Authors :
Presenting Author: Kathleen Galligan, PA-C – Children’s Hospital of Philadelphia
Samuel Tomlinson, MD – Department of Neurosurgery – Hospital of the University of Pennsylvania; Sudha Kilaru Kessler, MD, MSCE – Division of Child Neurology – Children’s Hospital of Philadelphia; Benjamin Kennedy, MD – Division of Neurosurgery – Children's Hospital of Philadelphia
Rationale:
Hemispherotomy is an effective treatment for patients with drug-resistant epilepsy caused by a variety of hemispheric pathologies (1). Successful hemispherotomy leading to seizure cessation has been associated with improved neurodevelopmental outcomes and reduced healthcare utilization (2). Institutions and surgeons exhibit practice pattern varaibility in patient selection, peri-operative management, and hemispherotomy technique (3). Our aim was to describe seizures outcomes, functional outcomes, and complications in a prospectively enrolled, consecutive, single-surgeon hemispherotomy case series.Methods:
The cohort included 32 patients (aged 0-19 years) undergoing lateral peri-insular hemispherotomy (PIH) for hemispheric epilepsy between May 2017 and April 2021 at the Children’s Hospital of Philadelphia (CHOP). Preoperative variables included demographics, epilepsy history, anti-seizure medications, baseline functional and neurodevelopmental status, EEG features, and imaging findings. Patients underwent a modified PIH performed by a single surgeon (BCK) (4). Operative complications, hospital course, and seizure outcome (Engel class with a minimum of 12 months follow-up) were assessed. Results:
Mean age at seizure onset was 3.4 years (range: 3 days to 11 years), and mean age at time of surgery was 7.2 years (range 15 months – 19 years). 19/32 patients were male (59.4%). Anatomic substrates included developmental malformations (n=11, 34%), perinatal vascular injury (n=9, 28%), Rasmussen Encephalitis (n=7, 22%), trauma (n=4, 13%), and postnatal vascular injury (n=1, 3%). The median number of anti-seizure medications at the time of surgery was three. MRI demonstrated complete hemispheric disconnection in all cases. At a minimum 12 months of follow-up, 32/32 (100%) patients achieved Engel Class I outcome. No seizures since surgery (Engel IA) was observed in 30/32 cases (93.8%). One patient had a single provoked seizure in the setting of a viral illness that resolved without intervention (Engel 1B). One patient had seizures during medication taper that subsequently remitted (Engel 1D). One patient developed post-operative hydrocephalus requiring ventriculoperitoneal shunt placement. One patient with a history of complex hydrocephalus underwent shunt revisions during the follow-up period.Conclusions:
This study presents a large, heterogeneous series of pediatric hemispherotomy cases performed at a major US epilepsy center. Seizure outcomes observed in this cohort were superior to large meta-analyses as well as other comparable single-institution series (5). Complications were rare. The modified trans-sylvian PIH is an efficacious and safe treatment for refractory hemispheric epilepsy in well-selected patients.
Funding: N/A