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PubMed2001

Neurosurgical treatment of medically intractable status epilepticus.

Medically intractable status epilepticus can be defined as status epilepticus (SE) that persists or recurs despite medical treatment with intravenous agents that suppress cortical activity. We describe the successful neurosurgical treatment of three patients with medically intractable status epilepticus who responded either to focal resection, multiple subpial transection, or callosal section. The duration of medically intractable status epilepticus before surgery ranged between 23 and 42 days, and multiple medical complications occurred during the failed medical therapy. We suggest that patients with medically intractable status epilepticus who fail to respond to three courses of cerebral suppressant therapy for approximately 2 weeks be considered for surgical treatment in the absence of any known remitting etiology. Focal resection and/or subpial transection is preferred for intractable partial SE with focal electrographic changes or a focal lesion demonstrated by structural or functional neuroimaging. Corpus callosotomy may be used for patients with generalized or non-localizable intractable status epilepticus.

Adult↗

PubMed2001

Neurophysiological monitoring for epilepsy surgery: the Talairach SEEG method. StereoElectroEncephaloGraphy. Indications, results, complications and therapeutic applications in a series of 100 consecutive cases.

OBJECT OF THE STUDY: In some candidates for epilepsy surgery in whom the decision to operate is difficult to make, invasive presurgical investigations, namely depth electrode recordings, may be needed. The SEEG (StereoElectroEncephaloGraphy) method consists of stereotactic orthogonal implantation of depth electrodes (5 to 15, 11 on average). The object of this study is to clarify the indications for SEEG, to expose its complications, and to display its usefulness in terms of surgical strategy and results. PATIENTS AND METHODS: 100 patients, suffering from drug-resistant epilepsy and selected as candidates for surgical resection, underwent SEEG between 1996 and 2000. A total of 1,118 electrodes were implanted. For each single case, the sites of implantation of the electrodes were chosen in order to determine either the side of the onset of seizures, or the uni- or multilobar feature of them, or a possible operculo-insular propagation from a temporal onset, and also, using direct electrode stimulation, the proximity of speech or motor area. RESULTS: Complications occurred in 5 patients (2 superficial infections, 2 breakages of electrodes, and 1 intracerebral hematoma responsible for death). SEEG was helpful in most (84%) of the 100 patients to confirm or annul surgical indication, and to adjust the extent of the resection. In some cases (14%), SEEG allowed to propose a resection that might have been disputable based solely on noninvasive investigation data. For frontal epilepsy, SEEG was crucial in all cases to delineate the extent of resection. CONCLUSION: SEEG proved to be a relatively safe and a very useful method in 'difficult' candidates for epilepsy surgery. In addition, in some cases the implanted electrodes can be used to perform therapeutic RF thermocoagulation of epileptic foci or networks.

Adult↗

PubMed1996

Epileptic blindness in children: a localizing sign of various epileptic disorders.

UNLABELLED: The ictal manifestations, EEG, CT, and MRI correlates, as well as the management and outcome of 11 children with epileptic blindness are presented. Seven males and four females, aged 3 months to 12 years, experienced single or recurrent episodes of acute visual obscuration. Ictal blindness was the solitary epileptic phenomenon in only two children. The rest had other focal or generalized motor epileptic manifestations. Six children had either focal motor phenomena and/or unilateral EEG disturbances, with a normal head CT. The drug of choice in this group was carbamazepine and all became asymptomatic. Two patients had structural abnormalities of the brain, of which one had a low-grade occipital astrocytoma which was resected. His blindness abated shortly following initiation of carbamazepine, even prior to surgery. Status epilepticus amauroticus and focal motor seizures, secondary to focal cortical dysplasia, was detected in another 3-month-old infant. These required cortical resection and she regained full vision. Three patients had generalized epileptiform discharges on EEG, of which two were photic-induced. Blindness was accompanied with motor seizures and myoclonic jerks. Full seizure control could be achieved in only one child. CONCLUSION: our data suggest a relatively benign nature and a favorable outcome in most children with ictal blindness. Resection of a secondary temporo-parietal focus, as occurred in an infant with status epilepticus amauroticus which originated in the occipital region, may result in complete cessation of seizures and visual recovery.

Blindness↗

PubMed2002

[Magnetoencephalographic localization of multiple seizure foci for surgical treatment of intractable frontal lobe epilepsy: confirmation with intra-operative electrocorticography].

