Surgical Experiences on a Case by Case Basis for Intractable Childhood Epilepsy / 대한소아신경학회지

PURPOSE: This study aimed to reveal the benefits and the safety of surgical treatment in children with refractory epilepsy by reviewing our experiences on a case-by-case basis. METHODS: Twenty one patients who underwent epilepsy surgeries from September, 2003 to March, 2005 at Sanggye Paik Hospital were included. Data including clinical features and surgical outcomes were filed up through 2 years. RESULTS: The profiles of the 15 patients who underwent curative epilepsy surgeries were as follows. Characteristically, one patient had dual epilepsy including mesial temporal lobe epilepsy. Two patients had infantile spasms with cortical dysplasia, both of whom underwent epilepsy surgeries in early infancy. Also, there is a patient who underwent a re-operation, while another one patient had an epileptic focus in the insular lobe. Two patients were diagnosed Sturge-Weber syndrome, and three patients had nonlesional or lesional multilobar epilepsies. Furthermore, the surgical outcomes can be classified such as Engel class I in 10(66.7%) patients, class II in 3(20.0%) patients while one patient failed to obtain any seizure reduction after surgical treatment. In addition, palliative total corpus callosotomies were tried in 6 patients. But only one patient showed seizure reduction of more than 90%, while 4 patients exhibited 50-75% seizure reduction and the other one did not have any changes in seizure frequency. We also experienced various kinds of unwanted events such as memory deterioration (1), vascular infarction (1), hypoxic insult (1), transient hemiparesis (2), dysinhibition (1) and visual field defects (3). Most of neuroimaging studies were highly concordant to the ictal scalp and intracranial EEGs. CONCLUSION: Epilepsy surgery can be an effective therapeutic modality in localization related intractable childhood epilepsies. However, we should consider various surgical complications and carefully evaluate the epileptogenic and functionally eloquent areas.

Outcomes of Therapeutic Modalities for Intractable Childhood Epilepsy / 대한소아신경학회지

PURPOSE: This study sought to evaluate the clinical outcomes of various therapeutic modalities, including newly-developed anti-epileptic drugs (AEDs), prednisolone, ketogenic diet (KD) epilepsy surgery, and vagus nerve stimulation (VNS), in treating intractable childhood epilepsy. METHODS: Data of refractory epilepsy patients (n=297) treated from July 1995 through April 2003 at the epilepsy center of Sanggye Paik Hospital were retrospectively analyzed. RESULTS: Newly-developed AEDs were primarily prescribed to 290 patients, although only 20 patients (6.9%) maintained a seizure- free state. Of 138 patients for whom prednisolone was prescribed, 58 patients (42.0%) showed complete seizure controls while 41 patients experienced relapse. KD was attempted and evaluated at 12 months in 162 patients, at which time 74 (45.7%) remained on the diet and 68 (42.0%) showed seizure reduction of greater than 50%, including 37 (22.8%) who were completely seizure free. Epilepsy surgery was undergone in 38 patients, and Engel class I was identified in 25 (65.8%) patients. VNS was administered to five patients, only two of whom obtained a seizure reduction of more than 50%. RESULTS: Taken together, these findings suggest that considerable controls over intractable childhood epilepsy can be gained through KD and epilepsy surgery, whereas prednisolone treatment leads to somewhat more frequent relapses, and newly-developed AEDs are comparatively limited in their controls of refractory epilepsy.

Therapeutic Outcomes of Vagus Nerve Stimulation in Intractable Childhood Epilepsy / 대한소아신경학회지

PURPOSE: VNS has been used as a adjunctive treatment modality in medically intractable epilepsy patients since 1988, and is presently considered a safe and effective mode of treatment. However, its safety and efficacy in pediatric epilepsy patients have not been as well- studied. We the authors have experienced 12 pediatric patients who received VNS implantation, and evaluated the safety and efficacy of the procedure in the pediatric age group. METHODS: 12 patients who received VNS implantation in Yonsei University Medical Center and Sang-gye Paik Hospital Epilepsy Center from June 1999 to April 2004 have been evaluated for clinical symptoms, presence of reduction in seizure frequency, EEG changes and side-effects after VNS implantation. Datas were analyzed retrospectively through review of clinical records, with emphasis on evaluation of effectiveness and safety of the treatment. RESULTS: Mean age of the patients at the time of VNS implantation were 9 years 9 months (+/-60.5 months)(2 year 9 months-17 years 10 months). Mean duration of follow-up was 21.6 months (+/-23.3 months). Five patients out of twelve could be followed-up for more than 12 months. Nine out of twelve patients possessed Lennox-Gastaut syndrome, two were diagnosed as partial seizure with secondary generalization, and one patient had gelastic seizure caused by hypothalamic harmatoma. Eight patients showed more than 50% reduction in seizure frequency compared with baseline 3 months after the implantation, with two patients exhibiting complete seizure ablation. One patient showed a 25% decrease in seizure frequency, and VNS was ineffective in three patients. Among the patients with more than 50% reduction of seizures, two patients respectively showed a 75% and 90% decrease in seizure frequency at 12 months and 24 months post-operatively. One case of hoarseness, one case of dyspnea during sleep, one case of post-operative wound infection and one case of generator malfunction were noted after VNS, but most of these adverse effects improved through manipulation of output current. Wound infection necessitated surgical revision and generator failure required surgical removal of the device. EEG patterns of the two patients with complete seizure ablation exhibited marked improvement of background rhythms and reduction of epileptogenic discharges, but others did not show any significant improvement in their EEG. CONCLUSION: This study showed significant improvement in seizure frequencies among medically intractable pediatric epilepsy patients after VNS, and most of its adverse effects could be controlled without discontinuation of treatment. Therefore, we believe that VNS is a safe and effective treatment modality in pediatric patients with intractable epilepsy, and merits wider implementation for medically intractable epileptic children in the future.

