Abstracts

Rationale: Hypothalamic hamartomas (HH) often cause pharmacoresistent epilepsy, incapacitating behavioral abnormalities, and cognitive decline. Surgical intervention offers the patient the best opportunity for eradication of intractable epilepsy (up to 50% of patient achieve seizure free) and improvement in cognitive function and behavioral problems. For those who failed the first surgery, further treatment options are quite limited, and at times, second surgery may improve seizure outcome. We reviewed our surgery patients to document the success and complications of reoperation after failed first surgery. Methods: Data was obtained from our Hypothalamic hamartoma epilepsy surgery database at the Barrow Neurological Institute between 2003 and 2010. Surgical treatment consisted of open and endoscopic procedures, as well as radiosurgery and interstitial radiotherapy. Demographic details, seizure history, presurgical evaluation, and postoperative follow up data were evaluated. Results: In the last seven years 21 out of 157 patients (13%) underwent reoperation after failed first epilepsy surgery. Initial surgical approach of the 21 patients included: endoscopic (N=8; 38%), transcallosal (N=7; 33%), orbitozygomatic ( N= 3; 14%) , radiosurgery (N =2; 9 %), and transpshenoidal ( N=1; 4%). Of the 8 patients with failed endoscopic resection repeat procedures were: radiosurgery (N=4; 50%), orbiotozygomatic (N=2; 25%), repeat endoscopy (N=1) and transcallosal approach (N = 1). Reoperation for the failed transcallosal resection patients included: endoscopic (N=2); radiosurgery (N=1); orbitozygomatic (N=2) and repeat transcallosal resection (N=2). Predominant seizure types that recurred after failed surgery were: gelastic seizures, complex partial and tonic-clonic type. MRI brain in all patients prior to reoperation demonstrated residual HH. Review of patients with more than six months follow-up (vast majority) since the second operation showed that greater than 50% of patients had a >50% seizure reduction although none were seizure free. Following reoperation, none of the patients had any worsened behavioral issues like increased rage attacks, disruptive violent behavior. New postoperative complications after reoperation included: hemiparesis, thalamic stroke (asymptomatic and symptomatic), hyperphagia and panhypopituitarism. Conclusions: Reoperation should be considered in selected HH patients failing epilepsy surgery because more than half the patients have significant seizure reduction.