A successfully treated case of intractable FLE, of which preoperative magnetoencephalography (MEG) provided multiple spike localization and intraoperative corticogram (ECoG) confirmed the resection area. A 22-year-old male patient, with a history of subdural abscess at the age of 14 years, had suffered frequent simple (SPSs) and complex partial seizures (CPSs) and falling attacks since the age of 16 years. Although he underwent corpus callosotomy at the age of 17 years, additional surgical treatment was considered because of intractable and more frequent SPSs and CPSs. Magnetic resonance (MR) imaging demonstrated diffuse lesions in the right frontal lobe. Although, both interictal and ictal electroencephalography (EEG) failed to show focal epileptogenic localization, interictal MEG localized several clusters over the multiple anatomical lesions in the right prefrontal and frontal opercular regions. The patient underwent right fronto-temporal craniotomy, and anterior frontal lobectomy, followed by lesionectomy of the premotor area based on the intraoperative ECoG findings. The ECoG localized frequent spike discharges over the right prefrontal, frontal operculum and premotor cortices, which showed good correspondence with the MEG findings. MEG can be a useful noninvasive method for presurgical evaluation of intractable FLE.

Adult↗

PubMed2005

Naming ability after tailored left temporal resection with extraoperative language mapping: increased risk of decline with later epilepsy onset age.

Standard temporal resection in the left hemisphere carries the risk of postoperative naming ability decline, especially with later epilepsy onset age/absence of hippocampal sclerosis. Language mapping has been performed routinely at some centers to minimize postoperative primary language impairment, but its effect on changes in naming performance has not been explored. This study examined naming outcome in 24 patients with nonlesional epilepsy who had left temporal resection after extraoperative language mapping. The mean decline in Boston Naming Test (BNT) score was 7.8, and 13 (54%) patients had a BNT decline greater than the Reliable Change Index. Simple correlations found significant relationships between BNT score decline and: later onset age, higher preoperative BNT score, and resection of isolated language sites. A multiple regression analysis showed that onset age was the best predictor of BNT decline. Although naming ability in patients with early onset age is stable with language mapping, there is still a risk of decline for those with later onset age.

Adolescent↗

PubMed2001

Meningiomas of the orbit: contemporary considerations.

Meningiomas are the most frequently occurring benign intracranial neoplasms. Compared with other intracranial neoplasms they grow slowly, and they are potentially amenable to a complete surgical cure. They cause neurological compromise by direct compression of adjacent neural structures. Orbital meningiomas are interesting because of their location. They can compress the optic nerve, the intraorbital contents, the contents of the superior orbital fissure, the cavernous sinus, and frontal and temporal lobes. Because of its proximity to eloquent neurological structures, this lesion often poses a formidable operative challenge. Recent advances in techniques such as preoperative embolization and new modifications to surgical approaches allow surgeons to achieve their surgery-related goals and ultimately optimum patient outcome. Preoperative embolization may be effective in reducing intraoperative blood loss and in improving intraoperative visualization of the tumor by reducing the amount of blood obscuring the field and allowing unhurried microdissection. Advances in surgical techniques allow the surgeon to gain unfettered exposure of the tumor while minimizing the manipulation of neural structures. Recent advances in technology--namely, frameless computer-assisted image guidance--assist the surgeon in the safe resection of these tumors. Image guidance is particularly useful when resecting the osseous portion of the tumor because the tissue does not shift with respect to the calibration frame. The authors discuss their experience and review the contemporary literature concerning meningiomas of the orbit and the care of patients harboring such lesions.

Adult↗

PubMed1988

[Metastatic hepatoma presenting as intracranial hemorrhage: report of two cases].

Metastasis of hepatoma to the central nervous system is rare, although hepatoma is a relatively common malignant tumor in Japan. Much rarer is metastatic hepatoma presenting as intracranial hemorrhage and there have been only 4 cases reported in the past. Here, we report two such rare cases with a literature review. Case 1 was a 26 years-old female with a history of 60% hepatic resection in the diagnosis of hepatocellular carcinoma. Later, she developed bilateral lung metastasis. She was admitted with complaints of headache, nausea and vomiting. Neurological findings were clear consciousness, right homonymous hemianopsia and bilateral papilledema. CT showed high-density mass in the left occipital lobe. Evacuation of hematoma and removal of tumor were performed. Pathological diagnosis was hepatocellular carcinoma of clear cell type. Later, two other hemorrhage occurred from different metastatic lesions in the left occipital lobe and the right occipital lobe, and the patient underwent two more surgeries. The patient died of lung metastasis, three months from neurological onset. Case 2 was a 42 years-old male who developed an intracranial tumor adjacent to the right temporal bone without a history of hepatoma. The tumor was removed, which turned out to be hepatocellular carcinoma pathologically. Three months later, on admission, the patient showed sudden neurological deterioration into deep coma. CT showed an irregular high-density mass in the right temporal lobe and evacuation of hematoma coupled with tumor removal was performed. Pathology was of trabecular type. Later, intracranial recurrence and bony metastasis to C5, L3 and the left iliac bone appeared.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed2005

