Abstracts

Rationale: Despite an initial epilepsy surgical resection, selected patients with continued medically refractory seizures may be considered for further surgery. There is little reported data on repeat operations performed in children who have not responded optimally to initial surgery. We retrospectively reviewed children who have undergone reoperation and examined their features and outcomes. Methods: We identified patients from our epilepsy surgery database who had cortical resection for medically intractable focal epilepsy and who had a minimum of 6 months follow up from the last surgical resection. Patients who had palliative procedures (corpus callosotomy, vagus nerve stimulator), or and an initial hemispherectomy were excluded. The databases and medical records were queried for demographics, video EEG and MRI findings, seizure focus location and etiology, number and type of surgical procedures that resulted in cortical resection, and outcome (Engle classification). Results: Twenty two of 153 patients (13%) had two or more surgical resections for epilepsy. Five of the 22 had more than 3 or more. Etiologies included: cortical dysplasia (8), tumor (6), encephalitis/Rasmussens (3), mesial temporal sclerosis (1) and nonlesional (4). Fourteen had an initial extratemporal surgery and 8 were temporal surgeries. All had complex partial seizures (one case with focal cortical dysplasia had mixed seizures including focal seizures). Eleven patients out of 17 (64%) with a repeat resection had a Class I Engle surgical outcome, while 3 (17%) were Class II. Only 2 (11%) had Class IV outcome. Of the five who had 3 resections, 3 (60%) had Class I outcome, 2 were Class IV (1 became seizure free when a new antiepileptic drug was started). Of those who had Class IV outcomes, 2 were nonlesional, 1 had dysplasia and 1 had dual pathology on the contralateral hemisphere with mixed seizures and multifocal spikes. All had an initial extratemporal resection. New neurologic deficits seen after the second resection consists of 1 with homonymous hemianopsia, 5 with mild hemiparesis (2 with visual field cut and 1 with homonymous hemianopsia), and 1 with mild facial weakness. In five of these patients, they were expected deficits that led to a limited first surgery. No new deficits were seen with those with 3 resections. Only one patient had a complication developing a subgaleal hematoma postoperatively. Conclusions: Selected patients may be candidates for further surgery if they continue to have refractory seizures. Good outcome were seen in cases were extension of the previous resection site was done and a lesionectomy was completed. An initial extratemporal resection, dual pathology and nonlesional cases were predictors of poor outcome. Minimal complication or expected neurologic deficits were seen in the second and third reoperations. Persistent re-evaluation and re-operation may be necessary to achieve seizure freedom.