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Kristian Aquilina, Dave F. Clarke, James W. Wheless and Frederick A. Boop

Temporal lobe encephaloceles can be associated with temporal lobe epilepsy. The authors report on the case of an adolescent with multiple microencephaloceles, in the anterolateral middle fossa floor, identified at surgery (temporal lobectomy) for intractable partial-onset seizures of temporal origin. Magnetic resonance imaging revealed only hippocampal atrophy. Subdural electrodes demonstrated ictal activity arising primarily from the anterior and lateral temporal lobe, close to the microencephaloceles, spreading to the anterior and posterior mesial structures. Pathological examination revealed diffuse temporal gliosis involving the hippocampus, together with microdysgenesis of the amygdala. The literature on epilepsy secondary to encephaloceles is reviewed and the contribution of the microencephaloceles to the seizure disorder in this patient is discussed.

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M. Scott Perry, David J. Donahue, Saleem I. Malik, Cynthia G. Keator, Angel Hernandez, Rohit K. Reddy, Freedom F. Perkins Jr., Mark R. Lee and Dave F. Clarke

OBJECTIVE

Seizure onset within the insula is increasingly recognized as a cause of intractable epilepsy. Surgery within the insula is difficult, with considerable risks, given the rich vascular supply and location near critical cortex. MRI-guided laser interstitial thermal therapy (LiTT) provides an attractive treatment option for insular epilepsy, allowing direct ablation of abnormal tissue while sparing nearby normal cortex. Herein, the authors describe their experience using this technique in a large cohort of children undergoing treatment of intractable localization-related epilepsy of insular onset.

METHODS

The combined epilepsy surgery database of Cook Children’s Medical Center and Dell Children’s Hospital was queried for all cases of insular onset epilepsy treated with LiTT. Patients without at least 6 months of follow-up data and cases preoperatively designated as palliative were excluded. Patient demographics, presurgical evaluation, surgical plan, and outcome were collected from patient charts and described.

RESULTS

Twenty patients (mean age 12.8 years, range 6.1–18.6 years) underwent a total of 24 LiTT procedures; 70% of these patients had normal findings on MRI. Patients underwent a mean follow-up of 20.4 months after their last surgery (range 7–39 months), with 10 (50%) in Engel Class I, 1 (5%) in Engel Class II, 5 (25%) in Engel Class III, and 4 (20%) in Engel Class IV at last follow-up. Patients were discharged within 24 hours of the procedure in 15 (63%) cases, in 48 hours in 6 (24%) cases, and in more than 48 hours in the remaining cases. Adverse functional effects were experienced following 7 (29%) of the procedures: mild hemiparesis after 6 procedures (all patients experienced complete resolution or had minimal residual dysfunction by 6 months), and expressive language dysfunction after 1 procedure (resolved by 3 months).

CONCLUSIONS

To their knowledge, the authors present the largest cohort of pediatric patients undergoing insular surgery for treatment of intractable epilepsy. The patient outcomes suggest that LiTT can successfully treat intractable seizures originating within the insula and offers an attractive alternative to open resection. This is the first description of LiTT applied to insular epilepsy and represents one of only a few series describing the use of LiTT in children. The results indicate that seizure reduction after LiTT compares favorably to that after conventional open surgical techniques.

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Mark Van Poppel, James W. Wheless, Dave F. Clarke, Amy McGregor, Mark H. McManis, Freedom F. Perkins Jr., Katherine Van Poppel, Stephen Fulton and Frederick A. Boop

Object

Functional mapping is important for determining surgical candidacy and also in epilepsy surgery planning. However, in young children and uncooperative patients, language mapping has been particularly challenging despite the advances in performing noninvasive functional studies. In this study the authors review a series of children with epilepsy who underwent language mapping with magnetoencephalography (MEG) while sedated or sleeping, to determine receptive language localization for presurgical evaluation.

Methods

The authors undertook a retrospective review of patients who underwent MEG between December 2007 and July 2009, and identified 15 individuals who underwent passive language testing as part of their presurgical evaluation because they were unable to participate in traditional language testing, such as Wada or functional MRI. Factors necessitating passive language testing included age and neurocognitive development.

Results

Three of the 15 patients were deemed candidates for epilepsy surgery based on the results from standard preoperative testing, including video electroencephalography, MRI, and passive receptive language testing using MEG technology. The MEG studies were used successfully to localize language in all 3 patients, creating opportunities for seizure freedom through surgery that would not otherwise have been available. All 3 patients then underwent resective epilepsy surgery without experiencing postoperative language deficits.

Conclusions

This case series is the first to look at language mapping during sleep (passive language mapping) in which MEG was used and is the first to evaluate passive language testing in a patient population with intracranial pathological entities. This case series demonstrates that MEG can provide an alternative method for receptive language localization in patients with barriers to more traditional language testing, and in these 3 cases surgery was performed safely based on the results.

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Robert J. Ogg, Fred H. Laningham, Dave Clarke, Stephanie Einhaus, Ping Zou, Michael E. Tobias and Frederick A. Boop

Object

In this study, the authors examined whether passive range of motion (ROM) under conscious sedation could be used to localize sensorimotor cortex using functional MR (fMR) imaging in children as part of their presurgical evaluation.

Methods

After obtaining institutional review board approval (for retrospective analysis of imaging data acquired for clinical purposes) and informed consent, 16 children underwent fMR imaging. All 16 had lesions; masses were found in 9 patients and cortical dysplasia was found in 4; the lesions in 3 patients were not diagnosed. Passive ROM was performed during blood oxygen level–dependent MR imaging sequences. Three of the patients also performed active motor tasks during the fMR imaging study. All patients were evaluated using passive ROM of the hand and/or foot; 3 patients were evaluated for passive touch of the face. In 9 cases, intraoperative electrocorticography (ECoG) was used. Five of the patients underwent intraoperative ECoG to evaluate for seizure activity. Four patients had intraoperative ECoG for motor mapping. Five of the patients had subdural grids placed for extraoperative monitoring.

Results

In 3 cases, the active and passive ROMs colocalized. In 4 patients ECoG was used to identify motor cortex, and in all 4 motor ECoG yielded results consistent with the passive ROM localization. Thirteen of 16 children have undergone resection based on passive ROM fMR imaging findings with no unanticipated deficits.

Conclusions

These preliminary data suggest that passive ROM fMR imaging can accurately detect functional hand, leg, and face regions of the sensorimotor cortex in the sedated child. This extends current extraoperative mapping capabilities to patients unable or unwilling to cooperate for active motor tasks.