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Purpose: To investigate reasons for patients not proceeding to resective epilepsy surgery after subdural grid evaluation (SDE). To correlate noninvasive investigation results with invasive EEG observations in a set of patients with nonlesional brain MRIs. Methods: Retrospective study of adult epilepsy patients undergoing SDE during an 8-year period at Cleveland Clinic. Construction of semiquantitative "scores" and Bayesian predictors summarizing the localizing value and concordance between noninvasive parameters in a subset with nonlesional MRIs. Results: One hundred forty patients underwent SDE, 25 of whom were subsequently denied resective surgery. In 10 of 25, this was caused by a nonlocalizing subdural ictal EEG onset. Eight of 10 such patients were nonlesional on MRI. Among all nonlesional patients (n = 34 of 140), n 1 = 10 of 34 patients had nonlocalizing and n2 = 24 of 34 had localizing, subdural ictal onsets. As groups, n1 and n 2 were statistically disjoint relative to their noninvasive scores. Bayesian measures predictive of focal invasive ictal EEG were highest for complete concordance of noninvasive parameters, decreasing with lesser degrees of concordance. A localizing scalp interictal EEG was a particularly good Bayesian prognosticator. Conclusions: A small but significant proportion of SDE patients are denied subsequent therapeutic resective surgery. This is due to several reasons, including a nonlocalizing intracranial ictal EEG. The majority of such patients have nonlesional MRIs. The noninvasive data may be summarized by a semiquantitative score, as well as Bayesian likelihood ratios, which correlate with subsequent invasive outcome. This approach may find use in the selection and counseling of potential surgical candidates offered SDE.

Introdução: a cirurgia de epilepsia é uma opção de tratamento para pacientes com epilepsia refratária. A hemisferotomia pode produzir um controle notável da epilepsia hemisférica clinicamente intratável em crianças. O resultado final desejável, após a hemisferotomia, é o controle de crises e a redução ou retirada de fármacos antiepiléticos, visando a melhora cognitiva e do desenvolvimento da criança. Objetivos: verificar a efetividade da hemisferotomia no controle de crises e na retirada ou redução de fármacos antiepilépticos em pacientes classificados como Engel 1, e analisar os desfechos cognitivo e de desenvolvimento após a abordagem cirúrgica e redução de fármacos antiepilépticos. Métodos: revisão de prontuários médicos e banco de dados de pacientes crianças e adolescentes, com idade inferior a 19 anos no momento da cirurgia, submetidos a hemisferotomia para tratamento de epilepsia refratária no Centro de Epilepsia de Ribeirão Preto do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, entre anos de 1995 e 2015. Resultados: foram avaliados 120 prontuários médicos, dos quais foram considerados aptos 82. Amostra sem diferença significativa entre sexos. Para o manejo de fármacos foram considerados 44 pacientes que eram classificados como Engel 1 no segundo ano pós cirúrgico. Para estes pacientes foram avaliadas variáveis como retirada ou redução de fármacos antiepilépticos, bem como o tempo para que esse manejo fosse realizado, além do desfecho cognitivo e de desenvolvimento. Conclusão: A hemisferotomia é uma cirurgia eficaz para pacientes com doença hemisférica, possibilitando que paciente fique livre de crises e, eventualmente, livre de fármacos antiepilépticos. O desfecho de sucesso cirúrgico é dependente de inúmeras variáveis e o manejo de fármacos é realizado conforme experiência de profissionais de cada serviço. / Introduction: Epilepsy surgery is a treatment option for patients with refractory epilepsy. Hemisferotomy can produce a remarkable control of clinically intractable hemispheric epilepsy in children. The intended outcome, after hemispherotomy, is the seizure control and the reduction or withdrawal of antiepileptic drugs, aiming at the cognitive and developmental improvement of the child. Objectives: To verify the effectiveness of the hemispherotomy in the crisis control and in the withdrawal or reduction of antiepileptic drugs in patients classified as Engel 1, and to analyze the cognitive and developmental outcomes after the surgical approach and reduction of antiepileptic drugs. Methods: review of medical records and database of children and adolescents under 19 years of age at the time of surgery submitted to hemispherotomy for the treatment of refractory epilepsy at the Epilepsy Center of Ribeirão Preto, Hospital das Clínicas, Faculdade de Medicina of Ribeirão Preto between 1995 and 2015. Results: 120 medical records were evaluated, of which 82 were considered suitable. Sample with no significant difference between gender. For the management of drugs, 44 patients were classified as Engel 1 in the second postoperative year. For these patients, variables such as withdrawal or reduction of antiepileptic drugs were evaluated, as well as the time for this management to be performed, in addition to the cognitive and developmental outcome. Conclusion: Hemispherotomy is an effective surgery for patients with hemispheric disease, allowing patients to be seizure free and eventually free of antiepileptic drugs. The outcome of surgical success depends on innumerable variables and the management of drugs is performed according to the experience of professionals of each service.

