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Shanta T, Tomari YK, Higashi T, Madan B, Hosoyama H, Otsubo T, Yamahata H, Hanaya R. Hypometabolism in the Posteromedial Temporal and Medial Occipital Cortex on Preoperative 2-Deoxy-2-(18F) Fluoro-D-Glucose Positron Emission Tomography Suggests Exacerbation of Visual Field Defects After Surgery for Temporal Lobe Epilepsy: A Retrospective Long-Term Follow-Up Study. World Neurosurg 2024; 188:e223-e232. [PMID: 38777318 DOI: 10.1016/j.wneu.2024.05.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE Surgery is a good treatment option for drug-resistant temporal lobe epilepsy (TLE). 2-deoxy-2-(18F) fluoro-D-glucose (FDG) positron emission tomography (PET) is used to detect epileptic foci as hypometabolic lesions in presurgical evaluation. Visual field defects (VFDs) in the contralateral homonymous upper quadrant are common postoperative complications in TLE. This study aimed to quantify VFDs using pattern deviation probability plots (PDPPs) and examine the effect of hypometabolism in FDG-PET on VFDs. METHODS This study included 40 patients. Both visual fields were assessed using the Humphrey field analyzer preoperatively and 3 months and 2 years postoperatively. PDPPs with <0.5% confidence level counted in the contralateral homonymous upper quadrant. FDG-PET results were compared between groups with (15 patients) and without (24 patients) hypometabolism in the optic radiation. RESULTS All 40 patients were evaluated by Humphrey field analyzer at 3 months postoperatively and 39 at 2 years postoperatively. The incidence of VFDs 3 months postoperatively was 35/40 (87.5%), and 17/40 (42.5%) patients had severe VFDs. In cases of surgery on the left temporal lobe, ipsilateral eyes appeared to be more significantly affected than contralateral eyes. VFDs were more severe in patients with FDG hypometabolism than in those without hypometabolism in posteromedial temporal and medial occipital cortex (P < 0.01); however, 85% of patients with FDG hypometabolism had a reduced VFD 2 years postoperatively. CONCLUSIONS PDPP counting is useful for quantifying VFDs. Preoperative dysfunction indicated by preoperative FDG-PET in the posteromedial temporal and medial occipital cortex could enhance VFDs early after TLE surgery.
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Affiliation(s)
- Thapa Shanta
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Yumi Kashida Tomari
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Takuichiro Higashi
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Bajagain Madan
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Hiroshi Hosoyama
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Toshiaki Otsubo
- Department of Neurosurgery, Fujimoto General Hospital, Miyakonojo, Kagoshima, Japan
| | - Hitoshi Yamahata
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Ryosuke Hanaya
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan.
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Hoppe C, Beeres K, Witt J, Sassen R, Helmstaedter C. How are they doing as adults? Psychosocial and socioeconomic outcomes 11-30 years after pediatric epilepsy surgery. Epilepsia Open 2023; 8:797-810. [PMID: 37003960 PMCID: PMC10472367 DOI: 10.1002/epi4.12736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 03/26/2023] [Indexed: 04/03/2023] Open
Abstract
OBJECTIVE Pediatric epilepsy surgery yields cure from epilepsy or complete seizure control with continued medication in many patients early in life. This study aimed to evaluate the long-term (>10 years) psychosocial and socioeconomic outcomes of pediatric epilepsy surgery and examine the role of comorbid disability, type of surgery, seizure freedom, and age at surgery. METHODS A novel ad hoc parent/patient questionnaire was used to assess educational and occupational attainment, marital/familial status, mobility, and other outcomes in patients who underwent unilobar or multilobar surgery for drug-refractory epilepsy during their childhood. The questionnaire also captured information on comorbid disability. RESULTS Of the 353 eligible patients, 203 could still be contacted and 101 of these (50%) returned appropriately filled-in questionnaires (follow-up intervals: 11-30 [mean: 19.6] years). The cure from epilepsy rate was 53%. Type of surgery was strongly confounded by comorbid disability. Patients with comorbid disabilities had significantly lower rates of regular school degrees, gainful employment, marriage, and driving license (N = 29; 12%, 4%, 0%, 3%) compared with non-disabled patients (N = 69; 89%, 80%, 43%, and 67%, respectively). Patients achieved lower school degrees than their siblings and parents. Non-disabled seizure-free patients had better employment and mobility outcomes compared with non-seizure-free patients. Age at surgery (<10 vs. ≥10 years of age) did not have any effect on any outcome in patients with preschool seizure onset. SIGNIFICANCE Pediatric epilepsy surgery can lead to permanent relief from epilepsy in many patients, but comorbid disability strongly impacts adult life achievement. In non-disabled patients, favorable outcomes in academic, occupational, marital, and mobility domains were achieved, approaching respective rates in the German population. Complete seizure freedom had additional positive effects on employment and mobility in this group. However, in case of chronic comorbid disability the overall life prospects may be limited despite favorable seizure outcomes.
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Affiliation(s)
- Christian Hoppe
- Department of EpileptologyUniversity Hospital BonnBonnGermany
| | | | | | - Robert Sassen
- Department of EpileptologyUniversity Hospital BonnBonnGermany
- Department of NeuropediatricsUniversity Hospital BonnBonnGermany
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Pitskhelauri D, Kudieva E, Vlasov P, Eliseeva N, Zaitsev O, Kamenetskaya M, Kozlova A, Shishkina L, Danilov G, Sanikidze A, Kuprava T, Ishkinin R, Melikyan A. Burr hole microsurgical subtemporal selective amygdalohippocampectomy. Acta Neurochir (Wien) 2023; 165:1215-1226. [PMID: 36867249 DOI: 10.1007/s00701-023-05536-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/15/2023] [Indexed: 03/04/2023]
Abstract
INTRODUCTION At present, selective amygdalohippocampectomy (SAH) has become popular in the treatment of drug-resistant mesial temporal lobe epilepsy (TLE). However, there is still an ongoing discussion about the advantages and disadvantages of this approach. METHODS The study included a consecutive series of 43 adult patients with drug-resistant TLE, involving 24 women and 19 men (1.8/1). Surgeries were performed at the Burdenko Neurosurgery Center from 2016 to 2019. To perform subtemporal SAH through the burr hole with the diameter of 14 mm, we used two types of approaches: preauricular, 25 cases, and supra-auricular, 18 cases. The follow-up ranged from 36 to 78 months (median 59 months). One patient died 16 months after surgery (accident). RESULTS By the third year after surgery, Engel I outcome was achieved in 80.9% (34 cases) of cases and Engel II in 4 (9.5%) and Engel III and Engel IV in 4 (9.6%) cases. Among the patients with Engel I outcomes, anticonvulsant therapy was completed in 15 (44.1%), and doses were reduced in 17 (50%) cases. Verbal and delayed verbal memory decreased after surgery in 38.5% and 46.1%, respectively. Verbal memory was mainly affected by preauricular approach in comparison with supra-auricular (p = 0.041). In 15 (51.7%) cases, minimal visual field defects were detected in the upper quadrant. At the same time, visual field defects did not extend into the lower quadrant and inside the 20° of the upper affected quadrant in any case. CONCLUSIONS Burr hole microsurgical subtemporal SAH is an effective surgical procedure for drug-resistant TLE. It involves minimal risks of loss of visual field within the 20° of the upper quadrant. Supra-auricular approach, compared to preauricular, results in a reduction in the incidence of upper quadrant hemianopia and is associated with a lower risk of verbal memory impairment.
