Fifty Consecutive Hemispherectomies

Abstract

Background Techniques for achieving hemispheric disconnection in patients with epilepsy continue to evolve. Objective To review the outcomes of the first 50 hemispherectomy surgeries performed by a single surgeon with an emphasis on outcomes, complications, and how these results led to changes in practice. Methods The first 50 hemispherectomy cases performed by the lead author were identified from a prospectively maintained database. Patient demographics, surgical details, clinical outcomes, and complications were critically reviewed. Results From 2004 to 2012, 50 patients underwent hemispherectomy surgery (mean follow-up time 3.5 years). Modified lateral hemispherotomy (MLH) became the preferred technique and was performed on 44 patients. Forty patients (80%) achieved complete seizure freedom (Engel I). Pre- and post-surgical neuropsychological evaluations demonstrated cognitive stability. Two cases were performed for palliation only. Previous hemispherectomy surgery was associated with worsened seizure outcome (2 of 6 seizure-free, P = .005). The use of Avitene was associated with a higher incidence of postoperative hydrocephalus (56% v. 18%, P = .03). In MLH patients without the use of Avitene, the incidence of hydrocephalus was 13%. Complications included: infection (3), incomplete disconnection requiring reoperation (1), reversible ischemic neurologic deficit (1), and craniosynostosis (1). There were no (unanticipated) permanent neurological deficits or deaths. Minor technique modifications were made in response to specific complications. Conclusion The modified lateral hemispherotomy is effective and safe for both initial and revision hemispherectomy surgery. Avitene use appears to result in a greater incidence of postoperative hydrocephalus.

Neurosurgical approaches to pediatric epilepsy: Indications, techniques, and outcomes of common surgical procedures

“…A recent systematic review showed that anatomical hemispherectomy had the highest seizure freedom rate, but this was not statistically significant [79]. Reported seizure freedom rates vary significantly between 50% and 85%, with additional patients having significant seizure burden reduction [68,71,73,75,76,[79][80][81][82]. Etiology is the most important prognostic variable of seizure outcome, with acquired and progressive diseases have significantly better outcomes than developmental malformations (particularly hemimegalencephaly) [68][69][70]76,80,83].…”

“…While EEG would ideally only show epileptogenicity in one hemisphere, epileptic activity in the contralateral hemisphere is not an absolute contraindication [68,72]. Additionally, hemispherectomy has been rarely described for palliative reduction of seizure burden in bilateral cases [75].…”

Modified hemispherectomy for infantile hemiparesis and epilepsy

“…The modified hemispherectomy also showed good effects on epilepsy control, resulting in Engel I in 91% and Engel II in 9% at follow-up of 7–15 years. In other reports, the rate of seizure freedom following hemispherectomy has been reported to be 52–89%, with a link in improved seizure control and cognitive motor outcomes [ 3 , 9 – 11 ]. After hemispherectomy, the abnormal waves on EEG on the healthy hemisphere might disappear completely or greatly reduce in the frequency clinically.…”

“…Since the introduction of this surgical technique as a therapeutic approach for epilepsy in 1938 [ 4 ], various modifications have been reported to ameliorate the outcome and minimize procedure-related complications [ 4 , 6 – 8 ]. The rate of seizure freedom following hemispherectomy has been reported to be 52–89%, with a link in improved seizure control and cognitive motor outcomes [ 3 , 9 – 11 ]. The postoperative mortality rate of hemispherectomy in recent decades has been shown to range from 0 to 1% [ 3 ] or 6.6% [ 12 ].…”

Interhemispheric Vertical Hemispherotomy: A Single Center Experience

“…Extensive clinical experience has established the effectiveness of PIH [10,11], and the efficacy and safety of vertical hemispherotomy have recently been investigated [4,6,12]. In a recent series of 40 cases of vertical hemispherotomy [12], a permanent cerebrospinal fluid shunt was necessary in only 2.5% of cases, compared to the 5-26% incidence in previous series of PIH [10,11]. Blood replacement was necessary in only 2 infants (5.0%) [12].…”