Anatomo-electro-clinical correlations with video sequences
Epileptic Disord 2009; 11 (3): 251-7

Anatomo-electro-clinical correlations:
the Freiburg, Germany Case Report
Case 02-2009

Copyright © 2019 John Libbey Eurotext. Téléchargé par KAROLINSKA INSTITUTET KIB le 23/01/2019.

Functional hemispherectomy in adults
with intractable epilepsy syndromes:
a report of 4 cases
Bernhard J. Steinhoff1, Anke Maren Staack1, Sofia Bilic1, Uwe Kraus1, Andreas Schulze-Bonhage2,
Josef Zentner3
1

Kork Epilepsy Center, Kehl-Kork
Epilepsy Centre, University Hospital Freiburg
3
University Department of Neurosurgery, Freiburg, Germany
2

Received July 27, 2008; Accepted June 23, 2009

ABSTRACT – [Case records of Epileptic Disorders. Anatomo-electro-clinical correlations. Case 02-2009]
Background. Functional hemispherectomy (FH) is mainly performed in children with catastrophic epilepsies and preexisting severe hemiparesis. It is accepted that mainly patients at young ages with more or less complete loss of their
hand function are suitable candidates for FH. However, we feel that FH should be considered also in some adults with
devastating unilateral epilepsy syndromes. Patients and methods. We report four cases of adults who underwent FH
because of their intractable epilepsy syndromes. Three of the four patients had reduced but not complete loss of hand
function. Careful weighing-up of the risk-benefit ratio still led to the decision to perform FH in order to achieve complete
seizure relief. Results. All patients had a surgical outcome of Engel class I; one of them suffered from post-operative psychogenic non-epileptic seizures which were treated successfully by psychotherapy. No clinically relevant complications
occurred. Conclusion. We wish to point out that FH is a possible surgical option in cases with catastrophic epilepsies in
adulthood. Patients and relatives should strongly consider that the likelihood of at least partially, impaired hand function
or other surgery-related additional handicaps may be outweighed by the chance of freedom of seizures in a limited number of patients. In all of our cases, patients and relatives agreed that the surgical outcome led to a marked improvement
of quality of life and that it had been the right decision to proceed with FH in spite of the expected negative impacts of
the operation. Video examples of the pre- and post-surgical hand function of one sample patient are enclosed.
[Published with video sequences]

doi: 10.1684/epd.2009.0263

Key words: epilepsy surgery, functional hemispherectomy, adults, risk-benefit ratio

Correspondence:
Prof. B.J. Steinhoff
Medical Director,
Epilepsiezentrum Kork,
Landstrasse 1,
77694 Kehl-Kork, Germany
<bsteinhoff@epilepsiezentrum.de>

Epileptic Disord Vol. 11, No. 3, September 2009

Functional hemispherectomy (FH) was introduced as a
surgical procedure performed in patients primarily with
brain tumours and later performed in cases with drugresistant, highly active epilepsy syndromes in childhood
(de Almeida and Marino, 2005). However, the mortality
rate was relatively high mainly due to post-operative

251

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B.J. Steinhoff, et al.

intracranial bleeding complications (de Almeida and
Marino, 2005). Mortality rates could be markedly reduced
by modifications of the procedure, namely by the contributions of Rasmussen (1983) and later by the introduction
of hemispherical deafferentiation. The latter consists of a
hippocampectomy or a resection of the anterior temporal
lobe combined with differentation of the temporal, occipital, parietal and frontal lobes as well as a transventricular
callosotomy leaving the insular cortex in place which
may be also resected in selected cases (Schramm et al.,
1995). This approach requires a transcortical transventricular or a transsylvian key hole approach and allows a
smaller trepanation, less operation time and less blood
loss (Binder and Schramm, 2006; Schramm et al., 1995,
2001). Since the concept of FH requires the complete separation of the frontal and occipital lobes, a removal of the
temporal lobe and a discontinuation of the motor tract,
further deterioration of muscle strength and tone,
especially of the hand, is a natural consequence which
may however partially recover over time in children
(Van Empelen et al., 2004; Schropp et al., 2006). In general, children suffering from severe and often progressive
central nervous disorders that affect mainly one hemisphere with additional impairments beyond the epilepsy,
(i.e. hemiparesis including the hand function) are considered as candidates for FH. Typical underlying aetiologies
comprise Sturge Weber syndrome, Rasmussen’s encephalitis, hemimegalencephaly or post-ischemic lesions
(González-Martinez et al., 2005). Therefore, only patients
with a more or less complete loss of their hand function
are usually considered as suitable FH candidates,
although recovery of an initial motor impairment over
time has been described (Van Empelen et al., 2004) and
may depend on the underlying aetiology (de Bode et al.,
2005).
Since the introduction of FH, the success rates in appropriate patients were among the highest in epilepsy surgery
(Engel et al., 1993). Therefore FH is one of the most common resective epilepsy surgery techniques in childhood
(Cross, 2002). In adults, this type of surgery is rare. Data
on a first retrospective series of nine adult patients, collected over decades, reported similarly excellent outcome
data as were seen for children (McClelland and Maxwell,
2007). In adults, the sequelae of FH and the general surgical risk should be weighed up even more critically against
the epileptological benefit since, due to reduced compensatory potential, the neurological, psychological and
social consequences may be more radical than in young
children.
In 2006 and 2007, we had four cases of adult patients
where the discussion arose as to whether or not FH
could be an appropriate method of treatment, despite
the elevated risk in adulthood and especially the fact
that three out of the four were still able to use their paretic
hand for movements in daily life, even though they were
suffering from severely drug-resistant epilepsy with fre-

