Sehra Rahmany, Dr. Nicolle Ionascu, Dr. Rachel Kuperman, Dr....
1
RESEARCH POSTER PRESENTATION DESIGN © 2012 www.PosterPresentations.com Epilepsy affects approximately 50,000,000 people worldwide and 1-2 percent of these patients are children [1]. Studies show that in one-third of new onset epilepsy patients, seizures will become refractory to medical management [2]. Recurrent seizures [3] and the medications used to control them [4] can be harmful to the developing brain in children. Epilepsy surgery has the potential to control seizures, improve patient quality of life and reduce the cost of medical care [5]. Typically, this type of surgery is performed at large, tertiary care medical facilities that are university-based. Children’s Hospital of Oakland (CHO) is an independent community hospital that is not connected to a university or other institution. Recently, CHO recruited specialists to focus on treating childhood epilepsy. This team consists of Neurosurgeons, Neurologists, Neuropsychologists and Neuroradiologists. With the arrival of this team, CHO has been capable of providing the same type of surgical options for children with epilepsy as are available at large, university-affiliated children’s hospitals. The focus of this study was to evaluate the performance of this surgical specialty group with respect to patient referral pattern, case volume, case complexity, neuropsychologic profiles and seizure control rates. 1. Introduc,on 2. Methods 3. Results This study illustrates how the creation of a specialty team dedicated to the treatment of pediatric epilepsy surgery can dramatically increase the volume and complexity of cases performed. Our comparison data showed that case numbers more than doubled after the arrival of such a team. Moreover, the types of surgeries performed changed from the implantation of a seizure control device called a vagal nerve stimulator (a device with a cure rate of approximately 30%) to include complex cranial procedures such as craniotomies , lobectomies, and hemispherectomies. Common causes of medically-refractory pediatric epilepsy amenable to surgery include tumors, malformations due to abnormal cortical development ,vascular abnormalities and certain epileptic syndromes. In the present study, the majority of patients 62% had focal cortical dysplasias, most of which were ILAE Type III (50%), followed by Type I (45%). Most patients did well after epilepsy surgery with 45% achieving Engel Class I and 50% ILAE Class I. Seizure freedom rates are typically high (usually 60-80%) following tailored focal resection, lesionectomy, and hemispherectomy in other studies[8] and our results are consistent with these findings. In addition to seizure outcome rates, we looked at neuropsychologic testing for our patients. Iwatani et al demonstrated that motor function, developmental age, language skills and sociopsychological function improved following surgery in children with epilepsy [7]. Our results also demonstrate similar outcomes. For pre- and post-operative memory, full scale IQ, processing index and test results improved as a result of surgery. 4. Discussion 5. Conclusion The addition of a multidisciplinary specialty team to treat pediatric epilepsy can have a profound positive impact on the nature of patient care, even at smaller, non-university- based children’s hospitals. Case numbers can increase, surgery complexity can be enhanced and excellent seizure and psychosocial outcomes can result. References [1] Hauser WA, Kurland LT. The epidemiology of epilepsy in Rochester, Minnesota, 1935 through 1975. Epilepsia (1975) 16: 1-66. [2] Kwan P and Brodie MJ. Early identification of refractory epilepsy. N Eng J Med (2000) 342: 314-319. [3] Laurent A, Arzimanoglou A. Cognitive impairments in children with nonidiopathic temporal lobe epilepsy. Epilepsia (2006) 47(Suppl 2): 99-102. [4] Bittigau P, Sifringer M, Genz K, Reith E, Pospischil D, Govindarajalu S, Dzietko M, Pesditschek S, Mai I, Dikranian K, Olney JW, Ikonomidou C. Antiepileptic drugs and apoptotic neurodegeneration in the developing brain. Proc Natl Acad Sci (2002) Nov 12; 99(23): 15089-94. [5] Spencer SS, Berg AT, Vickrey BG, Sperling MR, Bazil CW, Shinnar S, Langfitt JT, Walczak TS, Pacia SV. Predicting long-term seizure outcome after resective epilepsy surgery: the multicenter study. Neurology. (2005) Sep 27;65(6):912-8. [6] Ibrahim GM , Barry BW , Fallah A , Snead OC 3rd , Drake JM , Rutka JT , Bernstein M . Inequities in access to pediatric epilepsy surgery: a bioethical framework. Neurosurg Focus. 