Advanced treatment of intractable childgood epilepsy.

Twenty to thirty percent of children with epilepsy continue to have seizures despite anti-epileptic drugs (AEDs) treatment and are defined as medically intractable epilepsy. Intractable epilepsy frequently has developmental impact, causing permanent neurodevelopmental deficits in children. Recently developed neurodiagnostic studies and treatment modalities have substantially altered the management of patients with intractable epilepsy. The newly developed AEDs are frequently used for the treatment of patients unresponsive to conventional AEDs. Nonpharmacologic options for intractable epilepsy include dietary therapy such as ketogenic diet and modified Atkins diet, epilepsy surgery, and neuromodulatory treatments such as vagus nerve stimulation. Ketogenic diet is an effective and safe treatment for epilepsy in children; increasing use has led to modification of protocol for higher efficacy and better tolerability. When epilepsy is intractable to medical treatment, epilepsy surgery including surgical resection of epileptogenic area, or palliative surgery can be considered. Vagal Nerve Stimulation is recommended for patients who are not candidates for resective surgery. These nonpharmcologic treatments could result in resumption of developmental progress in patients with childhood intractable epilepsy.Active application of newly developed medical and surgical treatments could provide better outcome in seizure control and developmental progress in patients with intractable epilepsyope

Localization of ictal onset zones in Lennox-Gastaut syndrome using directional connectivity analysis of intracranial electroencephalography

INTRODUCTION: Neuroscientists are becoming interested in the application of computational EEG analysis to the identification of ictal onset zones; however, most studies have focused on the localization of ictal onset zones in focal epilepsy. The present study aimed to estimate the ictal onset zone of Lennox-Gastaut syndrome (LGS) with bilaterally synchronous epileptiform discharges from intracranial electroencephalography (iEEG) recordings using directional connectivity analysis. METHODS: We analyzed ictal iEEG data acquired from three LGS patients who underwent epileptic surgery with favorable surgical outcomes. To identify the ictal onset zones, we estimated the functional directional connectivity network among the intracerebral electrodes using the directed transfer function (DTF) method. RESULTS: The analysis results demonstrated that areas with high average outflow values corresponded well with the surgical resection areas identified using electrophysiologic data and conventional neuroimaging modalities. DISCUSSIONS: Our results suggest that the DTF analysis can be a useful auxiliary tool for determining surgical resection areas prior to epilepsy surgery in LGS patients. This is the first research article demonstrating that directional connectivity analysis of iEEG recording data can be used for delineating surgical resection areas in generalized epilepsy patients who need surgical treatment.ope

측두염외 간질 소아 환자의 간질 수술 후 결과 및 예후 인자

PURPOSE: In this study, we reviewed surgical outcomes in children with extratemporal lobe epilepsy in our institution and suggested prognostic factors from these results. METHODS: We retrospectively analyzed the records of 59 patients(males n=35, females n=24; mean age of 10 years, mean age of seizure onset of 3 years, mean age of epilepsy surgery of 8 years) who received extratemporal lobe surgery between October 2003 to May 2008. Every patients were performed preoperative evaluation to determine the anatomical location of the ictal onset zone employing video electroencephalography(EEG) monitoring, intraoperative electrocorticography, intracranial EEG monitoring and neuroimagings such as Magnetic Resonance Imaging (MRI), positron emission tomography, interictal/ictal single photon emission computed tomography. Developmental test was taken at pre- and post-operation. RESULTS: Postoperative outcome as defined by Engel's classification were as follows; class I in 42(71.2%), II in 6(10.2%), III in 4(6.8%), and IV in 7(11.9%) patients. We considered six favorable prognostic factors from our data; age at operation, matching accuracy of video-EEG monitoring results, presence of a structural lesion on MRI, using specialized neuromodalities, involvement of lobe at surgery, and nature of the epileptogenic lesion. We also focused on unfavorable prognostic factors; no structural lesion on MRI, low grade of surgical pathology, postoperative epileptiform discharges on EEG. CONCLUSION: Early surgical intervention in pediatric patients with medically refractory seizure who possess focal epileptogenic foci of extratemporal lobe origin has been an effective and safe treatmentope

Comparison of various imaging modalities in localization of epileptogenic lesion using epilepsy surgery outcome in pediatric patients

PURPOSE: We employed the results of imaging modalities from pediatric patients who received successful epilepsy surgery to determine the accuracy of each imaging tool in identifying epileptic zones in youngsters. METHODS: All Engel class I pediatric patients who received epilepsy surgery between October 2003 and April 2008 were selected. Their pathology, EEG, MRI, PET, and subtraction ictal SPECT coregistered to MRI (SISCOM) results were compared for accuracy in locating the epileptic foci, defined as "area that resulted in seizure ablation after resection". RESULTS: Forty-two patients were enrolled (23 temporal lobectomy, 19 extratemporal resections). MRI showed concordance in 84.2% of extratemporal cases, all of which had precise localization of lesions. In temporal cases, lateralization was 91.3% and localization was 82.6%. PET showed a concordance rate of 95.5% and localization was 72.7% for temporal lesions. For extratemporal lesions, concordance was only 68.4%. SISCOM showed concordance in 100% of temporal and 92.3% of extratemporal cases, with localization in 66.7% of temporal and 84.6% of extratemporal cases. Most temporal lobe cases had hippocampal sclerosis, and cortical dysplasia was observed in extratemporal cases. DISCUSSION: MRI was invariably reliable in all cases. PET results were as reliable in lateralizing the temporal epileptic area, while its efficacy was lower for extratemporal cases. SISCOM effectively localized lesions in extratemporal cases, but its efficacy was lower in temporal lesions. In cases of conflicting pre-surgical results, MRI, with supplementary data from PET, helped to establish correct decisions in temporal epilepsies, while utilization of SISCOM and MRI data is advised for extratemporal casesope