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Resective surgery for intractable epilepsy in children: radiologic evaluation
R B Dietrich1, S el Saden, H T Chugani
1Department of Radiological Sciences, University of California, Los Angeles 90024.
Insights
Epilepsy surgery, particularly hemispherectomy, is effective for children with intractable seizures and brain lesions. Postoperative imaging is crucial for detecting complications early, guiding treatment, and improving outcomes.
Area of Science:
- Pediatric Neurology
- Neuroradiology
- Neurosurgery
Background:
- Epilepsy surgery, including hemispherectomy, is increasingly used for pediatric intractable seizures linked to structural brain lesions.
- Accurate pre- and post-operative imaging is vital for surgical planning and management.
Purpose of the Study:
- To evaluate pre- and postoperative imaging findings in pediatric patients undergoing hemispherectomy.
- To establish a recommended radiologic evaluation protocol for hemispherectomy candidates.
Main Methods:
- Retrospective review of imaging (CT, MR, PET, EEG, angiography) and pathological findings in 29 pediatric patients (22 days to 19 years) who underwent hemispherectomy.
- Correlation of imaging findings with clinical outcomes and pathological diagnoses.
Main Results:
- Preoperative PET and EEG showed abnormalities but often lacked lesion characterization.
- CT/MR identified focal/unilateral lesions in 19/29 patients, providing crucial lesion nature information.
- Postoperative CT/MR detected early complications (hemorrhage, infection, hydrocephalus) and specific findings (septations, hemosiderin) associated with poor outcomes.
Conclusions:
- Hemispherectomy is a viable surgical option for pediatric intractable epilepsy with structural lesions.
- A comprehensive pre- and postoperative imaging protocol, including CT, MR, PET, EEG, and angiography, is essential for optimizing patient selection, surgical planning, and complication management.
Abstract:
Epilepsy surgery is gaining popularity for the treatment of children with intractable seizures in whom either a focal or extensive unilateral structural brain lesion is demonstrated. We evaluated the pre- and postoperative imaging findings in 29 patients (aged 22 days to 19 years) who underwent hemispherectomies, 12 total and 17 subtotal. Pathologic correlation was obtained in all cases. Preoperatively, positron emission tomography and electroencephalography demonstrated abnormalities in all of the 28 children studied, but frequently could not characterize the lesion. CT or MR or both demonstrated focal or unilateral lesions in only 19 of these but gave additional information regarding the nature of the lesion. Preoperative angiographic findings were abnormal in five of 17 patients studied and were particularly useful in the evaluation of the extent of abnormality in patients with Sturge-Weber syndrome. Postoperatively, CT and MR demonstrated early complications such as the development of epidural blood and fluid collections, parenchymal hemorrhage, infection, and early hydrocephalus. Postoperatively, MR demonstrated the early development of septations, the presence of subarachnoid hemorrhage, and/or the deposition of hemosiderin in four patients, findings that historically have been associated with the development of devastating clinical complications. From these data, a recommended protocol of radiologic evaluation for patients undergoing hemispherectomy has been established.