1Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland.
2Case Western Reserve University School of Medicine, Cleveland.
J Neurosurg Pediatr. 2023 Dec 15;33(3):199-206. doi: 10.3171/2023.11.PEDS23341. Print 2024 Mar 1.
Hemispherectomy surgery is an effective procedure for pediatric patients with intractable hemispheric epilepsy. Hydrocephalus is a well-documented complication of hemispherectomy contributing substantially to patient morbidity. Despite some clinical and operative factors demonstrating an association with hydrocephalus development, the true mechanism of disease is incompletely understood. The aim of this study was to investigate a range of clinical and surgical factors that may contribute to hydrocephalus to enhance understanding of the development of this complication and to aid the clinician in optimizing peri- and postoperative surgical management.
A retrospective chart review was conducted on all pediatric patients younger than 21 years who underwent hemispherectomy surgery at the Cleveland Clinic between 2002 and 2016. Data collected for each patient included general demographic information, neurological and surgical history, surgical technique, pathological analysis, presence and duration of perioperative CSF diversion, CSF laboratory values obtained while an external ventricular drain (EVD) was in place, length of hospital stay, postoperative aseptic meningitis, and in-hospital surgical complications (including perioperative stroke, hematoma formation, wound breakdown, and/or infection). Outcomes data included hemispherectomy revision and Engel grade at last follow-up (based on the Engel Epilepsy Surgery Outcome Scale).
Data were collected for 204 pediatric patients who underwent hemispherectomy at the authors' institution. Twenty-eight patients (14%) developed hydrocephalus requiring CSF diversion. Of these 28 patients, 13 patients (46%) presented with hydrocephalus during the postoperative period (within 90 days), while the remaining 15 patients (54%) presented later (beyond 90 days after surgery). Multivariate analysis revealed postoperative aseptic meningitis (OR 7.0, p = 0.001), anatomical hemispherectomy surgical technique (OR 16.3 for functional/disconnective hemispherectomy and OR 7.6 for modified anatomical, p = 0.004), male sex (OR 4.2, p = 0.012), and surgical complications (OR 3.8, p = 0.031) were associated with an increased risk of hydrocephalus development, while seizure freedom (OR 0.3, p = 0.038) was associated with a decreased risk of hydrocephalus.
Hydrocephalus remains a prominent complication following hemispherectomy, presenting both in the postoperative period and months to years after surgery. Aseptic meningitis, anatomical hemispherectomy surgical technique, male sex, and surgical complications show an association with an increased rate of hydrocephalus development while seizure freedom postsurgery is associated with a decreased risk of subsequent hydrocephalus. These findings speak to the multifactorial nature of hydrocephalus development and should be considered in the management of pediatric patients undergoing hemispherectomy for medically intractable epilepsy.
半球切除术是治疗小儿难治性半球性癫痫的有效方法。脑积水是半球切除术的一种常见并发症，严重影响患者的生活质量。尽管一些临床和手术因素与脑积水的发生有关，但疾病的确切机制仍不完全清楚。本研究旨在探讨一系列可能导致脑积水的临床和手术因素，以加深对该并发症发生机制的理解，并为临床医生优化围手术期手术管理提供帮助。
对 2002 年至 2016 年在克利夫兰诊所接受半球切除术的 21 岁以下儿科患者进行了回顾性病历分析。每位患者的数据均包括一般人口统计学信息、神经和手术史、手术技术、病理分析、围手术期脑脊液分流的存在和持续时间、外部脑室引流（EVD）期间获得的脑脊液实验室值、住院时间、术后无菌性脑膜炎和院内手术并发症（包括围手术期卒中、血肿形成、伤口破裂和/或感染）。预后数据包括半球切除术修订和最后一次随访时的 Engel 分级（根据 Engel 癫痫手术预后量表）。
对 204 名在本机构接受半球切除术的儿科患者进行了数据分析。28 名患者（14%）出现需要脑脊液分流的脑积水。这 28 名患者中，13 名患者（46%）在术后期间（90 天内）出现脑积水，而其余 15 名患者（54%）在术后 90 天后出现脑积水。多变量分析显示，术后无菌性脑膜炎（OR 7.0，p=0.001）、解剖性半球切除术手术技术（OR 16.3 用于功能性/去连接性半球切除术，OR 7.6 用于改良解剖性，p=0.004）、男性（OR 4.2，p=0.012）和手术并发症（OR 3.8，p=0.031）与脑积水发生风险增加相关，而术后无癫痫发作（OR 0.3，p=0.038）与脑积水发生风险降低相关。
脑积水仍然是半球切除术后的一个突出并发症，可在术后期间和术后数月至数年出现。无菌性脑膜炎、解剖性半球切除术手术技术、男性和手术并发症与脑积水发生率增加相关，而术后无癫痫发作与随后发生脑积水的风险降低相关。这些发现表明脑积水的发生具有多因素性，在对接受难治性癫痫半球切除术的儿科患者进行管理时应予以考虑。