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Affiliation(s)
- David Pitskhelauri
- N. N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of the Russian Federation, 16 4th Tverskaya-Yamskaya St, 125047, Moscow, Russia.
| | - Elina Kudieva
- N. N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of the Russian Federation, 16 4th Tverskaya-Yamskaya St, 125047, Moscow, Russia
| | - Pavel Vlasov
- N. N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of the Russian Federation, 16 4th Tverskaya-Yamskaya St, 125047, Moscow, Russia
| | - Natalya Eliseeva
- N. N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of the Russian Federation, 16 4th Tverskaya-Yamskaya St, 125047, Moscow, Russia
| | - Oleg Zaitsev
- N. N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of the Russian Federation, 16 4th Tverskaya-Yamskaya St, 125047, Moscow, Russia
| | - Maria Kamenetskaya
- N. N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of the Russian Federation, 16 4th Tverskaya-Yamskaya St, 125047, Moscow, Russia
| | - Antonina Kozlova
- N. N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of the Russian Federation, 16 4th Tverskaya-Yamskaya St, 125047, Moscow, Russia
| | - Ludmila Shishkina
- N. N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of the Russian Federation, 16 4th Tverskaya-Yamskaya St, 125047, Moscow, Russia
| | - Gleb Danilov
- N. N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of the Russian Federation, 16 4th Tverskaya-Yamskaya St, 125047, Moscow, Russia
| | - Alexander Sanikidze
- N. N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of the Russian Federation, 16 4th Tverskaya-Yamskaya St, 125047, Moscow, Russia
| | | | - Ruslan Ishkinin
- N. N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of the Russian Federation, 16 4th Tverskaya-Yamskaya St, 125047, Moscow, Russia
| | - Armen Melikyan
- N. N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of the Russian Federation, 16 4th Tverskaya-Yamskaya St, 125047, Moscow, Russia
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Pruckner P, Nenning KH, Fischmeister FPS, Yildirim MS, Schwarz M, Reitner A, Aull-Watschinger S, Koren J, Baumgartner C, Prayer D, Rössler K, Dorfer C, Czech T, Pataraia E, Kasprian G, Bonelli S. Visual outcomes after anterior temporal lobectomy and transsylvian selective amygdalohippocampectomy: A quantitative comparison of clinical and diffusion data. Epilepsia 2023; 64:705-717. [PMID: 36529714 DOI: 10.1111/epi.17490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 12/13/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Anterior temporal lobectomy (ATL) and transsylvian selective amygdalohippocampectomy (tsSAHE) are effective treatment strategies for intractable temporal lobe epilepsy but may cause visual field deficits (VFDs) by damaging the optic radiation (OpR). Due to the OpR's considerable variability and because it is indistinguishable from surrounding tissue without further technical guidance, it is highly vulnerable to iatrogenic injury. This imaging study uses a multimodal approach to assess visual outcomes after epilepsy surgery. METHODS We studied 62 patients who underwent ATL (n = 32) or tsSAHE (n = 30). Analysis of visual outcomes was conducted in four steps, including the assessment of (1) perimetry outcome (VFD incidence/extent, n = 44/40), (2) volumetric OpR tractography damage (n = 55), and the (3) relation of volumetric OpR tractography damage and perimetry outcome (n = 35). Furthermore, (4) fixel-based analysis (FBA) was performed to assess micro- and macrostructural changes within the OpR following surgery (n = 36). RESULTS Altogether, 56% of all patients had postoperative VFDs (78.9% after ATL, 36.36% after tsSAHE, p = .011). VFDs and OpR tractography damage tended to be more severe within the ATL group (ATL vs. tsSAHE, integrity of contralateral upper quadrant: 65% vs. 97%, p = .002; OpR tractography damage: 69.2 mm3 vs. 3.8 mm3 , p = .002). Volumetric OpR tractography damage could reliably predict VFD incidence (86% sensitivity, 78% specificity) and could significantly explain VFD extent (R2 = .47, p = .0001). FBA revealed a more widespread decline of fibre cross-section within the ATL group. SIGNIFICANCE In the context of controversial visual outcomes following epilepsy surgery, this study provides clinical as well as neuroimaging evidence for a higher risk and greater severity of postoperative VFDs after ATL compared to tsSAHE. Volumetric OpR tractography damage is a feasible parameter to reliably predict this morbidity in both treatment groups and may ultimately support personalized planning of surgical candidates. Advanced diffusion analysis tools such as FBA offer a structural explanation of surgically induced visual pathway damage, allowing noninvasive quantification and visualization of micro- and macrostructural tract affection.
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Affiliation(s)
- Philip Pruckner
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Karl-Heinz Nenning
- Computational Imaging Research Lab, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
- Center for Biomedical Imaging and Neuromodulation, Nathan Kline Institute, Orangeburg, New York, USA
| | - Florian Ph S Fischmeister
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
- Institute of Psychology, University of Graz, Graz, Austria
- BioTechMed-Graz, Graz, Austria
| | - Mehmet-Salih Yildirim
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Michelle Schwarz
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Andreas Reitner
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | | | - Johannes Koren
- Department of Neurology, Clinic Hietzing, Vienna, Austria
| | - Christoph Baumgartner
- Department of Neurology, Clinic Hietzing, Vienna, Austria
- Karl Landsteiner Institute for Clinical Epilepsy Research and Cognitive Neurology, Vienna, Austria
- Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Daniela Prayer
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Karl Rössler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Christian Dorfer
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Czech
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | | | - Gregor Kasprian
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Silvia Bonelli
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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Hoppe C, Beeres K, Witt JA, Sassen R, Helmstaedter C. Clinical adult outcome 11-30 years after pediatric epilepsy surgery: Complications and other surgical adverse events, seizure control, and cure of epilepsy. Epilepsia 2023; 64:335-347. [PMID: 36468792 DOI: 10.1111/epi.17477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/25/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Pediatric epilepsy surgery promises seizure freedom or even cure of epilepsy. We evaluated the long-term (≥10 years) adult clinical outcome including surgery-related adverse events and complications, which are generally underreported. METHODS A monocentric, single-arm, questionnaire study in now adult patients who underwent epilepsy surgery during childhood. A novel ad hoc parental/patient questionnaire, which addressed diverse outcome domains was applied. RESULTS From a total of 353 eligible patients, 203 could be contacted (3 patients died of causes unknown) and 101 (50%) returned appropriately filled-in surveys. No evidence for a survey-response bias was found. The rate of surgical complications according to the patient records was 9%. As regards the survey, half of the parents/patients reported surgical adverse events (expected and unexpected issues) and one-third reported permanent aversive sequels. Two-thirds of the patients were seizure-free during the last year before follow-up; 63% were Engel class 1A; favorable seizure outcomes (including auras only) were obtained in 73%; and 54% were seizure-free and off antiseizure medicine (ASM), that is, cured of epilepsy. In non-seizure-free patients, seizure relapse occurred at any time during the follow-up interval but 87% of those with a seizure-free first postoperative year were seizure-free at follow-up. One patient experienced a seizure relapse during the ASM withdrawal trial but became seizure-free again with ASMs. Eleven patients reported an increased number of ASMs as compared to the time before surgery. Earlier focal surgery did not affect the long-term clinical outcome. SIGNIFICANCE Pediatric epilepsy surgery was capable of curing epilepsy in about one-half of the children and to significantly control seizures in about three-fourths. Long-term success of focal surgery did not depend on age at surgery or duration of epilepsy. Surgical adverse events including complications may be underreported and must be assessed more thoroughly.