2012 Mar; 32(3):E2. [7] Iwatani Y, Kagitani-Shimono K, Tominaga K, Okinaga T, Mohri I, Kishima H, Kato A, Sanefuji W, Yamamoto T, Tatsumi A, Murata E, Taniike M, Nagai T, Ozono K. Long-term developmental outcome in patients with West syndrome after epilepsy surgery. Brain Devel (2012) Feb 13[Epub ahead of print] [8] Obeid M, Wyllie E, Rahi AC, Mikati MA. Approach to pediatric epilepsy surgery: State of the art, Part II: Approach to specific epilepsy syndromes and etiologies. Eur J Paediatr Neurol. (2009) Mar;13(2):115-27. Acknowledgements This work was supported by the Neurosurgery department of Children’s Hospital of Oakland and the Team of Epilepsy Specialists. List of Surgeries Performed Pre‐Epilepsy Team Post‐Epilepsy Team VNS (Vagal Nerve S,mula,on) 32 26 Craniotomy:grid 1 36 Craniotomy: Lesionectomy +ECOG 1 10 Corpus Collasotomy 0 14 Hemispherectomy 2 1 Childrens Hospital of Oakland Sehra Rahmany, Dr. Nicolle Ionascu, Dr. Rachel Kuperman, Dr. Peter Sun, Dr. KurFs Auguste The Impact of a Dedicated Team of Specialists on Epilepsy Surgery at Children's Hospital Oakland. Engel classifica,on Engel classificaFon includes: Class I‐ free of disability seizure Class II‐ rare disability seizure Class III‐ worthwhile improvement Class IV‐ no worthwhile improvement ILAE Classifica,on Class I: seizure free, auras Class II: (+) auras, seizure Class III: 1‐3 seizures/year +/‐auras Class IV: 4 seizure days/year‐50% baseline reducFon Class V: <50% baseline reducFon Class VI: >100% increase of baseline seizure days ILAE FCD(Focal Cor,cal Displasure) Classifica,on Isolated lesion of dyslaminated neocortex Ia. Radial, Ib. tangenFal Isolated dyslaminaFon + dysmorphic neuron IIa. w/o balloon cells, IIb. With balloon cells a: hippocampal sclerosis b. tumors c. vascular malformaFon d: lesion acquired in early life (trauma, encephaliFs, ischemia) 0 20 40 60 80 100 120 Working Memory Working Memory(Pre) Working Memory(Post) 0 10 20 30 40 50 60 70 80 90 100 full scale IQ(Pre) full scale IQ(Post) Full Scale(IQ) 0 10 20 30 40 50 60 70 80 Processing Index(Pre) Processing Index (Post) Processing Index 0 5 10 15 20 25 30 35 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Amount of Surgery Year Epilepsy(Pre) Team and Epilepsy(Post) Team Cranial Pre Team Total Pre Team Cranial Post Team Total Post Team Table 3 Pathological Range and Types within the Patients Fig. 3-5. Neuropsychology Data ; shows the examination of each patients , trials of pre and post surgery. From the data, it is obvious that patients have increased in memory, IQ, and processing skills after neurosurgery. Table 4 Seizure Outcomes that are classified by Engel, showing whether improvement, reduction od seizures, no improvement, or if patients are seizure free after surgery. We retrospectively reviewed clinic charts, medication regimens, imaging data, neuropsychologic testing, operative reports and pathology specimens for all children undergoing epilepsy surgery at Children’s Hospital Oakland between 2001 and 2012. In order to classify each patient’s seizure outcomes, the Engel and International League Against Epilepsy (ILAE) classification systems were used. These systems are based on patient seizure frequencies and time intervals. Neuropsychology testing was performed by a dedicated pediatric neuropsychologist and consisted of: full scale intelligence quotient (IQ), processing index, and working memory. Tissue removed during surgery was analyzed by a neuropathologist. Specimens that were determined to be focal cortical dysplacia (FCD) were further sub-classified according to the ILAE- FCD classification system. Table 2 Types of Pediatric Neurosurgery Table 1 Pre and Post Epilepsy Team Comparison of patients Ninety-nine epilepsy surgeries were performed at CHO from 2001 to 2012 (Figure 1). From 2001-2008, a total of thirty-seven epilepsy surgeries were performed. Of the thirty-seven