Multiple hippocampal transections for refractory pediatric mesial temporal lobe epilepsy: seizure and neuropsychological outcomes

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  • 1 Division of Pediatric Neurology, University of Washington/Seattle Children’s Hospital, Seattle, Washington; and
  • 2 Divisions of Pediatric Neuropsychology,
  • 3 Pediatric Neurosurgery, and
  • 4 Pediatric Radiology, Children’s Wisconsin/Medical College of Wisconsin, Milwaukee, Wisconsin
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OBJECTIVE

Temporal lobe epilepsy (TLE) is the most common focal epilepsy across adult and pediatric age groups. It is also the most amenable to surgery, with excellent long-term seizure outcome. Most TLE cases have an epileptogenic zone in the mesial temporal structures, namely the hippocampus. Resecting the dominant hippocampus has been shown to be associated with significant verbal memory deficits, especially in patients with intact verbal memory scores presurgically. Multiple hippocampal transection (MHT) is a relatively new surgical technique designed to interrupt the longitudinal hippocampal circuitry involved in seizure propagation yet preserve the circular fibers involved in memory function. This technique has been used to treat mesial TLE in both dominant- and nondominant-hemisphere cases, almost exclusively in adults. It has been applied to normal and sclerotic hippocampi.

METHODS

In this study, information on 3 pediatric patients who underwent MHT for mesial TLE at Children’s Wisconsin between 2017 and 2018 is included. Clinical, electroencephalographic, and neuropsychological features and outcomes are described in detail.

RESULTS

MRI revealed a tumor in the amygdala with a normal hippocampus in 1 patient and hippocampal sclerosis in 2 patients. All patients underwent stereoelectroencephalography confirming the involvement of the hippocampus in seizure onset. MHTs were completed under intraoperative monitoring, with amygdala and temporal tip resection in all patients due to early spread to these regions. All patients had excellent seizure outcomes at 1 year, and 2 of the 3 patients remain seizure free at last follow-up (range 20–36 months), all with stable or improved neuropsychological profiles, including verbal memory.

CONCLUSIONS

MHT is a relatively new surgical procedure designed to preserve essential memory circuitry while disrupting seizure propagation pathways in the hippocampus. A growing body of literature shows good seizure and neuropsychological results, but mainly in adults. This is the first series of MHTs used exclusively in children at one medical center, showcasing excellent seizure control and preservation of neuropsychological functioning. One of the patients is also the first described to have MHT in the setting of an amygdalar tumor abutting the hippocampus, further expanding the pathological setting in which MHT can be used effectively.

ABBREVIATIONS AED = antiepileptic drug; ECoG = electrocorticography; EEG = electroencephalography; fMRI = functional MRI; iEEG = intracranial EEG; ILAE = International League Against Epilepsy; MHT = multiple hippocampal transection; MST = multiple subpial transection; MTG = middle temporal gyrus; MTLE = mesial TLE; RCI = reliable change index; SEEG = stereo-EEG; SLA = stereotactic laser ablation; STG = superior temporal gyrus; TLE = temporal lobe epilepsy; WRAML1 = Wide Range Assessment of Memory and Learning, 1st Edition; WRAML2 = Wide Range Assessment of Memory and Learning, 2nd Edition.

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Contributor Notes

Correspondence Ahmad Marashly: University of Washington/Seattle Children’s Hospital, Seattle, WA. ahmad.marashly@seattlechildrens.org.

INCLUDE WHEN CITING Published online June 26, 2020; DOI: 10.3171/2020.4.PEDS19760.

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

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