Hemispherectomy in infants: a safe procedure and argument for earlier surgery in selected cases. A review of 22 patients.

Introduction: Early life epilepsy refractory to medication may be caused by multiple etiologies with structural correlates. Surgical treatment via hemispherectomy is frequently effective, but historically has significant morbidity, and has not always been the treatment of choice in infants as they have been thought less physiologically able to tolerate large surgeries. The aim of this review is to summarize our institutional experience with hemispherectomy in very young children to show that it remains a safe and effective technique in this age group.

Methods: A retrospective chart review was conducted to identify children aged 12 mo or less who underwent functional hemispherectomy to treat medically refractory epilepsy at Seattle Children’s Hospital from 2000 to present. Surgical and functional outcomes were assessed as well as complication rate.

Results: Twenty-two children were identified, with average age at date of surgery being 5.8 mo. The most common etiology was hemimegalencephaly in 59% of patients, and all underwent functional hemispherectomy. No serious cardiac, pulmonary, or coagulopathic adverse events occurred. The most common complications included: post op hydrocephalus (3), asymptomatic CVST (2), and electrolyte derangements (2). Average ICU length of stay was 5 days. Three patients ultimately required shunt placement, though this occurred >1 yr later in 2/3. Estimated blood loss averaged 338cc and all patients received a transfusion during their operation. Engel class 1 outcome was achieved in 18/22 patients.

Conclusion : This case series demonstrates that functional hemispherectomy is a safe and reasonably well tolerated procedure even in very young children, with a high success rate in select etiologies. Surgical technique, a focus on minimizing operative blood loss, and multidisciplinary care of these patients are critical elements of ensuring the safety and success of this surgery in these patients. Future studies are needed to compare long term functional outcomes between these and older patients.