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Affiliation(s)
- Christian Hoppe
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Kassandra Beeres
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | | | - Robert Sassen
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
- Department of Neuropediatrics, University Hospital Bonn, Bonn, Germany
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Anterior transtemporal endoscopic selective amygdalohippocampectomy: a virtual and cadaveric feasibility study. Acta Neurochir (Wien) 2022; 164:2841-2849. [PMID: 35809147 DOI: 10.1007/s00701-022-05295-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/20/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE Selective amygdalohippocampectomy (SelAH) is one of the most common surgical treatments for mesial temporal sclerosis. Microsurgical approaches are associated with the risk of cognitive and visual deficits due to damage to the cortex and white matter (WM) pathways. Our objective is to test the feasibility of an endoscopic approach through the anterior middle temporal gyrus (aMTG) to perform a SelAH. METHODS Virtual simulation with MRI scans of ten patients (20 hemispheres) was used to identify the endoscopic trajectory through the aMTG. A cadaveric study was performed on 22 specimens using a temporal craniotomy. The anterior part of the temporal horn was accessed using a tubular retractor through the aMTG after performing a 1.5 cm corticectomy at 1.5 cm posterior to the temporal pole. Then, an endoscope was introduced. SeIAH was performed in each specimen. The specimens underwent neuronavigation-assisted endoscopic SeIAH to confirm our surgical trajectory. WM dissection using Klingler's technique was performed on five specimens to assess WM integrity. RESULTS This approach allowed the identification of collateral eminence, lateral ventricular sulcus, choroid plexus, inferior choroidal point, amygdala, hippocampus, and fimbria. SelAH was successfully performed on all specimens, and CT neuronavigation confirmed the planned trajectory. WM dissection confirmed the integrity of language pathways and optic radiations. CONCLUSIONS Endoscopic SelAH through the aMTG can be successfully performed with a corticectomy of 15 mm, presenting a reduced risk of vascular injury and damage to WM pathways. This could potentially help to reduce cognitive and visual deficits associated with SelAH.
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Pitskhelauri DI, Kudieva ES, Melikyan AG, Vlasov PA, Kamenetskaya MI, Zaitsev OS, Kozlova AB, Eliseeva NM, Shishkina LV, Danilov GV, Nagorskaya IA, Sanikidze AZ, Melnikova-Pitskhelauri TV, Pronin IN, Konovalov AN. [Surgical treatment of drug-resistant epilepsy following hippocampal sclerosis]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:31-40. [PMID: 34714001 DOI: 10.17116/neiro20218505131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Surgery is an effective approach for drug-resistant temporal lobe epilepsy following hippocampal sclerosis. There is still no clear and unanimous opinion about advantages and disadvantages of certain surgical technique. MATERIAL AND METHODS There were 103 surgical interventions in 101 patients. Females prevailed (1.45:1). Age of patients ranged from 16 to 56 years (median 28). Anteromedial temporal lobectomy and selective amygdaloghippocampectomy were performed in 49 (47.6%) and 54 (52.4%) patients, respectively. In the latter group, 30 patients were operated via a 14-mm burr hole-subtemporal approach. Postoperative outcomes were assessed using the Engel grading system. The follow-up period ranged from 2 to 8 years (median 4 years). RESULTS By the 2nd year, Engel class I was observed in 74 (72%) patients, Engel II, III and IV - in 20 (19.4%), 6 (5.8%) and 3 (2.9%) patients, respectively. Engel class I was achieved after anteromedial temporal lobectomy in 68% of cases, selective amygdaloghippocampectomy via standard approaches in 75% of cases, amygdaloghippocampectomy via subtemporal burr hole approach - in 80% of cases. Neurocognitive impairments after anteromedial lobectomy and selective amygdaloghippocampectomy were similar. At the same time, mental disorders de novo prevailed in the group of anteromedial lobectomy (p<0.05). There were no severe visual field disorders after subtemporal burr-hole access. In other cases, these disorders occurred in 36.2% of patients (p<0.05). There were 8 (7.8%) postoperative complications: 5 (10.2%) - after anterior temporal lobectomy, 3 (5.5%) - after selective surgeries via standard approaches. There were no complications after burr-hole surgery. CONCLUSION Selective amygdaloghippocampectomy is not inferior to anteromedial lobectomy. Moreover, this procedure is associated with a lower risk of complications and adverse events.
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Affiliation(s)
| | - E S Kudieva
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - P A Vlasov
- Burdenko Neurosurgical Center, Moscow, Russia.,Center for Epileptology and Neurology, Moscow, Russia
| | | | - O S Zaitsev
- Burdenko Neurosurgical Center, Moscow, Russia.,Privolzhskiy Research Medical University, Nizhniy Novgorod, Russia
| | - A B Kozlova
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | | - G V Danilov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | | | | - I N Pronin
- Burdenko Neurosurgical Center, Moscow, Russia
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Delev D, Hakvoort K, Krüger MT, Blume C, Clusmann H, Neuloh G. Choroidal artery ischemic events after temporal lobe epilepsy surgery: clinical outcome, quality of life, and surgical pitfalls. J Neurosurg 2021; 136:536-542. [PMID: 34450583 DOI: 10.3171/2021.1.jns203092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 01/04/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Ischemic events within the territory of the choroidal artery are an important cause of morbidity after temporal lobe epilepsy (TLE) surgery. The aim of the present study was to evaluate the rate of these ischemic events, their clinical presentation, and impact on patients' health-related quality of life (HRQoL) after TLE surgery. METHODS Four hundred twenty-two consecutive patients undergoing temporal resections for drug-resistant TLE were retrospectively analyzed. All patients underwent presurgical multidisciplinary assessment using a standard protocol comprising clinical, neuroradiological, neuropsychological, and EEG data. Postoperative complications with corresponding imaging, neurological deficits, and disease-specific HRQoL questionnaires were evaluated. RESULTS The overall complication rate was 7.8% (n = 33). Fourteen patients (3.3%) suffered from ischemic events causing 6 permanent motor deficits, 3 with permanent aphasias, and 6 visual field defects that exceeded quadrantanopia. In 8 patients with anterior choroidal artery infarction, accounting for 57% of all ischemic events, infarction volume correlated positively with the occurrence of new permanent neurological deficits (8666 vs 1692 mm3, p = 0.032). Despite the occurrence of ischemic events, HRQoL improved in 71% of patients. However, infarction volume showed a negative correlation trend with HRQoL (Pearson's r = -0.390, p = 0.094). There was a trend toward increased risk for ischemic events in patients who underwent selective amygdalohippocampectomy compared to patients who underwent anterior temporal lobectomy or temporal lesionectomy (RR 0.96, 95% CI 0.93-0.99, p = 0.08). CONCLUSIONS Choroidal artery infarctions are rare but relevant complications after TLE surgery, presenting with variable clinical courses ranging from devastating neurological deterioration to complete recovery. Despite the occurrence of postoperative infarction, most patients report improvement of HRQoL after TLE surgery. This study showed that the type of surgery appears to modulate the risk for these ischemic events.
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Affiliation(s)
- Daniel Delev
- 1Department of Neurosurgery, RWTH University Aachen, University Medical Center, Aachen, Germany
| | - Karlijn Hakvoort
- 1Department of Neurosurgery, RWTH University Aachen, University Medical Center, Aachen, Germany
| | - Marie Therese Krüger
- 2Department of Neurosurgery, Cantonal Hospital St. Gallen, Switzerland; and.,3Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Christian Blume
- 1Department of Neurosurgery, RWTH University Aachen, University Medical Center, Aachen, Germany
| | - Hans Clusmann
- 1Department of Neurosurgery, RWTH University Aachen, University Medical Center, Aachen, Germany
| | - Georg Neuloh
- 1Department of Neurosurgery, RWTH University Aachen, University Medical Center, Aachen, Germany
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Vakharia VN, Vos SB, Winston GP, Gutman MJ, Wykes V, McEvoy AW, Miserocchi A, Sparks R, Ourselin S, Duncan JS. Intraoperative overlay of optic radiation tractography during anteromesial temporal resection: a prospective validation study. J Neurosurg 2021; 136:543-552. [PMID: 34330090 DOI: 10.3171/2020.12.jns203437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 12/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Anteromesial temporal lobe resection (ATLR) results in long-term seizure freedom in patients with drug-resistant focal mesial temporal lobe epilepsy (MTLE). There is significant anatomical variation in the anterior projection of the optic radiation (OR), known as Meyer's loop, between individuals and between hemispheres in the same individual. Damage to the OR results in contralateral superior temporal quadrantanopia that may preclude driving in 33%-66% of patients who achieve seizure freedom. Tractography of the OR has been shown to prevent visual field deficit (VFD) when surgery is performed in an interventional MRI (iMRI) suite. Because access to iMRI is limited at most centers, the authors investigated whether use of a neuronavigation system with a microscope overlay in a conventional theater is sufficient to prevent significant VFD during ATLR. METHODS Twenty patients with drug-resistant MTLE who underwent ATLR (9 underwent right-side ATLR, and 9 were male) were recruited to participate in this single-center prospective cohort study. Tractography of the OR was performed with preoperative 3-T multishell diffusion data that were overlaid onto the surgical field by using a conventional neuronavigation system linked to a surgical microscope. Phantom testing confirmed overlay projection errors of < 1 mm. VFD was quantified preoperatively and 3 to 12 months postoperatively by using Humphrey and Esterman perimetry. RESULTS Perimetry results were available for all patients postoperatively, but for only 11/20 (55%) patients preoperatively. In 1/20 (5%) patients, a significant VFD occurred that would prevent driving in the UK on the basis of the results on Esterman perimetry. The VFD was identified early in the series, despite the surgical approach not transgressing OR tractography, and was subsequently found to be due to retraction injury. Tractography was also used from this point onward to inform retractor placement, and no further significant VFDs occurred. CONCLUSIONS Use of OR tractography with overlay outside of an iMRI suite, with application of an appropriate error margin, can be used during approach to the temporal horn of the lateral ventricle and carries a 5% risk of VFD that is significant enough to preclude driving postoperatively. OR tractography can also be used to inform retractor placement. These results warrant a larger prospective comparative study of the use of OR tractography-guided mesial temporal resection.
