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Anatomical Classification of the Fistula the anatomy of an anal fistula has a direct impact on the outcome of operative intervention 10mg atomoxetine with visa treatment urticaria. Anal fistula is classified based on the course of the fistulous tract and its relationship to both the internal and external sphincter muscles buy generic atomoxetine from india medicine to prevent cold. It was based on the analysis of 400 cases of anal fistulas treated over a 15-year period [15] purchase 10 mg atomoxetine amex treatment meaning. According to Parks and colleagues the majority of anal fistulas can be described as the following four types: (1) intersphincteric, (2) trans-sphincteric, (3) suprasphincteric, and (4) extrasphincteric. Other types of fistulas that involve adjacent organs include anoperineal, anovaginal or rectovag- inal, and rectourethral. Traditionally the fistula anatomy in an individual patient is determined by physical examination or delineated at time of operative intervention (Fig. Routine imaging of anal fistula is not warranted but the selective use of radiologic studies can be helpful in patients with recurrent or complex fistulas and may decrease opera- tive failure [16 – 19]. Abbas care of patients with prior failed surgery and/or complex sphincteric 54 %, unclassified 49 %, and intersphincteric anatomy such as multiple fistulous openings. In an analysis of 179 patients treated for anal fistula at Garcia-Aguilar and colleagues from the University of Kaiser Permanente Los Angeles, a regional tertiary referral Minnesota reported their results in 624 patients with anal fis- center for the 14 Kaiser Permanente hospitals in Southern tula [2]. The overall fistula recurrence rate was 8 and 45 % of California, Abbas and colleagues found similar associations the patients complained of some degree of incontinence after between fistula type, operative failure rate, and incontinence surgery. The overall operative failure rate in their study was rate between fistula types: intersphincteric 4 %, trans- 15. High trans-sphincteric and suprasphincteric fistulas were predictors of incontinence (adjusted odds ratio, 22. Another study from Spain reported by Jordan and colleagues analyzed the impact of fistula classifi- cation on postoperative outcome in 279 patients with anal fis- tula [20]. Suprasphincteric and extrasphincteric fistulas were associated with the highest failure rates (28. In general supra- sphincteric fistula has been associated with some of the high- est failure/recurrence rate and incontinence risk in numerous studies including a German study that reported the outcome of 224 patients [21]. Postoperative incontinence was noted in 43 % of patients with suprasphincteric fistula compared to 21 % of patients with trans-sphincteric fistula. Anal fistulas that involve the vagina have been associated with a higher operative failure rate. The majority of anovagi- nal and rectovaginal fistulas are secondary to obstetrical trauma or Crohn’s disease. In general such fistulas are more complex because of various factors including anal sphincter defects, multiple and/or higher tracts, and/or active mucosal inflammation. Abbas Angeles reported their results with 36 patients who underwent similar finding in 125 patients [10]. Patients with rectovaginal fistula had a higher patients with one to two repairs and 50 % in patients with failure rate compared to patients with anal fistula (67 % more than three repairs. In a review of the Cleveland Clinic viously reported by another study from the Netherlands [26 ]. Ohio experience with 99 endorectal flaps, Sonada and col- Schouten and colleagues examined 44 endorectal advance- leagues noted a higher failure rate in patients rectovaginal ment flaps performed over a 5-year period. In the previously mentioned Canadian study patients with two or more prior repairs. Similarly Nelson and looking at the impact of selective use of seton combined with colleagues from Chicago reported their results in 65 patients infliximab infusion in Crohn’s patients, complete healing undergoing the island-flap anoplasty for trans-sphincteric was noted in 67 % of patients with anal fistula compared to fistula-in-ano [27]. Over a 10-year period, leagues from the Netherlands who reported a recurrence rate 147 Crohn’s patients underwent 292 operations for anorectal of 22 % in patients with one or no previous repair compared or rectovaginal fistula. The majority of patients had Crohn’s