stimulation, 21 % (10/47) were seizure-free and 64 % (30/47) experienced >50 % reduction in seizure frequency compared with baseline. CONCLUSION: Meticulous presurgical evaluation and selection of appropriate surgical procedures can, to a certain extent, effectively control seizures. Therefore, various surgical procedures should be considered when treating patients with genetically refractory epilepsy.

Asunto(s)

Epilepsia Refractaria , Humanos , Epilepsia Refractaria/cirugía , Epilepsia Refractaria/genética , Resultado del Tratamiento , Procedimientos Neuroquirúrgicos , Estimulación del Nervio Vago

RESUMEN

OBJECTIVE: To identify the rate of successful antiseizure medication (ASM) withdrawal after resective surgery in patients with long-term epilepsy-associated tumors (LEATs). METHODS: A retrospective analysis (from our prospectively archived data) on the post-operative ASM profile of 123 consecutive patients who completed a minimum of 2 years after resection of LEATs for ASM-resistant epilepsy. A comparison between recurred and non-recurred groups in terms of seizure recurrence was used to identify the potential predictors of seizure recurrence whose attributes were further analyzed using univariate and multiple logistic regression analysis. Kaplan-Meier survival curves were used to study the probability of ASM freedom following surgery. RESULTS: We attempted ASM withdrawal in 102 (82.9 %) patients. Forty-eight (47.1 %) had seizure recurrence while reducing ASM, of which 22 (21.6 %) continued to have seizures even after ASM optimisation. On univariate analysis, presence of pre-operative secondary generalized seizure(s) was the only factor associated with seizure recurrence. At a mean follow-up of 6.1 years, 72 (58.5 %) patients were seizure-free and aura-free at terminal follow-up (53 patients were off any ASM). The cumulative probability of achieving complete ASM-free status was 29 % at fourth year, 42 % at sixth year, 55 % at eighth year, and 59 % at 10th year after surgery. CONCLUSIONS: Following resective surgery for LEATs, ASM(s) could be successfully discontinued in half of the patients. About one-third of the patients may have recurrent seizures on follow-up. Presence of secondary generalized seizure(s) prior to surgery predicts seizure recurrence, whereas MRI defined completeness of resection will not. This information will help in rationalising decisions on ASM management post-resection.

Asunto(s)

Anticonvulsivantes , Neoplasias Encefálicas , Humanos , Anticonvulsivantes/uso terapéutico , Masculino , Femenino , Adulto , Persona de Mediana Edad , Estudios Retrospectivos , Neoplasias Encefálicas/cirugía , Neoplasias Encefálicas/complicaciones , Adulto Joven , Epilepsia/cirugía , Epilepsia/tratamiento farmacológico , Adolescente , Resultado del Tratamiento , Convulsiones/tratamiento farmacológico , Convulsiones/etiología , Convulsiones/cirugía , Procedimientos Neuroquirúrgicos , Anciano , Recurrencia , Estudios de Seguimiento , Epilepsia Refractaria/cirugía , Epilepsia Refractaria/tratamiento farmacológico

RESUMEN

In patients suffering from focal drug-resistant epilepsy, intracranial explorations are the gold standard for identifying the epileptogenic zone and evaluating the possibility of a surgical resection. Amongst them, stereoelectroencephalography (SEEG), using depth electrodes, is a safe procedure. However, complications occur on average in 2% of cases, notably haemorrhages or infections. Vasogenic cerebral oedema constitutes a rarely reported complication. Amongst the 85 patients explored with SEEG between January 2017 and September 2023, three had a clinically and electrophysiologically relevant vasogenic cerebral oedema. In these three patients, the surgical procedure was uneventful. In all three as well, electrodes exploring areas away from the epileptogenic zone recorded some unexpected focal delta slowing with clinically asymptomatic superimposed discharges, a pattern so far only reported in cases of bleeding. Moreover, one patient experienced confusion 10 days after explantation. Post-explantation magnetic resonance imaging showed, in all three patients, a vasogenic oedema that fully resolved a few months later. We did not identify any contributing factors, and there were no particularities concerning the number of electrodes, their implantation site or the recording duration. Focal delta slowing and rhythmic discharges during SEEG can indicate a vasogenic oedema. Clinical consequences can occur after explantation. Evolution is favourable but this misleading pattern must be identified.

