Comparison of Hemispheric Surgery Techniques for Pediatric Drug-Resistant Epilepsy: An Individual Patient Data Meta-analysis

Jia-Shu Chen¹, William B Harris¹, Katherine J Wu¹, H Westley Phillips¹, Chi-Hong Tseng¹, Alexander G Weil¹, Aria Fallah²

Affiliations

¹ From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles.
² From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles. afallah@mednet.ucla.edu.

PMID: 37202158
PMCID: PMC10435062
DOI: 10.1212/WNL.0000000000207425

Meta-Analysis

Comparison of Hemispheric Surgery Techniques for Pediatric Drug-Resistant Epilepsy: An Individual Patient Data Meta-analysis

Jia-Shu Chen et al. Neurology. 2023.

. 2023 Jul 25;101(4):e410-e424.

doi: 10.1212/WNL.0000000000207425. Epub 2023 May 18.

Authors

Jia-Shu Chen¹, William B Harris¹, Katherine J Wu¹, H Westley Phillips¹, Chi-Hong Tseng¹, Alexander G Weil¹, Aria Fallah²

Affiliations

¹ From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles.
² From the The Warren Alpert Medical School of Brown University (J.-S.C.), Providence, RI; Department of Neurosurgery (W.B.H.), University of Colorado Anschutz, Aurora; Department of Neurosurgery (K.J.W., H.W.P., A.F.), University of California Los Angeles; Department of Neurosurgery (H.W.P.), University of Pittsburgh Medical Center, PA; Department of Medicine (C.-H.T.), University of California Los Angeles; Department of Neurosurgery (A.G.W.), Université de Montréal, Quebec, Canada; and Department of Pediatrics (A.F.), University of California Los Angeles. afallah@mednet.ucla.edu.

PMID: 37202158
PMCID: PMC10435062
DOI: 10.1212/WNL.0000000000207425

Abstract

Background and objectives: Hemispheric surgery effectively treats unihemispheric pediatric drug-resistant epilepsy (DRE) by resecting and/or disconnecting the epileptic hemisphere. Modifications to the original anatomic hemispherectomy have generated multiple functionally equivalent, disconnective techniques for performing hemispheric surgery, termed functional hemispherotomy. While a myriad of hemispherotomy variants exist, all of them can be categorized according to the anatomic plane they are performed in, which includes vertical approaches at or near the interhemispheric fissure and lateral approaches at or near the Sylvian fissure. This meta-analysis of individual patient data (IPD) aimed to compare seizure outcomes and complications between the hemispherotomy approaches to better characterize their relative efficacy and safety in the modern neurosurgical treatment of pediatric DRE, given emerging evidence that outcomes may differ between them.

Methods: CINAHL, Embase, PubMed, and Web of Science were searched from inception to September 9, 2020, for studies reporting IPD from pediatric patients with DRE who underwent hemispheric surgery. Outcomes of interest were seizure freedom at last follow-up, time-to-seizure recurrence, and complications including hydrocephalus, infection, and mortality. The χ² test compared the frequency of seizure freedom and complications. Multivariable mixed-effects Cox regression controlling for predictors of seizure outcome was performed on propensity score-matched patients to compare time-to-seizure recurrence between approaches. Kaplan-Meier curves were made to visualize differences in time-to-seizure recurrence.

Results: Fifty-five studies reporting on 686 unique pediatric patients treated with hemispheric surgery were included for meta-analysis. Among the hemispherotomy subgroup, vertical approaches resulted in a greater proportion of seizure free patients (81.2% vs 70.7%, p = 0.014) than lateral approaches. While there were no differences in complications, lateral hemispherotomy had higher rates of revision hemispheric surgery due to incomplete disconnection and/or recurrent seizures than vertical hemispherotomy (16.3% vs 1.2%, p < 0.001). After propensity score matching, vertical hemispherotomy approaches independently conferred longer time-to-seizure recurrence than lateral hemispherotomy approaches (hazard ratio 0.44, 95% CI 0.19-0.98).

Discussion: Among functional hemispherotomy techniques, vertical hemispherotomy approaches confer more durable seizure freedom than lateral approaches without compromising safety. Future prospective studies are required to definitively determine whether vertical approaches are indeed superior and how it should influence clinical guidelines for performing hemispheric surgery.

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Conflict of interest statement

The authors report no relevant disclosures. Go to Neurology.org/N for full disclosures.

Figures

**Figure 1. PRISMA IPDMA Flow Diagram of Search Results and Study Selection**
IPD = individual patient data; IPDMA = IPD meta-analysis; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analysis.

**Figure 2. Comparison of Kaplan-Meier Curves Depicting the Seizure Freedom Functions for Patients Treated With Lateral Hemispherotomy and Vertical Hemispherotomy**

See this image and copyright information in PMC

References

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Comparison of Hemispheric Surgery Techniques for Pediatric Drug-Resistant Epilepsy: An Individual Patient Data Meta-analysis

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Comparison of Hemispheric Surgery Techniques for Pediatric Drug-Resistant Epilepsy: An Individual Patient Data Meta-analysis

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Conflict of interest statement

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