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Alain Bouthillier, Alexander G. Weil, Laurence Martineau, Laurent Létourneau-Guillon, and Dang Khoa Nguyen

OBJECTIVE

Patients with refractory epilepsy of operculoinsular origin are often denied potentially effective surgical treatment with operculoinsular cortectomy (also termed operculoinsulectomy) because of feared complications and the paucity of surgical series with a significant number of cases documenting seizure control outcome. The goal of this study was to document seizure control outcome after operculoinsular cortectomy in a group of patients investigated and treated by an epilepsy team with 20 years of experience with this specific technique.

METHODS

Clinical, imaging, surgical, and seizure control outcome data of all patients who underwent surgery for refractory epilepsy requiring an operculoinsular cortectomy were retrospectively reviewed. Tumors and progressive encephalitis cases were excluded. Descriptive and uni- and multivariate analyses were done to determine seizure control outcome and predictors.

RESULTS

Forty-three patients with 44 operculoinsular cortectomies were studied. Kaplan-Meier estimates of complete seizure freedom (first seizure recurrence excluding auras) for years 0.5, 1, 2, and 5 were 70.2%, 70.2%, 65.0%, and 65.0%, respectively. With patients with more than 1 year of follow-up, seizure control outcome Engel class I was achieved in 76.9% (mean follow-up duration 5.8 years; range 1.25–20 years). With multivariate analysis, unfavorable seizure outcome predictors were frontal lobe–like seizure semiology, shorter duration of epilepsy, and the use of intracranial electrodes for invasive monitoring. Suspected causes of recurrent seizures were sparing of the language cortex part of the focus, subtotal resection of cortical dysplasia/polymicrogyria, bilateral epilepsy, and residual epileptic cortex with normal preoperative MRI studies (insula, frontal lobe, posterior parieto-temporal, orbitofrontal).

CONCLUSIONS

The surgical treatment of operculoinsular refractory epilepsy is as effective as epilepsy surgeries in other brain areas. These patients should be referred to centers with appropriate experience. A frontal lobe–like seizure semiology should command more sampling with invasive monitoring. Recordings with intracranial electrodes are not always required if the noninvasive investigation is conclusive. The complete resection of the epileptic zone is crucial to achieve good seizure control outcome.

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Alain Bouthillier, Alexander G. Weil, Laurence Martineau, Laurent Létourneau-Guillon, and Dang Khoa Nguyen

OBJECTIVE

Operculoinsular cortectomy (also termed operculoinsulectomy) is increasingly recognized as a therapeutic option for perisylvian refractory epilepsy. However, most neurosurgeons are reluctant to perform the technique because of previously experienced or feared neurological complications. The goal of this study was to quantify the incidence of basic neurological complications (loss of primary nonneuropsychological functions) associated with operculoinsular cortectomies for refractory epilepsy, and to identify factors predicting these complications.

METHODS

Clinical, imaging, and surgical data of all patients investigated and surgically treated by our team for refractory epilepsy requiring an operculoinsular cortectomy were retrospectively reviewed. Patients with tumors and encephalitis were excluded. Logistic regression analysis was used for uni- and multivariate statistical analyses.

RESULTS

Forty-four operculoinsular cortectomies were performed in 43 patients. Although postoperative neurological deficits were frequent (54.5% of procedures), only 3 procedures were associated with a permanent significant neurological deficit. Out of the 3 permanent deficits, only 1 (2.3%; a sensorimotor hemisyndrome) was related to the technique of operculoinsular cortectomy (injury to a middle cerebral artery branch), while the other 2 (arm hypoesthesia and hemianopia) were attributed to cortical resection beyond the operculoinsular area. With multivariate analysis, a postoperative neurological deficit was associated with preoperative insular hypometabolism on PET scan. Postoperative motor deficit (29.6% of procedures) was correlated with fewer years of neurosurgical experience and frontal operculectomies, but not with corona radiata ischemic lesions. Ischemic lesions in the posterior two-thirds of the corona radiata (40.9% of procedures) were associated with parietal operculectomies, but not with posterior insulectomies.

CONCLUSIONS

Operculoinsular cortectomy for refractory epilepsy is a relatively safe therapeutic option but temporary neurological deficits after surgery are frequent. This study highlights the role of frontal/parietal opercula resections in postoperative complications. Corona radiata ischemic lesions are not clearly related to motor deficits. There were no obvious permanent neurological consequences of losing a part of an epileptic insula, including on the dominant side for language. A low complication rate can be achieved if the following conditions are met: 1) microsurgical technique is applied to spare cortical branches of the middle cerebral artery; 2) the resection of an opercula is done only if the opercula is part of the epileptic focus; and 3) the neurosurgeon involved has proper training and experience.

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Michel W. Bojanowski, Romuald Seizeur, Khaled Effendi, Patrick Bourgouin, Elsa Magro, and Laurent Letourneau-Guillon

Animal studies have shown that Listeria monocytogenes can probably access the brain through a peripheral intraneural route, and it has been suggested that a similar process may occur in humans. However, thus far, its spreading through the central nervous system (CNS) has not been completely elucidated. The authors present a case of multiple L. monocytogenes cerebral abscesses characterized by a pattern of distribution that suggested spread along white matter fiber tracts and reviewed the literature to identify other cases for analysis. They elected to include only those cases with 3 or more cerebral abscesses to make sure that the distribution was not random, but rather followed a pattern. In addition, they included those cases with abscesses in both the brainstem and the cerebral hemispheres, but excluded cases in which abscesses were located solely in the brainstem.

Of 77 cases of L. monocytogenes CNS abscesses found in the literature, 17 involved multiple abscesses. Of those, 6 were excluded for lack of imaging and 3 because they involved only the brainstem. Of the 8 remaining cases from the literature, one was a case of bilateral abscesses that did not follow a fiber tract; another was also bilateral, but with lesions appearing to follow fiber tracts on one side; and in the remaining 6, to which the authors added their own case for a total of 7, all the abscesses were located exclusively in the same hemisphere and distributed along white matter fiber tracts.

The findings suggest that after entering the CNS, L. monocytogenes travels within the axons, resulting in a characteristic pattern of distribution of multiple abscesses along the white matter fiber tracts in the brain. This report is the first description suggesting intraaxonal CNS spread of L. monocytogenes infection in humans following its entry into the brain. This distinct pattern is clearly seen on imaging and its recognition may be valuable in the diagnosis of listeriosis. This finding may allow for earlier diagnosis, which may improve outcome.