Epilepsy is one of the most common neurological disorders in children, with both seizures and their medical treatment associated with increased risk of neuropsychological impairments. Adaptive functioning in children with epilepsy is poorly understood. This study sought to identify the neuropsychological and medical predictors of optimal adaptive functioning in pediatric epilepsy. Forty-six children with epilepsy and 16 typically developing children and their parents participated in this study at two time points. Overall, adaptive functioning was found to be in the average to low average range in children with epilepsy. A composite measure assessing cumulative seizure history was able to significantly predict Adaptive Behavior Assessment System-II (ABAS-II) scores. Whether a child had experienced one or more seizures in the last year was the only individual seizure and treatment variable able to significantly predict adaptive functioning as measured by the ABAS-II. Verbal learning, executive functioning, and internalizing and externalizing behavior problems assessed at Time 1 predicted performance on the ABAS-II at Time 2. Verbal memory and attention, however, were not significant predictors of adaptive functioning. Consistent with what was hypothesized, executive functioning was found to mediate the relationship between seizure history and adaptive functioning when controlling for behavior problems at both Times 1 and 2. When behavior problems were the mediator and executive functioning was controlled for, mediation was not found. Executive functioning also mediated the relationship between group membership (monotherapy, polytherapy, and typically developing) and ABAS-II scores at Time 1, but not at Time 2 when a post-surgical group also was represented. Secondary analyses showed that the relationship between executive and adaptive functioning at Time 2 was moderated by whether or not a child had ever experienced seizures, such that children diagnosed with epilepsy evidenced greater correlations between these constructs than typically developing children. The results of this study suggest that a subset of children with epilepsy, those with active seizures and/or executive dysfunction, are at increased risk of adaptive deficits. These findings highlight the risk factors for suboptimal adaptive functioning in this population, and also suggest potential avenues for remediation.

Introdução: a cirurgia de epilepsia é uma opção de tratamento para pacientes com epilepsia refratária. A hemisferotomia pode produzir um controle notável da epilepsia hemisférica clinicamente intratável em crianças. O resultado final desejável, após a hemisferotomia, é o controle de crises e a redução ou retirada de fármacos antiepiléticos, visando a melhora cognitiva e do desenvolvimento da criança. Objetivos: verificar a efetividade da hemisferotomia no controle de crises e na retirada ou redução de fármacos antiepilépticos em pacientes classificados como Engel 1, e analisar os desfechos cognitivo e de desenvolvimento após a abordagem cirúrgica e redução de fármacos antiepilépticos. Métodos: revisão de prontuários médicos e banco de dados de pacientes crianças e adolescentes, com idade inferior a 19 anos no momento da cirurgia, submetidos a hemisferotomia para tratamento de epilepsia refratária no Centro de Epilepsia de Ribeirão Preto do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, entre anos de 1995 e 2015. Resultados: foram avaliados 120 prontuários médicos, dos quais foram considerados aptos 82. Amostra sem diferença significativa entre sexos. Para o manejo de fármacos foram considerados 44 pacientes que eram classificados como Engel 1 no segundo ano pós cirúrgico. Para estes pacientes foram avaliadas variáveis como retirada ou redução de fármacos antiepilépticos, bem como o tempo para que esse manejo fosse realizado, além do desfecho cognitivo e de desenvolvimento. Conclusão: A hemisferotomia é uma cirurgia eficaz para pacientes com doença hemisférica, possibilitando que paciente fique livre de crises e, eventualmente, livre de fármacos antiepilépticos. O desfecho de sucesso cirúrgico é dependente de inúmeras variáveis e o manejo de fármacos é realizado conforme experiência de profissionais de cada serviço. / Introduction: Epilepsy surgery is a treatment option for patients with refractory epilepsy. Hemisferotomy can produce a remarkable control of clinically intractable hemispheric epilepsy in children. The intended outcome, after hemispherotomy, is the seizure control and the reduction or withdrawal of antiepileptic drugs, aiming at the cognitive and developmental improvement of the child. Objectives: To verify the effectiveness of the hemispherotomy in the crisis control and in the withdrawal or reduction of antiepileptic drugs in patients classified as Engel 1, and to analyze the cognitive and developmental outcomes after the surgical approach and reduction of antiepileptic drugs. Methods: review of medical records and database of children and adolescents under 19 years of age at the time of surgery submitted to hemispherotomy for the treatment of refractory epilepsy at the Epilepsy Center of Ribeirão Preto, Hospital das Clínicas, Faculdade de Medicina of Ribeirão Preto between 1995 and 2015. Results: 120 medical records were evaluated, of which 82 were considered suitable. Sample with no significant difference between gender. For the management of drugs, 44 patients were classified as Engel 1 in the second postoperative year. For these patients, variables such as withdrawal or reduction of antiepileptic drugs were evaluated, as well as the time for this management to be performed, in addition to the cognitive and developmental outcome. Conclusion: Hemispherotomy is an effective surgery for patients with hemispheric disease, allowing patients to be seizure free and eventually free of antiepileptic drugs. The outcome of surgical success depends on innumerable variables and the management of drugs is performed according to the experience of professionals of each service.