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Affiliation(s)
- Vejay N Vakharia
- 1Department of Clinical and Experimental Epilepsy, University College London and Epilepsy Society MRI Unit, London.,2National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Sjoerd B Vos
- 3Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, United Kingdom
| | - Gavin P Winston
- 1Department of Clinical and Experimental Epilepsy, University College London and Epilepsy Society MRI Unit, London.,2National Hospital for Neurology and Neurosurgery, Queen Square, London.,4Department of Medicine, Division of Neurology, Queen's University, Kingston, Ontario, Canada
| | | | - Victoria Wykes
- 6Institute of Cancer and Genomic Sciences, University of Birmingham.,7Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham; and
| | - Andrew W McEvoy
- 1Department of Clinical and Experimental Epilepsy, University College London and Epilepsy Society MRI Unit, London.,2National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Anna Miserocchi
- 1Department of Clinical and Experimental Epilepsy, University College London and Epilepsy Society MRI Unit, London.,2National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Rachel Sparks
- 8School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, United Kingdom
| | - Sebastien Ourselin
- 8School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, United Kingdom
| | - John S Duncan
- 1Department of Clinical and Experimental Epilepsy, University College London and Epilepsy Society MRI Unit, London.,2National Hospital for Neurology and Neurosurgery, Queen Square, London
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10
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Serra C, Akeret K, Staartjes VE, Ramantani G, Grunwald T, Jokeit H, Bauer J, Krayenbühl N. Safety of the paramedian supracerebellar-transtentorial approach for selective amygdalohippocampectomy. Neurosurg Focus 2021; 48:E4. [PMID: 32234984 DOI: 10.3171/2020.1.focus19909] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 01/24/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to assess the reproducibility and safety of the recently introduced paramedian supracerebellar-transtentorial (PST) approach for selective amygdalohippocampectomy (SA). METHODS The authors performed a retrospective analysis of prospectively collected data originating from their surgical register of patients undergoing SA via a PST approach for lesional medial temporal lobe epilepsy. All patients received thorough pre- and postoperative clinical (neurological, neuropsychological, psychiatric) and instrumental (ictal and long-term EEG, invasive EEG if needed, MRI) workup. Surgery-induced complications were assessed at discharge and at every follow-up thereafter and were classified according to Clavien-Dindo grade (CDG). Epilepsy outcome was defined according to Engel classification. Data were reported according to common descriptive statistical methods. RESULTS Between May 2015 and May 2018, 17 patients underwent SA via a PST approach at the authors' institution (hippocampal sclerosis in 13 cases, WHO grade II glioma in 2 cases, and reactive gliosis in 2 cases). The median postoperative follow-up was 7 months (mean 9 months, range 3-19 months). There was no surgery-related mortality and no complication (CDG ≥ 2) in the whole series. Transitory CDG 1 surgical complications occurred in 4 patients and had resolved in all of them by the first postoperative follow-up. One patient showed a deterioration of neuropsychological performance with new slight mnestic deficits. No patient experienced a clinically relevant postoperative visual field defect. No morbidity due to semisitting position was recorded. At last follow-up 13/17 (76.4%) patients were in Engel class I (9/17 [52.9%] were in class IA). CONCLUSIONS The PST approach is a reproducible and safe surgical route for SA. The achievable complication rate is in line with the best results in the literature. Visual function outcome particularly benefits from this highly selective, neocortex-sparing approach. A larger patient sample and longer follow-up will show in the future if the seizure control rate and neuropsychological outcome also compare better than those achieved with current common surgical techniques.
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Affiliation(s)
- Carlo Serra
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich
| | - Kevin Akeret
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich
| | - Victor E Staartjes
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich
| | - Georgia Ramantani
- 2Division of Pediatric Neurology, University Children's Hospital, Zurich
| | - Thomas Grunwald
- 3Department of Neuropsychology, Swiss Epilepsy Clinic, Klinik Lengg AG, Zurich; and
| | - Hennric Jokeit
- 3Department of Neuropsychology, Swiss Epilepsy Clinic, Klinik Lengg AG, Zurich; and
| | - Julia Bauer
- 3Department of Neuropsychology, Swiss Epilepsy Clinic, Klinik Lengg AG, Zurich; and
| | - Niklaus Krayenbühl
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich.,4Division of Pediatric Neurosurgery, Children's University Hospital Zurich, Switzerland
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11
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Hulou MM, Mirza FA. Commentary: Microsurgical and Tractographic Anatomical Study of Transtemporal-Transchoroidal Fissure Approaches to the Ambient Cistern. Oper Neurosurg (Hagerstown) 2021; 20:E249-E250. [PMID: 33377162 DOI: 10.1093/ons/opaa402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 10/10/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- M Maher Hulou
- Department of Neurosurgery, Kentucky Neuroscience Institute (KNI), University of Kentucky, Lexington, Kentucky
| | - Farhan A Mirza
- Department of Neurosurgery, Kentucky Neuroscience Institute (KNI), University of Kentucky, Lexington, Kentucky
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12
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Abstract
PURPOSE OF REVIEW Surgery can provide a robust long-standing seizure remission in drug-refractory mesial temporal lobe epilepsy (MTLE). Despite this, a significant proportion of postoperative patients are ineligible to gain a driving licence due to the size of the subsequent visual field defect (VFD). The amygdala and hippocampus are intimately related to several important white fibre association tracts and damage to the optic radiation results in a contralateral superior quadrantanopia. For this reason, several different modifications to established surgical approaches and novel techniques have recently been applied to mitigate or prevent damage to the optic radiation. There is still no consensus on which operative technique results in optimal outcomes regarding seizure remission, neuropsychological sequelae and VFD rates. We explore contemporary surgical approaches to the mesial temporal lobe and describe the intraoperative use of tractography and iMRI in preventing VFDs. RECENT FINDINGS Established approaches for the surgical treatment of MTLE include standardized approaches in the form of anterior temporal lobectomies, selective approaches and various modifications thereof. Recent advancements in microsurgical techniques have seen numerous modifications to these approaches to spare the optic radiation as well as the introduction of minimally invasive alternatives such as laser interstitial thermal therapy (LITT) and stereotactic radiosurgery (SRS). The intraoperative use of optic radiation tractography through overlays in the operative microscope and interventional MRI suites to correct for brain shift have been shown to reduce VFDs. SUMMARY VFDs following the surgical treatment of drug-refractory MTLE can have a significant impact on the quality of life. Each of the surgical techniques carries a risk to the visual pathways but the use of minimally invasive techniques as well as surgical adjuncts may reduce or prevent acquired VFDs.
