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JOURNAL READING III

WEDNESDAY, 10TH JUNE 2015

LONG-TERM FUNCTIONAL OUTCOMES


AND THEIR PREDICTORS AFTER
HEMISPHERECTOMY IN 115 CHILDREN
Epilepsia, 54(10):1771-1779,2013

Presenter : dr. M. Taufiq Regia Arnaz


Moderator : dr. Fasihah Irfani Fitri, M.Ked (Neu), Sp.S

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BACKGROUND

EFFECTIVE TREATMENT

REFRACTORY EPILEPSY
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FAMILY FACED WITH A CHILD
REQUIRING HEMISPHERECTOMY
OFTEN ASK

1) Can the hemiplegia get worse?


2) Can he walk unaided?
3) How does the visual field defect affect daily life?
4) Will she talk and read like her peers?
5) What are the behaviour and mental health
challanges?
6) Will he attend a mainstream school and work
independently as an adult?
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Few studies have attempted
to address these functional
outcomes by reporting either
general observations or using
a battery of
neuropsychological test
(Maehara et al., 2002);
however, none looked at the
long-term functional
outcomes using a patient
centred approach (Wiebe &
Berg, 2013)
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PURPOSE
To examine the functional outcome after
hemispherectomy in the key functional domains of
daily life-ability to walk, visual symptomps, spoken
language skills, reading abilty, behaviour, and
academics/employment-as perceived by the famillies
and patients

To identify the prognostic factors that determine the


functional outcomes

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MATERIAL AND METHODS
PREOPERATIVE DATA

1) They reviewed the medical records of all patients who


underwent hemispherectomy between January 1997 and June
2009.
2) Preoperative clinical, EEG, Video-EEG, radiologic and surgical
data were collected.
3) Preoperative neurologic deficits including presence and
severity of motor deficits, ability to walk, language skills,
and visual deficits were documented.

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POSTOPERATIVE FUNCTIONAL OUTCOME

ASSESSED

Structured questionnaire
inquiring about functional
(ambulation, visual
symptomps, spoken language
and reading ability,
behavioural, and
academic/employment) and
seizure outcomes.
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OUTCOME DEFINITION
Poor outcome
Good outcome Unable to walk.
Independent walking Severe delay or 2-3
Age appropriate
word phrases only or
speaking or just below unclear words or
age level. nonverbal in speaking.
Age appropriate Able to read only
reading or few years familiar words or
below age. alphabets or unable to
No or minimal
read.
behavioural problems. Behavioural problems.

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Statistical Analysis

USING

Wilcoxon rank-sum, chi-square,


and fishers exact test

TO COMPARE

Favourable vs Unfavourable functional outcomes

PROVIDED DATA

Potential prognostic factors


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RESULT

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PREDICTORS OF POOR
FUNCTIONAL OUTCOME
Ambulatory Status
Structural abnormalities
in the nonoperated
hemisphere on MRI
Preexixting bilateral
Spoken Language Skills motor deficits
Preoperative language
delay or indeterminate
languange status (young
Reading Ability infants)
Postoperative seizure
recurrence
Behavioural Problem

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DISCUSSION
Plasticity proponents argue that
Boatman et brain in the growing phase is
al., 1999 & considered to be more plastic,
Ballantyne et and hence early injury may
al., 2007 be better compensated
especially if surgical treatment
is offered early

FOR EXAMPLE

Varga- Language deficits due to large infarcts


Khadem et of the left hemisphere are very well
al., 1992 & compensated if ischemic stroke occurs
Ballantyne et in early childhood compared to an older
al., 2008 child or adult with similar injury

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Proponents of the early
vulnerability model have reported
poorer
Anderson et cognitive and academic skills in
al., 2009, children with early brain
2010. injury compared to a similar
degree of brain injury in older
children

CONSEQUENTLY

Poor language skills in these


Liegeois et
patients may in fact be an index
al., 2008
of poor short term memory and
verbal intelligence measures
rather than a localized
dysfunction of the language
cortex per se
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Left hemispherectomy in older
children and adults is
Curtiss et
frequently a cause of concern
al., 2001
because of potential language
areas in the left hemisphere.
However, they did not find a
significant difference in
language outcome between
right and left
hemispherectomy as in
another study

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LIMITATION

- The preoperative assessment of developmental quotient


and behavior could not be rigorous due to limitations
such as young age, difficulties in testing, frequent
seizures, and parenting style (bias).
- Use of a rather simplistic questionnaire for
ambulatory, language, reading, and behavior assessment
may be viewed as a limitation of this study.
- They were unable to reach 61 patients in the study
primarily owing to changes in their contact information.

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SUMMARY

* Impairments affecting the life of


patient/family after hemispherectomy, in the
order of most to least significance, are
reading skills, spoken language, behavior, vision
issues, and ambulation.
* Seizure freedom after hemispherectomy is a
strong independent predictor of better
functional outcome in all functional domains.

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* Brain MRI abnormalities in the nonoperated
hemisphere predict poor motor and language
outcomes.
* Early interventions after hemispherectomy
to control seizure recurrence and provide
intensive language rehabilitation, when
appropriate, may seem prudent to improve
long-term functional outcome

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THANK YOU

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