Purpose
Over the past two decades, vagus nerve stimulation (VNS) has become an accepted and viable treatment modality for intractable epilepsy both in children and adults. Earlier studies have ...demonstrated short-term seizure outcomes, usually for up to 5 years; so far, none have reported an extended outcome in children. We aimed to assess long term seizure outcome in children with intractable epilepsy for more than 5 years.
Methods
We identified patients who had VNS implantation for treatment of intractable epilepsy from March 2000 to March 2015 at our Epilepsy Center and collected data including demographic, age at epilepsy onset and VNS implantation, duration of epilepsy, seizure type, number of antiepilepsy drugs (AEDs), and monthly seizure frequency before VNS implantation and at the last clinic visit. Phone surveys were conducted with patients without recent clinic follow-up.
Results
Fifty-six patients (aged 4–17 at the time of implant) are the subjects of the study. Seizure reduction of >50 % was achieved in 9.8 % (6th month), 24 % (2nd year), 46.4 % (3rd year), and 54 %(5th year), and overall 35 (62.5 %) of the 56 subjects had a greater than 50 % reduction in seizure frequency at the last follow-up. Eleven patients became seizure free. The results, once obtained, were maintained steadily or even improved over time without any loss of efficacy during the follow-up. The only parameter, significantly related with clinical response, was age at seizure onset. The most frequent adverse events were hoarseness, cough, sore throat, and anorexia, experienced by 13 patients. Two patients had local wound infections and lead to the removal of the stimulator. An improvement in alertness, attention, and psychomotor activity, independent of the efficacy of vagal nerve stimulation, was observed in 8 patients.
Conclusion
To our knowledge, this is the first pediatric study evaluating seizure outcome over more than 5 years of follow-up, and demonstrates a favorable seizure outcome of >50 % seizure frequency in 62.5 % of patients and seizure freedom in 11 patients. It is well tolerated over an extended period of time.
Although different surgical approaches to the mesial temporal area are used, the best surgical approach to treat temporal lobe epilepsy (TLE) has not been established yet. Therefore, resective ...surgery is currently considered to be the most effective treatment for medically intractable TLE. The aim of this study is to evaluate the long-term efficacy of TLE surgery and to emphasize the factors affecting seizure outcomes such as surgical technique nuances and micro-neuroanatomical details in TLE cases.
In this retrospective analysis, 238 patients who underwent epilepsy surgery at Ankara University (Faculty of Medicine, Department of Neurosurgery) between 1990 and 2019 were included. All patients presented with symptoms of TLE. They were divided into two groups: those with neoplastic lesions and those with non-neoplastic brain lesions presenting with medically intractable epilepsy. In the non-neoplastic group, the patients underwent anterior temporal lobectomy with amygdalo-hippocampectomy (ATL+AH), whereas in the neoplastic group, the patients underwent tumor resection in addition to ATL+AH.
This study included 126 female (52.9%) and 112 male (47.1%) patients. The mean duration of epilepsy was 14.65 ± 9.29 years (0.08-46 years). The number of patients in the non-neoplastic and neoplastic groups was 190 and 48, respectively. The mean duration of follow-up was 15.82 ± 6.55 years (1-28 years). In the neoplastic and non-neoplastic groups, the Engel I seizure-free rates were 91.6% (44/48) and 90.5% (172/190), respectively. Furthermore, no mortality was observed among the groups.
Overall, effective seizure control was achieved with acceptable morbidity and complication rates in the neoplastic and non-neoplastic groups with surgical and micro-neuroanatomical nuances.
An anatomical study of the vascularization of the hippocampus was performed on 30 hemispheres. There were a total of 140 arteries supplying the hippocampi, for an average of 4.7 arteries per ...hemisphere (range three to seven arteries). Based on the origin and caliber of the arteries supplying the hippocampus, the hemispheres were divided into five groups: A) in 57% of the hemispheres studied, the origin was mixed and included the anterior choroidal artery (AChA), the main trunk of the posterior cerebral artery (PCA), and the inferior temporal, lateral posterior choroidal, and splenial branches of the PCA; B) in 27%, all of the inferior temporal branches of the PCA predominantly supplied the hippocampus; C) in 10%, the anterior inferior temporal branch of the PCA was the predominant supplier: D) in 3%, the hippocampus was predominantly supplied by arteries originating from the main trunk of the PCA (Uchimura artery); and E) in 3%, the AChA gave origin to the hippocampal vessel. It was found as a result of this study that the PCA directly and by its branches contributes much more to the blood supply of the hippocampal formation than the AChA. The uncal sulcus was found to be an important anastomotic site between the hippocampal branches of the AChA and the hippocampal branches of the PCA. In 26.6% of hemispheres, one of the hippocampal arteries arose from the lateral posterior choroidal artery. The splenial artery made a loop close to the extraventricular part of the hippocampal tail and gave off multiple vessels to this structure in 36.6% of hemispheres. The finding that the AChA passes through the choroid fissure as a trunk and its later division into the lateral plexal and medial perforating branches within the choroid plexus may be of surgical significance.