The objective of the current research was to develop an automated algorithm with no or little user assistance for extraction of Subdural Grid Electrodes (SGE) from post-implant MRI scans for epilepsy surgery. The algorithm utilizes the knowledge about the artifacts created by Subdural Electrodes (SE) in MRI scans. Also the algorithm does not only extract individual electrodes, but it also extracts them as a SGE structures. Information about the number and type of implanted electrodes is recorded during the surgery [1]. This information is used to reduce the search space and produce better results. Currently, the extraction of SGE from post-implant MRI scans is performed manually by a technologist [1, 2, 3]. It is a time-consuming process, requiring on average a few hours, depending on the number of implanted SE. In addition, the process does not conserve the geometry of the structures, since electrodes are identified individually. Usually SGE extraction is complicated by nearby artifacts, making manual extraction a non-trivial task that requires a good visualization of 3D space and orientation of SGE in it. Currently, most of the technologists use 2D slice viewers for extraction of SGE from 3D MRI scans. There is no commercial software to perform the automated extraction task. The only algorithm suggested in the literature is [4]. The goal of the proposed algorithm is to improve the performance of the algorithm in [4]. As a goal, the proposed algorithm performs extraction of SGE not only for individual electrodes, but by applying geometric constraints on SGE.

Pacientes com epilepsia do lobo temporal farmacorresistente, frequentemente, possuem esclerose hipocampal como lesão epileptogênica. Muitas vezes, estes pacientes se beneficiam de lobectomia temporal para redução da ocorrência de crises epilépticas. Para que possam se submeter a este procedimento, é necessário o uso da videoeletroencefalografia prolongada para delimitação apurada da zona epileptogênica. Apesar dos avanços dos métodos diagnósticos nesta área, a busca por um instrumento que permita uma avaliação clara da chance de uma vida livre de crises após cirurgia permanece. No presente trabalho, a apresentação do padrão eletroencefalográfico ictal foi estudado, de forma a se pesquisar se existe relação entre a sua ocorrência e permanência em apenas um hemisfério cerebral com um melhor prognóstico pós-cirúrgico. Foram revisados os dados eletroencefalográficos ictais e os prontuários médicos de 284 pacientes. Procedeu-se à classificação de seus padrões eletroencefalográficos ictais em unilaterais ou bilaterais, e seu prognóstico após um, dois e cinco anos após cirurgia em livre de crise ou não livre de crise epiléptica. Apresentavam padrão unilateral 132 pacientes, e 152 apresentavam padrão bilateral. Estavam livres de crises 236 pacientes, e 48 ainda persistiam com crises epilépticas após cirurgia. Não houve associação entre padrões ictais unilaterais e uma vida livre de crises epilépticas após a cirurgia (diferença de 7,5%; p=0,092; chi-quadrado). Dessa forma, não se pode aplicar o padrão ictal eletroencefalográfico como ferramenta para predição de uma vida livre de crises após lobectomia temporal em pacientes com epilepsia da região mesial do lobo temporal associada à esclerose hipocampal. / Patients with drug-resistant temporal lobe epilepsy usually have hippocampal sclerosis as an epileptogenic lesion. Most of the times, these patients are benefited from temporal lobectomy for seizure relief. For this procedure to occur, a long-term videoelectroencephalogram is necessary for the accurate delineation of the epileptogenic zone. Despite the developments in the diagnostic methods on this area, the quest continues for an instrument that allows a clear evaluation of the chance to obtain a seizure-free life after epilepsy surgery. In the present study, the electroencephalographic ictal patterns were evaluated, and the relationship between its occurrence and permanence in one cerebral hemisphere and the possibility of a seizure-free outcome after surgery were compared. The ictal electroencephalografic and medical records of 284 patients were analyzed. A classification of ictal patterns, whether unilateral or bilateral, was issued, and the seizure outcome after one, two, and five years after surgery annotated. Unilateral ictal patterns occurred in 132 patients, and bilateral ictal patterns in 152. Seizure-free status was obtained in 236 patients, and 48 still persisted with seizures. There was no association between a unilateral ictal status and a seizure-free outcome after surgery (difference of 7.5%, p=0.092; chi-square). So, the electroencephalographic ictal pattern is not a valuable tool for predictions regarding seizure outcome in patients with mesial temporal lobe epilepsy associated with hippocampal sclerosis that are submitted to temporal lobectomy.