to 71 % in patients with two or more prior repairs [28]. A higher recurrence rate was noted in patients also important to note that patients with prior failed repair are with complex fistulas such as rectovaginal (45. The length of an anal fistula may also impact the outcome Toyonaga and colleagues from Japan also reported that mul- of surgical intervention. McGee and colleagues from Case tiple previous surgeries were an independent risk factor for Western University reported their experience with the anal postoperative incontinence [29 ]. Failure rate was higher in patients with a the Impact of Patient-Related Characteristics fistulous tract <4 cm compared to those with a tract >4 cm (79 % vs. A g e Population-based studies have reported an annual incidence Prior Fistula Repair of anal fistula of 6. Infants and children can develop anal Several studies have examined the impact of prior fistula fistula but the majority of patients present in adulthood repair on the subsequent outcome of additional operative [32–36]. This finding is most fistula includes an acute abscess, a recurrent abscess, or a likely due to a combination of factors: failure following the chronically draining fistula. A study from Kaiser Permanente initial operative intervention may be related to the complex- Los Angeles examined the risk of developing recurrent peri- ity of the fistula which predisposes the patient to subsequent anal sepsis and/or chronic fistula following one episode of failure and prior failure may lead to alteration of the anatomy acute perianal sepsis [1]. Based on the and colleagues from the University of Alabama reported results of that study, it appears that young age is a predispos- their experience with 95 endorectal and anodermal flaps ing factor for recurrent perianal sepsis or developing a performed between 2000 and 2003 [25]. In addition, young age seems to increase higher in patients with a prior repair compared to those with the risk of operative failure. In his review of the Clinic Ohio experience with anorectal and rectovaginal fistulas, Cleveland Clinic Florida experience with Crohn’s-related Sonada and colleagues reported an association between age rectovaginal fistula over a 10 year period, Pinto reported a and operative failure [9]. In their study, the operative failure 22 Causes of Operative Failure 183 rate was 54. It is important to note however colleagues from the Netherlands reported their results in 179 that no difference in recurrence has been noted in other stud- patients treated for anal fistula over an 8-year period [48]. In both groups that underwent fistulotomy or rectal advance- In their review of the University of Alabama’s experience ment flap, no difference in recurrence rate was noted between with anal flap, Ellis and Clark found no difference in recur- genders. Garcia-Aguilar and colleagues from the University of rence rate between patients younger than 40 years compared Minnesota surveyed 375 patients who had undergone anal fis- to those older than 40 years. A female analyzed the functional outcome of 179 patients operated at gender was associated with a higher risk of incontinence. Patients older than 45 years had a higher postoperative incon- tinence rate compared with patients younger than 45 years Smoking (adjusted odds ratio, 2. This finding is not surprising considering that aging can lead to Smoking has been implicated as a risk factor for the develop- weakness of the anal and pelvic floor musculature. A study reported from the Department tula surgery can further decrease baseline resting and squeeze of Veterans Affairs hospital in San Diego compared the pressure as previously demonstrated by anal manometry risk of developing anal abscess and fistula in smokers vs. Smoking has been associated with a higher rate Gender of postoperative complications following various anorectal operations including anal fistula surgery. Zimmerman and Gender has been implicated as a risk factor for developing colleagues from the Netherlands compared the outcome of anal sepsis and chronic anal fistula. Fistula-in-ano is uncommon in the pediatric followed for a median time of 14 months. Healing rate was population, but the majority of infants who present with anal 60 % in smokers compared to 79 % in nonsmokers (p= 0. Interestingly a higher incidence of In an effort to understand the effect of smoking on healing, a fistula-in-ano has been documented in male dogs compared subsequent study by the same researchers measured blood to females [46].