Abstract Objective This study aimed to investigate the efficacy of resective surgery in children with focal lesional epilepsy by evaluating the predictive value of pre- and postsurgical factors in ...terms of seizure freedom. Methods This study included 61 children aged between 2 and 18 years who were admitted to the pediatric video-EEG unit for presurgical workup. Each patient was evaluated with a detailed history, video-EEG, neuroimaging, and postsurgical outcomes according to Engel classification to predict postsurgical seizure freedom. All the possible factors including history, etiology, presurgical evaluation, surgical procedures, and postsurgical results were analyzed for their predictive value for postoperative seizure freedom. Results Of the 61 patients, 75% were diagnosed as having temporal lobe epilepsy (TLE), and 25% were diagnosed with extra-TLE. Two years after the surgery, 78.6% were seizure-free, of which 89% had TLE, and 50% had extra-TLE ( p < 0.05). Patients were more likely to have a favorable outcome for seizure freedom if they had rare seizure frequency, focal EEG findings, and focal seizures; had a temporal epileptogenic zone; or had TLE and hippocampal sclerosis. On the other hand, patients were more likely to have unfavorable results for seizure freedom if they had younger age of seizure onset, frequent seizures before the surgery, a frontal or multilobar epileptogenic zone, secondarily generalized seizures, extra-TLE with frontal lobe surgery, or focal cortical dysplasia. Significance Resective surgery is one of the most effective treatment methods in children with intractable epilepsy. A history of young age of seizure onset, frequent seizures before surgery, secondarily generalized seizures, a multilobar epileptogenic zone, frontal lobe surgery, and focal cortical dysplasia (FCD) are the most important predictive factors indicating that a patient would continue having seizures after surgery. On the other hand, focal seizure semiologies, temporal lobe localization, and hippocampal sclerosis indicate that a patient would have better results in terms of seizure freedom.
A peculiar case of intrasacral meningocele and spinal cord tethering is reported. Contents of the intrasacral meningocele and importance of CSF flow analyses with MRI are discussed. Demonstration of ...CSF flow from the thecal sac to meningocele in the CSF flow MR imaging may be helpful for determining the possibility of meningocele growth. In this report, we have presented the determination of CSF flow as a new surgical indication in this type of cases.
Gliomatosis cerebri is a rare primary glial neoplasm of the central nervous system characterized by excessive involvement of the brain tissue. Dispersion and infiltrative growth pattern of this ...insidious pathology limit the utility of total surgical removal and are underlying causes of its poor prognosis. Furthermore, unresponsiveness of gliomatosis cerebri to radiotherapy and its classification as high grade or type 2 is reportedly associated with poor long-term survival. Contrary to our current knowledge, we report the case of a 54-year-old male who was diagnosed with gliomatosis cerebri. He presented with an exceptional clinical and pathological course and poor prognostic factors but was successfully treated with total surgical resection after radiotherapy. The present case findings indicate the potential utility of surgery, usually underestimated, as a curative treatment for gliomatosis cerebri. Clinicians should be aware of negative predictive factors that may help identify a small subset of patients suitable for total surgical tumor removal, as in the present case.
Objectives: Depression and anxiety are the most common psychiatric disorders in patients with drug resistant temporal lobe epilepsy. This study evaluated depression, anxiety and quality of life in ...patients with temporal lobe epilepsy before and after ATL. Methods: This prospective study was performed in 23 patient with resistant temporal lobe epilepsy. Clinical seizure characteristics, temporal lobe localization, seizure frequency, educational and socioeconomic status, antiepileptic medication, cranial MRI and pathology of cases were evaluated. BDE, BAI and SF-36 scales administered before and after ATL with standard interval. Results: We found a rate of 43.5% for depression and anxiety before surgical treatment. Depression and anxiety were found to be related only seziure frequency in terms of clinical and demographic features. The rate of depression and anxiety increased with increased frequency of seizures (p<0.001 and p=0.012 respectively). Depression and anxiety improved markedly following ATL in our cases. This improvement is directly associated with attaining a seizure-free state following surgical treatment (p<0.001). We found a marked improvement in all subscales of SF 36. Conclusion: We found in this series that ATL can benefit carefully-chosen drug resistant TLE cases both with an improvement in epileptic seizures and also in the psychopathology. A seizure-free state following surgical treatment is the most powerful predictor of improvement findings of depression, anxiety and quality of life. Key words: Anterior temporal lobectomy; temporal lobe epilepsy; quality of life. Amac: Depresyon ve anksiyete direncli temporal lob epilepsisinde (TLE) en sik izlenen psikiyatrik hastaliklardir. Bu calismada, direncli temporal lob epilepsili olgularda anterior temporal lobektomi (ATL) oncesi ve sonrasi