In patients with medically intractable epilepsy and diffuse unilateral hemispheric disease, functional hemispherectomy is a widely accepted and successful treatment option. If recurrent seizures develop after hemispherectomy, management options become more complex and include conversion to anatomic hemispherectomy. There is a paucity of data regarding re-operative hemispherectomy.

     We present the outcomes of all patients operated on in one institution by one surgeon since 1998.

     The medical records, operative reports, and imaging studies for 36 patients undergoing re-operative hemispherectomy for continuing medically intractable epilepsy from 1998 to present at Cleveland Clinic were reviewed.

     Patient characteristics, seizure etiology, imaging findings, surgery related complications and long term seizure outcomes were evaluated.

     Patients presented with a variety of seizure etiologies included Rasmussen’s encephalitis, perinatal infarction, cortical dysplasia and hemimegalencephaly. No deaths or intraoperative complications were noted, but a small percentage developed symptomatic anemia and coagulopathy requiring transfusion. Overall, 28% of patients were seizure free following conversion to anatomic hemispherectomy. Fifty-seven percent reported a decrease in seizure frequency by 90% or greater. An additional 25% reported no improvement. Generalized ictal EEG tended to confer a poorer prognosis.

     This is a retrospective study.

     The possibility that epileptogenic tissue in the operated hemisphere remains connected should be considered after failed functional hemispherectomy as our data suggest that improvement in seizure frequency is possible after re-operative hemispherectomy, but the chance of obtaining seizure freedom is relatively low.

     The decision to proceed with re-operative hemispherectomy should be made after proper discussion with the patient and family.