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Surgical treatment of intractable neonatal-onset seizures

The role of positron emission tomography

Department of Neurology, UCLA School of Medicine, Los Angeles, CA (Drs. Chugani, Shewmon, Shields, and Mazziotta)
Department of Pediatrics, UCLA School of Medicine, Los Angeles, CA (Drs. Chugani, Shewmon, and Shields)
Division of Neurosurgery, UCLA School of Medicine, Los Angeles, CA (Dr. Peacock)
Brain Research Institute, UCLA School of Medicine, Los Angeles, CA (Dr. Chugani)
Division of Nuclear Medicine and Biophysics, Department of Radiological Sciences, and Laboratory of Nuclear Medicine, UCLA School of Medicine, Los Angeles, CA (Drs. Chugani, Mazziotta, and Phelps)

We have performed positron emission tomography (PET) with 2-deoxy-2[¹⁸F]fluoro-D-glucose (FDG) in eight infants and children (aged 18 days to 5 years) with medically refractory epilepsy of neonatal onset. It was hypothesized that in at least some of these infants a surgical approach (focal resection, cerebral hemispherectomy) might be of benefit in achieving seizure control, and that PET might assist in surgical selection. In three of the eight subjects, interictal PET revealed unilateral diffuse hypometabolism; following cerebral hemispherectomy in these three patients, all seizures ceased and there were no adverse effects. In one child, ictal PET showed hypermetabolism in the left frontal cortex, left striatum, and right cerebellum; a partial left cerebral hemispherectomy guided by intraoperative electrocorticography was performed, following which all seizures ceased. One infant had relative hypermetabolism in the right temporal and occipital lobes, right thalamus, and left frontal lobe on ictal PET, and EEG telemetry revealed a right occipitotemporal epileptic focus; this infant died from anesthetic complications following right occipitotemporal cortical resection. Of the three unoperated patients, one is a potential candidate for right frontal lobectomy, but the other two were not considered to be surgical candidates due to bilateral epileptogenicity. Neuropathologic correlation in our series revealed that PET is a sensitive test capable of detecting cytoarchitectural disturbances whereas CT and MRI failed in this regard. In addition, PET provides a very unique and important assessment of the functional integrity of brain regions outside the area of potential resection.

Address correspondence and reprint requests to Dr. Chugani, Division of Pediatric Neurology, Room MDCC 22–464, UCLA School of Medicine, Los Angeles, CA 90024.

Supported by Department of Energy contract No. DE-ACO3-SF7600012 and by USPHS grants nos. 5RO1-MH37916–04 and 2POI-NS15654–06. H.T.C. and J.C.M. are the recipients of Teacher-Investigator Developmental Awards 1-KO7-NS00886–03 and 1-KO7-NS00588–05 from the National Institute of Neurological and Communicative Disorders and Stroke.

Received November 17, 1987. Accepted for publication in final form January 11, 1988.

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