252

quent and violent seizures, as well as from severe hemiparesis. Finally, extensive discussions of the risk-benefit
ratio made the patients and relatives decide to proceed
with FH. Clinical data and the post-operative outcome
of these patients, including video documentations of the
pre-and post-operative hand function for one patient, are
reported.

Patients and methods
All four patients reported were subjected to extensive presurgical evaluation. Each of them had highly active and
difficult-to-treat epilepsy. Pre-surgical diagnostics at our
centre regularly comprise the careful collecting of all relevant clinical data, long-term video-EEG with recording of
several typical seizures, imaging including 1.5 or 3 Tesla
magnetic resonance imaging (MRI) and additional functional MRI if necessary. Additional information was
obtained by PET or SPECT studies. In addition, every
patient underwent extensive neuropsychological investigations. Table 1 displays the relevant clinical and diagnostic pre-surgical data.
All patients were extensively discussed in our regular epilepsy management conference and it was ultimately
decided to propose FH for all of the cases presented. FH
was also proposed for another case of severely intractable
epilepsy resulting from hemimegalencephaly. In this case
the patient’s family decided not to proceed with FH and
seizure frequency has since remained unchanged with
optimized AED treatment. For patient 3, the first surgical
procedure failed to render seizure freedom, since it was
intended to spare any potential loss of hand functions by
addressing the removal of postcentral tissue exclusively.
Since this patient did not achieve seizure freedom, we
proposed FH with all potential consequences thereafter.
For all other cases, the option of less radical operations
was extensively discussed, but finally not suggested
since the massive extent of the pre-surgical lesions
(table 1, figure 1) and the pre-surgical monitoring data
did not convincingly suggest an epileptogenic lesion distinct enough to be removed in order to achieve seizure
freedom.
Parents acted as legal representatives for only two of four
cases, as the two remaining patients suffered from moderate (case 1) to marked cognitive impairment (see presurgical neuropsychological data in table 1). A rule, we
would only proceed with a radical epilepsy surgical technique, such is FH, if the patients themselves and close
family would both accept this strategy after extensive
and repeated information on the risk-benefit ratio. For
the cases with legal representatives, both patients agreed
to have the operation, although in both cases a sufficient
understanding of the potential success and safety hazards
was certainly not the case. In these cases the legal representatives had to take over almost the full responsibility

Epileptic Disord Vol. 11, No. 3, September 2009

Functional hemispherectomy in adults

Table 1. Clinical, neurophysiological and neuroimaging pre-surgical data.
Patient 1, male, 27 years
Age at seizure 3
onset (years)
Etiology
Pre- or perinatal infarction
after occlusion of left
carotid artery
Seizure types SPS, CPS, GTCS

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Neurological
findings

Mental status

EEG
monitoring

Ictal
semiology

MRI

Patient 2, female, 26 years Patient 3, female, 26 years

Patient 4, male, 24 years

10

8

Rasmussens’s encephalitis, Encephalitis age 10 months,
right hemisphere
not unequivocally proven

