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Explorations préchirurgicales chez l’ Enfant :
Particularités et Risques spécifiques Christine BULTEAU MD PhD
Fondation ROTHSCHILD, Service de Neurochirurgie Pédiatrique, Paris, FranceHôpital Robert DEBRE, Service Neurologie Pédiatrique, Paris, FranceInserm UMR 1129, Hôpital NECKER Enfants Malades Paris, France
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
– 1. Diagnostic syndromique
– 2. Objectifs chirurgie: pas de class I
– 3. Etiologies hétérogènes
– 4. Localisation variées
– 5. Investigations: âge (myelinisation, langage),
expérience des équipes (FOR: FO et SEEG) ,
disponibilité des techniques d’exploration
– 6. Procédures chirurgicales: résection multilobaire,
résection –déconnexion, déconnexion d’hamartome,
déconnexion hémisphérique, callosotomie, …
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
Particularités
• 1.crise.wmv • 2. crise.MPG
1. Diagnostic syndromique
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
• 3. crise.MPG • 4. crise.avi
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
1. Diagnostic syndromique
1. Diagnostic syndromique
Océane née le 30/11/98: début crises en 12/2003 (5ans): CP avec pâleur, Hypersalivation, mâchonnement,
regard fixe: EEG: Foyer de P Temporal Gauche. Tt par VPA.
IRM du 06/02/2004 (5A 3M)
IRM du 15/09/2004 (5A 10M)
IRM du 14/01/2005 (6A 2M)
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
1. Diagnostic syndromique ?
Structural disordersSynaptic imbalance
« Co-morbidities » precede onset of seizuresIndependant of structural lesions
Effects of seizures
Seizures
seiz
ure
s
Neurologicalcourse
Cognitive and schooling
Psychiatric
and behavioralstatusH
QO
L
Non ictalSyndrome
Davidson 1975, Lindsay 1984, Duchowny 1989, Fish 1993, Wyllie 1998 Mathern 1999, Jarrer 2002, Kossof 2002, Davies 1993, Curtiss 1999,Vargha-Khadem 1997, Devlin2003….Perry 2013
2. Objectifs de la chirurgie
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
80 ADULT patients with TLE :
– Surgical group (40)
– Medical group (40)
Class I evidence: Randomized controlled trial of surgical versus medical management in TLE
Wiebe et al. N Engl J Med 2001
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
Structural disordersSynaptic imbalance
« Co-morbidities » precede onset of seizuresIndependant of structural lesions
Effects of seizures
SeizuresNon ictalSyndrome
Davidson 1975, Lindsay 1984, Duchowny 1989, Fish 1993, Wyllie 1998 Mathern 1999, Jarrer 2002, Kossof 2002, Davies 1993, Curtiss 1999,Vargha-Khadem 1997, Devlin2003….Perry 2013
+
-
2. Objectifs de la chirurgie
AES 2013 Presidentiel Symposium Surgery
Lack of neurologist education
Structural disordersSynaptic imbalance
« Co-morbidities » precede onset of seizuresIndependant of structural lesions
Effects of seizures
SeizuresNeurological courseCognitive and schoolingPsychiatric and behavioral statusHQOL
Non ictalSyndrome
Davidson 1975, Lindsay 1984, Duchowny 1989, Fish 1993, Wyllie 1998 Mathern 1999, Jarrer 2002, Kossof 2002, Davies 1993, Curtiss 1999,Vargha-Khadem 1997, Devlin2003….Perry 2013
seizures
+
-
3. Etiologies hétérogènes
ETIOLOGIES PROCEDURE CHIRURGICALE
- Dysplasies Corticales Focales: Type I/ Type II / Type III- DNET: simple, complex, semi-specific- Syndromes Hemispheriques:
- Encéphalite de Rasmussen- Hemimegalencephaly
- AVC néo nataux
- Sturge Weber hémisphérique
- Sd Neurocutanés: - Tuberous Sclerosis (TSC)- Sturge Weber (SW)
- Hamartomes Hypothalamic- SH isolée : exceptionnelle
4. Localisations variées
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
Population < 18years: - 543 children- 720 surgical procedures
FCD in Pediatric
Population
ILAE Survey 2004
4. Localisations variées
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
Cross et al Epilepsia 2006Harvey et al, Epilepsia 2008
65
23
5 4 3
0
10
20
30
40
50
60
70
80