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13
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David B, Eberle J, Delev D, Gaubatz J, Prillwitz CC, Wagner J, Schoene-Bake JC, Luechters G, Radbruch A, Wabbels B, Schramm J, Weber B, Surges R, Elger CE, Rüber T. Multi-scale image analysis and prediction of visual field defects after selective amygdalohippocampectomy. Sci Rep 2021; 11:1444. [PMID: 33446810 PMCID: PMC7809286 DOI: 10.1038/s41598-020-80751-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 12/24/2020] [Indexed: 01/29/2023] Open
Abstract
Selective amygdalohippocampectomy is an effective treatment for patients with therapy-refractory temporal lobe epilepsy but may cause visual field defect (VFD). Here, we aimed to describe tissue-specific pre- and postoperative imaging correlates of the VFD severity using whole-brain analyses from voxel- to network-level. Twenty-eight patients with temporal lobe epilepsy underwent pre- and postoperative MRI (T1-MPRAGE and Diffusion Tensor Imaging) as well as kinetic perimetry according to Goldmann standard. We probed for whole-brain gray matter (GM) and white matter (WM) correlates of VFD using voxel-based morphometry and tract-based spatial statistics, respectively. We furthermore reconstructed individual structural connectomes and conducted local and global network analyses. Two clusters in the bihemispheric middle temporal gyri indicated a postsurgical GM volume decrease with increasing VFD severity (FWE-corrected p < 0.05). A single WM cluster showed a fractional anisotropy decrease with increasing severity of VFD in the ipsilesional optic radiation (FWE-corrected p < 0.05). Furthermore, patients with (vs. without) VFD showed a higher number of postoperative local connectivity changes. Neither in the GM, WM, nor in network metrics we found preoperative correlates of VFD severity. Still, in an explorative analysis, an artificial neural network meta-classifier could predict the occurrence of VFD based on presurgical connectomes above chance level.
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Affiliation(s)
- Bastian David
- grid.15090.3d0000 0000 8786 803XDepartment of Epileptology, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Jasmine Eberle
- grid.15090.3d0000 0000 8786 803XDepartment of Epileptology, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany ,Clinic for Neurology and Palliative Medicine, Municipal Hospital Köln-Merheim, Cologne, Germany
| | - Daniel Delev
- grid.1957.a0000 0001 0728 696XDepartment of Neurosurgery, RWTH University Aachen, Aachen, Germany
| | - Jennifer Gaubatz
- grid.15090.3d0000 0000 8786 803XDepartment of Epileptology, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Conrad C. Prillwitz
- grid.15090.3d0000 0000 8786 803XDepartment of Epileptology, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Jan Wagner
- grid.488560.70000 0000 9188 2870Department of Neurology, University of Ulm and Universitäts- and Rehabilitationskliniken Ulm, Ulm, Germany
| | - Jan-Christoph Schoene-Bake
- grid.10423.340000 0000 9529 9877Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Guido Luechters
- grid.10388.320000 0001 2240 3300Center for Development Research, University of Bonn, Bonn, Germany
| | - Alexander Radbruch
- grid.15090.3d0000 0000 8786 803XDepartment of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Bettina Wabbels
- grid.15090.3d0000 0000 8786 803XDepartment of Ophthalmology, University Hospital Bonn, Bonn, Germany
| | - Johannes Schramm
- grid.15090.3d0000 0000 8786 803XMedical Faculty, University Hospital Bonn, Bonn, Germany
| | - Bernd Weber
- grid.15090.3d0000 0000 8786 803XInstitute of Experimental Epileptology and Cognition Research, University Hospital Bonn, Bonn, Germany
| | - Rainer Surges
- grid.15090.3d0000 0000 8786 803XDepartment of Epileptology, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Christian E. Elger
- grid.15090.3d0000 0000 8786 803XDepartment of Epileptology, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Theodor Rüber
- grid.15090.3d0000 0000 8786 803XDepartment of Epileptology, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany ,grid.7839.50000 0004 1936 9721Department of Neurology, Epilepsy Center Frankfurt Rhine-Main, Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
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14
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Baran O, Balak N, Baydin S, Aydin I, Kayhan A, Evran S, Kemerdere R, Tanriover N. Assessing the connectional anatomy of superior and lateral surgical approaches for medial temporal lobe epilepsy. J Clin Neurosci 2020; 81:378-389. [PMID: 33222947 DOI: 10.1016/j.jocn.2020.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/15/2020] [Accepted: 10/03/2020] [Indexed: 12/13/2022]
Abstract
The most common approaches in the treatment of epilepsy, the trans-sylvian selective amygdalohippocampectomy (SAH) and the anterior temporal lobe resection (ATLR) reach the medial temporal lobe through different surgical routes. Our aim was to delineate the white matter (WM) fiber tracts at risk in relation to trans-sylvian SAH and ATLR by defining each fascicle en route to medial temporal lobe during each approach. ATLR and trans-sylvian SAH were performedand related WM tracts en route to medial temporal region were presented in relation to the relevant approaches and surrounding neurovascular structures. The WM tracts most likely to be disrupted during trans-sylvian SAH along the roof of the temporal horn were the UF - and less commonly IFOF - at the layer of the external capsule, anterior commissure, anterior bend of optic radiations, and sublenticular internal capsule. Amygdaloid projections to the claustrum, putamen and globus pallidus, the tail of caudate and the peduncle of the lentiform nucleus were also in close proximity to the resection cavity. Fiber tracts most likely to be impaired during ATLR included the UF, ILF, IFOF, anterior commissure, optic radiations, and, less likely, the vertical ventral segment of the arcuate fascicle. Both ATLR and trans-sylvian SAH carry the risk of injury to WM pathways, which may result in unpredictable functional loss. A detailed 3-D knowledge of the related connectional anatomy will help subside neurocognitive, neuroophtalmologic, neurolinguistic complications of epilepsy surgery, providing an opportunity to tailor the surgery according to patient's unique connectional and functional anatomy.
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Affiliation(s)
- Oguz Baran
- Department of Neurosurgery, Koç University Hospital, Istanbul, Turkey; Istanbul University - Cerrahpasa, Cerrahpasa Medical Faculty, Department of Neurosurgery, Microsurgical Neuroanatomy Laboratory, Istanbul, Turkey
| | - Naci Balak
- Istanbul Medeniyet University, Goztepe Education and Research Hospital, Istanbul, Turkey
| | - Serhat Baydin
- Istanbul University - Cerrahpasa, Cerrahpasa Medical Faculty, Department of Neurosurgery, Microsurgical Neuroanatomy Laboratory, Istanbul, Turkey; Ondokuz Mayis University, Medical Faculty, Department of Neurosurgery, Samsun, Turkey
| | - Ilhan Aydin
- Istanbul University - Cerrahpasa, Cerrahpasa Medical Faculty, Department of Neurosurgery, Microsurgical Neuroanatomy Laboratory, Istanbul, Turkey; Medical Park Hospital, Neurosurgery Clinic, Istanbul, Turkey
| | - Ahmet Kayhan
- Istanbul University - Cerrahpasa, Cerrahpasa Medical Faculty, Department of Neurosurgery, Microsurgical Neuroanatomy Laboratory, Istanbul, Turkey; Haseki Research and Training Hospital, Neurosurgery Clinic, Istanbul, Turkey
| | - Sevket Evran
- Haseki Research and Training Hospital, Neurosurgery Clinic, Istanbul, Turkey
| | - Rahsan Kemerdere
- Istanbul University - Cerrahpasa, Cerrahpasa Medical Faculty, Department of Neurosurgery, Istanbul, Turkey
| | - Necmettin Tanriover
- Istanbul University - Cerrahpasa, Cerrahpasa Medical Faculty, Department of Neurosurgery, Microsurgical Neuroanatomy Laboratory, Istanbul, Turkey; Istanbul University - Cerrahpasa, Cerrahpasa Medical Faculty, Department of Neurosurgery, Istanbul, Turkey.