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After the quadriceps tendon and suprapatellar bursa are identified buy atomoxetine online treatment 5 shaving lotion, the bursa is evaluated for enlargement atomoxetine 10mg lowest price medicine symbol, inflammation purchase 40mg atomoxetine fast delivery symptoms 6 dpo, crystals, rice bodies, hemorrhage, and infection (Figs. Correct longitudinal position for ultrasound transducer for ultrasound evaluation of the suprapatellar bursa. Ultrasound image of the knee joint demonstrating the suprapatellar bursa lying beneath the quadriceps tendon. Longitudinal sagittal ultrasound image demonstrating suprapatellar crystal bursitis and crystal deposition. Longitudinal ultrasound image (with the probe backward) demonstrating suprapatellar bursitis and plica formation. Ultrasound image showing the vascularization of the synovial membrane in the suprapatellar bursa (arrows) in a male patient with hemophilic synovitis. The role of ultrasonography in the diagnosis of the musculo-skeletal problems of haemophilia. Longitudinal ultrasound image of the knee flexed to 15 degrees demonstrating suprapatellar bursitis. At the usual 90 degrees of flexion, the prefemoral fat pad is often difficult to assess. Note also the patellar femoral joint space is narrowed, and there is a fat pad remnant at the line. Given that bursitis is usually the result of either trauma or abnormal function of the affected joint, one should assume that additional pathology other than the bursitis being treated is present. Transverse ultrasound image of the femoral trochlea demonstrating crystal arthropathy of the knee. The prepatellar bursa lies between the anterior subcutaneous tissues of the knee and the anterior surface patella (Fig. The bursa serves to cushion and facilitate sliding of the skin and subcutaneous tissues of the anterior knee over the patella (Fig. The prepatellar bursa is held in place by patellar tendon which is an extension of the common tendon of the quadriceps tendon. Both the quadriceps tendon and its expansions as well as the patellar tendon and the prepatellar bursa are subject to the development of inflammation caused by overuse, misuse, or direct trauma. The quadriceps tendon is made up of fibers from the four muscles that comprise the quadriceps muscle: the vastus lateralis, the vastus intermedius, the vastus medialis, and the rectus femoris. The tendons of these muscles converge and unite to form a single, exceedingly strong tendon. The patella functions as a sesamoid bone within the quadriceps tendon, with fibers of the tendon expanding around the patella and forming the medial and lateral patella retinacula, which help strengthen the knee joint. These fibers are called expansions and are subject to strain; the tendon proper is subject to the development of tendinitis (Fig. The prepatellar, infrapatellar, and suprapatellar bursae also may concurrently become inflamed with dysfunction of the quadriceps tendon. The bursa serves to cushion and facilitate sliding of the skin and subcutaneous tissues of the anterior knee over the patella. The patella functions as a sesamoid bone within the quadriceps tendon, with fibers of the tendon expanding around the patella and forming the medial and lateral patella retinacula, which help strengthen the knee joint. These fibers are called expansions and are subject to strain; the tendon proper is subject to the development of tendinitis. The prepatellar bursa lies between the anterior subcutaneous tissues of the knee and the anterior surface of the patella (Fig. The bursa serves to cushion and facilitate sliding of the skin and subcutaneous tissues of the anterior knee over the patella. The bursa is subject to inflammation from a variety of causes with acute trauma to the knee and repetitive microtrauma being the most common. Acute injuries to the bursa can occur from direct blunt trauma to the anterior knee from falls onto the knee as well as from overuse injuries including running on uneven or soft surfaces or jobs that require crawling on the knees like scrubbing floors, carpet laying, and coal mining. If the inflammation of the bursa is not treated and the condition becomes chronic, calcification of the bursa with further functional disability may occur. Gout and other crystal arthropathies may also precipitate acute prepatellar bursitis, as may bacterial, tubercular, or fungal infections. The patient suffering from prepatellar bursitis most frequently presents with the complaint of pain in the anterior knee which may radiate over the entire knee. Physical examination of the patient