title: Utility of diffusion tensor imaging studies linked to neuronavigation and other modalities in repeat hemispherotomy for intractable epilepsy.
abstract: OBJECT Hemispherectomy for unilateral, medically refractory epilepsy is associated with excellent long-term seizure control. However, for patients with recurrent seizures following disconnection, workup and investigation can be challenging, and surgical options may be limited. Few studies have examined the role of repeat hemispherotomy in these patients. The authors hypothesized that residual fiber connections between the hemispheres could be the underlying cause of recurrent epilepsy in these patients. Diffusion tensor imaging (DTI) was used to test this hypothesis, and to target residual connections at reoperation using neuronavigation. METHODS The authors identified 8 patients with recurrent seizures following hemispherectomy who underwent surgery between 1995 and 2012. Prolonged video electroencephalography recordings documented persistent seizures arising from the affected hemisphere. In all patients, DTI demonstrated residual white matter association fibers connecting the hemispheres. A repeat craniotomy and neuronavigation-guided targeted disconnection of these residual fibers was performed. Engel class was used to determine outcome after surgery at a minimum of 2 years of follow-up. RESULTS Two patients underwent initial hemidecortication and 6 had periinsular hemispherotomy as their first procedures at a median age of 9.7 months. Initial pathologies included hemimegalencephaly (n = 4), multilobar cortical dysplasia (n = 3), and Rasmussen's encephalitis (n = 1). The mean duration of seizure freedom for the group after the initial procedure was 32.5 months (range 6-77 months). In all patients, DTI showed limited but definite residual connections between the 2 hemispheres, primarily across the rostrum/genu of the corpus callosum. The median age at reoperation was 6.8 years (range 1.3-14 years). The average time taken for reoperation was 3 hours (range 1.8-4.3 hours), with a mean blood loss of 150 ml (range 50-250 ml). One patient required a blood transfusion. Five patients are seizure free, and the remaining 3 patients are Engel Class II, with a minimum follow-up of 24 months for the group. CONCLUSIONS Repeat hemispherotomy is an option for consideration in patients with recurrent intractable epilepsy following failed surgery for catastrophic epilepsy. In conjunction with other modalities to establish seizure onset zones, advanced MRI and DTI sequences may be of value in identifying patients with residual connectivity between the affected and unaffected hemispheres. Targeted disconnection of these residual areas of connectivity using neuronavigation may result in improved seizure outcomes, with minimal and acceptable morbidity.
authors.affiliation: Division of Neurosurgery, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California and 
authors.forename: Erin N
authors.initials: EN
authors.lastname: Kiehna
authors.affiliation: Divisions of 2 Diagnostic Imaging.
authors.forename: Elysa
authors.initials: E
authors.lastname: Widjaja
authors.affiliation: Divisions of 2 Diagnostic Imaging.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Holowka
authors.affiliation: Neurology and.
authors.forename: O
authors.initials: O
authors.lastname: Carter Snead
authors.affiliation: Pediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada.
authors.forename: James
authors.initials: J
authors.lastname: Drake
authors.affiliation: Neurology and.
authors.forename: Shelly K
authors.initials: SK
authors.lastname: Weiss
authors.affiliation: Neurology and.
authors.forename: Ayako
authors.initials: A
authors.lastname: Ochi
authors.affiliation: Pediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada.
authors.forename: Eric M
authors.initials: EM
authors.lastname: Thompson
authors.affiliation: Neurology and.
authors.forename: Cristina
authors.initials: C
authors.lastname: Go
authors.affiliation: Neurology and.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Otsubo
authors.affiliation: Neurology and.
authors.forename: Elizabeth J
authors.initials: EJ
authors.lastname: Donner
authors.affiliation: Pediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada.
authors.forename: James T
authors.initials: JT
authors.lastname: Rutka
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D056324:Diffusion Tensor Imaging / Q000379:methods*; D000069279:Drug Resistant Epilepsy / Q000601:surgery*; D005260:Female; D038421:Hemispherectomy / Q000379:methods*; D006801:Humans; D007223:Infant; D008297:Male; D038361:Neuronavigation / Q000379:methods*; D017063:Outcome Assessment, Health Care / Q000379:methods*; D012008:Recurrence; D012086:Reoperation / Q000379:methods*
keywords: DTI = diffusion tensor imaging; EEG = electroencephalography; HD = hemidecortication; MEG = magnetoencephalography; PIH = periinsular hemispherotomy; VP = ventriculoperitoneal; diffusion tensor imaging; epilepsy surgery; hemispherectomy; neuronavigation; periinsular hemispherotomy