daily weekly monthy < monthly uncertain
Frequence of seizure before surgery
4. Localisations variées
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
4. Localisations variées
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
• Homogène:
- Diagnostic syndromique: Epileptologue d’enfant
- EEG surface vidéo critique: sommeil +++
- IRM (voir séquences en fx de l’âge)
6 months
19 months
5. Investigations / Age
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
• Mandatory :
- Diagnostic syndromique: Epileptologue d’enfant
- EEG surface vidéo critique
- IRM (voir séquences en fx de l’âge)
• Recommended– Les méthodes d’exploration varient: expérience selon les
équipes, les méthodes disponibles d’imagerie fx et métaboliques selon les pays
– Limitations participation de l’enfant: Age, Troubles cognitifs, Troubles psychopathologiques
5. Investigations / Outils
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
Focal Cortical Dysplasia
Semiology according to the localization of the seizureTemporal,Occipital,Frontal,…
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
5. Investigations / Age
L1
L2
L3
L4
L5
L6
1971
• Disruption of the normal cortical lamination • Malformed cells concentrated deeper layers and underlying white matter
EPODES - Brno, Czech Republic, 13-17 January 2014
Focal Cortical Dysplasia
• EPODES - Brno, Czech Republic, 13-17 January 2014
Focal Cortical Dysplasia
Normal cortex lesional
cortex
Seizuregenerator
Microscopicabnormalities
Zoom = 40 millions from macro to channel1 cm= 5000 neurons
Three-tiered ILAE classification system for FCDs
Blümcke et al 2011
» NEUROPATHOLOGY
VIII Congresso de Neuropediatria Dilemas em Epilepsia 2013
FCD Type Ia: abnormal radial lamination and abundant microcolumns
FCD Type Ib: abnormal tangential layer composition
VIII Congresso de Neuropediatria Dilemas em Epilepsia 2013
NEUROPATHOLOGY
FCD I = Architectural type FCD
NEUROPATHOLOGY
FCDII = Taylor type FCD
VIII Congresso de Neuropediatria Dilemas em Epilepsia 2013
Taylor et al 1971Tassi et al, Brain 2002
Normal Taylor dysplasia
FCD Type II a: dysmorphic neurons
FCD Type II b: dysmorphic
neurons + ballon cells
Semiologie attendue
• Sensation épigastrique
• RC, semble lointain
• Mâchonnement
• Semble avoir peur
• Rougeur visage
• Cyanose des lèvres
• ..
Présentation pédiatrique
• 7 mois: Spasme Infantile (GVG)
• 18 mois: Crises Partielles: ralentissement du comportement, pas de réponse, RC
• 5.Left Temporal sleep.MPG
5. Investigations / Expérience equipe
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
Foramen Ovale Electrode: inserted percutaneously through the foramen ovale underfluoroscopic guidance may provide a less invasive way to explore the mesial temporal lobe neurophysiologically
Epilepsie temporale si pas de langage: EEG surface couplée à une électrodes du FO
TLE (N=38)
Sz, MRI and EEG
video Scalp EEG + FOE
28 (74%)
Temporal Sz +
17 Surgery
Engel 1: 94%
11 SEEG
Engel 1 : 73%
10 excluded (26%)
Multifocal (6)
No Seizures (4)
- FCD : I (6) III (9)
- Isolated HS (3)
- Others: Gliosis (4) DNE (2) Ischem (2), OligoDg, Angiome
Histologie
38 patients TLE < 16years
- MRI+: 100%
- Age of onset: 4,6 years (40% <2y)
- Seizures:
. CP (33)
. Extratemporal Focus
. Tonic or Clonic tonic
. Spasms (2) / Lennox -Gastaut (1)
Age at FO-EEG: 9,8 years (2,3 à 15,4 years)
Duration of Seizure: 6,3 years (0,6 à 12,8 yeas)
– 1. Devenir crises: class III
– 2. Devenir cognitif et psychopathologique
– 3. Vulnérabilité / plasticité
– 4. Cas particulier: Situation d’hémisphérotomie
– 5. Procédure chirurgicale : Service de
Réanimation Pédiatrique pour les plus jeunes
(poids / perte sanguine)
– 6. Attendre l’âge adulte, ne pas référer
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
Risques
Results:
- 36 studies included 1318 pediatric patients with a mean age
(± SEM) of 10.7 ± 0.3 years, at least 1 year of follow-up.