suffering from prepatellar bursitis will reveal point tenderness over the anterior knee. If there is significant inflammation, rubor and color may be present and the entire area may feel boggy or edematous to palpation. At times, massive effusion may be present which can be quite distressing to the patient (Fig. Active resisted extension and passive flexion of the affected knee will often reproduce the patient’s pain. If calcification or gouty tophi of the bursa and surrounding tendons are present, the examiner may appreciate crepitus with active 922 extension of the knee and the patient may complain of a catching sensation when moving the affected knee, especially on awaking. Occasionally, the prepatellar bursa may become infected, with systemic symptoms, including fever and malaise, as well as local symptoms, with rubor, color, and dolor being present (Fig. Prepatellar bursitis is also known as housemaid’s, carpet layer’s, and coal miner’s knee and is associated with significant effusions over the anterior knee. Prepatellar bursitis due to Brucella abortus: case report and analysis of the local immune response. Based on the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging or ultrasound imaging of the affected area may also confirm the diagnosis and help delineate the presence of other knee bursitis, calcific tendinitis, tendinopathy, triceps tendinitis, or other knee pathology (Figs. Rarely, the inflamed bursa may become infected and failure to diagnosis and treat the acute infection can lead to dire consequences (Fig. T1-weighted magnetic resonance image showing a 16 mm × 12 mm well-defined lucency with central calcific densities, suggesting chronic osteomyelitis with sequestrum. A linear high frequency ultrasound transducer is placed over the previously identified patella in a longitudinal orientation (Fig. A survey scan is taken which demonstrates the hyperechoic margin of the skin and subcutaneous tissues, the prepatellar bursa and the patella beneath it (Fig. After the skin and subcutaneous tissues and the prepatellar bursa are identified, the bursa is evaluated for enlargement, inflammation, crystals, rice bodies, hemorrhage, and infection (Figs. The patella is then evaluated for abnormalities including infections, anatomic abnormalities, and 924 fracture (Fig. Correct longitudinal position for ultrasound transducer for ultrasound evaluation of the prepatellar bursa. Ultrasound image of the knee joint demonstrating an enlarged prepatellar bursa lying above the patella. Transverse image anterior to the patella demonstrates fluid in the prepatellar bursa consistent with prepatellar bursitis.

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However discount atomoxetine 40 mg mastercard in treatment, this should not caregivers need to be informed about the nature of the disease buy atomoxetine 18 mg mastercard symptoms 3 dpo, its be achieved at all costs order atomoxetine 10mg on-line treatment meaning. Antiepileptic drugs can produce severe ad- prognostic implications, the objectives of therapy, the risks and verse efects, particularly when they are administered at high dos- benefts of drug treatment (including the risks associated with poor ages or in combination, and the situation should never arise where a compliance and with abrupt drug withdrawal) and the availability person is made to sufer more from the adverse efects of treatment of alternative therapeutic strategies, including epilepsy surgery. Whenever complete sei- timal management should also include a discussion of factors that zure freedom proves to be a non-realistic goal, optimal treatment could impact negatively on seizure control (e. Coun- imize seizure frequency and the need to maintain adverse efects selling about marriage, reproduction, driving regulations and other within acceptable limits. Even in afuent societies, epilepsy is still associated with stigma, and people with epilepsy may sufer Reduction of seizure severity more from prejudice and discrimination than from the actual man- Although most outcome studies in epilepsy have focused on seizure ifestations of the disease. As a result, psychological and social sup- frequency, seizure severity, particularly with respect to occurrence port is ofen required and should be a major component of clinical of potentially injurious ictal manifestations, is by itself an important management in individual cases. In individuals whose seizures can- The purpose of this chapter is to review the general principles of not be controlled completely, it makes sense to aim at suppressing medical management. Specifc therapeutic strategies in