Therapeutic Outcomes of Vagus Nerve Stimulation in Intractable Childhood Epilepsy / 대한간질학회지

PURPOSE: This study is to evaluate the efficacy and safety of vagus nerve stimulation (VNS) in intractable childhood onset epilepsy by reviewing our experiences. MEHTHOD: Involved in the study are five patients who underwent VNS from July 23th, 1999 and had been followed up over 12 months. We reviewed data prospectively collected with a focus on clinical features, therapeutic outcomes and safety, developmental progress, and EEG findings. RESULTS: Three patients were classified as Lennox-Gastaut syndrome. One patient of the two remaining patients had gelastic seizure caused by hypothalamic harmatoma, while the other patient had partial seizure with secondary generalization. Among the 5 patients, one patient showed a seizure frequency reduction rate of about 50% from baseline in 3 months after VNS implantation and more than 90% in 12 months, 2 patients of about 50% in 3 months and of about 75% in 12 months, but the other two patients didn't show any change in seizure frequency. Side effects such as hoarseness, dyspnea during sleep and wound infection could be controlled simply through the adjustment of output current or wound revision. However, efficacy in cognitive function and EEG findings was not satisfactory. CONCLUSIONS: VNS might be an effective adjunctive therapy for intractable childhood epilepsy and transient side effects can be controlled without discontinuation of VNS therapy.

Surgical Treatment of Medically Refractory Epilepsy in Childhood / 대한간질학회지

PURPOSE: Recent advances in neurophysiology and neuroimaging provided surgical application in intractable childhood epilepsy with improved outcome. The aim of this study is to reveal benefit and safety of epileptic surgery in childhood by reviewing our experiences. METHOD: Thirty patients who underwent epilepsy surgery from February, 1997 to June, 2002 at epilepsy center, Inje University Sang-gye Paik Hospital, were included. We reviewed clinical features and outcomes according to temporal/extratemporal epilepsies including generalized or undertermined epileptic syndromes. RESULTS: In 8 patients of temporal lobe epilepsy, surgical procedures were as follows, anterior temporal lobectomy (ATL) was in 6 patients, ATL and extended temporal resection in 1, ATL and multiple subpial transection (MST) in 1. Pathologic findings showed cortical dysplasia, hippocampal sclerosis, tumor and old infarction. Engel class I was in 6 (75%) patients and class II was in 2 (25%) patients. Six patients (75%) showed developmental progress. In 22 patients of extratemporal lobe epilepsy, various surgical methods such as partial or total lobectomy, functional lobectomy, corticectomy, functional hemispherectomy, peri-insular hemispherotomy, multiple subpial transection, lesionectomy and palliative corpus callosotomy were done according to the location of epileptic focus and epileptic syndromes. Engel class I was in 16 (72.7%) patients, class II in 4 (18.2%) and class III in 2 (9.1%) patients. Eight patients (66.6%) among 12 patients could have been followed for more than 12 months showed developmental progress. Most of neuroimaging studies were highly concordant to ictal EEG's. CONCLUSIONS: Epilepsy surgery is effective in most of localization related intractable childhood epilepsy and developmental acceleration can be expected in successfully treated patients.

Lipid Profiles in Patient with Ketogenic Diet for Intractable Childhood Epilepsy / 대한간질학회지

PURPOSE: Ketogenic diet has been frequently used in the treatment of intractable childhood epilepsy since proven strong antiepileptic effects. Because of prolonged maintenance of high fat diet, long-term side effects of hyperlipidemia and atherosclerosis has been concerned, but there are no sufficient data revealing lipid profile from ketogenic diet. This study is intended to investigate the changes of lipid profiles in patients with ketogenic diet. METHODS: Sixty-six children (0.8-14.7 yrs, mean age 4.6+/-3.6 yrs, 33 males and 33 females) with intractable epilepsy treated with the classic (4:1) ketogenic diet were studied at Inje University Sang-gye Paik Hospital, from January 1997 to July 2001. Follow-up period was more than 1year (range:1-2 yrs). Cholesterol, HDL-cholesterol and Triglyceride (TG) concentrations were measured at 1 day, 7 days, 6 months, 12 months, 18 months and 24 months, and LDL-cholesterol concentrations were measured. RESULTS: 1) Total cholesterol concentrations were significantly increased from 7 days to 24 months after ketogenic diet than that before ketogenic diet (p<0.05). 2) HDL-cholesterol concentrations were not significantly changed for 2 years. 3) LDL-cholesterol concentrations were significantly increased at 6 months (119.9 mg/dL, p<0.05), and 24 months (128.0 mg/dL, p<0.05). 4) TG concentrations were significantly increased at 7 days (164.9 mg/dL, p<0.05), 6 months (209.7 mg/dL, p<0.01), and 12 months (192.0 mg/dL, p<0.01), and were normalized at 18 months, 24 months. CONCLUSION: Most of lipid profiles were significantly changed during ketogenic diet. Long-term complication for cardio-vascular diseases should be further investigated.