Surgery for Intractable Epilepsy Due to Unilateral Brain Disease: A Retrospective Study Comparing Hemispherectomy Techniques
Surgery for Intractable Epilepsy Due to Unilateral Brain Disease: A Retrospective Study Comparing Hemispherectomy Techniques
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DOI：
10.1016/j.pediatrneurol.2014.05.018
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发表时间：
2014-09-01
影响因子：
3.8
通讯作者：
Poduri, Annapurna
中科院分区：
文献类型：
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作者：
Pinto, Anna L. R.;Lohani, Subash;Poduri, Annapurna
背景：大脑半球切除术是一种外科手术，用于治疗继发于获得性脑或先天性病变的严重单侧皮质疾病儿童的难治性癫痫。大脑半球切除术的手术入路主要有解剖半球切除术、传统功能性半球切除术和半岛半球切除术。我们描述了因难治性癫痫而行大脑半球切除术的脑畸形患者或后天性脑损伤患者的癫痫结局，包括半球切除术后再次手术的必要性。方法：我们在波士顿儿童医院进行了一项回顾性观察研究。病例是从1997至2011年间接受癫痫手术的患者的研究数据库中确定的。数据来自电子病历和办公室图表。手术后的结果被定义为癫痫发作(数量和严重程度)的改善，由最后一次随访时测量的Engel分类评分表示，至少随访12个月。需要重新手术以完成大脑半球的切断。我们还检查了大脑半球切除后是否需要放置脑室-腹膜分流术是次要结果。结果：我们确定了36例因严重的、药物难治性癫痫而行大脑半球切除术的患者。第1组(n=14)为静态获得性损害，第2组(n=22)为皮质发育畸形。第一组的平均手术年龄为9岁(S.D.5.5)，第二组的平均手术年龄为2.77岁(S.D.4.01；P<；0.001)。两组的癫痫发作结果都很好(Engel评分I为25分，II分为3分，III分为6分，IV分为2例)，两组之间没有差异。在第一组中，5例患者接受了解剖半球切除(1例有局灶性切除)，4例患者接受了功能性半球切除，5例患者接受了脑岛半球切开术；没有患者需要第二次手术。在第二组中，共有14例患者接受了解剖半球切除(其中3例先前进行了局限性局部切除)，5例患者接受了功能性半球切除，3例患者接受了岛叶旁半脑切除术。在第2组患者中，1例因癫痫持续发作而需再次手术以完成切断，1例因持续性癫痫发作而需行脑岛旁半脑切开术。在第一组中，3例患者接受了脑室-腹膜分流术，其中2例患者接受了解剖半球切除，1例患者接受了功能性半球切除。第2组：脑室-腹膜分流术12例，均为第一次或第二次解剖半球切除。结论：后天性病变和发育性畸形患者大脑半球切除术后癫痫发作预后良好。虽然三种手术的癫痫结局相似，但解剖半球切除术的并发症发生率高于较新的功能性半球切除术和脑岛半球切开术。患有皮质畸形的患者通常在较小的年龄就接受了手术；两名皮质发育畸形的患者接受了功能性半球切除，需要进行第二次手术。在这些病例中需要再次手术可能反映了发育性大脑半球畸形的解剖复杂性，这可能导致不完全的连接断开。
BACKGROUND: Hemispherectomy is a surgical procedure used to treat medically intractable epilepsy in children with severe unilateral cortical disease secondary to acquired brain or congenital lesions. The major surgical approaches for hemispherectomy are anatomic hemispherectomy, traditional functional hemispherectomy, and peninsular hemispherotomy. We describe the epilepsy outcome, including the need for reoperation, after hemispherectomy in patients with brain malformations or acquired brain lesions who underwent hemispherectomy for refractory epilepsy. METHODS: We conducted a retrospective observational study at Children's Hospital Boston. Cases were ascertained from a research database of patients who underwent epilepsy surgery from 1997 to 2011. Data were obtained from electronic medical records and office charts. Outcome after surgery was defined as improvement in seizures (quantity and severity) represented by the Engel classification score measured at last follow-up, with a minimum of 12 months of follow-up. The need for reoperation for completion of hemispheric disconnection. We also examined whether placement of ventriculoperitoneal shunt was required after hemispherectomy was a secondary outcome. RESULTS: We identified 36 patients who underwent hemispherectomy for severe, medically intractable epilepsy. Group 1 (n = 14) had static acquired lesions, and group 2 (n = 22) had malformations of cortical development. Mean age at surgery for group 1 was 9 years (S.D. 5.5) and 2.77 years for group 2 (S.D. 4.01; P < 0.001). The seizure outcome was good in both groups (Engel score I for 25, II for three, III for six, and IV for two patients) and did not differ between the two groups. In group 1, five patients underwent anatomic hemispherectomy (one had prior focal resection), four underwent functional hemispherectomy, and five underwent pen-insular hemispherotomy; none required a second procedure. In group 2, a total of 14 patients had anatomic hemispherectomy (of these, three had had limited prior focal resection), five had functional hemispherectomy, and three had pen-insular hemispherotomy. Among the patients in group 2 who had had functional hemispherectomy, one required reoperation to complete the disconnection and one required pen-insular hemispherotomy because of persistent seizures. In group 1, three patients underwent a ventriculoperitoneal shunt, and from these patients two underwent anatomic hemispherectomy and one had functional hemispherectomy. In group 2, 12 patients had ventriculoperitoneal shunt, and all of them had anatomic hemispherectomy as a first or second procedure. CONCLUSION: Seizure outcome after hemispherectomy is good in patients with acquired lesions and with developmental malformations. Although the seizure outcome was similar in the three procedures, the complication rate was higher with anatomic hemispherectomy than with the more recent functional hemispherectomy and pen-insular hemispherotomy. The group with cortical malformations generally had surgery at a younger age; two patients with malformations of cortical development who underwent functional hemispherectomy required second surgeries. The need for reoperation in these cases may reflect the anatomic complexity of developmental hemispheric malformations, which may lead to incomplete disconnection.