Introduction
A hemispherectomy is a rare and complex neurosurgical procedure involving the removal or functional disconnection of one cerebral hemisphere of the brain. This operation is typically performed to alleviate severe, intractable epilepsy that cannot be controlled with medication or less invasive treatments. Despite its radical nature, hemispherectomy can significantly improve the quality of life for patients suffering from debilitating seizures.
History
The first hemispherectomy was performed in the early 20th century. Initially, the procedure was met with skepticism due to its radical nature and the considerable risks involved. However, as surgical techniques and postoperative care improved over the decades, the procedure gained acceptance as a viable treatment for severe epilepsy. Notable contributions to the development of this surgery were made by neurosurgeons such as Dr. Walter Dandy and Dr. Ben Carson.
Types of Hemispherectomy
There are two primary types of hemispherectomy: anatomical and functional.
Anatomical Hemispherectomy
This involves the complete removal of one cerebral hemisphere. Due to its invasiveness and potential complications, this type is less commonly performed today.
Functional Hemispherectomy
In functional hemispherectomy, the focus is on disconnecting the problematic hemisphere from the rest of the brain rather than removing it entirely. This approach reduces the risk of complications and has become more prevalent in modern practice.
Indications
Hemispherectomy is generally indicated for patients with severe, drug-resistant epilepsy originating from one hemisphere. Specific conditions that may warrant this procedure include:
- Rasmussen’s encephalitis
- Hemimegalencephaly
- Sturge-Weber syndrome
- Severe cortical dysplasia
Procedure
The surgical procedure involves several critical steps:
- Preoperative Evaluation: Patients undergo extensive evaluations, including MRI, PET scans, and electroencephalography (EEG), to localize the seizure focus and assess brain function.
- Anesthesia: General anesthesia is administered to ensure the patient’s comfort and immobility during the operation.
- Craniectomy: A portion of the skull is removed to access the brain.
- Disconnection or Removal: Depending on the type of hemispherectomy, the problematic hemisphere is either disconnected or removed.
- Closure: The surgical site is carefully closed, and the skull is replaced.
Risks and Complications
Like any major surgical procedure, hemispherectomy carries certain risks and potential complications, including:
- Hemorrhage
- Infection
- Hydrocephalus
- Weakness or paralysis on the opposite side of the body
- Cognitive and speech impairments
Despite these risks, the potential benefits often outweigh the dangers for patients suffering from severe, intractable epilepsy.
Recovery and Rehabilitation
Recovery from a hemispherectomy is a lengthy process that requires intensive rehabilitation. Postoperative care typically includes:
- Physical therapy to improve motor skills and strength
- Occupational therapy to assist with daily activities
- Speech therapy to address communication challenges
Children, in particular, exhibit remarkable neuroplasticity, allowing the remaining hemisphere to compensate for some of the lost functions. Many patients experience significant reductions in seizure frequency and improvements in their quality of life.
Outcomes
The outcomes of hemispherectomy can be highly variable, depending largely on the underlying condition, age at the time of surgery, and the extent of preoperative brain damage. However, many patients achieve substantial seizure control and enhanced overall functioning. Long-term studies have shown that early intervention is associated with better outcomes, particularly in pediatric patients.
Nursing Care of Patients with Hemispherectomy
Despite the severity of the procedure, many patients experience significant improvements in seizure control and quality of life. Nursing care for these patients is crucial to their recovery and long-term well-being.
Preoperative Care
Patient and Family Education
- Educate the patient and their family about the surgical procedure, anticipated outcomes, and potential risks.
- Provide information on the expected postoperative course, including the need for intensive rehabilitation.
- Address any concerns or questions the patient and family may have.
Psychological Support
- Offer emotional support to the patient and their family, acknowledging the anxiety and stress associated with the upcoming surgery.
- Connect the family with support groups or other families who have undergone similar experiences.
Physical Preparation
- Conduct a thorough preoperative assessment, including baseline neurological and physical status.