relation to preferentially those seizures that are most disabling. For example, in the stage of the disease and to individual characteristics, including patients with Lennox–Gastaut syndrome, controlling drop attacks age, gender, associated learning disability, other comorbidities and may produce greater beneft than suppressing associated focal or associated drug treatments, are discussed in detail in the following atypical absence seizures. Criteria for choosing specifc antiepileptic drugs are ad- secondary generalization would be expected to have a major im- dressed in Chapter 27. In fact, there is a risk that any improvement sec- ternal observer, but the perceptions of the afected person are more ondary to suppression of such discharges be overshadowed by di- important. A seizure component that may appear trivial or negligi- rect negative efects of the drugs on cognitive function or behaviour. Unfortu- nately, the ways in which antiepileptic drugs modify seizure com- Reduction of seizure-related mortality and morbidity ponents have been little studied, but in some people with epilepsy In some cases where seizures are triggered by a treatable cause, such this issue can have an important impact on management decisions. Over the years, however, evidence Avoidance of adverse effects has also accumulated that seizures per se can be associated with an The prescription of antiepileptic medication entails a signifcant increased morbidity and mortality. While many individuals with recently di- physical injuries, including burns, head trauma and bone fractures, agnosed epilepsy can be controlled at low dosages, which produce as well as accidents resulting in fatalities (e. This should be kept in mind to avoid overtreatment, and a lated mortality and morbidity. Consistent with this prediction, a strategy to reduce drug toxicity should be part of routine manage- recent meta-analysis of randomized adjunctive-therapy trials found ment (see Chapter 20). Specifc non-pharmacological measures, including At times, available medications do not seem to have any signifcant providing nocturnal supervision, may also be considered among a efect on an individual’s seizures. Treatment may also not be indicated Many symptomatic epilepsies are aetiologically related to malform- in people with very infrequent seizures, especially when these occur ative, vascular, neoplastic, degenerative, infammatory or metabolic only at night or in relation to predictable and avoidable precipitating disorders that afect the central nervous system, and appropriate events, such as severe sleep deprivation, or have no important impact management of these conditions must be part of the comprehensive on the person’s psychological, social or professional conditions. Neuropsychiatric disorders are also relatively common in people Suppression of subclinical epileptic activity with epilepsy [20]. In a community-based Canadian study of 36 984 Antiepileptic drug therapy should be aimed primarily at suppress- individuals, the lifetime prevalence of anxiety disorder was twice as ing the clinical manifestations of seizures, and normalization of high in people with epilepsy than in those without epilepsy (22. The lifetime prevalence of major de- necessarily an attainable objective, nor in some cases even desir- pressive disorder and suicidal ideation was 17. In certain situations, however, suppression of epileptiform ple with epilepsy, compared with 10. In the latter conditions, however, the beneft of early seizure or pharmacodynamic level. Drug interactions are not restricted to control seems to relate more to cognitive outcome than to the histo- those resulting from combinations of antiepileptic drugs, but also ry of epilepsy per se [15,16]. Physicians should be aware of this, and take all prevention of epilepsy by using antiepileptogenic drugs in individ- necessary steps to minimize potential adverse consequences. Development of drugs with antiepileptogenic the infuence of diferent drugs on liver drug-metabolizing isoen- efects could be made easier by advances in the understanding of zymes (see Chapter 25), and in many cases they can be managed the molecular mechanisms involved in epileptogenesis [26,29,30]. The treatment of newly diagnosed epilepsy is discussed in more Avoidance of obstruction to patient’s life detail in Chapters 11, 13 and 14. As emphasized there, a correct Terapeutic outcome may be infuenced by a person’s ability to diagnosis should be formulated before treatment is instituted. Dif- identify and avoid situations that could afect susceptibility to sei- ferentiation between epileptic and non-epileptic