Long-term control after resection and gamma knife surgery of an intracranial clear cell meningioma: case report.

Clear cell meningioma (CCM) is a rare variant of meningioma characterized by sheets of polygonal cells with clear cytoplasm, a feature attributable to its high glycogen content. Authors have described its propensity to recur and metastasize despite its benign pathological characteristics. Clinical response to radiation in these reports has varied. The authors present the case of a 7-year-old girl with a large petroclival CCM who underwent a staged subtotal resection and subsequent gamma knife surgery (GKS). Initially, the residual tumor decreased in size, but 6 years later, it had regrown (9 mm in size). A second GKS treatment was performed and the mass completely regressed without further complication. The findings in this case suggest that GKS is a safe and effective adjunct for residual and recurrent CCM after resection. The delayed recurrence also emphasizes the importance of undertaking close follow-up examination after treating this potentially aggressive variant of meningioma.

Cerebellopontine Angle↗

PubMed2000

Contralateral cortical diaschisis in a patient with cerebellar astrocytoma after radiation therapy.

Contralateral cerebellar diaschisis, hypometabolism in the cerebellum contralateral to a cortical lesion, is a well described phenomenon in patients with stroke and brain tumor. However, few reports exist of patients with cerebellar lesions with the finding of contralateral cortical hypometabolism. The authors present a case of a patient with a right cerebellar astrocytoma after surgical resection and radiation therapy in which fluorine-18 fluorodeoxyglucose positron emission tomographic imaging, performed to rule out recurrent tumor, revealed global hypometabolism in the left cerebral cortex. The concept of contralateral cortical diaschisis and possible mechanisms and clinical implications are reviewed.

Adult↗

PubMed2000

Pure lesionectomy versus tailored epilepsy surgery in treatment of cavernous malformations presenting with epilepsy.

Cerebral cavernous malformations (CM) are well-circumscribed vascular malformations that often present with epileptic seizures. Although patients may initially benefit from antiepileptic drugs, surgical treatment may become necessary due to medically intractable seizures. However, it is unclear whether lesionectomy alone or tailored epilepsy surgery with previous invasive monitoring is the optimal strategy in such cases. We report two patients with epileptic seizures due to CM. One patient with few seizures prior to surgery became seizure-free following resection of the CM and the surrounding tissue. In the second patient with long-lasting epilepsy, lesionectomy was performed because of the proximity to a functioning left hippocampus. This limited resection failed and the patient still had seizures. Subsequently, invasive monitoring with intracranial depth and strip electrodes was performed in order to localize the epileptogenic area and determine whether the left hippocampus could be spared. The invasive study showed the seizure origin in the tissue around the former CM but no epileptic discharges in the hippocampus. In a second operation, an anterior temporal resection was performed with removal of the epileptogenic surrounding tissue and the patient became seizure-free without cognitive deficits. The optimal surgical strategy for CM presenting with epileptic seizures must take into account various factors such as underlying mechanisms and duration of epilepsy, and location of the lesion.

Adult↗

PubMed1999

[Noninvasive protocol for surgical treatment of focal epilepsies].

We present a non-invasive epilepsy surgery protocol, which includes EEG-video-monitoring, magnetic resonance imaging (MRI), interictal positron emission tomography (PET) and ictal single photon emission computerized tomography (SPECT). According to this non-invasive protocol 50 of 173 patients with medically intractable focal epilepsy underwent resective surgery. The localization of the epileptogenic zone was based on the congruence of the localizing results of EEG-video-monitoring, MRI, interictal PET and ictal SPECT. 46 (92%) of the patients had temporal and 4 (8%) had extratemporal epilepsies. 78% (n = 39) of all patients operated according to our non-invasive protocol were postoperatively completely or almost seizure free. Extramesiotemporal resections could be carried out without invasive EEG-recording if the epileptogenic zone was not adjacent to the eloquent cortex. We conclude from our results that in a considerable number of patients with medically intractable particularly temporal focal epilepsies, resective epilepsy surgery can be based on non-invasive EEG-evaluations and the risk of invasive recordings can be avoided.

