Authors :
Akshaya Rathin Sivaji, MD – Epilepsy Center, Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
Presenting Author: Imtiaz Nazam, MD – University Hospitals, Cleveland Medical Center
Mohamed Ahmed Abdelsabour Hasan, MD – University Hospitals Cleveland Medical Center, Cleveland, OH, USA
Adina Chirla, BSN, CPERN – UH Rainbow and Children's Hospital, Cleveland Medical Center
Michael D Staudt, MD – Department of Neurological Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
Jun Park, MD – Epilepsy Center, Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
Rationale:
There is an increased risk of developing epilepsy secondary to perinatal stroke, cortical malformation (MCD) and other cortical abnormalities in children. These patients often have extensive epileptogenic zone and drug-resistant epilepsy. Hemispherectomy is an established and effective surgical option in selected patients with excellent post-surgical outcomes. We aimed to identify favorable prognostic factors in children undergoing hemispherectomy.
Methods:
We retrospectively analyzed our epilepsy surgery database at UH Rainbow Babies & Children’s Hospital from 2010-2024 for children (< 16 years) who underwent hemispherectomy secondary to medically refractory epilepsy. Clinical variables were collected pertaining to etiology, seizure semiology/frequency, anti-seizure medications, neuro-imaging, VEEG, and post operative outcomes.
Results:
A total of 15 patients underwent hemispherectomy secondary to stroke(n=4), MCD(n=5) and other causes(n=6). The mean age of seizure onset was 1.3±0.9 years. The mean duration of epilepsy was 3.6±2 years and age at surgery was 5.1±2.3 years. All patients were followed post operatively for a minimum duration >2 years. All patients underwent functional hemispherectomy(2 had subsequent anatomic hemispherectomy due to incomplete disconnection) and surgical outcomes was assessed using Engel Epilepsy Surgery Outcomes Scale.
Individual clinical variables were analyzed relative to surgical outcomes[Table 1]. Twelve patients achieved Engel I outcome while the remaining 3 had Engel II-IV. Engel I outcome was achieved in 5/5 patients with MCD, 3/4 in stroke and 4/6 in other etiologies. One patient in stroke group, who underwent FH did not achieve Engel I outcome due to suspected incomplete disconnection(based on persistence of identical seizure semiology pre and post-op).
Within the stroke subgroup all 4 patients had infarct localized to middle cerebral artery (MCA) vascular distribution, of which 3 achieved Engel I . Ten patients had unilateral(focal/multifocal spikes), while 5 had bilateral/generalized spike. Two of these 5 patients (1 MCD, 1 stroke) achieved Engel 1. All three patients with Engel II-IV outcome had generalized/bilateral muti-focal spikes. Seizure semiology in 14 out of 15 patients had focal onset seizures. Prior to surgery all patients were on an average of 3 anti-epileptic medications. Within the first post-operative week seizures were reported in 5 patients [pathology group(3), stroke(1) & MCD(1)]. 2/5 patients in the stroke and MCD group achieved Engel 1, while 1/3 patients in the other pathology group achieved Engel 1. The most common post-op complication was hydrocephalus, 3 (20%)/15 patients, requiring corrective VP shunt. Two patients with MCD, subsequently underwent anatomic hemispherectomy to achieve Engel I outcome.
Conclusions:
9/10 patients(5/5 with MCD and 4/6 with stroke, limited to one hemisphere) achieved Engel I after hemispherectomy, regardless of presence of bilateral or generalized spikes which were seen in 2 patients(1 MCD,1 stroke). VP shunt as a complication was seen in both functional(2) and anatomic hemispherectomy(1). 3/5 patients who had post-operative seizure within the first week of FH, achieved Engel 1.
Funding: None