depresyon, anksiyete ve yasam kalitesi (YK) degerlendirildi. Gerec ve Yontem: Calismamizda direncli TLE olan 23 olgu prospektif olarak incelendi. Olgularin klinik nobet ozellikleri, temporal lob lokalizasyonu, nobet sikligi, egitim duzeyleri, sosyoekonomik durumlari, antiepileptik ilaclari (AEI), kraniyal manyetik rezonans goruntulemeleri ve patoloji sonuclari incelendi. Cerrahi oncesi ve cerrahiden sonra standart araliklarla Beck depresyon envanteri (BDE), Beck anksiyete envanteri (BAE) ve Short Form 36 (SF-36) olcekleri uygulandi. Bulgular: Calismamizda cerrahi tedavi oncesi depresyon ve anksiyete orani %43.5 olarak bulundu. Olgularda depresyon ve anksiyetenin, demografik ve klinik ozellikler acisindan sadece nobet sikligi ile iliskili oldugu saptandi. Nobet sikligi arttikca depresyon ve anksiyete orani da artmaktadir (sirasi ile p<0.001 ve p=0.012). ATL sonrasi depresyon ve anksiyetenin belirgin olarak duzeldigi izlendi. Bu duzelme cerrahi tedavi sonrasi nobetsizlik halini saglamakla dogrudan baglantili idi (p<0.001). SF-36'nin alt olceklerinin tumunde cerrahi tedavi sonrasi belirgin duzelme izlendi. Sonuc: Bu seride titizlikle secilmis direncli TLE olgularinda ATL'nin sadece epileptik nobetlerin duzelmesini degil ayni zamanda psikopatolojinin de duzelmesini sagladigi gorulmustur. Cerrahi tedavi sonrasi nobetsizlik hali, depresyon, anksiyete ve YK'da duzelmenin en guclu prediktorudur. Anahtar sozcukler: Anterior temporal lobektomi; temporal lob epilepsisi; yasam kalitesi.
Abstract Background Vagus nerve stimulation (VNS) is an effective therapy for pharmacoresistant epilepsy. Nevertheless, information regarding the long-term outcome of VNS in children is limited. Aim ...To describe the long-term outcome of VNS in patients with pharmacoresistant epilepsy treated at the Gazi University Medical Faculty Epilepsy Center, Turkey. Patients and methods The study included 24 patients – all younger than 18 years of age (mean age: 14.31 years). Median age at the time of VNS device implantation was 11 years. Median age at onset of epilepsy was 21 months and median duration of epilepsy was 126 months. All the patients’ seizures were intractable with antiepileptic drug treatment and all had been treated with an average of 6 ± 2 antiepileptic medications. In all, 12 patients had secondary generalized seizures and 12 had partial seizures. Because this was a retrospective open study, the number of seizures could not be enumerated in most of these cases. Results The only factor that was associated with seizure reduction was duration of follow-up. Age at seizure onset and age at VNS device implantation were not associated with seizure reduction. The difference in seizure reduction between patients >12 years of age and patients <12 years of age was not significant. Mean percentage of seizure reduction after 6 months–7 years of treatment was, respectively, 22.5% ( n = 24) (6th month), 32% ( n = 20) (1st year), 42% ( n = 16) (2nd year), 50.45% ( n = 11) (3rd year), 52% ( n = 10) (4th year), 60% ( n = 8) (5th year), 61.25% ( n = 8) (6th year), and 61.6% ( n = 6) (7th year). The positive effect of VNS persisted throughout the follow-up period. Conclusions Although it is an expensive method, VNS is an effective treatment method. This series shows the necessity of long-term follow-up series for understanding the efficacy and advantages of VNS. Prospective, long-term double-blind studies with large samples are needed to confirm the present study's findings.
Craniopharyngiomas are benign neoplasms of epithelial origin that arise from the remnants of Rathke's pouch and are located in the sellar, parasellar, and third ventricular regions. Despite major ...advances in microsurgical techniques, total removal of these tumors is associated with a high risk of death, long-term endocrinological dependence, cognitive dysfunction, and behavioral disorders. For patients with monocystic craniopharyngiomas, encouraging postoperative survival rates and high rates of cyst regression after intracavitary administration of bleomycin have been reported. Moreover, only a few side effects have been reported for this treatment method. We report a patient with a cystic craniopharyngioma who was treated using intracavitary bleomycin administration and died as a result of the direct toxic effects of bleomycin on deep brain structures and the brainstem.
A 47-year-old woman with a cystic craniopharyngioma underwent stereotactic insertion of a catheter attached to a subcutaneous reservoir. Five months after the procedure, positive-contrast computed tomographic cystography was performed to confirm the absence of fluid leakage. Daily intracavitary injections of bleomycin were administered through the reservoir into the cyst, until a total dose of 56 mg had been administered in 8 days. After the treatment, the cystic cavity regressed but the patient exhibited neurological deterioration; magnetic resonance imaging scans revealed diffuse edema in the diencephalon and brainstem. The patient died 45 days after completion of the treatment.
Intracavitary administration of bleomycin is not a treatment protocol without risks or side effects, even if there is no fluid leakage into the cerebrospinal fluid. Although this is known to be an effective treatment for cystic craniopharyngiomas, previous reports cannot be used to establish a standard treatment method, and more research is needed to yield a safer effective protocol.
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