Bower Regina S, Wirrell Elaine C, Eckel Laurence J, Wong-Kisiel Lily C, Nickels Katherine C, Wetjen Nicholas M
Departments of 1 Neurosurgery.
Neurology, and.
J Neurosurg Pediatr. 2015 Jul;16(1):94-100. doi: 10.3171/2014.12.PEDS14150. Epub 2015 Apr 24.
OBJECT Resection can sometimes offer the best chance of meaningful seizure reduction in children with medically intractable epilepsy. However, when surgery fails to achieve the desired outcome, reoperation may be an option. The authors sought to investigate outcomes following resective reoperation in pediatric patients with refractory epilepsy, excluding tumoral epilepsies. Differences in preoperative workup between surgeries are analyzed to identify factors influencing outcomes and complications in this complex group. METHODS Medical records were reviewed for all pediatric patients undergoing a repeat resective surgery for refractory epilepsy at the authors' institution between 2005 and 2012. Tumor and vascular etiologies were excluded. Preoperative evaluation and outcomes were analyzed for each surgery and compared. RESULTS Ten patients met all inclusion criteria. The median age at seizure onset was 4.5 months. Preoperative MRI revealed no lesion in 30%. Nonspecific gliosis and cortical dysplasia were the most common pathologies. The majority of preoperative workups included MRI, video-electroencephalography (EEG), and SISCOM. Intracranial EEG was performed for 60% for the first presurgical evaluation and 70% for the second evaluation. The goal of surgery was palliative in 4 patients with widespread cortical dysplasia. The final Engel outcome was Class I in 50%. The rate of favorable outcome (Engel Class I-II) was 70%. The complication rate for the initial surgery was 10%. However, the rate increased to 50% with the second surgery, and 3 of these 5 complications were pseudomeningoceles requiring shunt placement (2 of the 3 patients underwent hemispherotomy). CONCLUSIONS Resective reoperation for pediatric refractory epilepsy has a high rate of favorable outcome and should be considered in appropriate candidates, even as a palliative measure. Intracranial EEG monitoring should be considered on initial workup in cases where the results of imaging or EEG studies are ambiguous or conflicting. Epilepsy secondary to cortical dysplasia, especially if the dysplasia is not seen clearly on MRI, can be difficult to cure surgically. Therefore, in these cases, as large a resection as can be safely accomplished should be done, particularly when the goal is palliative. The rate of complications, particularly pseudomeningocele ultimately requiring shunt placement, is much higher following reoperation, and patients should be counseled accordingly.
目的 对于药物治疗难治性癫痫的儿童，手术切除有时可能提供最有意义的减少癫痫发作的机会。然而，当手术未能达到预期效果时，再次手术可能是一种选择。作者试图研究难治性癫痫儿科患者（不包括肿瘤性癫痫）接受切除性再次手术后的结果。分析两次手术术前检查的差异，以确定影响这一复杂群体手术结果和并发症的因素。方法 回顾了2005年至2012年在作者所在机构接受难治性癫痫再次切除手术的所有儿科患者的病历。排除肿瘤和血管病因。分析每次手术的术前评估和结果并进行比较。结果 10例患者符合所有纳入标准。癫痫发作开始的中位年龄为4.5个月。术前MRI显示30%无病变。非特异性胶质增生和皮质发育异常是最常见的病理情况。大多数术前检查包括MRI、视频脑电图（EEG）和SISCOM。60%的首次术前评估和70%的第二次评估进行了颅内EEG检查。4例广泛皮质发育异常患者的手术目标是姑息性的。最终恩格尔结局为I级的占50%。良好结局（恩格尔I-II级）率为70%。初次手术的并发症发生率为10%。然而，第二次手术时该发生率增至50%，这5例并发症中有3例是需要放置分流管的假性脑膜膨出（3例患者中有2例接受了大脑半球切除术）。结论 儿科难治性癫痫的切除性再次手术有较高的良好结局率，即使作为一种姑息性措施，也应在合适的患者中考虑。在影像学或EEG研究结果不明确或相互矛盾的情况下，初次检查时应考虑颅内EEG监测。皮质发育异常继发的癫痫，特别是在MRI上未清晰显示发育异常时，手术难以治愈。因此，在这些情况下，应尽可能安全地进行大范围切除，尤其是当目标是姑息性治疗时。再次手术后并发症发生率，尤其是最终需要放置分流管的假性脑膜膨出发生率要高得多，应相应地对患者进行咨询。