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15
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Xu K, Wang X, Guan Y, Zhao M, Zhou J, Zhai F, Wang M, Li T, Luan G. Comparisons of the seizure-free outcome and visual field deficits between anterior temporal lobectomy and selective amygdalohippocampectomy: A systematic review and meta-analysis. Seizure 2020; 81:228-235. [DOI: 10.1016/j.seizure.2020.07.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 11/24/2022] Open
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16
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Donos C, Rollo P, Tombridge K, Johnson JA, Tandon N. Visual field deficits following laser ablation of the hippocampus. Neurology 2020; 94:e1303-e1313. [DOI: 10.1212/wnl.0000000000008940] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 10/02/2019] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo qualify the incidence of and risk factors for visual field deficits (VFD) following laser interstitial thermal ablation (LITT) for mesial temporal lobe epilepsy (MTLE) and to relate this to anterior temporal lobectomy (ATL).MethodsFifty-seven patients underwent LITT of the amygdalo-hippocampal complex (AH) for MTLE. Masks of ablation volumes, laser probe trajectories, and visual radiations (VRs) from individual subject space were transformed into standardized space using nonlinear registration. Voxel-wise statistics were performed to model relationships between VFDs vs ablation volumes, laser trajectories, VRs, and AH asymmetry. A review of VFDs following ATLs was performed.ResultsThe incidence of VFD after LITT is much lower than after ATLs. A total of 37.5% of patients developed a VFD, with the probability of this being much higher after left (50%) vs right hemisphere LITT (10%) (Fisher test, p = 0.05). This laterality effect on VFDs is mirrored but underappreciated in ATL series. The most consistent LITT-VFD occurred in the superior vertical octant. Ablation of Meyer loop as well as the summed probability of VRs within laser trajectories correlated with VFDs (p < 0.05). Left and right hippocampi have significantly distinct orientations in axial and coronal planes, which may be one reason for the variation in VFD probability.ConclusionsLITT results in lower rates of and smaller VFDs—typically an octantanopsia. VRs are at greater risk during surgery for left than right MTLE. Anatomical asymmetries in hippocampal anatomy may explain the hemispheric differences in deficits, and should factor into trajectory planning and also into preoperative patient counseling. Overall the incidence and extent of visual deficits following LITT for MTLE is lower than the reported data following anterior temporal lobectomy. VF tractography incorporated into LITT planning may reduce the occurrence of VFDs.
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17
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Fractional anisotropy of the optic radiations correlates with the visual field after epilepsy surgery. Neuroradiology 2019; 61:1425-1436. [DOI: 10.1007/s00234-019-02281-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 08/14/2019] [Indexed: 11/26/2022]
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18
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Abstract
BACKGROUND This is an updated version of the original Cochrane review, published in 2015.Focal epilepsies are caused by a malfunction of nerve cells localised in one part of one cerebral hemisphere. In studies, estimates of the number of individuals with focal epilepsy who do not become seizure-free despite optimal drug therapy vary between at least 20% and up to 70%. If the epileptogenic zone can be located, surgical resection offers the chance of a cure with a corresponding increase in quality of life. OBJECTIVES The primary objective is to assess the overall outcome of epilepsy surgery according to evidence from randomised controlled trials.Secondary objectives are to assess the overall outcome of epilepsy surgery according to non-randomised evidence, and to identify the factors that correlate with remission of seizures postoperatively. SEARCH METHODS For the latest update, we searched the following databases on 11 March 2019: Cochrane Register of Studies (CRS Web), which includes the Cochrane Epilepsy Group Specialized Register and the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid, 1946 to March 08, 2019), ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). SELECTION CRITERIA Eligible studies were randomised controlled trials (RCTs) that included at least 30 participants in a well-defined population (age, sex, seizure type/frequency, duration of epilepsy, aetiology, magnetic resonance imaging (MRI) diagnosis, surgical findings), with an MRI performed in at least 90% of cases and an expected duration of follow-up of at least one year, and reporting an outcome related to postoperative seizure control. Cohort studies or case series were included in the previous version of this review. DATA COLLECTION AND ANALYSIS Three groups of two review authors independently screened all references for eligibility, assessed study quality and risk of bias, and extracted data. Outcomes were proportions of participants achieving a good outcome according to the presence or absence of each prognostic factor of interest. We intended to combine data with risk ratios (RRs) and 95% confidence intervals (95% CIs). MAIN RESULTS We identified 182 studies with a total of 16,855 included participants investigating outcomes of surgery for epilepsy. Nine studies were RCTs (including two that randomised participants to surgery or medical treatment (99 participants included in the two trials received medical treatment)). Risk of bias in these RCTs was unclear or high. Most of the remaining 173 non-randomised studies followed a retrospective design. We assessed study quality using the Effective Public Health Practice Project (EPHPP) tool and determined that most studies provided moderate or weak evidence. For 29 studies reporting multivariate analyses, we used the Quality in Prognostic Studies (QUIPS) tool and determined that very few studies were at low risk of bias across domains.In terms of freedom from seizures, two RCTs found surgery (n = 97) to be superior to medical treatment (n = 99); four found no statistically significant differences between anterior temporal lobectomy (ATL) with or without corpus callosotomy (n = 60), between subtemporal or transsylvian approach to selective amygdalohippocampectomy (SAH) (n = 47); between ATL, SAH and parahippocampectomy (n = 43) or between 2.5 cm and 3.5 cm ATL resection (n = 207). One RCT found total hippocampectomy to be superior to partial hippocampectomy (n = 70) and one found ATL to be superior to stereotactic radiosurgery (n = 58); and another provided data to show that for Lennox-Gastaut syndrome, no significant differences in seizure outcomes were evident between those treated with resection of the epileptogenic zone and those treated with resection of the epileptogenic zone plus corpus callosotomy (n = 43). We judged evidence from the nine RCTs to be of moderate to very low quality due to lack of information reported about the randomised trial design and the restricted study populations.Of the 16,756 participants included in this review who underwent a surgical procedure, 10,696 (64%) achieved a good outcome from surgery; this ranged across studies from 13.5% to 92.5%. Overall, we found the quality of data in relation to recording of adverse events to be very poor.In total, 120 studies examined between one and eight prognostic factors in univariate analysis. We found the following prognostic factors to be associated with a better post-surgical seizure outcome: abnormal pre-operative MRI, no use of intracranial monitoring, complete surgical resection, presence of mesial temporal sclerosis, concordance of pre-operative MRI and electroencephalography, history of febrile seizures, absence of focal cortical dysplasia/malformation of cortical development, presence of tumour, right-sided resection, and presence of unilateral interictal spikes. We found no evidence that history of head injury, presence of encephalomalacia, presence of vascular malformation, and presence of postoperative discharges were prognostic factors of outcome.Twenty-nine studies reported multi-variable models of prognostic factors, and showed that the direction of association of factors with outcomes was generally the same as that found in univariate analyses.We observed variability in many of our analyses, likely due to small study sizes with unbalanced group sizes and variation in the definition of seizure outcome, the definition of prognostic factors, and the influence of the site of surgery AUTHORS' CONCLUSIONS: Study design issues and limited information presented in the included studies mean that our results provide limited evidence to aid patient selection for surgery and prediction of likely surgical outcomes. Future research should be of high quality, follow a prospective design, be appropriately powered, and focus on specific issues related to diagnostic tools, the site-specific surgical approach, and other issues such as extent of resection. Researchers should investigate prognostic factors related to the outcome of surgery via multi-variable statistical regression modelling, where variables are selected for modelling according to clinical relevance, and all numerical results of the prognostic models are fully reported. Journal editors should not accept papers for which study authors did not record adverse events from a medical intervention. Researchers have achieved improvements in cancer care over the past three to four decades by answering well-defined questions through the conduct of focused RCTs in a step-wise fashion. The same approach to surgery for epilepsy is required.