SPS left (clonic, myoclonic
face and arm,
sensorimotor, CPS, GTCS
Left-handed, spastic
Nystagmus to the left,
hemiparesis right side, no incomplete hemianopia,
fine motor abilities right
spastic hemiparesis left
hand, impaired sensibility side with leg
right side, incomplete
preponderance, partially
homonymous hemianopia preserved hand function
to the right
with impaired fine motor
skills
IQ 89, verbal and figural
IQ 83, attentional and
mnestic deficits, deficits in mental speed deficits,
executive and spatial tasks deficits of spatial memory
and planning

Interictal EEG:
continuous slow, left
hemisphere, temporal
maximum, IED,
intermittent, left
hemisphere, maximum T3,
rare IED right anterior
temporal (< 5%)
Ictal EEG:
increase of left IEDs,
flattening, ictal pattern
right with rapid evolution
to bilateral pattern, in 2 of
8 seizures ictal pattern left
side
Arrest, slight head and eye
version right, salivation,
one seizure with deviation
of head and eyes to the left
side, secondary
generalization without
lateralizing clinical signs
Massive atrophy of left
hemisphere, partial
preservation of basal
mesial temporal and
occipital structures, mesial
temporal atrophy without
signs hyperintensity on T2
or FLAIR, hyperintense
basal ganglia, atrophy of
left brain stem and right
cerebellum

14

SPS (tingling feeling in the
throat, no lateralized
symptoms), CPS, GTCS
Spastic hemiparesis of the left
side with leg preponderance,
slight strength deficit left
hand, complete hemianopia,
discrete impairment of
coordination, left side

Moderate mental retardation,
Impaired attention with
markedly prolonged reaction
and test ime, verbal thinking
at level 7 – 7.8 years, writes
her name without mistakes,
immediate recall for figures at
level 4.11 years, better
performance in figural recall
and memory, figural thinking
at level 6.3 – 7.2 years
Interictal EEG:
Interictal EEG:
continuous slow and
continuous slow, right
attenuation right
hemisphere, intermittent
hemisphere, IED with
rhythmic slow, right
maximum at F8, T4, T6.
hemisphere, IEDs intermittent,
Ictal EEG:
frontotemporal, bilateral
diffuse attenuation,
synchronous and
obscured by artifacts, no
independent, IEDs
unequivocal rhythmic
intermittent, regional,
pattern
maximum electrodes T4, T6,
TP8, TP 10, P4
Ictal EEG:
diffuse attenuation, obscured
by artefacts, no unequivocal
rhythmic pattern
Clonic movements of the
SPS as previously described,
face and the arm, left side, CPS with slight movements
no CPS or GTCS recorded. upper body, followed by
arrest, optional oroalimentary
automatisms, tonic and
dystonic elevation, both arms
or left arm, ictal speech, no
postictal aphasia
Massive atrophy of the
Atrophy right hemisphere,
right hemisphere. Parietal mesial temporal sclerosis and
region and the central
atrophy
sulcus are preserved. Hand
area shows signal
hyperintensity.

Perinatal infarction due to
occlusion of the left medial
cerebral artery
SPS (sensori-motor), GTCS
Left-handed, spastic
hemiparesis right side, no fine
motor abilities right hand,
impaired sensibility right side,
unreliable perimetric
assessment of visual field
Severe mental retardation,
almost no active speech,
autism-like behaviour

Interictal EEG:
continuous slow, generalized
and bilateral independent,
maximum frontal,
IEDs and PLEDs, intermittent,
lateralized left hemisphere,
maximum frontal, rare
contralateral IEDS
Ictal EEG:
ictal EEG pattern almost
resembling the interictal data:
repetitive epileptiform
discharges lateralized left,
maximum frontal or
frontocentral
Tonic movements maximum
upper body, maximum right
arm or tonic movement right
arm, optional secondary
generalization preponderance

Lesion of the frontal to the
parietal operculum including
insula, superior temporal
gyrus, inferior frontal gyrus
and adjacent parietal cortex,
left thalamus atrophic with
hyerintense signal

MRI: magnetic resonance imaging; SPS: simple partial seizures; CPS: complex partial seizures; GTCS: generalized tonic-clonic seizures;
IEDs: interictal epileptiform discharges; IQ: intelligence quotient.

Epileptic Disord Vol. 11, No. 3, September 2009

253

B.J. Steinhoff, et al.

