Predictive factors of hydrocephalus development in pediatric patients undergoing hemispherectomy for intractable epilepsy

Akshay Sharma Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland;

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Michael Mann Case Western Reserve University School of Medicine, Cleveland;

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Alan Gordillo Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland; and

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Ansh Desai Case Western Reserve University School of Medicine, Cleveland;

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Robert Winkleman Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland;

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Demitre Serletis Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland;

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Ahsan N. Moosa Department of Neurology, Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio

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Richard Rammo Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland;

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William Bingaman Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland;

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OBJECTIVE

Hemispherectomy surgery is an effective procedure for pediatric patients with intractable hemispheric epilepsy. Hydrocephalus is a well-documented complication of hemispherectomy contributing substantially to patient morbidity. Despite some clinical and operative factors demonstrating an association with hydrocephalus development, the true mechanism of disease is incompletely understood. The aim of this study was to investigate a range of clinical and surgical factors that may contribute to hydrocephalus to enhance understanding of the development of this complication and to aid the clinician in optimizing peri- and postoperative surgical management.

METHODS

A retrospective chart review was conducted on all pediatric patients younger than 21 years who underwent hemispherectomy surgery at the Cleveland Clinic between 2002 and 2016. Data collected for each patient included general demographic information, neurological and surgical history, surgical technique, pathological analysis, presence and duration of perioperative CSF diversion, CSF laboratory values obtained while an external ventricular drain (EVD) was in place, length of hospital stay, postoperative aseptic meningitis, and in-hospital surgical complications (including perioperative stroke, hematoma formation, wound breakdown, and/or infection). Outcomes data included hemispherectomy revision and Engel grade at last follow-up (based on the Engel Epilepsy Surgery Outcome Scale).

RESULTS

Data were collected for 204 pediatric patients who underwent hemispherectomy at the authors’ institution. Twenty-eight patients (14%) developed hydrocephalus requiring CSF diversion. Of these 28 patients, 13 patients (46%) presented with hydrocephalus during the postoperative period (within 90 days), while the remaining 15 patients (54%) presented later (beyond 90 days after surgery). Multivariate analysis revealed postoperative aseptic meningitis (OR 7.0, p = 0.001), anatomical hemispherectomy surgical technique (OR 16.3 for functional/disconnective hemispherectomy and OR 7.6 for modified anatomical, p = 0.004), male sex (OR 4.2, p = 0.012), and surgical complications (OR 3.8, p = 0.031) were associated with an increased risk of hydrocephalus development, while seizure freedom (OR 0.3, p = 0.038) was associated with a decreased risk of hydrocephalus.

CONCLUSIONS

Hydrocephalus remains a prominent complication following hemispherectomy, presenting both in the postoperative period and months to years after surgery. Aseptic meningitis, anatomical hemispherectomy surgical technique, male sex, and surgical complications show an association with an increased rate of hydrocephalus development while seizure freedom postsurgery is associated with a decreased risk of subsequent hydrocephalus. These findings speak to the multifactorial nature of hydrocephalus development and should be considered in the management of pediatric patients undergoing hemispherectomy for medically intractable epilepsy.

ABBREVIATIONS

EVD = external ventricular drain.
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Illustration from Caklili et al. (pp 223–235). © Savas Ceylan, published with permission.

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