- 76% Engel I outcome
- Predictors of seizure freedom: • abnormal findings on preoperative MRI • lack of generalized seizures. • lesional epilepsy etiology : Among lesional epilepsy cases,
there was a trend toward better outcome with gross-total
lesionectomy than with subtotal resection.
Meta-analysis of studies including 10 or more pediatric patients (age ≤ 19 years) published over the last 20 years examining seizure outcomes after temporal lobectomy for TLE.
1. Devenir crises: pas de class I
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
Results:
- 36 studies 1259 pediatric patients with at least 1 year of FU
- 54% Engel Class I outcome
- Predictors of seizure freedom: • shorter epilepsy duration (≤ 7 years)• Lesional epilepsy • Partial seizures only • Localizing ictal EEG findings• Gross-total than with subtotal resection
Meta-analysis of studies including 10 or more pediatric patients (age ≤ 19 years) published over the last 20 years examining seizure outcomes after resective surgery for Extra TLE, excluding hemispherotomy
Engel I Engel II-IV p
Meanduration Sz
6.2 ± 0.4 8.0 ± 0.7 <0.02
Lesional 61% 39% <0.001
Partial only 68% 32% <0.01
Ictal EEG 67% 33% <0.01
Extent of rexection
81% 19% <0.001
Workshop on Epilepsies and Psychiatric Comorbidities Paris, France 9-11 October 2014
1. Devenir crises: pas de class I
Inclusion criteria:- partial epilepsy, focal resections (lesionectomy, lobectomy, corticectomy,Selective amygdalohippocampectomy)- English language- sample size >20. - pre- and postsurgery data- criteria psychiatric disease (DSM / ICD )- method for obtaining information (review by psychiatrist, structured clinical interview,rating scales)
Exclusion criteria :- Hypothalamic Hamartoma- Subpial transections, - Hemispherectomies- Callosotomy- Other palliative procedures- “Stimulation” studies
1% of thestudies
Workshop on Epilepsies and Psychiatric Comorbidities Paris, France 9-11 October 2014
2. Devenir cognitif et psychopathologique
Rai D et al. Epilepsia 2012
• Pediatric studies report prevalence in the 20–40% range for psychiatric illness(Rutter et al., 1970; Brent, 1986; Jambaqué et al 1998, Dunn, 2003; Dunn et al., 2003; Plioplys, 2003; Ott et al., 2003, Caplan et al., 2004; Dunn & Austin, 2004; Caplan et al., 2005; Salpekar et al 2005; Jones et al., 2008; Saemundsen et al 2013,…).
• The most common psychiatric comorbidities in children include:– Depression
– Anxiety
– Dysthymia
– Conduct / Oppositional defiant disorder
– Social adjustment problems
– Attention Deficit Hyperactivity Disorder (ADHD)
– Autism Spectrum disorder (ASD)
– Psychogenic non-epileptic seizures(6 à 20% Durant 2011, Gallego 2011): Prognosis was found to be poor in adults, but good in children.