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A

Pre-op

B

Post-op

C

Pre-op

Pre-op

Post-op

Post-op

Figure 1. Pre- and post-operative magnetic resonance imaging (MRI) findings in patient 4. Comparable slices are displayed in parallel resembling the pre-operative (pre-op, left side) and post-operative (post-op, right side) status according to axial T2-weigthed, thickness 2.0 mm (A)
and sagittal T1 weighted, thickness 3.5 mm (B) and coronal T1 weigthed inversion recovery (C) images. Scans were performed on a 1.5 Tesla
Siemens Magnetom MRI Scanner.
R: right hemisphere; L: left hemisphere.

for the decision. In every case, extensive discussions of
the pros and cons of FH were repeatedly undertaken by
the epileptologists at the Epilepsy Centre Kork and independently by the neurosurgeons of the University of
Freiburg, with both the patients and their relatives.
FH was performed as a modification of the technique
described by Rasmussen (1983) and others (Schramm
et al., 1995, 2001; Binder and Schramm, 2006). For
every case, the temporal lobe including amygdalar and
hippocampal formation was removed, while the frontal,
parietal and occipital lobes were anatomically presented,
but completely disconnected. The frontal and temporal
opercula were removed or disconnected while the insula
was usually preserved to a large extent.
The surgical results based on interviews, clinical findings,
neuropsychological investigations, routine-EEG, MRI and
video documentation of the motor skills were documented at three months and at 12 months from surgery. For
patient 4, the video documentation was also performed
prior to surgery. The assessment of their quality of life
was performed by extensive video-taped interviews.
Three of the four patients were able to respond to questions addressing their individual quality of life. For all
cases, both the patients and their relatives were inter-

254

viewed. With regard to quality of life, no standardized
questionnaires were used prior to and after surgery.

Results
All patients achieved Engel class I (Engel, 1993) and
Wieser class 1 (Wieser et al., 2001) outcome. The postoperative course for each patient was as follows.
Patient 1
During the first weeks after surgery patient 1 suffered from
headaches, intermittent nausea and vomiting, intermittent
myoclonic jerks of the right side and ataxia. An MRI
revealed a small hygroma which did not change over
time. At subsequent visits these difficulties had
disappeared completely. Neurological findings showed a
slight deterioration of leg function which almost
completely resolved under extensive physiotherapy.
Neuropsychological investigations revealed a further
decline of executive functions and verbal memory.
Figural memory performance had been normal preoperatively and worsened after surgery. However, this
was not felt to deteriorate the patient’s performance of
daily life. The previously incomplete hemianopia was

Epileptic Disord Vol. 11, No. 3, September 2009

Functional hemispherectomy in adults

complete after surgery. No language impairment was
encountered.

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Patient 2
A large subdural cyst was seen on the MRI without any
neurological sequelae. Several controls including a
complete post-operative neurosurgical work-up revealed
no therapeutic consequences. The hemiparesis was
markedly deteriorated with a complete paresis of the
hand and an accentuated paresis of the upper extremity
including shoulder, according to levels 2-3. The findings
concerning the leg were unchanged. She had an almost
complete hemianopia. Neuropsychologically, verbal
memory had improved. All other functions were
unchanged.
She developed seizures again after an intial seizure-free
period of three months. Interestingly, careful evaluation
including video-EEG monitoring revealed that she now
suffered solely from psychogenic non-epileptic seizures
(PNES). We initiated extensive psychotherapeutic treatment at our centre which helped to achieve complete
seizure freedom including freedom from PNES.
Patient 3
This patient had undergone previous epilepsy surgery one
year before. At that time the motor cortex had been preserved in order to maintain functional integrity of motor
pathways. However, after a short period of seizure freedom, seizures relapsed with identical semiology and preoperative frequency. Extensive discussions with the patient
and her mother, as the legal representative, led to the
decision to proceed with FH and to consciously accept
the consequence of a considerable deterioration of her
hand function. After FH she remained seizure-free.
Prior to surgery the patient presented with left spastic
hemiparesis, predominating over the lower imb and
complete hemianopia. Neurospcyhological evaluation
revealed moderate cognitive impairment. Verbal recall
and memory functions were more impaired than figural
abilities. Following surgery she presented a transitory
facial hemiparesis. Spastic left hemiparesis persisted with
loss of the holding function hand.
Neuropsychological evaluation showed a slight improvement of attention and figural immediate recall. None of
the neuropsychological parameters assessed deteriorated.
Both the patient and her mother agreed that the individual
improvement of the quality of life was dramatic, in spite of
the almost complete paresis of the hand.
Patient 4
This severely mentally retarded patient suffered from a
medically intractable non-convulsive status epilepticus
and several motor seizures per day. Pre-operatively he
showed a marked spastic hemiparesis of the right side