Adolescent↗

PubMed1995

Treatment of complex partial status epilepticus unmasking acute intermittent porphyria in a patient with resected anaplastic glioma.

We report a 42-year-old woman with an established complex partial seizure disorder, who presented in refractory complex partial status epilepticus, the treatment of which with lorazepam, phenytoin, carbamazepine, and pentobarbital precipitated an attack of acute intermittent porphyria (AIP). The subsequent clinical course and management with gabapentin is discussed.

Adult↗

PubMed2003

Peculiar form of cerebral microdysgenesis characterized by white matter neurons with perineuronal and perivascular glial satellitosis: A study using a variety of human autopsied brains.

Microdysgenesis (MD) is a neuropathological term that implies a variety of minor developmental abnormalities of the brain. Recently, MD has been used for pathological diagnosis of cerebral tissues surgically resected from epileptic patients. However, criteria or consensus on pathological diagnosis of MD is still vague and controversial because of the lack of control studies. Therefore, this study paid special attention to the presence of white matter neurons with perineuronal glial satellitosis (WMN-GS) and perivascular glial satellitosis (PVGS) in the white matter, which are occasionally observed in epileptic foci, in order to clarify whether they could be handled as definite findings of MD. The materials included 80 autopsied whole brains ranging from normal subjects to patients with cerebrovascular disorder, neurodegenerative diseases and malformations. In each case, the presence of WMN-GS and/or PVGS was searched in 10 gyri in all five lobes (rostral frontal lobe, caudal frontal lobe, parietal lobe, temporal lobe and oc-cipital lobe) and evaluated. Statistically significant, WMN-GS and/or PVGS preferentially appeared in a diseased group consisting of neuronal migration disorder and related conditions, such as polymicrogyria, nodular heterotopia or tuberous sclerosis, leading to a suggestive conclusion that the presence of WMN-GS and/or PVGS could be a peculiar form of MD possibly derived from neuronal migrational arrest or related events, even if they appear alone without any other gross abnormalities.

Adolescent↗

PubMed2000

Language mapping in pretreatment planning of patients with cerebral arteriovenous malformation: a PET study.

PURPOSE: Three patients who had cerebral arteriovenous malformations underwent language mapping by positron emission tomography (PET) to identify the dominant hemisphere for language and the spatial relation of lesions to language areas. METHODS: Mapping was performed to assess the risk that surgery could cause neurologic deficits and to plan other therapeutic strategies. RESULTS: The information obtained by PET language mapping changed the course of management for these patients. Two patients were treated with stereotactic radiosurgery and one patient with surgical resection. CONCLUSIONS: PET imaging can be a valuable noninvasive tool for mapping the functional cortex and for preoperative planning of different treatment options in patients with arteriovenous malformations.

Adolescent↗

PubMedDate not supplied

Dysembryoplastic neuroepithelial tumor: a curable cause of seizures.

Dysembryoplastic neuroepithelial tumor (DNT) was first characterized in 1988 by Daumas-Duport and Scheithauer [1], who described 39 cases in children with morphologically distinct brain tumors. Partial complex seizures (PCSs), well-defined neuroimages, and typical pathologic findings were characteristic. Surgical resection of the tumor was usually curative. We present a new case of a child with PCSs who was diagnosed and treated for DNT. The clinical presentation and the difficulties of the differential diagnosis are discussed.

Anticonvulsants↗

PubMed2000

N-Acetylaspartate and creatine levels measured by (1)H MRS relate to recognition memory.