Workshop on Epilepsies and Psychiatric Comorbidities Paris, France 9-11 October 2014
2. Devenir cognitif et psychopathologique
• 5 patients (3 M), age of onset (1 week to 21 months) , age at surgery (2 to 8 years), 3 Right TLE, 1 left TLE, 1 parieto-occipital
“These results suggest that families should be counseled that PDD symptoms in children with focal epileptogenic lesions may or may not improve after epilepsy surgery, even if the surgery is successful with respect to seizure control “ Szabo et al Pediatric Neurology 1999
Workshop on Epilepsies and Psychiatric Comorbidities Paris, France 9-11 October 2014
2. Devenir cognitif et psychopathologique
60 children (35 males): undergone temporal lobe resection; mean age at time of operation 10y 7mo, (SD 4y 11mo)range.
. 50/60 (83%) of children had a diagnosis of psychiatric disorder
The same proportion of children had psychiatric diagnoses pre- and postoperatively ([72%] and 72%] respectively).
Parents require counselling on these issues in the preoperative work-up.
Workshop on Epilepsies and Psychiatric Comorbidities Paris, France 9-11 October 2014
2. Devenir cognitif et psychopathologique
71 children (35males): undergone extra temporal lobe resection; mean age at time of operation 9.5y: Frontal (73%), Parietal (13%), occipital (10%)
. 37/71 (51%) of children had a diagnosis of mental health problem
The same proportion of children had psychiatric diagnoses pre- and postoperatively ([44%] and 45%] respectively).
Workshop on Epilepsies and Psychiatric Comorbidities Paris, France 9-11 October 2014
2. Devenir cognitif et psychopathologique
Singh et al. Brain and Dev 2012 :
On psychiatric evaluation, psychopathological illnesses in children with epilepsy was present in 47% of case.Attention deficit, hyperkinetic disorder, conduct disorder and depression were found to be commonly associated with:
- poor educational performance (47%)
- decreased learning opportunities (22.2%)
- borderline intelligence (19.4%)
HOW ? : Depending on the goal of the evaluation : Routinely(Minimal requirements ?) / Research / Outcome / Psychosocial assessment / Prospective or Retrospective study.
External factors and
cognitive factors
Workshop on Epilepsies and Psychiatric Comorbidities Paris, France 9-11 October 2014
2. Devenir cognitif et psychopathologique
• Behavioral scales= Questionnaires• Fullfilled by
– Psychiatrist: Diagnostic and Statistical Manual of Mental Disorder :DSM-IV TR
– Parents: Child Behavioral Checklist CBCL, ADHD scalesSwanson JM: School-Based Assessments and Interventions for ADD Students. Irvine, CA, KC Publications, 1992/CCQ-B5 – Big Five scales for California Child Q-Set)John OP et al. Child Development, 1994
– Child: Multidimensional Anxiety Scale MASC March JS al. J Am Acad Child Adolesc Psychiatry 1997; March JS, Sullivan K J Anxiety Disord 1999 /Child Depression Inventory CDI Kovacs M Psychopharmacol Bull 1985; Smucker MR et al. J Abnorm Child Psychol 1986
• In the office or waiting room / outpatient
Psychiatric Evaluation – How ?
Child and adolescent Psychiatrist
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
• Interview (Salpekar et Dunn Semin Pediatr Neurol 2007)
Psychiatric Evaluation – How ?
Child and adolescent Psychiatrist
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
Cormack et al. Epilepsia, vol 48, N°1, 201- 204, 2007
A: Efficience intellectuelle chez 79 enfants avec une ELT unilatérale comparée à la population normale
Spirrow et al. Neurology 2011
Groupe chirurgie : 42 enfantsGroupe Control: 11 enfants
DIU Neuropédiatrie et Epileptologie – 13 février 2015
3. Vulnérabilité et Plasticité
25 patients (8 to18 years) with TLR for refractory TLE 50 age-matched healthy controls Emotional memory recognition tasks involving faces and words. Recollection and familiarity memory: R/K/G paradigm (identification of emotional faces)
Cortex 2013
25 patients (8 to18 years) with TLR for refractory TLE 50 age-matched healthy controls Emotional memory recognition tasks involving faces and words. Recollection and familiarity memory: R/K/G paradigm (identification of emotional faces)
Cortex 2013
The specializations of amygdaloid complex nuclei and MTL for neutral and fearfulfaces across groups.