Epileptic Disord Vol. 11, No. 3, September 2009

without fine motor abilities of the hand. Clinical findings
suggested hemianopia although perimetric measurement
was not reliably possible.
FH led to complete post-operative abolishment of
seizures.
The post-operative EEG showed a reduction of interictal
epileptifom discharges. Follow-up investigations after
three months and one year suggested down-regulation of
still recordable epileptiform activity. Prior to surgery, the
patient had a relatively well preserved verbal perception
but almost no spontaneous speech. He exhibited autismlike behaviour. Post-operatively, his attention ability and
his verbal and non-verbal communication behaviour
improved.
In spite of a further loss of hand function, the postoperative situation was judged by the relatives to be an
extraordinary success. Pre- and post-operative MRI scans
are shown in figure 1, video clips show the hand function
prior to and after surgery with identical tasks during
working therapy (see video sequence).
In summary, in all patients the motor and especially the
hand function deteriorated post-operatively, and two
patients who did not have a visual deficit pre-operatively
developed complete homonymous hemianopia. In spite
of these consequences, interviews with the relatives and
three of the four patients clearly revealed that the quality
of life of the patients and their families had improved dramatically. All four patients and their relatives emphasized
that they were certainly in favour of FH.
Table 2 summarizes the post-operative outcome of the
four patients.

Discussion
The main purpose of epilepsy surgery is to achieve seizure
control without additional handicaps. The decision as to
whether epilepsy surgery should be proposed has to be
guided mainly by the careful weighing up of the individual risk-benefit ratio including the epilepsy-related
impairment of the quality of life. Finally, one should
keep in mind that epilepsy surgery aims to improve the
quality of life and usually is not performed for vital
indications.
Nevertheless, there may be situations where continuation
of conservative antiepileptic drug treatment or additional
therapeutic approaches such as vagal nerve stimulation
are not able to change the situation of so-called catastrophic epilepsy at all, even in adulthood. Whereas for
children with catastrophic epilepsies based on a welldefined aetiology harbouring severe hemiparesis, functional hemispherectomy is considered to be the therapeutic approach of choice, similar data and guidelines in
adults are still lacking.

255

B.J. Steinhoff, et al.

Table 2. Clinical, neurophysiological and neuroimaging post-surgical data and outcome.
Patient 1

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Complications Postoperative temporary
of FH
headache, nausea and
vomiting, myoclonic jerks
right side, ataxia, complete
recovery within weeks
Changes of
Moderate deterioration of
right leg muscle strength
neurological
findings

Changes of
mental status

Deterioration of figural
memory, not relevant for
daily-life activities

EEG

Continuous slow and
flattening left hemisphere,
infrequent slowing right
hemisphere, no IEDs

MRI

Complete removal of
temporal lobe, diffuse
lesional defects occipital
lobe, temporary small
hygroma
Engel Ia, Wieser 1

Seizure
outcome

Patient 2

Patient 3

Patient 4

Postoperative headache
and fatigue, onset of
somatoform psychogenic
symptoms and PNES (see
text)
No active extension of the
fingers, flexibility of the
shoulder reduced, almost
complete hemianopia

No complications

Temporary headache and
increased CSF pressure

Marked deterioration of
hand function, no fine
motor skills preserved (see
Video), slight improvement
during the postoperative
one-year follow-up
Improvement of verbal
Moderate attentional
Attentional improvement,
memory , no further
improvement, improvement no deteriorations, markedly
changes
of figural immediate recall, improved abilities of verbal
no deterioration
and non-verbal
communication
Continuous slow and
Continuous slow and
Continuous attenuation
attenuation right
attenuation, lateralized,
and intermittent slow,
hemisphere, Intermittent
right hemisphere, rare IEDs, lateralized, left
slow and single sharp
regional, right frontal or
hemisphere, IEDs,
waves, regional, left frontal, parietal
intermittent, regional left
intermittent IEDs, regional,
frontal and temporal, rare
right temporal posterior,
IEDs regional, right frontal,
Last EEG recording:
after 3 months and 1 year
Continuous slow and
cessation of IEDs, only
attenuation right
single left frontal spikes
hemisphere, Intermittent
slow, regional, left frontal
Subdural hygroma with
Removal of temporal lobe, Complete removal of
space occupying effect,
disconnection of adjacent temporal lobe, complete
stable over 2 years with
frontal and posterior cortex disconnection of adjacent
several MRI controls
frontal and posterior cortex

