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  • Author or Editor: Lara Jehix
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Temporal lobe epilepsy surgery failures: predictors of seizure recurrence, yield of reevaluation, and outcome following reoperation

Clinical article

Lara E. Jehi, Diosely C. Silveira, William Bingaman, and Imad Najm

Object

The authors provide a systematic analysis of electroclinical characteristics in patients with persistent seizures following temporal lobe epilepsy (TLE) surgery and identify ideal candidates for reoperation.

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The authors retrospectively reviewed the records of 68 adult patients (mean follow-up 8.7 years) who underwent a video electroencephalography evaluation and high-resolution imaging after failed TLE surgery performed between 1990 and 2004 at The Cleveland Clinic. Multivariate logistic regression analyses were performed to identify predictors of the yield of a repeat evaluation, location of the recurrence focus, and outcome following reoperation.

Results

Although a focus of recurrence was identified in 44 patients, only 15 underwent reoperation, and only 6 of these became seizure free. Localized foci of recurrence were successfully identified in patients with early (within 1 postoperative year) and frequent (≥ 4 per month) recurrent seizures (yield of 100% if both conditions were fulfilled). Predictors of contiguity of the focus of recurrence to the initial surgical bed were variable depending on the type of the initial surgery: patients with baseline contralateral temporal spiking were 6 times (OR 6.34, p < 0.05) more likely to experience seizure recurrence from the contralateral temporal lobe after a “standard” temporal lobectomy, while the need to use subdural electrodes and the timing of recurrence were more significant following limited temporal resections. The focus of recurrence was distant to the original surgical bed when subdural electrodes were used prior to first surgery (OR 28.0, p = 0.01) or when seizures recurred early (within < 6 postoperative months; OR 12.5, p = 0.04). With reoperation, only patients with mesial and basal extension of the temporal resections became seizure free. Interestingly, seizure freedom was achieved with medical therapy alone in 42% of patients with a nonidentifiable recurrence focus as opposed to 4% of those with an unoperated identifiable focus.

Conclusions

反复发作的时间和频率符合lowing unsuccessful TLE surgery provide useful guidelines for the yield of a surgical reevaluation, and potentially for the mechanisms of surgical failure.

InJournal of Neurosurgery Volume 113 (2010): Issue 6 (Dec 2010)

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Correlation between magnetoencephalography-based “clusterectomy” and postoperative seizure freedom

Sumeet Vadera, Lara Jehi, Richard C. Burgess, Katherine Shea, Andreas V. Alexopoulos, John Mosher, Jorge Gonzalez-Martinez, and William Bingaman

Object

During the presurgical evaluation of patients with medically intractable focal epilepsy, a variety of noninvasive studies are performed to localize the hypothetical epileptogenic zone and guide the resection. Magnetoencephalography (MEG) is becoming increasingly used in the clinical realm for this purpose. No investigators have previously reported on coregisteration of MEG clusters with postoperative resection cavities to evaluate whether complete “clusterectomy” (resection of the area associated with MEG clusters) was performed or to compare these findings with postoperative seizure-free outcomes.

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The authors retrospectively reviewed the charts and imaging studies of 65 patients undergoing MEG followed by resective epilepsy surgery from 2009 until 2012 at the Cleveland Clinic. Preoperative MEG studies were fused with postoperative MRI studies to evaluate whether clusters were within the resected area. These data were then correlated with postoperative seizure freedom.

Results

Sixty-five patients were included in this study. The average duration of follow-up was 13.9 months, the mean age at surgery was 23.1 years, and the mean duration of epilepsy was 13.7 years. In 30 patients, the main cluster was located completely within the resection cavity, in 28 it was completely outside the resection cavity, and in 7 it was partially within the resection cavity. Seventy-four percent of patients were seizure free at 12 months after surgery, and this rate decreased to 60% at 24 months. Improved likelihood of seizure freedom was seen with complete clusterectomy in patients with localization outside the temporal lobe (extra–temporal lobe epilepsy) (p = 0.04).

Conclusions

In patients with preoperative MEG studies that show clusters in surgically accessible areas outside the temporal lobe, we suggest aggressive resection to improve the chances for seizure freedom. When the cluster is found within the temporal lobe, further diagnostic testing may be required to better localize the epileptogenic zone.

