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Hemispherectomy for treatment of refractory epilepsy in the pediatric age group: a systematic review
Christoph J Griessenauer1, Smeer Salam, Philipp Hendrix
1Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Alabama;
Insights
Hemispherectomy is highly effective for pediatric refractory epilepsy, especially for acquired and progressive causes. While procedure type doesn't impact seizure freedom, hemispherotomy offers a better safety profile.
Area of Science:
- Neurosurgery
- Pediatric Neurology
- Epilepsy Surgery
Background:
- Retrospective studies document institutional experience with hemispherectomy.
- A comprehensive systematic review on hemispherectomy for pediatric refractory epilepsy was lacking.
Purpose of the Study:
- To systematically review the efficacy and safety of hemispherectomy in pediatric patients with refractory epilepsy.
- To analyze seizure outcomes based on hemispherectomy type and underlying etiology.
Main Methods:
- Systematic review of studies up to October 2013.
- Inclusion criteria: ≥10 pediatric patients (≤20 years), ≥1-year follow-up, reported seizure outcome and hemispherectomy type.
- Data extraction by two independent reviewers.
Main Results:
- 29 studies with 1161 patients analyzed; 73.4% achieved seizure freedom.
- No significant difference in seizure outcome between hemispherectomy types (p=0.737).
- Acquired and progressive etiologies showed higher seizure-free rates than developmental ones (p<0.001).
- Complications reported in 69% of studies; 14% hydrocephalus, 2.2% 30-day mortality.
Conclusions:
- Hemispherectomy is a highly effective treatment for pediatric refractory epilepsy.
- Acquired and progressive etiologies predict better seizure outcomes.
- Hemispherotomy procedures are associated with a more favorable complication profile compared to other hemispherectomy types.
Object:
Evidence in support of hemispherectomy stems from a multitude of retrospective studies illustrating individual institutions' experience. A systematic review of this topic, however, is lacking in the literature.
Methods:
A systematic review of hemispherectomy for the treatment of refractory epilepsy available up to October 2013 was performed using the following inclusion criteria: reports of a total of 10 or more patients in the pediatric age group (≤ 20 years) undergoing hemispherectomy, seizure outcome reported after a minimum follow-up of 1 year after the initial procedure, and description of the type of hemispherectomy. Only the most recent paper from institutions that published multiple papers with overlapping study periods was included. Two reviewers independently applied the inclusion criteria and extracted all the data.
Results:
Twenty-nine studies with a total of 1161 patients met the inclusion criteria. Seizure outcome was available for 1102 patients, and the overall rate of seizure freedom at the last follow-up was 73.4%. Sixteen studies (55.2%) exclusively reported seizure outcomes of a single type of hemispherectomy. There was no statistically significant difference in seizure outcome and type of hemispherectomy (p = 0.737). Underlying etiology was reported for 85.4% of patients with documented seizure outcome, and the overall distribution of acquired, developmental, and progressive etiologies was 30.5%, 40.7%, and 28.8%, respectively. Acquired and progressive etiologies were associated with significantly higher seizure-free rates than developmental etiologies (p < 0.001). Twenty of the 29 studies (69%) reported complications. The overall rate of hydrocephalus requiring CSF diversion was 14%. Mortality within 30 days was 2.2% and was not statistically different between types of hemispherectomy (p = 0.787).
Conclusions:
Hemispherectomy is highly effective for treating refractory epilepsy in the pediatric age group, particularly for acquired and progressive etiologies. While the type of hemispherectomy does not have any influence on seizure outcome, hemispherotomy procedures are associated with a more favorable complication profile.
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