Reoperation for Refractory Epilepsy in Childhood: A Second Chance for Selected Patients
Reoperation for Refractory Epilepsy in Childhood: A Second Chance for Selected Patients
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DOI：
10.1227/neu.0000000000000081
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发表时间：
2013-10-01
期刊：
影响因子：
4.8
通讯作者：
Bast, Thomas
中科院分区：
文献类型：
--
作者：
Ramantani, Georgia;Strobl, Karl;Bast, Thomas
目的：探讨儿童难治性癫痫再次手术的预后及其预测因素。方法：回顾分析2000年至2011年间收治的23例儿童难治性癫痫再次手术的术前表现、手术切除及预后。结果：病因包括皮质发育不良合并/不合并神经胶质细胞肿瘤19例(83%)，单纯神经胶质细胞肿瘤2例，结节硬化症和拉斯穆森脑炎各1例。首次手术失败的原因有8例(35%)为功能性考虑，8例(35%)致痫灶勾画不正确，7例(30%)未按原计划切除。最终手术包括叶内切除8例(35%)，多叶切除8例(35%)，半脑切除7例(30%)。再次手术后，14例(61%)患者癫痫发作消失，6例(26%)有显著或有价值的改善，3例(13%)对手术无效。8例3岁前首次切除的患儿中有6例，6例首次切除受限于功能因素，7例以大脑半球切开术为最终切除，均在再次手术后癫痫发作缓解。结论：对于首次有限和(或)早期切除无效，但广泛手术后癫痫发作缓解的难治性癫痫合并皮质发育不良患儿，再次手术尤为有利。如有需要，应在最年轻的年龄进行再次手术，以从较高的功能可塑性中获益，以弥补神经功能的缺失。
BACKGROUND: Reoperations account for >10% in pediatric epilepsy surgery cohorts, and they are especially relevant in young children with catastrophic epilepsy.OBJECTIVE: To determine surgical outcomes and their predictive factors in reoperations for refractory epilepsy in childhood.METHODS: We retrospectively analyzed presurgical findings, resections, and outcomes of 23 consecutive children who underwent reoperations from 2000 to 2011.RESULTS: Etiology included cortical dysplasia with/without glioneuronal tumor in 19 patients (83%), sole glioneuronal tumor in 2, and tuberous sclerosis and Rasmussen encephalitis in 1 each. The reasons for the failure of the initial surgery were functional considerations in 8 (35%), incorrect delineation of the epileptogenic zone in 8 (35%), and resection not performed as initially planned in 7 (30%) cases. Final procedures included 8 (35%) intralobar, 8 (35%) multilobar resections, and 7 (30%) hemispherotomies. Following reoperations, 14 (61%) patients were seizure free, 6 (26%) showed significant or worthwhile improvement, and 3 (13%) did not respond to surgery. Six of 8 patients who underwent the first resection before the age of 3 years, 6 of 8 whose first resection was limited by functional considerations, and all 7 with hemispherotomy as the final resection achieved seizure freedom after reoperation.CONCLUSION: Reoperation is particularly beneficial for selected children with refractory epilepsy associated with cortical dysplasia that did not respond to an initial limited and/or early resection but achieved seizure freedom after extensive procedures. When indicated, reoperation should be performed at the youngest possible age to profit from higher functional plasticity in compensating for neurological deficit.