In 8–12 years children encoding encodingneutral faces fearful faces
Left centro-mesial amygdaloid complex nuclei + +Left hippocampal tail + -
Workshop on Epilepsies and Psychiatric Comorbidities Paris, France 9-11 October 2014
In 13–17 years children encoding encodingneutral faces fearful faces
Bilat Baso-lateral amygdaloid complex nuclei - +Parahippocampal gyrus - +Hippocampal head + +Hippocampal body + -Hippocampal tail - +Temporo polar + -Perirhinal Cortex + -Enthorhinal + -
1. Hemispheric 2. Sturge Weber 3. Vascular 4. Rasmussen
cortical dysplasia, (Hemispheric) Sequellae Encephalitis
HME
Rasmussen & Villemure,1989 ; Vining et al. 1997, Duchowny, 2004, Cross 2006, Harvey 2008
4. La situation d’hémisphérotomie
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
– HEMISPHERECTOMY…to…….HEMISPHEROTOMY
Vertical Approach
(Delalande, Bulteau et al.1992, 2007)
Lateral or Peri-insular Approach
(Villemure 1993, Schramm 1995, Jonas 2004)
- The smallest resection necessary to performcomplete hemisphericdisconnection- Reduce loss of blood intra-operatively
Anatomical Functional
Hemispherotomy
Lateral Vertical
5. Les procédures chirugicales
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
Right HME:
Figures from: Woo et al 2001, Salamon et al 2006, Di Rocco et al 2006, Delalande et al 2007
Hemimegalencephaly1. Etiologie
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
EPODES - Brno, Czech Republic, 13-17 January 2014
Hemimegalencephaly1. Etiologie
N Syndromic
Di Rocco et al (2000) 15 7 (47%) Hemifacial gigantism /Neurocutaneous
syndrome: Hypomelanosis of Ito, TS, NF,
Epidermal naevus syndrome, Klippel-Trenonay-
Weber syndrome
Sasaki et al (2005)Epidemiological study
Japon
44 16 (36%) Neurocutaneous syndrome:
Epidermal nevus syndrome (Linear nevus
syndrome /Sebaceous nevus syndrome),
hypomelanosis of Ito, TS complex, Klippel-
Trénaunay-Weber syndrome.
Tinkle et al (2005) 15 7 (47%) Body hemi-hypertrophy (ipsilateral ) / other
unilateral congenital somatic abnormalities:
polycystic kidney disease,
hypothyroidism , multiple angiomyolipomas
Neurocutaneous syndrome: epidermal nevus,
linear nevus sebaceum
Syndromic HEMIMEGALENCEPHALY: almost half the patient
14th Annual Meeting of Infantile Seizure Society International Symposium on Surgery for Catastrophic Epilepsy in Infants (ISCE):Towards early diagnosis and treatment February 18-19, 2012, Tokyo
Cook et al, 2004
Modified lateral hemispherotomy offers various advantages related to operative bloodloss and reoperation compared with anatomical and functional hemispherectomies
Shunt 78% 9% 22% 16%
5. Les procédures chirurgicales
14th Annual Meeting of Infantile Seizure Society International Symposium on Surgery for Catastrophic Epilepsy in Infants (ISCE):Towards early diagnosis and treatment February 18-19, 2012, Tokyo
HME patients had the greatest perioperative blood loss, and the longest surgery time.
Jonas et al, 2004
5. Les procédures chirurgicales
Jonas, R., Nguyen, S., Hu, B., Asarnow, R. F., LoPr esti, C., Curtiss, S., de Bode, S., Yudovin, S., Shields, W.D., Vinters, H.V., & Mather n, G.W. (2004). Cerebral hemispherectomy: Hospital course, seizure, developm ental, language, and motor outcomes. Neurology, 62, 1712-1721.