attacks (e. In addition, every efort should be made to identify as ear- propriate counselling given, it is equally important to avoid undue ly as possible seizure type and syndromic form, because these are restrictions on an individual’s lifestyle. Although should be actively discouraged, but there is no reason to prohibit making a syndromic diagnosis is not always easy at the outset, expe- one glass of beer or wine at meal times. In general, people with epi- rienced physicians can identify correctly the vast majority of epilep- lepsy should be encouraged to live a normal life, while avoiding ex- sy syndromes at the very beginning [32]. This is not the case, how- treme deviations from what would be considered a regular lifestyle. Antiepileptic drugs that can be who had no previous contact with the local epilepsy services found given once or twice daily are less likely to obstruct daily routines that approximately 55% had never received specialist advice, a situ- and to cause psychosocial embarrassment, and they are associat- ation that clearly resulted in suboptimal management [33]. For drugs that can be given once or Antiepileptic drug treatment is indicated whenever expected twice daily but do not have a long half-life, a twice-daily schedule benefts outweigh the risks. The risk–beneft equation, in turn, is may be preferable because it minimizes the adverse consequences determined by many factors, including the type of epilepsy, the fre- of missing one dose. In general, once-daily dosing does not entail quency and severity of the seizures, the age and the occupation of better compliance than twice-daily dosing, but it may have psycho- the individual, associated pathological conditions, the character- logical advantages, particularly in individuals who are seizure-free istics of the drug(s) being considered and the presumed infuence and perceive each act of pill-taking as the only unpleasant reminder of treatment on the individual’s well-being and aspirations. In many situations, the decision on whether to start treatment or Prevention of epileptogenesis to withhold it will involve no uncertainty, but grey areas exist where Experiments in animal models suggest that some antiepileptic the optimal therapeutic strategy is uncertain [34]. In any case, the drugs not only exert a symptomatic efect by raising seizure thresh- individual should always be involved in the therapeutic decision, old, but might also antagonize epileptogenic processes (i. The suggestion has been made that recurrent clinical establishing the indications for treatment. The actual decision de- seizures may also lead to irreversible neuroanatomical changes that pends on individual factors. A number of diferent scenarios are may render the disease more difcult to control, but evidence for discussed briefy in this chapter, and other aspects are covered in this is controversial [27]. However, available stud- The most common situation where there may be uncertainty about ies suggest that currently available antiepileptic drugs exert merely whether chronic treatment is justifed is when a person presents a symptomatic efect and do not afect the natural course of the with a single unprovoked tonic–clonic seizure whose nature is con- disease [28,29]. Admittedly, special conditions may exist in which sidered to be probably epileptic [35]. Because many such individu- early efective treatment may improve the ultimate prognosis, als will not have a recurrence when lef untreated [36], and because General Principles of Medical Management 113 treatment afer a frst seizure does not improve long-term progno- Other situations sis [34,37], indiscriminate prescription of antiepileptic drugs afer Occasionally, treatment may be justifed without a clear diagnosis of a frst tonic–clonic seizure, while efective in reducing the risk of epilepsy. When even intensive monitoring fails to provide diferen- relapse [34,38], will unnecessarily expose many patients to adverse tiation between epileptic seizures and pseudoseizures, in rare cases efects. Terefore, drug therapy is generally deferred until a second a therapeutic trial may be indicated. Treatment afer a frst seizure, however, may be suggests a non-epileptic nature of the attacks, but it should not be considered when specifc prognostic factors indicate a high risk of regarded as a conclusive proof for this. Interpretation of response to treatment is also situations where a diagnosis of epilepsy can be made afer a single complicated by the fact that epileptic seizures and pseudoseizures seizure [40], treatment decisions should not be automatically linked may coexist.

