Use of anterior temporal lobectomy for epilepsy in a community-based population

Advances in the Surgical Management of Epilepsy: Drug-Resistant Focal Epilepsy in the Adult Patient

Pharmacoresistant seizures occur in nearly one-third of people with epilepsy. Medial temporal lobe and lesional epilepsy are the most favorable surgically remediable epileptic syndromes. Successful surgery may render the patient seizure-free, reduce antiseizure drug(s) adverse effects, improve quality of life, and decrease mortality. Surgical management should not be considered a procedure of "last resort." Despite the results of randomized controlled trials, surgery remains an underutilized treatment modality for patients with drug-resistant epilepsy (DRE). Important disparities affect patient referral and selection for surgical treatment. This article discusses the advances in surgical treatment of DRE in adults with focal seizures.

What can Google Trends and Wikipedia-Pageview analysis tell us about the landscape of epilepsy surgery over time?

BACKGROUND

Epilepsy surgery is an effective treatment for drug-resistant epilepsy. Some centers have noticed changes in referral patterns.

AIM

The aim of this study was to determine if online infodemiological data related to epilepsy surgery reflect reported changes in referrals to surgical centers.

METHODS

Google Trends and Pageview analysis of temporal trends of searches conducted in Google and Wikipedia for epilepsy surgery, using key search terms such as "epilepsy surgery" and terms related to pathology, operation type, and investigative practice.

RESULTS

Over the 15-year time period studied by Google trend analysis, when the initial three-year epoch and final three-year epoch are compared, a 56.1% decline in search volume for "epilepsy surgery" was observed. Vagus nerve stimulation and laser ablation are increasingly searched items. Pageview analysis shows that temporal lobe epilepsy remains the most commonly searched subtype of epilepsy and hippocampal sclerosis was searched for more than focal cortical dysplasia.

CONCLUSION

This study suggests a lower search interest over time in epilepsy surgery, and various associated terms, with increased interest in vagus nerve stimulation and laser ablation procedures over time. There is no clear indication from these data regarding the apparent shift from mesial temporal cases to an increase in extratemporal case workload.

Thirty-day postoperative morbidity and mortality after temporal lobectomy for medically refractory epilepsy

OBJECTIVE

Temporal lobectomy is a well-established treatment modality for the management of medically refractory epilepsy in appropriately selected patients. The aim of this study was to assess 30-day morbidity and mortality after temporal lobectomy in cases registered in a national database.

METHODS

A retrospective cohort analysis was conducted using a multiinstitutional surgical registry compiled between 2006 and 2014. The authors identified patients who underwent anterior temporal lobectomy and/or amygdalohippocampectomy for a primary diagnosis of intractable epilepsy. Univariate and multivariable analyses with regard to patient demographics, comorbidities, operative characteristics, and 30-day outcomes were applied.

RESULTS

A total of 216 patients were included in the study. The median age was 38 years and 46% of patients were male. The median length of stay was 3 days and the 30-day mortality rate was 1.4%. Fourteen patients (6.5%) developed at least one major complication. Return to the operating room was observed in 7 patients (3.2%). Readmission within 30 days and discharge to a location other than home were available for 2011–2014 (n = 155) and occurred in 11% and 10.3% of patients, respectively. Multivariable regression analysis revealed that increasing age was an independent predictor of discharge disposition other than home and that male sex was a significant risk factor for the development of a major complication. Interestingly, the presence of the attending neurosurgeon and a resident during the procedure was significantly associated with decreased odds of prolonged length of stay (i.e., > 75th percentile [5 days]) and discharge to a location other than home.

CONCLUSIONS

Using a multiinstitutional surgical registry, 30-day outcome data after temporal lobectomy for medically intractable epilepsy demonstrates a mortality rate of 1.4%, a major complication rate of 6.5%, and a readmission rate of 11%. Temporal lobectomy is an extremely effective therapy for seizures originating there—however, surgical intervention must be weighed against its morbidity and mortality outcomes.

Change of Patient Selection Strategy and Improved Surgical Outcome in MRI-negative Neocortical Epilepsy

Background and Purpose

It is crucial to make selection strategy to identify surgical candidates among medically refractory MRI-negative neocortical epilepsy patients. In our previous study, we suggested two or more concordance between noninvasive studies (EEG, ictal scalp EEG, interictal FDG-PET, and SPECT) as a new patient selection strategy for MRI-negative neocortical epilepsy surgery. The objective of this study was to evaluate the surgical outcomes of MRI-negative neocortical epilepsy patients before and after the implementation of a new selection strategy.