OBJECTIVES: To investigate the relationship between recognition memory and metabolite levels in medial structures of the temporal lobes in the living human brain. METHODS: Proton MRS ((1)H MRS) and the intracarotid amobarbital test were performed in 16 epileptic patients found suitable for temporal lobectomy. All patients had mesial temporal sclerosis. Metabolite ratios between N:-acetylaspartate (NAA), creatine and phosphocreatine (Cr + PCr), and choline-containing compounds (Cho) [NAA/(Cr + PCr), NAA/Cho, and NAA/(Cr + PCr + Cho)] were calculated for (1)H MRS voxels that included the amygdala, anterior half of the hippocampus, and underlying subiculum. Metabolite ratios were correlated with unilateral memory scores estimated by the intracarotid amobarbital test for words, objects, faces, and total score. RESULTS: The total memory score, memory for objects and faces, and NAA/(Cr + PCr) were significantly lower for the hemisphere ipsilateral to the resection. The asymmetry indexes for NAA/(Cr + PCr) correlated with asymmetry indexes for words (rho = 0.82, p = 0.0001) and total memory (rho = 0. 72, p = 0.002). Analysis of memory scores and metabolite ratios from all 32 hemispheres revealed a correlation between NAA/(Cr + PCr) and memory for words (rho = 0.45, p = 0.009). A correlation between memory for words and NAA/(Cr + PCr) existed in the contralateral (rho = 0.58, p = 0.019) and in the right (rho = 0.51, p = 0.045) hemispheres, and a trend was found in the left hemispheres (rho = 0. 48, p = 0.06). CONCLUSION: There is a correlation between memory for words and the NAA/(Cr + PCr) ratio from medial temporal structures in patients with mesial temporal sclerosis. The findings suggest that medial temporal structures and adjacent neocortex play a significant role in recognition memory in humans, particularly for words.

Adolescent↗

PubMed2001

Strategies for reoperation after comprehensive epilepsy surgery.

OBJECT: Prior reports of seizure control following reoperation for failed epilepsy surgery have shown good results. These studies included patients who presented during the era preceding magnetic resonance (MR) imaging, and the patients were often not monitored intracranially or underwent subtotal hippocampal resections. In this study, the authors hypothesized that reoperation for recurrent seizures following a more comprehensive initial workup and surgery would not yield such good results. METHODS: The authors examined a consecutive series of patients who underwent two operations at Yale-New Haven Hospital for medically intractable epilepsy and in whom there was a minimum of 1-year follow up after the second surgery. All patients were evaluated and treated according to a standard protocol, including preoperative MR imaging, a low threshold for invasive monitoring, and a radical amygdalohippocampectomy when indicated. Twenty-seven patients were identified (five with mesial temporal sclerosis, 20 with neocortical disease, and two with multifocal sites of seizure onset) of whom six (22%) underwent intentionally palliative second surgery (corpus callostomy or placement of a vagus nerve stimulator [VNS]). Of the remaining 21 patients, only four (19%) became seizure free after a second resective operation. The most common causes of treatment failure were dual pathology, recurrent tumor, limited resection to preserve function, widespread developmental abnormalities, and electrographic sampling error. Successful outcomes resulted from removal of recurrent tumors, completion of a functional hemispherectomy, or repeated invasive monitoring to correct a sampling error. Five (83%) of the six intentionally palliative second operations resulted in more than a 50% decrease in seizure frequency. CONCLUSIONS: If an aggressive preoperative evaluation and surgical resection are performed, reoperation for recurrent seizures has a much lower likelihood of cure than previously reported. Intentionally palliative surgery such as placement of a VNS unit may be considered for patients in whom the initial operation fails to decrease seizure frequency.

Adolescent↗

PubMed2001

The early identification of candidates for epilepsy surgery.

The effectiveness of resective surgery for the treatment of carefully selected patients with medically intractable, localization-related epilepsy is clear. Seizure-free rates following temporal lobectomy are consistently 65% to 70% in adults and 68% to 78% in children. Extratemporal resections less commonly lead to a seizure-free outcome, although one recent childhood series reported a seizure-free rate of 62% following extratemporal epilepsy surgery. With both temporal and extratemporal resections, additional patients have a reduction in seizures following surgery but are not completely seizure free. The identification of favorable surgical candidates has been the subject of extensive research, and many investigators have examined predictors of outcome following epilepsy surgery. However, the early identification of the potential epilepsy surgery candidate and the optimal timing of surgery have only occasionally been addressed in the literature. This issue is methodologically challenging to study since studies require large numbers of patients with new-onset partial epilepsy who are followed over time. The purpose of this article is to review the current ability for early prediction of medical intractability in patients with surgically remediable epilepsy. Emphasis will be placed on the early prediction of intractable temporal lobe epilepsy in children and adolescents, since temporal lobectomy remains the prototype epilepsy surgery, and early surgery may improve psychosocial outcome in younger patients.

Child↗