epilepsy patients, thirty-three were implantation of VNS, four were for more complex cranial procedures. These cranial procedures included 2 hemispherectomies, one resection of tumor and one corpus callosotomy (Table 2). During that time frame, patients traveled an average of 57.5 miles to receive care at Children’s Hospital of Oakland. From 2009-2012, a total of sixty-two epilepsy surgeries were performed. This included twenty-six VNS implantations and thirty-six complex cranial procedures (Table 2). The average miles a patient traveled throughout 2009-2012 was approximately 52 miles. Fig.1. Pre-Epilepsy and Post-Epilepsy Team are shown below; given the graph Post Epilepsy Team has increased the amount of surgery from previous years. Fig. 2. Intraoperative photograph of subdural grid and strip array used to localize seizure focus. Fig.4. shows that the patients IQ stayed constant even after surgery. On the left, the numbers show the scores of the exam. Fig.5. shows that the processing speed of one patient has increased after surgery. IQ Score Processing Score Memory Score
Transcript of Sehra Rahmany, Dr. Nicolle Ionascu, Dr. Rachel Kuperman, Dr....
RESEARCH POSTER PRESENTATION DESIGN © 2012
www.PosterPresentations.com
Epilepsy affects approximately 50,000,000 people worldwide and 1-2 percent of these patients are children [1]. Studies show that in one-third of new onset epilepsy patients, seizures will become refractory to medical management [2]. Recurrent seizures [3] and the medications used to control them [4] can be harmful to the developing brain in children. Epilepsy surgery has the potential to control seizures, improve patient quality of life and reduce the cost of medical care [5]. Typically, this type of surgery is performed at large, tertiary care medical facilities that are university-based. Children’s Hospital of Oakland (CHO) is an independent community hospital that is not connected to a university or other institution. Recently, CHO recruited specialists to focus on treating childhood epilepsy. This team consists of Neurosurgeons, Neurologists, Neuropsychologists and Neuroradiologists. With the arrival of this team, CHO has been capable of providing the same type of surgical options for children with epilepsy as are available at large, university-affiliated children’s hospitals. The focus of this study was to evaluate the performance of this surgical specialty group with respect to patient referral pattern, case volume, case complexity, neuropsychologic profiles and seizure control rates.
1.Introduc,on
2.Methods
3.Results
This study illustrates how the creation of a specialty team dedicated to the treatment of pediatric epilepsy surgery can dramatically increase the volume and complexity of cases performed. Our comparison data showed that case numbers more than doubled after the arrival of such a team. Moreover, the types of surgeries performed changed from the implantation of a seizure control device called a vagal nerve stimulator (a device with a cure rate of approximately 30%) to include complex cranial procedures such as craniotomies , lobectomies, and hemispherectomies. Common causes of medically-refractory pediatric epilepsy amenable to surgery include tumors, malformations due to abnormal cortical development ,vascular abnormalities and certain epileptic syndromes. In the present study, the majority of patients 62% had focal cortical dysplasias, most of which were ILAE Type III (50%), followed by Type I (45%). Most patients did well after epilepsy surgery with 45% achieving Engel Class I and 50% ILAE Class I. Seizure freedom rates are typically high (usually 60-80%) following tailored focal resection, lesionectomy, and hemispherectomy in other studies[8] and our results are consistent with these findings. In addition to seizure outcome rates, we looked at neuropsychologic testing for our patients. Iwatani et al demonstrated that motor function, developmental age, language skills and sociopsychological function improved following surgery in children with epilepsy [7]. Our results also demonstrate similar outcomes. For pre- and post-operative memory, full scale IQ, processing index and test results improved as a result of surgery.