Methods

From 1995 to 2011, we included 153 consecutive MRI-negative neocortical epilepsy patients who received focal resection and had a follow-up period of at least 2 years. These patients were divided into two groups according to their date of surgery (before and after July 2002). The old group consisted of 89 patients and the new one consisted of 53 patients. Clinical characteristics, presurgical evaluations, and pathology were reviewed.

Results

The new patient selection strategy led to a significant increase in the concordance between two or more modalities. The improvement in surgical outcome after 2002 was significant (seizure-free outcome, 47.2% vs. 75.5%; p = 0.001). Concordance between two or more presurgical evaluations and localizing PET were related to a seizure-free outcome in a multivariate analysis.

Conclusions

After a change in surgical strategy to select patients with two or more concordance between noninvasive studies, the seizure-free outcome improved up to 75.5%. MRI-negative neocortical epilepsy patients with two or more concordance between noninvasive studies seem to be good candidates for epilepsy surgery.

Epilepsy surgery: current status and ongoing challenges

This article reviews the current status of surgical treatment of epilepsy and introduces the ongoing challenges. Seizure outcome of resective surgery for focal seizures associated with focal lesions is satisfactory. Particularly for mesial temporal lobe epilepsy, surgical treatment should be considered from the earlier stage of the disease. Meanwhile, surgical outcome in nonlesional extratemporal lobe epilepsy is still to be improved using various approaches. Disconnective surgeries reduce surgical complications of extensive resections while achieving equivalent or better seizure outcomes. Multiple subpial transection is still being modified expecting a better outcome by transection to the vertical cortices along the sulci- and multi-directional transection from a single entry point. Hippocampal transection is expected to preserve memory function while interrupting the abnormal epileptic synchronization. Proper selection or combination of subdural and depth electrodes and a wide-band analysis of electroencephalography may improve the accurate localization of epileptogenic region. Patients for whom curative resective surgery is not indicated because of generalized or bilateral multiple nature of their epilepsies, neuromodulation therapies are options of treatment which palliate their seizures.

Why is there still doubt to cut it out?

Surgical treatment for epilepsy has made tremendous strides in the past few decades as a result of advances in neurodiagnostics-particularly structural and functional neuroimaging-and improved surgical techniques. This has not only resulted in better outcomes with respect to epileptic seizures and quality of life, and reduced surgical morbidity and mortality, but it has also increased the population of patients now considered as surgical candidates, particularly in the pediatric age range, and enhanced cost-effectiveness sufficient to make surgical treatment available to countries with limited resources. Yet surgical treatment for epilepsy remains arguably the most underutilized of all accepted medical interventions. In the United States, less than 1% of patients with pharmacoresistant epilepsy are referred to epilepsy centers. Although the number of epilepsy surgery centers has increased appreciably over the past two decades, the number of therapeutic surgical procedures performed for epilepsy has not increased at all. For patients who are referred, the average delay from onset of epilepsy to surgery is more than 20 years-too late for many to avoid a lifetime of disability or premature death. Not only has there been no consistent message to convince neurologists and primary care physicians to refer patients for surgery, but the increase in epilepsy surgery centers in the United States has appeared to result in a divergence of approaches to surgical treatment. Efforts are still needed to further improve the safety and efficacy of surgical treatment, including the identification of biomarkers that can reliably determine the extent of the epileptogenic region; however, the greatest benefits would derive from increasing access for potential surgical candidates to epilepsy surgery facilities. Information is needed to determine why appropriate surgical referrals are not being made. Consensus conferences are necessary to resolve controversies that still exist regarding presurgical evaluation and surgical approaches. Standards should be established for certifying epilepsy centers as recommended by the Institute of Medicine's report on epilepsy. Finally, the epilepsy community should not be promoting epilepsy surgery per se but instead emphasize that epilepsy centers do more than epilepsy surgery, promoting the message: All patients with disabling pharmacoresistant seizures deserve evaluation by specialists at epilepsy centers who can provide a variety of advanced diagnostic and therapeutic services.