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Affiliation(s)
- Siobhan West
- Royal Manchester Children's HospitalDepartment of Paediatric NeurologyHathersage RoadManchesterUKM13 0JH
| | - Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Jennifer Cotton
- The Clatterbridge Cancer Centre NHS Foundation TrustWirralUK
| | - Sacha Gandhi
- NHS Ayrshire and ArranDepartment of General SurgeryAyrUKKA6 6DX
| | - Jennifer Weston
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
| | - Ajay Sudan
- Royal Manchester Children's HospitalDepartment of Paediatric NeurologyHathersage RoadManchesterUKM13 0JH
| | - Roberto Ramirez
- Royal Manchester Children's HospitalHospital RoadPendleburyManchesterUKM27 4HA
| | - Richard Newton
- Royal Manchester Children's HospitalDepartment of Paediatric NeurologyHathersage RoadManchesterUKM13 0JH
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Pitskhelauri D, Konovalov A, Kudieva E, Bykanov A, Pronin I, Eliseeva N, Melnikova-Pitskhelauri T, Melikyan A, Sanikidze A. Burr Hole Microsurgery for Intracranial Tumors and Mesial Temporal Lobe Epilepsy: Results of 200 Consecutive Operations. World Neurosurg 2019; 126:e1257-e1267. [DOI: 10.1016/j.wneu.2019.02.239] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 12/26/2022]
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Clusmann H, Höllig A. Craniopharyngioma: The Benefits of a Conservative Approach. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 116:319-320. [PMID: 31219032 PMCID: PMC6620758 DOI: 10.3238/arztebl.2019.0319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 04/17/2019] [Indexed: 06/09/2023]
Affiliation(s)
- Hans Clusmann
- Department of Neurosurgery, University Hospital RWTH Aachen
| | - Anke Höllig
- Department of Neurosurgery, University Hospital RWTH Aachen
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21
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Eliseeva NM, Pitskhelauri DI, Serova NK, Kudieva ES. [Visual field disorder after surgery of temporal lobe epilepsy associated to hippocampus sclerosis]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2019; 83:14-20. [PMID: 31825371 DOI: 10.17116/neiro20198305114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Assessment of frequency and severity of visual field disorders after neurosurgical operations at patients with pharmacoresistant form of epilepsy in hippocampus sclerosis. MATERIAL AND METHODS The study included 48 patients having surgical operations for a pharmacoresistant form of temporal lobe epilepsy due to hippocampus sclerosis. Anterior lobectomy with amygdalohippocampectomy (LE + AHE) was performed in 25 patients; Selective amygdalohippocampectomy (SAHE) was performed in 23 patients. We evaluated both the frequency of cases of homonymous visual field disorders and their severity. RESULTS After surgery the normal visual field was preserved at 7 (14.6%) patients. The appearance of visual field disorder by the type of homonymous hemianopsia was observed at 41 (85.4%) patients. When assessing the severity of visual field disorder, the smallest disorder was at patients who underwent sub-temporal access of SAHE: a statistically significant difference in the frequency of severe visual field disorder was revealed when comparing this group with patients having LE + AHE (p<0.02), as well as with patients having SAHE with access through sylvian gap (p<0.02). CONCLUSION SAHE with sub-temporal access allows maintaining or minimally injuring the central optic neuron fibers, including the Meyer loop at patients operated for symptomatic temporal lobe epilepsy.
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Affiliation(s)
| | | | - N K Serova
- Burdenko Neurosurgical Center, Moscow, Russia
| | - E S Kudieva
- Burdenko Neurosurgical Center, Moscow, Russia
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22
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Vogt VL, Delev D, Grote A, Schramm J, von Lehe M, Elger CE, Witt JA, Helmstaedter C. Neuropsychological outcome after subtemporal versus transsylvian approach for selective amygdalohippocampectomy in patients with mesial temporal lobe epilepsy: a randomised prospective clinical trial. J Neurol Neurosurg Psychiatry 2018; 89:1057-1063. [PMID: 29273691 DOI: 10.1136/jnnp-2017-316311] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 08/29/2017] [Accepted: 11/20/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the effects of different surgical approaches for selective amygdalohippocampectomy in patients with pharmacoresistant mesial temporal lobe epilepsy with regard to the neuropsychological outcome and to replicate an earlier study employing a matched-pair design. METHOD 47 patients were randomised to subtemporal versus transsylvian approaches. Memory, language, attentional and executive functions were assessed before and 1 year after surgery. Multivariate analyses of variance (MANOVAs) with presurgical and postsurgical assessments as within-subject variables and approach and side of surgery as between-subject factors were calculated. Additionally, the frequencies of individual performance changes based on reliable change indices were analysed. RESULTS Seizure freedom International League Against Epilepsy (ILAE) 1a, was achieved in 62% of all patients without group difference. MANOVAs revealed no significant effects of approach on cognition. Tested separately for each parameter, verbal recognition memory declined irrespective of approach. Post hoc tests revealed that on group level, the subtemporal approach was associated with a worse outcome for verbal learning and delayed free recall as well as for semantic fluency. Accordingly, on individual level, more patients in the subtemporal group declined in verbal learning. Left side of surgery was associated with decline in naming regardless of approach. CONCLUSION The main analysis did not confirm the effects of approach on memory outcome seen in our previous study. Post hoc testing, however, showed greater memory losses with the subtemporal approach. Previous findings were replicated for semantic fluency. The discrepant results are discussed on the background of the different study designs.
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Affiliation(s)
- Viola Lara Vogt
- Department of Epileptology, University of Bonn-Medical Center, Bonn, Germany
| | - Daniel Delev
- Department of Neurosurgery, University of Bonn-Medical Center, Bonn, Germany.,Department of Neurosurgery, University Medical Center, Freiburg, Germany
| | - Alexander Grote
- Department of Neurosurgery, University of Bonn-Medical Center, Bonn, Germany
| | - Johannes Schramm
- Department of Neurosurgery, University of Bonn-Medical Center, Bonn, Germany
| | - Marec von Lehe
- Department of Neurosurgery, Knappschaftskrankenhaus Bochum, Bonn, Germany
| | | | - Juri-Alexander Witt
- Department of Epileptology, University of Bonn-Medical Center, Bonn, Germany
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Sheng J, Liu S, Qin H, Li B, Zhang X. Drug-Resistant Epilepsy and Surgery. Curr Neuropharmacol 2018; 16:17-28. [PMID: 28474565 PMCID: PMC5771378 DOI: 10.2174/1570159x15666170504123316] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 06/23/2017] [Accepted: 04/25/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Epilepsy is a chronic brain disease that is caused by various factors and characterized by recurrent, episodic and temporary central nervous system dysfunction which results due to excessive discharge of brain neurons. In the past decades, despite the continuous development of antiepileptic drugs, there are still many patients with epilepsy progressing to drugresistant epilepsy. Currently, surgical treatment is one of important way to cure drug-resistant epilepsy. METHODS Data were collected from Web of Science, Medline, Pubmed, through searching of these keywords: "surgery" and "drug-resistant epilepsy". RESULTS An increasing number of studies have shown that surgery plays an important role in the treatment of drug-resistant epilepsy. Moreover, the comprehensive treatment mainly based on surgery can achieve the remission and even cure of drug-resistant epilepsy. CONCLUSION In this review, we discuss the pathogenesis of drug-resistant epilepsy and the comprehensive treatment mainly based on surgery; this review may provide a reference for the clinical treatment of drug-resistant epilepsy.