Postoperative PNES,
meanwhile complete
seizure freedom
Engel Ia, Wieser 1
Follow-up and 35 months, Considerable
29 months,
comments
improvement of quality of Reintegration in working
life witnessed by the patient life, clear improvement of
and his relatives
personal quality of life
under the conditions of
permanent psychotherapy

Temporary facial
hemiparesis, aggravated
paresis of upper and lower
extremities, loss of holding
functions left hand

Engel Ia, Wieser 1

Engel Ia, Wieser 1

16 months
Considerable improvement
of quality of life witnessed
by the patient and her
mother

13 months, Considerable
improvement of quality of
life witnessed by the patient
and his relatives

MRI: magnetic resonance imaging; IEDs: interictal epileptiform discharges; PNES: psychogenic non-epileptic seizures; CSF: cerebrospinal fluid.

For all four cases, reluctance to perform FH would have
resulted in definite continuation of drug-resistant epilepsy
syndromes with increased morbidity and mortality. In one
patient (patient 3) the first surgical approach was aimed to
preserve motor functions but failed to obtain noticeably
epileptological improvement. Seizure relief was only
achieved with FH, and both the patient and her mother
post-operatively confirmed that they definitely agreed
that FH was the right choice, even with the experience
of the additional post-operative motor deficit. For the
three other cases, the pre-surgical clinical, EEG and imag-

256

ing data, in line with the underlying aetiologies (two cases
of large perinatal infarctions and one case of Rasmussen’s
encephalitis), indicated a more aggressive or less selective
surgical procedure, in order to obtain potential seizure
relief. Therefore, the conclusion of our case conference
was either to proceed with FH or not to offer epilepsy
surgery. Moreover, the large lesions in two of the three
remaining patients would have prevented us placing invasive EEG electrodes, in order to obtain more information
of potentially more distinctive and removable epileptogenic lesions.

Epileptic Disord Vol. 11, No. 3, September 2009

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Functional hemispherectomy in adults

From our experience, it is absolutely essential to inform
patients and relatives extensively about the probable
sequelae of FH. It is certainly not useful to speculate
about the possibility of the less aggressive alternative of
multilobar resections, which in our third patient, did not
lead to any worthwhile improvement and ultimately
resulted in FH that was successful. From our experience,
we clearly advocate the surgical procedure with the best
possible seizure outcome in such catastrophic cases, as
are reported here. The fact that there were no major complications in our series supports this opinion. We therefore
conclude, in line with a larger retrospective series of
adults who even partially underwent traditional FH
(McClelland and Maxwell, 2007), that the risk-benefit
ratio appears to be similar to that of children.
An interesting additional finding in this case series is that
one patient developed psychogenic non-epileptic seizures after a seizure-free post-operative period. In order
to identify the nature of these post-operative events it
was essential to perform another long-term video-EEG to
discuss this diagnosis clearly both with the patient and the
relatives and to initiate regular psychotherapeutic care.
This case also underscores the considerable interference
of severe and active epilepsy with the sociobiographic
interactions and daily life activities in these patients.
The video sequence clearly demonstrates the deterioration of the hand motor function in patient 4. However,
one has to point out that surgery did not result in complete
hemiplegia. The post-operative follow-up revealed that
our patients became more and more accustomed to the
additional deficit. This process was supported by regular
physiotherapy. Whether or not additional partial recovery
will occur in time due to brain plasticity mechanisms in
adults, as previously described in children (Van Empelen
et al., 2004; Schropp et al., 2006), cannot be definitively
determined at this moment.
We conclude that as a result of a multidisciplinary group
analysis functional hemispherectomy is a possible surgical option in cases with catastrophic epilepsies in adulthood. Patients and relatives should consider that the probable loss of an already pre-operatively impaired hand
function may be outweighed by the chance of seizure
relief after FH.

□

Acknowledgments.
MRI scans were performed by Matthias Bacher, M.D., and Peter
Martin, M. D. Werner Butzkies recorded the video clips during work
therapy. These contributions are gratefully acknowledged.

Disclosures.
None.

Epileptic Disord Vol. 11, No. 3, September 2009

Legend for video sequence
Patient No. 4 prior to and after functional hemispherectomy of the left hemisphere. The video clips show
him during working therapy performing identical
tasks.

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