4.Discussion 5.Conclusion
The addition of a multidisciplinary specialty team to treat pediatric epilepsy can have a profound positive impact on the nature of patient care, even at smaller, non-university- based children’s hospitals. Case numbers can increase, surgery complexity can be enhanced and excellent seizure and psychosocial outcomes can result.
References
[1] Hauser WA, Kurland LT. The epidemiology of epilepsy in Rochester, Minnesota, 1935 through 1975. Epilepsia (1975) 16: 1-66.
[2] Kwan P and Brodie MJ. Early identification of refractory epilepsy. N Eng J Med (2000) 342: 314-319.
[3] Laurent A, Arzimanoglou A. Cognitive impairments in children with nonidiopathic temporal lobe epilepsy. Epilepsia (2006) 47(Suppl 2): 99-102.
[4] Bittigau P, Sifringer M, Genz K, Reith E, Pospischil D, Govindarajalu S, Dzietko M, Pesditschek S, Mai I, Dikranian K, Olney JW, Ikonomidou C. Antiepileptic drugs and apoptotic neurodegeneration in the developing brain. Proc Natl Acad Sci (2002) Nov 12; 99(23): 15089-94.
[5] Spencer SS, Berg AT, Vickrey BG, Sperling MR, Bazil CW, Shinnar S, Langfitt JT, Walczak TS, Pacia SV. Predicting long-term seizure outcome after resective epilepsy surgery: the multicenter study. Neurology. (2005) Sep 27;65(6):912-8.
[6] Ibrahim GM, Barry BW, Fallah A, Snead OC 3rd, Drake JM, Rutka JT, Bernstein M. Inequities in access to pediatric epilepsy surgery: a bioethical framework. Neurosurg Focus. 2012 Mar; 32(3):E2.
[7] Iwatani Y, Kagitani-Shimono K, Tominaga K, Okinaga T, Mohri I, Kishima H, Kato A, Sanefuji W, Yamamoto T, Tatsumi A, Murata E, Taniike M, Nagai T, Ozono K. Long-term developmental outcome in patients with West syndrome after epilepsy surgery. Brain Devel (2012) Feb 13[Epub ahead of print]
[8] Obeid M, Wyllie E, Rahi AC, Mikati MA. Approach to pediatric epilepsy surgery: State of the art, Part II: Approach to specific epilepsy syndromes and etiologies. Eur J Paediatr Neurol. (2009) Mar;13(2):115-27.
Acknowledgements
This work was supported by the Neurosurgery department of Children’s Hospital of Oakland and the Team of Epilepsy Specialists.
ListofSurgeriesPerformed
Pre‐EpilepsyTeam Post‐EpilepsyTeam
VNS(VagalNerveS,mula,on)
32 26
Craniotomy:grid 1 36
Craniotomy:Lesionectomy+ECOG
1 10
CorpusCollasotomy
0 14
Hemispherectomy 2 1
ChildrensHospitalofOakland
SehraRahmany,Dr.NicolleIonascu,Dr.RachelKuperman,Dr.PeterSun,Dr.KurFsAuguste
TheImpactofaDedicatedTeamofSpecialistsonEpilepsySurgeryatChildren'sHospitalOakland.
