Abstracts

Rationale: To determine the likelihood of efficacy of focal resective surgery in patients with infarctions, including those in large middle cerebral artery distributions.Methods: Retrospective chart review of patients who underwent epilepsy surgery by the Comprehensive Pediatric Epilepsy Program, with medically-refractory epilepsy in association with cerebral infarction.Results: Since 1992, 12 patients who have undergone epilepsy surgery had previous cerebral infarction. Ten of these infarctions were arterial; one was venous; and one undetermined. The strokes were perinatal (including neonatal) in 10 patients (including one venous infarction), in utero in one patient, and during childhood in one patient. Distribution of the arterial strokes was the left middle cerebral artery in 8 patients, and the right middle cerebral artery (MCA) in two. The venous infarct was located in the temporal region, and the undetermined infarct was frontal. Two patients, one with left MCA stroke and one with right MCA stroke, also had mesial temporal sclerosis (MTS). Five patients underwent hemispherectomy between 21 months of age and 15 years of age. One of these patients (with perinatal left MCA infarct) underwent hemispherectomy 2 years 7 months after focal frontal resection was performed due to inadequate seizure control. Seven patients had focal resections alone. Resections included frontal, temporal, temporal/parietal, temporal with mesial temporal structures without evidence of MTS (2), and temporal with mesial structures with MTS (2). One of these patients who underwent focal resection went on to have a second surgery for residual dysplasia (temporal) within 14 months of initial surgery. Surgical outcomes in 9 of our 12 patients (75%) are classified within Engel class I, including both patients who underwent 2 surgeries. This includes 4 of 5 (80%) of the patients who had hemispherectomy, and 5 of the 7 (71%) patients who had focal resections alone (including temporal, temporal plus mesial structures, temporal/parietal, and frontal resections). Less successful outcomes occurred in 1 patient after hemispherectomy; this patient was presumed to have had a perinatal right MCA infarct, but had features suggestive of diffuse cerebral abnormality, namely microcephaly and autism. His outcome is classified as Engel 3A. One patient, with outcome classified as Engel 4B, had in utero right MCA infarct with MTS and underwent temporal resection with mesial structures at age 22 9/12 years. The last patient, with outcome Engel 3A, had perinatal left MCA infarct and underwent temporal resection with mesial structures after subdural electrode monitoring at age 12 11/12 years. Conclusions: In patients with history of cerebral infarction, including MCA distribution, a focal or tailored resection can be considered, with potential for excellent surgical outcome being high. Our findings support the use of electrocorticography/subdural electrode monitoring in order to assist with complete resection of the epileptogenic zone, and the consideration of resective surgery at an early age.