title: Neurosurgical management of intractable rolandic epilepsy in children: role of resection in eloquent cortex. Clinical article.
abstract: OBJECTIVE
  The authors undertook this study to review their experience with cortical resections in the rolandic region in children with intractable epilepsy.
  
  
  METHODS
  The authors retrospectively reviewed the medical records obtained in 22 children with intractable epilepsy arising from the rolandic region. All patients underwent preoperative electroencephalography (EEG), MR imaging, prolonged video-EEG recordings, functional MR imaging, magnetoencephalography, and in some instances PET/SPECT studies. In 21 patients invasive subdural grid and depth electrode monitoring was performed. Resection of the epileptogenic zones in the rolandic region was undertaken in all cases. Seizure outcome was graded according to the Engel classification. Functional outcome was determined using validated outcome scores.
  
  
  RESULTS
  There were 10 girls and 12 boys, whose mean age at seizure onset was 3.2 years. The mean age at surgery was 10 years. Seizure duration prior to surgery was a mean of 7.4 years. Nine patients had preoperative hemiparesis. Neuropsychological testing revealed impairment in some domains in 19 patients in whom evaluation was possible. Magnetic resonance imaging abnormalities were identified in 19 patients. Magnetoencephalography was performed in all patients and showed perirolandic spike clusters on the affected side in 20 patients. The mean duration of invasive monitoring was 4.2 days. The mean number of seizures during the period of invasive monitoring was 17. All patients underwent resection that involved primary motor and/or sensory cortex. The most common pathological entity encountered was cortical dysplasia, in 13 children. Immediately postoperatively, 20 patients had differing degrees of hemiparesis, from mild to severe. The hemiparesis improved in all affected patients by 3-6 months postoperatively. With a mean follow-up of 4.1 years (minimum 2 years), seizure outcome in 14 children (64%) was Engel Class I and seizure outcome in 4 (18%) was Engel Class II. In this series, seizure outcome following perirolandic resection was intimately related to the child's age at the time of surgery. By univariate logistic regression analysis, age at surgery was a statistically significant factor predicting seizure outcome (p < 0.024).
  
  
  CONCLUSIONS
  Resection of rolandic cortex for intractable epilepsy is possible with expected morbidity. Accurate mapping of regions of functional cortex and epileptogenic zones may lead to improved seizure outcome in children with intractable rolandic epilepsy. It is important to counsel patients and families preoperatively to prepare them for possible worsened functional outcome involving motor, sensory and/or language pathways.
authors.affiliation: Divisions of Neurosurgery, The Hospital for Sick Children, The University of Toronto, Ontario, Canada.
authors.forename: Mony
authors.initials: M
authors.lastname: Benifla
authors.forename: Francesco
authors.initials: F
authors.lastname: Sala
authors.forename: John
authors.initials: J
authors.lastname: Jane
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Otsubo
authors.forename: Ayako
authors.initials: A
authors.lastname: Ochi
authors.forename: James
authors.initials: J
authors.lastname: Drake
authors.forename: Shelly
authors.initials: S
authors.lastname: Weiss
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Donner
authors.forename: Ayataka
authors.initials: A
authors.lastname: Fujimoto
authors.forename: Stephanie
authors.initials: S
authors.lastname: Holowka
authors.forename: Elysa
authors.initials: E
authors.lastname: Widjaja
authors.forename: O Carter
authors.initials: OC
authors.lastname: Snead
authors.forename: Mary Lou
authors.initials: ML
authors.lastname: Smith
authors.forename: Mandeep S
authors.initials: MS
authors.lastname: Tamber
authors.forename: James T
authors.initials: JT
authors.lastname: Rutka
mesh_terms: D000293:Adolescent; D002541:Cerebral Decortication / Q000379:methods*; D002648:Child; D015331:Cohort Studies; D004569:Electroencephalography; D019305:Epilepsy, Rolandic / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D006801:Humans; D015225:Magnetoencephalography; D008297:Male; D009043:Motor Activity / Q000502:physiology; D038361:Neuronavigation; D020127:Recovery of Function; D012189:Retrospective Studies; D016896:Treatment Outcome