Engelclassifica,onEngelclassificaFonincludes:ClassI‐freeofdisabilityseizureClassII‐raredisabilityseizureClassIII‐worthwhileimprovementClassIV‐noworthwhileimprovementILAEClassifica,onClassI:seizurefree,aurasClassII:(+)auras,seizureClassIII:1‐3seizures/year+/‐aurasClassIV:4seizuredays/year‐50%baselinereducFonClassV:<50%baselinereducFonClassVI:>100%increaseofbaselineseizuredaysILAEFCD(FocalCor,calDisplasure)Classifica,onIsolatedlesionofdyslaminatedneocortexIa.Radial,Ib.tangenFalIsolateddyslaminaFon+dysmorphicneuronIIa.w/oballooncells,IIb.Withballooncellsa:hippocampalsclerosisb.tumorsc.vascularmalformaFond:lesionacquiredinearlylife(trauma,encephaliFs,ischemia)
0
20
40
60
80
100
120
Working Memory
WorkingMemory(Pre)
WorkingMemory(Post)
0102030405060708090
100
fullscaleIQ(Pre) fullscaleIQ(Post)
Full Scale(IQ)
0
10
20
30
40
50
60
70
80
ProcessingIndex(Pre)ProcessingIndex(Post)
Processing Index
0
5
10
15
20
25
30
35
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Amou
ntofS
urgery
Year
Epilepsy(Pre)TeamandEpilepsy(Post)Team
CranialPreTeam
TotalPreTeam
CranialPostTeam
TotalPostTeam
Table 3 Pathological Range and Types within the Patients
Fig. 3-5. Neuropsychology Data ; shows the examination of each patients , trials of pre and post surgery. From the data, it is obvious that patients have increased in memory, IQ, and processing skills after neurosurgery.
Table 4 Seizure Outcomes that are classified by Engel, showing whether improvement, reduction od seizures, no improvement, or if patients are seizure free after surgery.
We retrospectively reviewed clinic charts, medication regimens, imaging data, neuropsychologic testing, operative reports and pathology specimens for all children undergoing epilepsy surgery at Children’s Hospital Oakland between 2001 and 2012. In order to classify each patient’s seizure outcomes, the Engel and International League Against Epilepsy (ILAE) classification systems were used. These systems are based on patient seizure frequencies and time intervals. Neuropsychology testing was performed by a dedicated pediatric neuropsychologist and consisted of: full scale intelligence quotient (IQ), processing index, and working memory. Tissue removed during surgery was analyzed by a neuropathologist. Specimens that were determined to be focal cortical dysplacia (FCD) were further sub-classified according to the ILAE-FCD classification system.
Table 2 Types of Pediatric Neurosurgery
Table 1 Pre and Post Epilepsy Team Comparison of patients
Ninety-nine epilepsy surgeries were performed at CHO from 2001 to 2012 (Figure 1). From 2001-2008, a total of thirty-seven epilepsy surgeries were performed. Of the thirty-seven epilepsy patients, thirty-three were implantation of VNS, four were for more complex cranial procedures. These cranial procedures included 2 hemispherectomies, one resection of tumor and one corpus callosotomy (Table 2). During that time frame, patients traveled an average of 57.5 miles to receive care at Children’s Hospital of Oakland. From 2009-2012, a total of sixty-two epilepsy surgeries were performed. This included twenty-six VNS implantations and thirty-six complex cranial procedures (Table 2). The average miles a patient traveled throughout 2009-2012 was approximately 52 miles.
Fig.1. Pre-Epilepsy and Post-Epilepsy Team are shown below; given the graph Post Epilepsy Team has increased the amount of surgery from previous years.
Fig. 2. Intraoperative photograph of subdural grid and strip array used to localize seizure focus.
Fig.4. shows that the patients IQ stayed constant even after surgery. On the left, the numbers show the scores of the exam.
Fig.5. shows that the processing speed of one patient has increased after surgery.
IQScore
ProcessingScore
Mem
oryScore
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