Asunto(s)

Edema Encefálico , Epilepsia Refractaria , Electroencefalografía , Humanos , Edema Encefálico/etiología , Edema Encefálico/fisiopatología , Edema Encefálico/diagnóstico por imagen , Femenino , Masculino , Epilepsia Refractaria/fisiopatología , Epilepsia Refractaria/cirugía , Epilepsia Refractaria/diagnóstico , Adulto , Técnicas Estereotáxicas , Electrodos Implantados/efectos adversos , Persona de Mediana Edad

RESUMEN

BACKGROUND: Mesial temporal lobe epilepsy associated with hippocampal sclerosis (MTLE/HS) is the most common cause of drug-resistant focal seizures and surgical resection is the primary treatment option, with seizure-free rates ranging from 60 to 80%. However, data on postsurgical seizure outcomes in patients ≥ 50 years of age are limited. This study aimed to assess the efficacy and safety of surgery in this age group compared to younger patients. METHODS: We performed a retrospective analysis of data from resective surgeries conducted in patients with MTLE/HS between 1990 and 2022. We focused on patients aged ≥ 50 years and compared the surgical safety and efficacy variables between this group and a control group of patients aged < 50 years through a case-control study. RESULTS: Among the 450 MTLE/HS patients who underwent surgery during the inclusion period, 61 (13.6%) were aged ≥ 50 years and matched with 183 younger patients, totaling 244 study participants. The two groups had similar characteristics. At the last follow-up (median 5.7 years), Engel I outcomes were achieved in 80.3% of the older patients and 81.4% of the younger patients, with no significant difference (p = 0.85). Postoperative cognitive and psychiatric outcomes did not differ between the groups. Major complication rates were also comparable, at 3.3% in the older group and 2.7% in the younger group (p = 0.83). The extratemporal ictal abnormalities observed on video-EEG were the only variable that demonstrated a significant association with an unfavorable seizure outcome in the older group (OR 9.3, 95% CI [1.8-47.6], p = 0.005). CONCLUSIONS: This study provides grade 3 evidence that resective surgery for MTLE/HS patients aged ≥ 50 years is as effective and safe as it is for younger patients, and thus should be considered as the primary treatment option for drug-resistant cases.

Asunto(s)

Epilepsia del Lóbulo Temporal , Hipocampo , Esclerosis , Humanos , Epilepsia del Lóbulo Temporal/cirugía , Persona de Mediana Edad , Masculino , Femenino , Esclerosis/cirugía , Hipocampo/cirugía , Hipocampo/patología , Estudios de Casos y Controles , Adulto , Estudios Retrospectivos , Anciano , Adulto Joven , Epilepsia Refractaria/cirugía , Epilepsia Refractaria/etiología , Factores de Edad , Procedimientos Neuroquirúrgicos/efectos adversos , Adolescente , Estudios de Seguimiento , Resultado del Tratamiento , Esclerosis del Hipocampo

RESUMEN

Vagus nerve stimulation (VNS) is an effective neuromodulatory treatment for patients with drug resistant epilepsy who cannot undergo curative surgical resection. Safety information states that the use of radiofrequency ablation devices may damage the VNS generator and leads. However, documented cases are scarce. This 62-year-old patient with bitemporal lobe epilepsy treated with VNS underwent radiofrequency ablation of an atrial fibrillation without any perioperative or postoperative complications.

Asunto(s)

Fibrilación Atrial , Ablación por Radiofrecuencia , Estimulación del Nervio Vago , Humanos , Fibrilación Atrial/cirugía , Fibrilación Atrial/terapia , Estimulación del Nervio Vago/efectos adversos , Estimulación del Nervio Vago/métodos , Persona de Mediana Edad , Ablación por Radiofrecuencia/métodos , Ablación por Radiofrecuencia/efectos adversos , Masculino , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodos , Epilepsia del Lóbulo Temporal/cirugía , Epilepsia del Lóbulo Temporal/terapia , Epilepsia Refractaria/cirugía , Epilepsia Refractaria/terapia