InNeurosurgical Focus Volume 34 (2013): Issue 6 (Jun 2013): Epilepsy

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Determinants of epileptogenic zone identification and seizure outcome in children with refractory epilepsy undergoing stereoelectroencephalography

Jason K. Hsieh, Swetha J. Sundar, Elaine Lu, Ansh Desai, Ajay Gupta, Ahsan N. Moosa, William Bingaman, Lara Jehi, and Juan Bulacio

OBJECTIVE

The objective of this paper was to investigate the factors associated with successful epileptogenic zone (EZ) identification and postsurgical seizure freedom in pediatric patients with drug-resistant epilepsy who underwent first-time stereoelectroencephalography (SEEG).

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The authors conducted a retrospective cohort study of all consecutive patients younger than 18 years of age at the time of recommendation for invasive evaluation with SEEG who were treated from July 2009 to June 2020. The authors excluded patients who had undergone failed prior resective epilepsy surgery or prior intracranial electrode evaluation for seizure localization. For their primary outcome, the authors evaluated the relationship between clinical and radiographic factors and successful identification of a putative EZ. For their secondary outcome, the authors investigated whether these factors had a significant relationship with seizure freedom (according to the Engel classification) at last follow-up.

RESULTS

The authors included 101 patients in this study. SEEG was safe, with no major morbidity or mortality experienced. The population was complex, with an MRI lesion present in less than 40% of patients and patients as young as 2.9 years included. A proposed EZ was identified in 88 (87%) patients. Patients with an older onset of epilepsy (OR 1.20/year, p = 0.04) or epilepsy etiology suspected to be due to a developmental lesion (OR 8.38, p = 0.02) were more likely to have proposed EZ identification. Patients with a preimplantation bilateral seizure-onset hypothesis (OR 0.29, p = 0.047) and those who underwent longer periods of monitoring (OR 0.86/day, p = 0.006) were somewhat less likely to have proposed EZ identification. The presence of an MRI lesion was a positive factor on secondary analyses (OR 4.18, p = 0.049; 1-tailed test). Fifty percent of patients who underwent surgical treatment with resection or laser ablation achieved Engel class I outcomes, in contrast to 0% of patients who underwent neuromodulation. Patients with a preimplantation hypothesis in the frontal/parietal lobes had increased odds of seizure freedom compared with patients with a hypothesis in other locations (OR 3.64, p = 0.01).

CONCLUSIONS

Pediatric SEEG is safe and often identifies a proposed resectable EZ. These results suggest that SEEG is effective in patients with frontal/parietal preimplantation hypothesis, with or without identified lesions on MRI.

In开云手机版app下载安装最新版神经外科杂志:儿科开云体育app官方网站下载入口Publish Before Print

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The impact of skull thickness on pediatric stereoencephalography electrode implantation and technical considerations

Ansh Desai, Akshay Sharma, Swetha J. Sundar, Jason K. Hsieh, Efstathios Kondylis, Arpan Patel, Juan Bulacio, Ajay Gupta, Lara Jehi, and William Bingaman

OBJECTIVE

一个伪装成sideration in pediatric stereoencephalography (SEEG) is decreased skull thicknesses compared with adults, which may limit traditional bolt-based anchoring of electrodes. The authors aimed to investigate the safety profile, complication rates, and technical adaptations of placing SEEG electrodes in pediatric patients.

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The authors retrospectively reviewed all patients aged 12 years or younger at the time of SEEG implantation at their institution. Postimplantation CT scans were used to measure skull thickness at the entry point of each SEEG lead. Postimplantation lead accuracy was also assessed.

RESULTS

Fifty-three patients were reviewed. The median skull thickness was 4.1 (interquartile range [IQR] 3.15–5.2) mm. There were 5 total complications: 1 retained bolt fragment, 3 asymptomatic subdural hematomas, and 1 asymptomatic intracranial hemorrhage. Median radial error from the lead target was 3.5 (IQR 2.24–5.25) mm. Linear regression analysis revealed that increasing skull thickness decreased the deviation from the intended target, implying an improved accuracy to target at thicker skull entry points; this trended towards improved accuracy, but did not achieve statistical significance (p = 0.54).

CONCLUSIONS

This study found a 1.9% hardware complication rate and a 9.4% asymptomatic hemorrhage rate. Suturing electrodes to the scalp may represent a reasonable option if there are concerns of young age or a thin skull. These data indicate that invasive SEEG evaluation is safe among patients 12 years old or younger.

In开云手机版app下载安装最新版神经外科杂志:儿科开云体育app官方网站下载入口Publish Before Print

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