Sturge–Weber syndrome The hemispherotomy is now complete order 40mg atomoxetine overnight delivery symptoms 9 days past iui, having isolated the entire n = 24 (12%) epileptic cortex from the subcortical structures purchase atomoxetine with a mastercard medicine 75. The vertical black bar towards the temporal horn represents the laterothalamic incision purchase cheap atomoxetine online treatment glaucoma. Following anterior completion of the callosotomy, the posterior part of the gyrus rectus is resected (6) and, from here, the dissection line is guided laterally across the frontal horn and the caudate nucleus (8), thus completing the disconnection of the entire hemisphere. In none of the aeti- tifcation of the anatomical key landmarks adjacent to the ventri- ology subgroups did the patient’s age at surgery and the duration of cle and facilitates the hemispheric dissection around these core epilepsy correlate with the seizure outcome. In 90–95% of the patients, surgery leads Teoretically, persistent or recurrent seizures might be explained to a worthwhile improvement from seizure reduction, and between by one of the following mechanisms: 65% and 80% of the patients (all pathologies included) will be sei- • The epileptogenic tissue within the afected hemisphere has not zure free [14,18,19,29,51]. However, children with migrational disorders and hemime- such as the basal ganglia, that were not included in the tissue vol- galencephaly, who have the lowest seizure-free rates in all published ume to be resected or disconnected. Long-term fol- a possible incomplete disconnection, and this proved to be the case low-up in our own population (mean: 4. This has been addressed by only higher probability of fnding dysplastic tissue within the subcortical a few authors, as most epilepsy surgeons who perform hemispheric structures. This is particularly the case in children with hemimegal- surgery use only one single technique, and all but one published encephaly or with extensive multifocal cortical dysplasias. In hemimegalencephaly, some bilateral neuropatho- spherotomy techniques in 13 participating centres. Regarding the diferent techniques, the best results were achieved Early and late complications with hemispherotomy and with Adam’s modifcation (81. However, this excessive blood loss, as may be particularly the case in children Hemispheric operations for epilepsy 893 with hemimegalencephaly, a disorder associated with very early contralateral hemisphere by means of structural and functional im- and severe seizure onset. Signifcantly higher blood loss, which an irreversible contralateral motor and visual feld defcit. Seizure can reach an entire blood volume or more, and longer duration of outcome will depend primarily on the underlying pathology and is surgery in children with hemimegalencephaly compared with all inferior in patients with extensive malformations of cortical devel- other aetiology groups (from authors’ personal experience: see also opment, including hemimegalencephaly. Abnormal venous connection, with the same indications and the same efect on sei- drainage can in turn be the reason for considerable postoperative zure control. In young infants in particular, possible problems hemispherotomy, as well as that of other neurosurgeons with the from hypothermia, volume derangement, electrolyte imbalances lateral approach hemispherotomy, overall surgery-related morbid- and coagulative impairment during long surgery, and blood loss ity and hospital stay are signifcantly reduced, due to a very limited have to be taken into account. Moreover, the inci- operative blood loss seems to be a critical distinguishing param- dence of shunt-dependent hydrocephalus seems to be improved by eter. The timing of surgery depends primarily on factors such as du- Among the surgery-related morbidities, the development of ration and severity of the seizure disorder, dynamic evolution of internal and/or external hydrocephalus is relatively frequent, oc- the disease, and actual neurological and cognitive state. The incidence of postoperative hydrocephalus varies the best possible long-term cognitive development, degree of au- from 5% to 39% as reported in several recent series using difer- tonomy and quality of life. Note that some authors do not consider hydrocephalus to be a postoperative complication [51]. The incidence seems to be elevated in children with hemimeg- References alencephaly [14,25,58], although other authors have not found sig- 1. Removal of right cerebral hemisphere for certain tumors with hemi- nifcant diferences among the diferent pathologies [51]. L’ablation complète de l’hémisphère droit dans les cas de tumeur cérébrale localisée compliquée d’hémiplégie: la décérébration