RESUMEN

INTRODUCTION: Patients with medication-resistant disabling epilepsy should be considered for potential epilepsy surgery. If noninvasive techniques are unable to identify the location of the seizure onset zone (SOZ), it becomes necessary to consider intracranial investigations. Stereo-electroencephalography (SEEG) is currently the preferred method for such monitoring, however foramen ovale (FO) electrodes offer a less invasive alternative that may be suitable in certain situations. Previous studies have demonstrated the effectiveness of FO electrodes in suspected mesial temporal epilepsy, nevertheless, increased experience with FO electrode use could further enhance their safety and efficacy. Therefore, we conducted an analysis of recent FO electrode investigations to assess their utility in surgical decision making, post resection outcomes, and complication rates. METHODS: We conducted a retrospective analysis of 61 patients who underwent FO placement at Mass General Brigham between 2009 and 2020. Patient and seizure characteristics, preoperative investigation data, and seizures outcomes were collected. In addition, identified predictors of FO utility using logistic regression. RESULTS: A total of 61 patients were identified. FO evaluation localized the SOZ in 56 % of patients. Complications were encountered in 1.6 % of patients. Subsequent surgical resection was pursued by 49 % of patients, with 56 % becoming seizure free, and 67 % having favorable seizure outcomes at last follow-up. Multivariate analysis identified younger patients with a higher number of preoperative ASMs as more likely to undergo subsequent treatment, however, these features were not predictive features of SOZ localization, seizure freedom, or favorable seizure outcomes. In patients with bitemporal or cross-over onsets on scalp EEG, FO was able to identify the SOZ in 79 %, whereas in patients with discordant or unclear onset, the rates were 71 % and 45 %, respectively. CONCLUSION: In a contemporary cohort, FO electrode placement had a low complication rate and a high utility primarily in cases of unclear laterality of mesial temporal onsets or discordance between scalp EEG and other pre-FO investigation data in cases of suspected mesial temporal onsets.

Asunto(s)

Epilepsia Refractaria , Electroencefalografía , Foramen Oval , Humanos , Femenino , Masculino , Adulto , Estudios Retrospectivos , Foramen Oval/cirugía , Electroencefalografía/métodos , Persona de Mediana Edad , Epilepsia Refractaria/cirugía , Epilepsia Refractaria/fisiopatología , Epilepsia Refractaria/diagnóstico , Adulto Joven , Convulsiones/cirugía , Convulsiones/fisiopatología , Convulsiones/diagnóstico , Electrodos Implantados , Técnicas Estereotáxicas , Adolescente , Electrodos

RESUMEN

Surgical resection of the epileptogenic zone (EZ) is an effective method for treating drug-resistant epilepsy. At present, the accuracy of EZ localization needs to be further improved. The characteristics of graph theory based on partial directed coherence networks have been applied to the localization of EZ, but the application of network control theory to effective networks to locate EZ is rarely reported. In this study, the method of partial directed coherence analysis was utilized to construct the time-varying effective brain networks of stereo-electroencephalography (SEEG) signals from 20 seizures in 12 patients. Combined with graph theory and network control theory, the differences in network characteristics between epileptogenic and non-epileptogenic zones during seizures were analyzed. We also used dung beetle optimized support vector machine classification model to evaluate the localization effect of EZ based on brain network characteristics of graph theory and controllability. The results showed that the classification of the average controllability feature was the best, and the area under the receiver operating characteristic (ROC) curve (AUC) was 0.9505, which is 1.32 % and 1.97 % higher than the traditional methods. The AUC value increased to 0.9607 after integrating the average controllability with other features. This study proved the effectiveness of controllability characteristic in identifying the EZ and provided a theoretical basis for the clinical application of network controllability in the EZ.

Asunto(s)

Epilepsia Refractaria , Electroencefalografía , Humanos , Masculino , Femenino , Electroencefalografía/métodos , Epilepsia Refractaria/cirugía , Epilepsia Refractaria/fisiopatología , Adolescente , Adulto , Encéfalo/fisiopatología , Encéfalo/cirugía , Adulto Joven , Máquina de Vectores de Soporte , Niño , Red Nerviosa/fisiopatología , Epilepsia/cirugía , Epilepsia/fisiopatología , Epilepsia/diagnóstico , Convulsiones/cirugía , Convulsiones/fisiopatología , Convulsiones/diagnóstico , Mapeo Encefálico/métodos , Curva ROC

