Outcomes after hemispherectomy in adult patients with intractable epilepsy: institutional experience and systematic review of the literature

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OBJECTIVE

Hemispherectomy is a surgical technique that is established as a standard treatment in appropriately selected patients with drug-resistant epilepsy. It has proven to be successful in pediatric patients with unilateral hemispheric lesions but is underutilized in adults. This study retrospectively evaluated the clinical outcomes after hemispherectomy in adult patients with refractory epilepsy.

METHODS

This study examined 6 cases of hemispherectomy in adult patients at Barrow Neurological Institute. In addition, all case series of hemispherectomy in adult patients were identified through a literature review using MEDLINE and PubMed. Case series of patients older than 18 years were included; reports of patients without clear follow-up duration or method of validated seizure outcome quantification were excluded. Seizure outcome was based on the Engel classification.

RESULTS

A total of 90 cases of adult hemispherectomy were identified, including 6 newly added by Barrow Neurological Institute. Sixty-five patients underwent functional hemispherectomy; 25 patients had anatomical hemispherectomy. Length of follow-up ranged from 9 to 456 months. Seizure freedom was achieved in 80% of patients. The overall morbidity rate was low, with 9 patients (10%) having new or additional postoperative speech or language dysfunction, and 19 patients (21%) reporting some worsening of hemiparesis. No patients lost ambulatory or significant functional ability, and 2 patients had objective ambulatory improvement. Among the 41 patients who underwent additional formal neuropsychological testing postoperatively, overall stability or improvement was seen.

CONCLUSIONS

Hemispherectomy is a valuable surgical tool for properly selected adult patients with pre-existing hemiparesis and intractable epilepsy. In published cases, as well as in this series, the procedure has overall been well tolerated without significant morbidity, and the majority of patients have been rendered free of seizures.

ABBREVIATIONS AED = antiepileptic medication; EEG = electroencephalography; ILAE = International League Against Epilepsy; IQ = intelligence quotient; PET = positron emission tomography.

Article Information

Correspondence Courtney M. Schusse, Department of Neurology, Barrow Neurological Institute at St. Joseph's Hospital and Medical Center, 240 W Thomas Rd., Ste. 404, Phoenix, AZ 85013. email: courtney.schusse@dignityhealth.org.

INCLUDE WHEN CITING Published online April 28, 2017; DOI: 10.3171/2016.9.JNS151778.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    Pre- and postoperative images of a left hemispheric surgery. Preoperative (A) and immediate postoperative (B) axial MR images obtained in a patient who underwent a minimally invasive functional hemispherectomy through a small centrally placed craniotomy. Note that by traversing the porencephalic cyst, the corpus callosum was completely disconnected from within the affected hemisphere's lateral ventricle. The amygdala and hippocampus were also removed separately in this procedure (as seen in the axial view [C] and the sagittal view [D]).

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    Illustration of the approach and technique of the procedure. A centrally placed, vertically oriented incision is used to perform the minimally invasive craniotomy (A). The procedure begins with transinsular amygdalohippocampectomy followed by disconnection of the corpus callosum from the splenium posteriorly to the subgenual region anteriorly (B). The subpial resection technique is used throughout to minimize bleeding and to avoid risk of injury to blood vessels and vital structures in the subarachnoid space (C). Copyright Barrow Neurological Institute. Published with permission.

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    Outline of search strategy.

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