- Ensure the patient is medically optimized for surgery, addressing any coexisting medical conditions.
- Administer preoperative medications as prescribed.
Postoperative Care
Immediate Postoperative Period
- Monitor vital signs, neurological status, and surgical site closely in the immediate postoperative period.
- Manage pain with appropriate analgesics, adjusting the dosage as needed based on the patient’s pain level and response.
- Prevent and manage potential complications, such as infection, hemorrhage, or increased intracranial pressure.
Neurological Assessments
- Conduct regular neurological assessments to monitor changes in the patient’s condition.
- Pay special attention to signs of seizure activity, changes in consciousness, and motor or sensory deficits.
Medication Management
- Administer antiepileptic medications as prescribed to prevent seizures.
- Monitor for side effects and therapeutic levels of medications, adjusting dosages as necessary.
Rehabilitation and Therapy
- Collaborate with a multidisciplinary team, including physical therapists, occupational therapists, and speech therapists, to develop a comprehensive rehabilitation plan.
- Encourage early mobilization to prevent complications such as deep vein thrombosis and pressure ulcers.
- Support the patient in relearning motor skills, daily activities, and communication strategies.
Long-term Care and Follow-Up
Ongoing Rehabilitation
- Continue rehabilitation efforts to maximize the patient’s functional recovery.
- Set realistic goals and milestones, celebrating the patient’s progress and achievements.
Monitoring and Managing Epilepsy
- Conduct regular follow-up appointments to monitor seizure activity and adjust antiepileptic medications as needed.
- Educate the patient and family on recognizing signs of seizures and managing them effectively.
Psychosocial Support
- Provide ongoing psychological support to the patient and their family, addressing any emotional or behavioral changes.
- Encourage participation in support groups and community activities to promote social integration.
Education and Empowerment
- Educate the patient and family on managing daily life with a hemispherectomy, including safety precautions and adaptive strategies.
- Empower the patient to take an active role in their care and rehabilitation, fostering a sense of independence and confidence.
REFERENCES
- Brain Injury Association of America. Functions of the Brain. https://www.biausa.org/brain-injury/about-brain-injury/basics/function-of-the-brain.
- Lew SM. Hemispherectomy in the treatment of seizures: a review. Transl Pediatr. 2014 Jul;3(3):208-17. doi: 10.3978/j.issn.2224-4336.2014.04.01. PMID: 26835338; PMCID: PMC4729844.
- Children’s Hemiplegia and Stroke Association. Hemispherectomy. https://chasa.org/medical/hemispherectomy/.
- Pediatric Epilepsy Seizure Alliance. Hemispherectomy for epilepsy. https://epilepsysurgeryalliance.org/about/what-is-epilepsy-surgery/hemispherectomy/.
- Schusse CM, Smith K, Drees C. Outcomes after hemispherectomy in adult patients with intractable epilepsy: institutional experience and systematic review of the literature. https://pubmed.ncbi.nlm.nih.gov/28452614/. J Neurosurg. 2018 Mar;128(3):853-861.
- Young CC, Williams JR, Feroze AH, et al. Pediatric functional hemispherectomy: operative techniques and complication avoidance (https://thejns.org/focus/view/journals/neurosurg-focus/48/4/article-pE9.xml?tab_body=pdf-25682). Neurosurgical Focus. 2020;48(4):E9.
- Smith, M.L., & Risse, G.L. (2000). “Hemispheric Surgery: Cognitive Outcome and Rehabilitation.” Journal of Epilepsy & Behavior.
- Vining, E.P.G., Freeman, J.M., Pillas, D.J. et al. (1997). “Why Would You Remove Half a Brain? The Outcome of 58 Children.” Pediatric Neurology.
- Englot, D.J., Chang, E.F., & Auguste, K.I. (2011). “Epilepsy Surgery Trends in the United States, 1990-2008.” Journal of Neurosurgery.
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