A epilepsia é uma desordem cerebral definida por pelo menos duas crises não provocadas ocorrendo em um intervalo maior que 24 horas, uma crise não provocada e uma probabilidade de futuras crises similar ao risco de recorrência geral depois de duas crises não provocadas (pelo menos 60%) nos próximos 10 anos; ou o diagnóstico de uma síndrome epiléptica. Após o diagnóstico do tipo de epilepsia, existem situações em que o paciente não responde ao tratamento medicamentoso, apresentando pelo menos uma crise epiléptica por mês por um período mínimo de 2 anos. Se durante esse período, dois ou três diferentes fármacos antiepilépticos foram utilizados em monoterapia ou politerapia, e o paciente não obtém controle das crises, configura-se o quadro de epilepsia farmacorresistente. A intervenção cirúrgica é uma opção para essas crianças, atuando no controle das crises e, potencialmente no desenvolvimento neuropsicomotor. Neste estudo, avaliamos as variáveis clínicas como a idade de início da epilepsia, duração da epilepsia, frequência de crises, etiologia e a Escala de Comportamento Adaptativo de Vineland (ECAV) para caracterizar aspectos referentes aos domínios da comunicação, socialização, habilidades diárias e habilidades motoras, no período pré e pós-operatório de cirurgia de epilepsia. A nossa intenção foi determinar o impacto da cirurgia de epilepsia no desempenho dos pacientes nessas esferas avaliadas pela ECAV. Como resultados, encontramos que o grupo de participantes livre de crises após a cirurgia de epilepsia apresentou melhor desempenho cognitivo na segunda avaliação pós-operatória, quando comparado ao grupo que não teve controle de crises. A variável clínica duração da epilepsia influenciou a equivalência etária e as pontuações padrão da ECAV no período pré-operatório, sendo considerada determinante para o atraso neuropsicomotor dos pacientes submetidos à cirurgia de epilepsia. Quanto aos fatores preditivos de melhora das crises pós-operatórias, observou-se que Engel e cirurgia foram as variáveis consideradas significativas. A maioria dos pacientes (63,9%) na segunda avaliação pós-operatória ainda apresentou convulsões ou não obteve melhora. Nos achados da investigação sobre o impacto das crises em relação ao desenvolvimento neuropsicomotor na primeira avaliação 21,3 meses após a cirurgia, foi observado um ganho abaixo do esperado de apenas 4,4 meses na equivalência etária, não evidenciando melhora em curto prazo após a cirurgia, independente do controle de crises. Após 41,3 meses do procedimento cirúrgico os pacientes que apresentaram controle de crises tiveram ganhos adaptativos significativos de 15 meses na equivalência etária quando comparados com os que não apresentavam controle das crises. Nesses últimos pacientes, a equivalência etária permaneceu praticamente estável com um incremento de apenas 3 meses quando analisada as fases pré e pós - operatória / Epilepsy is a disease of the brain defined by at least two unprovoked seizures occurring 24 h apart, one unprovoked seizure and a probability of further seizures like the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years or diagnosis of an epilepsy syndrome. After epilepsy diagnosis, there are situations where patients do not respond to drug treatment, developing one seizure per month for a minimum of 2 years. If during this period two or three antiepileptic drugs different used as monotherapy or in combination, a condition known as drug-resistant epilepsy. Epilepsy surgery is an option for children with drug-resistant epilepsy acting on the seizure control seizures and, potentially on neuropsychomotor development. In this study, we evaluated clinical variables such as epilepsy age of onset, epilepsy duration, seizure frequency, etiology and adaptive behavior scale of Vineland to characterize aspects related to age equivalence through the domains of communication, socialization, daily skills and motor skills pre- and post-surgical period. Our intention was to determine the impact of epilepsy surgery on the performance of patients in these areas evaluated by Vineland. Thus, we found that the seizure free group participants showed better cognitive performance in the second evaluation, compared to the group that not seizure controlled. The clinical variable duration of epilepsy influenced the age equivalence and standard Vineland scores in the preoperative period, being considered determinant for the neuropsychomotor delay of patients submitted to epilepsy surgery. Regarding the predictive factors of improvement of postoperative crises, it was observed that Engel and surgery were the variables considered significant. The majority of the patients (63.9%) in the second postoperative evaluation still had seizures or did not improve. The findings of the research on the impact of crises on neuropsychomotor were that in the first evaluation 21.3 months after surgery there was a below-expected gain of only 4.4 months of age equivalence, not showing improvement in the short term after surgery, independent of control crisis. After 41.3 months of the surgical procedure, the patients presenting with seizure control had significant adaptive gains of 15 months when compared to those without seizure control. In the latter patients, the age equivalence remained practically stable with an increase of o preoperative only 3 months, analyzing the phases pre and postoperative evaluation