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Affiliation(s)
- Jiyao Sheng
- Jilin Provincial Key Laboratory on Molecular and Chemical Genetic, Second Hospital of Jilin University, Changchun130041, P.R. China
| | - Shui Liu
- Jilin Provincial Key Laboratory on Molecular and Chemical Genetic, Second Hospital of Jilin University, Changchun130041, P.R. China
| | - Hanjiao Qin
- Jilin Provincial Key Laboratory on Molecular and Chemical Genetic, Second Hospital of Jilin University, Changchun130041, P.R. China
| | - Bingjin Li
- Jilin Provincial Key Laboratory on Molecular and Chemical Genetic, Second Hospital of Jilin University, Changchun130041, P.R. China
| | - Xuewen Zhang
- Jilin Provincial Key Laboratory on Molecular and Chemical Genetic, Second Hospital of Jilin University, Changchun130041, P.R. China
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Steensberg AT, Olsen AS, Litman M, Jespersen B, Kolko M, Pinborg LH. Visual field defects after temporal lobe resection for epilepsy. Seizure 2018; 54:1-6. [DOI: 10.1016/j.seizure.2017.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/23/2017] [Accepted: 11/14/2017] [Indexed: 10/18/2022] Open
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Schmeiser B, Daniel M, Kogias E, Böhringer D, Egger K, Yang S, Foit NA, Schulze-Bonhage A, Steinhoff BJ, Zentner J, Lagrèze WA, Gross NJ. Visual field defects following different resective procedures for mesiotemporal lobe epilepsy. Epilepsy Behav 2017; 76:39-45. [PMID: 28954709 DOI: 10.1016/j.yebeh.2017.08.037] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/15/2017] [Accepted: 08/26/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION One of the most common side effects of mesiotemporal lobe resection in patients with medically intractable epilepsy are visual field defects (VFD). While peripheral defects usually remain unnoticed by patients, extended VFD influence daily life activities and can, in particular, affect driving regulations. This study had been designed to evaluate frequency and extent of VFD following different surgical approaches to the mesiotemporal area with respect to the ability to drive. MATERIALS AND METHODS This study comprises a consecutive series of 366 patients operated at the Epilepsy Center in Freiburg for intractable mesiotemporal lobe epilepsy from 1998 to 2016. The following procedures were performed: standard anterior temporal lobectomy (ATL: n=134; 37%), anterior temporal or keyhole resection (KH: n=53; 15%), and selective amygdalohippocampectomy via the transsylvian (tsAHE: n=145; 40%) and the subtemporal (ssAHE: n=34; 9%) approach. Frequency and extent of postoperative VFD were evaluated in relation to different surgical procedures. According to the German driving guidelines, postoperative VFD were classified as driving-relevant VFD with the involvement of absolute, homonymous central scotoma within 20° and driving-irrelevant VFD with either none or exclusively minor VFD sparing the center. RESULTS Postoperative visual field examinations were available in 276 of 366 cases. Postoperative VFD were observed in 202 of 276 patients (73%) and were found to be driving-relevant in 133 of 276 patients (48%), whereas 69 patients (25%) showed VFD irrelevant for driving. Visual field defects were significantly less likely following ssAHE compared with other temporal resections, and if present, they were less frequently driving-relevant (p<0.05), irrespective of the side of surgery. CONCLUSION Subtemporal sAHE (ssAHE) caused significantly less frequently and less severely driving-relevant VFD compared with all other approaches to the temporal lobe, irrespective of the side of surgery.
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Affiliation(s)
- Barbara Schmeiser
- Department of Neurosurgery, Medical Center - University of Freiburg, Breisacherstrasse 64, 79106 Freiburg, Germany.
| | - Moritz Daniel
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Trust and UCL Institute of Ophthalmology, London, United Kingdom; Eye Center, Medical Center - University of Freiburg, Killianstrasse 5, 79106 Freiburg, Germany
| | - Evangelos Kogias
- Department of Neurosurgery, Medical Center - University of Freiburg, Breisacherstrasse 64, 79106 Freiburg, Germany
| | - Daniel Böhringer
- Eye Center, Medical Center - University of Freiburg, Killianstrasse 5, 79106 Freiburg, Germany
| | - Karl Egger
- Department of Neuroradiology, Medical Center - University of Freiburg, Breisacherstrasse 64, 79106 Freiburg, Germany
| | - Shan Yang
- Department of Neuroradiology, Medical Center - University of Freiburg, Breisacherstrasse 64, 79106 Freiburg, Germany
| | - Niels Alexander Foit
- Department of Neurosurgery, Medical Center - University of Freiburg, Breisacherstrasse 64, 79106 Freiburg, Germany
| | - Andreas Schulze-Bonhage
- Department of Epileptology, Medical Center - University of Freiburg, Breisacherstrasse 64, 79106 Freiburg, Germany
| | | | - Josef Zentner
- Department of Neurosurgery, Medical Center - University of Freiburg, Breisacherstrasse 64, 79106 Freiburg, Germany
| | - Wolf Alexander Lagrèze
- Eye Center, Medical Center - University of Freiburg, Killianstrasse 5, 79106 Freiburg, Germany
| | - Nikolai Johannes Gross
- Eye Center, Medical Center - University of Freiburg, Killianstrasse 5, 79106 Freiburg, Germany
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Dorfer C, Czech T, Aull-Watschinger S, Baumgartner C, Jung R, Kasprian G, Novak K, Pirker S, Seidl B, Stefanits H, Trimmel K, Pataraia E. Mesial temporal lobe epilepsy: long-term seizure outcome of patients primarily treated with transsylvian selective amygdalohippocampectomy. J Neurosurg 2017; 129:174-181. [PMID: 29027855 DOI: 10.3171/2017.4.jns162699] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to present long-term seizure outcome data in a consecutive series of patients with refractory mesial temporal lobe epilepsy primarily treated with transsylvian selective amygdalohippocampectomy (SAHE). METHODS The authors retrospectively analyzed prospectively collected data for all patients who had undergone resective surgery for medically refractory epilepsy at their institution between July 1994 and December 2014. Seizure outcome was assessed according to the International League Against Epilepsy (ILAE) and the Engel classifications. RESULTS The authors performed an SAHE in 158 patients (78 males, 80 females; 73 right side, 85 left side) with a mean age of 37.1 ± 10.0 years at surgery. Four patients lost to follow-up and 1 patient who committed suicide were excluded from analysis. The mean follow-up period was 9.7 years. At the last available follow-up (or before reoperation), 68 patients (44.4%) had achieved an outcome classified as ILAE Class 1a, 46 patients (30.1%) Class 1, 6 patients (3.9%) Class 2, 16 patients (10.4%) Class 3, 15 patients (9.8%) Class 4, and 2 patients (1.3%) Class 5. These outcomes correspond to Engel Class I in 78.4% of the patients, Engel Class II in 10.5%, Engel Class III in 8.5%, and Engel Class IV in 2.0%. Eleven patients underwent a second surgery (anterior temporal lobectomy) after a mean of 4.4 years from the SAHE (left side in 6 patients, right side in 5). Eight (72.7%) of these 11 patients achieved seizure freedom. The overall ILEA seizure outcome since (re)operation after a mean follow-up of 10.0 years was Class 1a in 72 patients (47.0%), Class 1 in 50 patients (32.6%), Class 2 in 7 patients (4.6%), Class 3 in 15 patients (9.8%), Class 4 in 8 patients (5.2%), and Class 5 in 1 patient (0.6%). These outcomes correspond to an Engel Class I outcome in 84.3% of the patients. CONCLUSIONS A satisfactory long-term seizure outcome following transsylvian SAHE was demonstrated in a selected group of patients with refractory temporal lobe epilepsy.
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Affiliation(s)
| | | | | | - Christoph Baumgartner
- 3Karl Landsteiner Institute for Clinical Epilepsy Research and Cognitive Neurology, General Hospital Hietzing with Neurological Center Rosenhügel, Vienna, Austria
| | | | - Gregor Kasprian
- 4Radiology and Nuclear Medicine, Medical University of Vienna; and
| | | | - Susanne Pirker
- 3Karl Landsteiner Institute for Clinical Epilepsy Research and Cognitive Neurology, General Hospital Hietzing with Neurological Center Rosenhügel, Vienna, Austria
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