Outcome after hemispherectomy in hemiplegic adult patients with refractory epilepsy associated with early middle cerebral artery infarcts.

Purpose: To study the outcome after hemispher-ectomy (HP) in a homogeneous adult patientpopulationwithrefractoryhemisphericepilepsy.Methods: Fourteen adult patients submitted toHP were studied. Patients had to be at least18 years old, and have refractory epilepsy, clearlyfocal lateralized seizures and unilateral poren-cephalus consistent with early middle cerebralartery infarct on magnetic resonance imaging(MRI). All patients were submitted to functionalhemispherectomy. We analyzed age of seizureonset, age by the time of surgery, gender, seizuretype and frequency, interictal and ictal electroen-cephalography (EEG) findings, MRI and IQ scorespreoperatively; seizure frequency, drug regimen,andIQoutcomewerestudiedpostoperatively.Results: Mean follow-up was 64 months. Allpatients had frequent daily seizures preopera-tively. All patients had unilateral simple partialmotor seizures (SPS); 11 patients had secondarilygeneralized tonic–clonic (GTC) seizures and fivepatients had complex partial seizures (CPS),preoperatively. All patients had hemiplegia andhemianopsia. Twelve patients had unilateral EEGfindings, and in two epileptic discharges were seenexclusively over the apparently normal hemi-sphere. Twelve patients were seizure-free aftersurgery and two patients had at least 90%improvement in seizure frequency. Pre- and post-operative mean general IQ was 84 and 88, respec-tively. Five of the twelve Engel I patients werereceiving no drugs at last follow-up. There was nomortalityormajormorbidity.Conclusions: Our results suggest that well-selected adult patients might also get good resultsafter HP. Although good results were obtained inour adult series, the same procedure yielded amuchmorestrikingresultifperformedearlierinlife.KEY WORDS: Outcome, Hemispherectomy,Adults.Hemispherectomy (HP) has been used to treatrefractory hemispheric epileptic syndromes. Patients withearly vascular insults, Rasmussen syndrome, hemisphericcortical disease, hemimegaloencephaly, and Sturge-Weber syndrome are the most suitable candidates for thisprocedure. In well-selected patients, a 70–95% seizureremission rate should be expected (Tinuper et al., 1988;CarreCoetal.,2002;Guzzettaetal.,2006).Hemispherectomy is usually performed in children.Thisisbecauserefractory epilepsyisusuallypresent earlyin these patients; in some of them catastrophic epilepsymaybe seen (Gonzlez-Martnez etal., 2005). Some tech-nical variants do exist, but the main common objective isto perform complete intra- and interhemispheric corticaldisconnection (Carson et al., 1996; Villemure & Daniel,2006). In most series, patients submitted to HP wereusually hemiplegic and hemianoptic preoperatively, andpatients with dominant hemisphere lesions usuallyshowed language deficits that did not worsen after earlysurgery. Results obtained from pediatric series haveclearly shown that seizure-free children also disclosed amarked postoperative neuropsychologic and motorimprovement.