Abstracts

Rationale: To demonstrate the safety and efficacy of surgical management in multilobar pediatric epilepsy with subhemispheric involvement. The prognosis for seizure freedom is thought to be poorer in the setting of several epileptogenic zones involving multiple lobes, where hemispherectomy is contraindicated. We describe 16 patients whose age, language or sensorimotor capabilities precluded hemispherectomy, who underwent multilobar resections and disconnections in the setting of medically intractable seizures. Methods: 13 children and three adults, aged 15 months to 46 years, with medically intractable epilepsy since childhood, were followed at the Comprehensive Pediatric Epilepsy Center at Beth Israel Medical Center in New York. Pre- and post-operative evaluations included EEG recordings with video monitoring, MRIs, PET scans, and functional MRIs. All patients were treated with staged operations spaced by at least one week, using invasive monitoring and functional mapping with grid and strip electrodes. Pre-operative MRI findings included perinatal infarction, post-traumatic encephalomalacia, cortical dysplasia, mesial temporal sclerosis and a treated arachnoid cyst. All patients experienced disabling complex partial seizures and impediments of language, social, academic and motor development. Results: Ten children underwent a combination of anatomic and functional posterior quadrantectomy. In three of these patients, a partial frontal resection accompanied the quadrantectomy. One child with a dominant hemisphere perinatal parieto-occipital stroke underwent a temporal and occipital resection. The remaining six patients had combined temporal and frontal resections. Language and sensorimotor functions were preserved in all cases. All patients have Engel I outcomes (10 Engel 1A, 2 each of Engel IB, IC, ID) with follow up ranging from 3 months to 3 years. Conclusions: Children and adults with multilobar epilepsy due to multiple pathogenic mechanisms, who are not candidates for hemispherectomy, can be safely and effectively treated with epilepsy surgery. Staged operations with invasive mapping are necessary to comprehensively delineate the epileptogenic zones and distinguish them from functional areas.