RESUMEN

BACKGROUND: Stereoelectroencephalography (SEEG) is a procedure used to localize the epileptogenic zone in patients with medically refractory epilepsy, involving the stereotactic implantation of electrodes into brain parenchyma. Magnetic Resonance Imaging (MRI), Digital Subtraction Angiography, and Computed Tomography have been used preoperatively to prevent Intracranial Hemorrhage (ICH) by identifying electrode-vessel conflicts (EVC's) on planned electrode trajectories. There is variation in the use of Digital Subtraction Angiography and non-invasive sequences for vascular planning. Digital Subtraction Angiography provides high spatial resolution, but carries risks of arterial dissection, groin and retroperitoneal hematoma, and a 0.5-1.9% risk of stroke. Our group has incorporated Intravenous Cone Beam Computed Tomography (CBCT A/V) Brain into our SEEG workflow, given its effective implementation in other neurosurgical domains. Primary aims include validating the safety of our CBCT A/V sequence for SEEG planning and determining if CBCT A/V is comparable to other modalities in detecting EVC's. Secondary aims include elucidating the relationship of conflicting vessel calibre with ICH incidence in SEEG using CBCT A/V imaging. METHODS: A single-center retrospective study was conducted of 20 patients who underwent preoperative CBCT A/V Brain and MRI Brain with gadolinium enhancement, encompassing 273 electrode implantations from August 2020 - July 2023. The incidence and grade of post-implant, post-explant symptomatic ICH and asymptomatic ICH was noted. The total number of EVC's identifiable on MRI and CBCT A/V was recorded, along with average diameter of conflicting vessels. RESULTS: Across 20 patients and 273 implanted electrodes, there were four ICH events, where two were symptomatic and two were asymptomatic. The mean diameter of EVC's across all patients was 1.4 mm (±0.5). A significant difference (P < 0.0001) was observed between the number of EVC's that CBCT A/V could identify (20) compared to MRI (6). Two EVC's were identified in the region of two symptomatic ICH's, with the mean diameter of these conflicted vessels being 1.5 mm (±0.4). The two symptomatic ICH-associated EVC's were observed on CBCT A/V but not MRI. CONCLUSIONS: In our series, CBCT A/V demonstrates an acceptable safety profile for SEEG planning compared to other imaging modalities. CBCT A/V identified significantly more EVC's compared to MRI, including those contributing to transient symptomatic intracranial hemorrhage. A conflicting vessel calibre of less than 1.2 mm on CBCT A/V did not contribute to ICH in our SEEG series.

Asunto(s)

Electroencefalografía , Humanos , Estudios Retrospectivos , Masculino , Femenino , Adulto , Electroencefalografía/métodos , Electrodos Implantados/efectos adversos , Persona de Mediana Edad , Imagen por Resonancia Magnética/métodos , Epilepsia Refractaria/cirugía , Epilepsia Refractaria/diagnóstico por imagen , Tomografía Computarizada de Haz Cónico/métodos , Técnicas Estereotáxicas/efectos adversos , Angiografía de Substracción Digital/métodos , Adulto Joven , Adolescente , Encéfalo/diagnóstico por imagen , Encéfalo/cirugía , Hemorragias Intracraneales/diagnóstico por imagen

RESUMEN

Functional changes in the pediatric brain following neural injuries attest to remarkable feats of plasticity. Investigations of the neurobiological mechanisms that underlie this plasticity have largely focused on activation in the penumbra of the lesion or in contralesional, homotopic regions. Here, we adopt a whole-brain approach to evaluate the plasticity of the cortex in patients with large unilateral cortical resections due to drug-resistant childhood epilepsy. We compared the functional connectivity (FC) in patients' preserved hemisphere with the corresponding hemisphere of matched controls as they viewed and listened to a movie excerpt in a functional magnetic resonance imaging (fMRI) scanner. The preserved hemisphere was segmented into 180 and 200 parcels using two different anatomical atlases. We calculated all pairwise multivariate statistical dependencies between parcels, or parcel edges, and between 22 and 7 larger-scale functional networks, or network edges, aggregated from the smaller parcel edges. Both the left and right hemisphere-preserved patient groups had widespread reductions in FC relative to matched controls, particularly for within-network edges. A case series analysis further uncovered subclusters of patients with distinctive edgewise changes relative to controls, illustrating individual postoperative connectivity profiles. The large-scale differences in networks of the preserved hemisphere potentially reflect plasticity in the service of maintained and/or retained cognitive function.

Asunto(s)

Imagen por Resonancia Magnética , Neuroimagen , Humanos , Niño , Imagen por Resonancia Magnética/métodos , Femenino , Masculino , Adolescente , Neuroimagen/métodos , Epilepsia/cirugía , Epilepsia/fisiopatología , Epilepsia/diagnóstico por imagen , Corteza Cerebral/diagnóstico por imagen , Corteza Cerebral/fisiopatología , Corteza Cerebral/cirugía , Plasticidad Neuronal/fisiología , Epilepsia Refractaria/cirugía , Epilepsia Refractaria/diagnóstico por imagen , Epilepsia Refractaria/fisiopatología , Mapeo Encefálico/métodos , Lateralidad Funcional/fisiología