supra-thalamique bly related to aseptic meningeal reaction, is a common observation unilatérale chez l’homme. The present status of a patient who had the right cerebral hemi- In general, postoperative wound infections and haemorrhages sphere removed. Neurochirurgie 1964;10: no cases reported in the more recent larger series with sufciently 507–522. Persistent intracranial bleeding as a complication ment to a meticulous haemostasis [19,60]. Can J Neurol Sci 1983; 10: documented, including a meticulous analysis of the integrity of the 71–78. Language recovery afer lef hemispherec- Lippincott Williams & Wilkins, 2000: 741–746. Exceptional verbal intelligence surgical procedures and clinical long-term outcomes in a population of 83 chil- afer hemispherotomy in a child with Rasmussen encephalitis. Complications related to delayed hemorrhage afer hem- Tuxhorn I, Holthausen H, Boenig H (eds). Epilepsy surgery for hemispheric syndromes in come with respect to epileptic seizures. Surgical Treatment of infants: hemimegalencephaly and hemispheric cortical dysplasia. Modifcation of peri-insular hemispherotomy and surgical initial description: Promising prospects and a dilemma. The nonmalformed hemisphere is secondari- The reorganization of sensorimotor function in children afer hemispherectomy. Brain 2006; 129: 1822– outcome of 58 children afer hemispherectomy: the Johns Hopkins experience: 1832. Late plasticity for language in a ale, indications, results, and comparison with callosotomy. Distinct right frontal lobe activation in intractable seizures: excellent seizure control, low morbidity and no superfcial language processing following lef hemisphere injury. Tere was laboratory evidence sup- forme fruste infantile hemiplegia, Rasmussen syndrome, Lennox– porting the rationale for this procedure, notably that of Erickson Gastaut syndrome, frontal lobe epilepsy and other secondarily gen- [2], who in non-human primates demonstrated prevention of the eralized epileptics. Slightly better outcomes were found in the frst spread of the epileptic discharge to the opposite hemisphere when two groups but there was sufcient improvement in all categories to the corpus callosum had been divided. Today, most epilepsy centres perform commis- by a number of investigators [13,14,19,21,25,29,33,38,39,44,45,50, surotomy, and it retains an important role in the armamentarium of 57,58,67,69,72,74,77,79,81,85,86,89,92,95,96,97,98,99,100,101,102, interventions for intractable epilepsy. The majority of patients have evi- Although resection of an epileptogenic region with the goal of sur- dence of bilaterally synchronous epileptiform activity and this does gical cure has always been the surgical procedure of choice, in those not necessarily represent a bad prognostic sign. The signifcance of patients with generalized seizures in whom a discrete epileptogenic bilateral, independent foci remains undetermined. Other palliative pro- has been believed to be associated with a better surgical outcome cedures, including multiple subpial transection, vagal nerve stim- [12,115], but in the selection process their presence or absence has ulation and deep brain stimulation, have also been developed, and always been secondary to clinical and electrophysiological informa- the strategy for optimal utilization or prioritization of these various tion. The impact of neuroimaging on the callosotomy experience non-ablative strategies remains to be determined [23,24,25]. As imaging technologies continue to evolve with From the earliest days of callosotomy it has been appreciated that increasing sensitivity and specifcity, they are directing such aspects drop attacks (variously classifed as atonic and akinetic seizures) of the seizure evaluation as intracranial recording electrode place- are among the most likely of seizure types to beneft from discon- ment, and this will obviously afect patient selection and perhaps nection; tonic and tonic–clonic generalized seizures similarly have the surgery itself. Patients in whom Given the difcult evaluation in this patient population, it is both seizure semiology, electrophysiological studies, neuroimaging and The Treatment of Epilepsy. The remaining candidate pool will be section [16], and difuse disease may render any partial section heterogeneous, including patients with infantile hemiplegia, forme futile. The correlation between extent of disease and successful fruste infantile hemiplegia, Rasmussen syndrome, Lennox–Gastaut section, however, is insufcient to place great reliance on these syndrome, frontal lobe epilepsy and other secondarily generalized factors. Although the outcome of a seizure-free patient most have not adopted this practice.

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