Pedro Paulo Mariani

Extended, One-stage Callosal Section for Treatment of Refractory Secondarily Generalized Epilepsy in Patients with Lennox–Gastaut and Lennox-like Syndromes

Summary:  Purpose: We report on the efficacy and safety of extended one‐stage callosal section performed in a large and homogeneous series of patients.

Outcome after extended callosal section in patients with primary idiopathic generalized epilepsy

Purpose:  We report the outcome of patients with refractory idiopathic generalized epilepsy (IGE) who were submitted to extended one‐stage callosal section.

Outcome after hemispherectomy in hemiplegic adult patients with refractory epilepsy associated with early middle cerebral artery infarcts.

Purpose:  To study the outcome after hemispherectomy (HP) in a homogeneous adult patient population with refractory hemispheric epilepsy.

Outcome after corticoamygdalohippocampectomy in patients with refractory temporal lobe epilepsy and mesial temporal sclerosis without preoperative ictal recording

Purpose:  We report on the surgical outcome obtained in patients with refractory temporal lobe epilepsy with mesial temporal sclerosis (MTS) who were evaluated preoperatively without ictal recording and were submitted to corticoamygdalohippocampectomy.

Outcome after cortico-amygdalo-hippocampectomy in patients with temporal lobe epilepsy and normal MRI

RATIONALE We describe seizure and neuropsychological outcome obtained after CAH in patients with TLE and normal MRI evaluated in the modern imaging era. METHODS Forty-five adult consecutive patients with TLE and normal MRI were studied. All patients had neuropsychological testing, interictal and ictal EEG recordings and MRI. They were divided into two groups: Group 1 (n=18), included patients in whom non-invasive neurophysiological evaluation was lateralizing and Group 2 (n=27) included patients with non-lateralizing neurophysiological data who were submitted to invasive recordings. RESULTS Seventy-seven percent of the Group 1 patients were rated as Engel I; 11% were rated as Engel II and 11% as Engel III. In Group 2, there were 57% of patients seizure-free, 26% in Engel II and 14% in Engel III. Pre-operatively, mean general IQ was 82 and 78 in Groups 1 and 2, respectively; post-operatively, mean general IQ was respectively 86 and 71. Some degree of verbal memory decline was noted in all patients submitted to dominant temporal lobe resection in both Groups 1 and 2. At last follow-up visit, 22% of Group 1 and 11% of Group 2 patients were receiving no antiepileptic drugs (AED). CONCLUSIONS Our data showed that patients with TLE and normal MRI could get good surgical results after CAH although 60% of them would need invasive recordings and their results regarding seizure control and cognition were worse than those obtained in patients with MRI defined temporal lobe lesions. Caution should be taken in offering dominant temporal lobe resection to this subset of patients.

Outcome after cortico-amygdalo-hippocampectomy in patients with severe bilateral mesial temporal sclerosis submitted to invasive recording

INTRODUCTION Although some degree of bilateral hippocampal involvement might be frequent in patients with temporal lobe epilepsy, severe bilateral mesial temporal sclerosis (MTS) is very rare. We present our experience while treating patients with severe bilateral MTS submitted to invasive recordings. METHODS Nine adult patients were studied. All patients had simple and complex partial seizures. All patients had bilateral independent interictal temporal lobe spiking and non-lateralizing video-EEG findings. MRI showed severe bilateral MTS and no other brain lesion. All patients had severe verbal and non-verbal memory deficits. All patients were submitted to invasive recordings after bilateral subdural grids implantation. Cortico-amygdalo-hippocampectomy (CAH) was performed in all patients on the side suggested by invasive recording. Follow-up time ranged from 5 to 10 years. RESULTS Invasive video-EEG showed exclusively unilateral seizure onset in seven patients; in two patients, seizures originating from both temporal lobes were found (80% of them originated from one side). Five patients were submitted to left and four to right CAH. Seven patients were rendered seizure-free after surgery (Engel I); the other two were rated as Engel II. There was no additional memory decline. There was no surgical morbidity or mortality. Pathological examination showed MTS in all patients. DISCUSSION Good surgical outcome (77% seizure-free patients) could be obtained even in this apparently unsuitable group of patients. All patients benefit from the procedure. We did not see any cognitive decline in our patients with severe bilateral MTS. Patients with severe bilateral MTS would need invasive recordings despite any findings during surface video-EEG.

Vagus nerve stimulation might have a unique effect in reflex eating seizures

We studied the effects of vagus nerve stimulation (VNS) on eating seizures, which theoretically would be triggered by neural activity and signaling from organs innervated by the vagus nerve. Three adult patients with daily nonreflex and reflex eating seizures were studied; one patient also had hot‐water seizures. One patient had bilateral polymicrogyria and two had normal magnetic resonance imaging (MRI) findings. All patients were submitted to VNS implantation and had at least 2 years of postimplantation follow‐up. Final stimulation parameters were 2.0–2.5 mA, 500 μs, and 30 Hz. Eating seizures decreased 70–95% and nonreflex seizures decreased 0–40% after VNS. There was no improvement in hot‐water seizures. VNS seems to be an especially useful treatment modality in patients with reflex eating seizures not amenable to resective surgery.

Surgical outcome in patients with refractory epilepsy associated to MRI-defined unilateral mesial temporal sclerosis

INTRODUCTION Several pre-operative work-up protocols have been used while selecting epileptic patients for surgery among different centers. The relative value of the different available pre-operative tests is still under discussion. OBJECTIVE We report on the surgical outcome obtained in patients with refractory temporal lobe epilepsy associated to mesial temporal sclerosis (MTS) and who were evaluated pre-operatively by interictal EEG and MRI alone. METHOD Forty one patients with refractory unilateral temporal lobe epilepsy were evaluated using interictal EEG and MRI. MRI disclosed unilateral MTS in all patients. All patients had at least 4 interictal EEG recordings. All patients were submitted to cortico-amygdalo-hippocampectomy at the side determined by MRI. RESULTS Interictal EEG showed unilateral epileptiform discharges compatible with MRI findings in 37 patients; in four out of the 41 patients, bilateral discharges were found. Mean follow-up time was 4.3+/-1.1 years. Thirty-nine patients (95.1%) were classified as Engels Class I (70.6% Engel I-A). Two patients (4.9%) were rated as Engels Class II. All patients in whom bilateral discharges were found were in Engels Class I. Pathological examination showed MTS in all patients. CONCLUSION It is possible to adequately select good surgical candidates for temporal lobe resection using MRI and interictal EEG alone. In patients with MRI-defined MTS we should expect a postoperative remission rate higher then 90%. The finding of MTS on MRI is the most important good prognostic factor after temporal lobe resection.

Seizure outcome after hippocampal deep brain stimulation in patients with refractory temporal lobe epilepsy: A prospective, controlled, randomized, double‐blind study

We designed a prospective, randomized, controlled, double‐blind study to evaluate the efficacy of hippocampal deep brain stimulation (Hip‐DBS) in patients with refractory temporary lobe epilepsy (TLE).

Hemisferectomia funcional precoce na hemimegalencefalia associada à epilepsia refratária

Hemimegalencephaly (HME) is a rare congenital brain malformation of unknown etiology. Patients with HME can present with an early onset epileptic syndrome which is often refractory to medical treatment and associated to impaired neurological development. Functional hemispherectomy (FH) has proven to be a valuable treatment alternative in patients with refractory epilepsy in this setting. Very few children operated under the age of 6 months and bearing HME and catastrophic epilepsy (CE) have been described in the literature. This study reports on 2 kids younger than 6 months with HME and CE submitted to FH with good clinical outcome.