Delalande, O., Bulteau, C., Dellatolas, G., Fohlen, M., Jalin, C., Buret , V., Viguier, D., Dorfmüller G., & Jambaqué, I. (2007). Vertical parasagittal hemispherotomySurgical procedures and clinical long-term outcomes in a population of 83 children. Neurosurgery, 60, 19-32.
N=52 / 115 (UCLA) N=58 / 83 (Rothschild)
The longer duration of seizures, the worst the autonomy
6. Référertrop tard
• Facteurs de mauvais pronostics sur le plan neuropsychologique:
– AGE PRECOCE DE DEBUT DE CRISES
– LESION SUR L’IRM
– PHARMACORESISTANCE AUX TT ANTI-EPILEPTIQUES
– POLYTHERAPIE
– FREQUENCE DE CRISES: quotidiennes ou hebdomadaires
6. Référertrop tard
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
The Rasmussen Encephalitis
6. Attendre ?
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
The « two faces»
Bien CG, Schramm J 2009
2 month 9 month 1 year 2 years
Rasmussen EncephalitisDiagnostic criteria
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
• Antecedent– Normal perinatal period and psychomotor development– Slight fever (50%) before the first seizure
• Epilepsy– Seizures Onset : 14 months - 14 years(Mean age: 6,8y)
: 80 % before 10 years of age
Rasmussen EncephalitisFirst description: MNI 1991 48 patients
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
Atteinte motrice
• 1Marche Pré.MPG • 2.tenue assise
pauline.mpg
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
Atteinte cognitive
H droite Hgauche
• 9.Anna Vocabulaire
OK.MPG
• 4.répétition mots
simples pauline.mpg
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
Récupération motrice post-hémisphérotomieStronger cortico-spinal pathway
Natural History Museum Smithsonian Institution, Washington DC
• 5.Marche J10 PO.MPG • 6.Marche 9M PO.MPG
Récupération motrice post-hémisphérotomie
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
• 9. Marche saute assis.MPG • HD Chad 3APo Mvts mirroir
2.MPG
Récupération motrice post-hémisphérotomie
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
Récupération du langage après
hémisphérotomie gauche• langage spontané1 -
Copie.MPG
• langage 3manque du
mot - Copie.MPG
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
• 12 Lina manque du mot
en spontanée à 3
semaines PO.3GP
• 13 Lina 1 an post-op
Chante Zaz.3GP
Récupération du langage après
hémisphérotomie gauche
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
PARTICULARITES
– 1. Diagnostic syndromique
– 2. Objectifs chirurgie: pas de class I
– 3. Etiologies hétérogènes
– 4. Localisation variées
– 5. Investigations: âgeexpérience des équipes , disponibilité des techniques d’exploration
– 6. Procédures chirurgicales: résection multilobaire, résection –déconnexion, déconnexion d’hamartome, déconnexion hémisphérique, callosotomie, …
RISQUES
– 1. Devenir crises: class III
– 2. Devenir cognitif et
psychopathologique
– 3. Vulnérabilité / plasticité
– 4. Cas particulier: Situation
d’hémisphérotomie
– 5. Procédure chirurgicale :
Service de Réanimation
Pédiatrique pour les plus
jeunes (poids / perte sanguine)
– 6. Attendre l’âge adulte, ne pas
référer
CONCLUSION
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
Sélection des patients: particularités syndromiques
Objectif principal: guérir les crises / suivi âge adulte
Guérison épilepsie: de 20 to 80 %
Avant 5ans: si possible, équipe pédiatrique
Etudes prospectives Multicentrique : population homogène fx étiologues, localisationsprocédures / Etude sur les tissus cérébraux
CONCLUSION
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015
Clinical
examination
Clinical
seizure
MRI
Interictal and
Ictal EEG
Epileptic
syndrome
LOBE ?
SIDE ?
When to think to surgery ?
+
-
DIU Epileptologie Option “Investigation des Epilepsies ” - Marseille 17/04/2015