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Abstract
Temporal lobe epilepsy (TLE) is the most common cause of refractory epilepsy amenable for surgical treatment and seizure control. Surgery for TLE is a safe and effective strategy. The seizure-free rate after surgical resection in patients with mesial or neocortical TLE is about 70%. Resective surgery has an advantage over stereotactic radiosurgery in terms of seizure outcomes for mesial TLE patients. Both techniques have similar results for safety, cognitive outcomes, and associated costs. Stereotactic radiosurgery should therefore be seen as an alternative to open surgery for patients with contraindications for or with reluctance to undergo open surgery. Laser interstitial thermal therapy (LITT) has also shown promising results as a curative technique in mesial TLE but needs to be more deeply evaluated. Brain-responsive stimulation represents a palliative treatment option for patients with unilateral or bilateral MTLE who are not candidates for temporal lobectomy or who have failed a prior mesial temporal lobe resection. Overall, despite the expansion of innovative techniques in recent years, resective surgery remains the reference treatment for TLE and should be proposed as the first-line surgical modality. In the future, ultrasound therapies could become a credible therapeutic option for refractory TLE patients.
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Affiliation(s)
- Bertrand Mathon
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Paris, France; Sorbonne University, Paris, France; Paris Brain Institute, Paris, France
| | - Stéphane Clemenceau
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Paris, France
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Gonçalves-Ferreira A, Rainha-Campos A, Franco A, Pimentel J, Bentes C, Peralta AR, Morgado C. Amygdalohippocampotomy for mesial temporal lobe sclerosis: Epilepsy outcome 5 years after surgery. Acta Neurochir (Wien) 2017; 159:2443-2448. [PMID: 28849383 DOI: 10.1007/s00701-017-3305-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 08/15/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND The goal of the present study is the evaluation of the long-term clinical outcome of epilepsy in patients with mesial temporal lobe sclerosis (MTLS) submitted to amygdalohippocampotomy (AHCo). AHCo consists of the lateral ablation of the amygdala and the peri-hippocampal disconnection instead of amygdalohippocampectomy (AHC), which involves the removal of both structures. We previously reported the short-term results of AHCo, so we here present the long-term results (> 5 years of follow-up) of the patients operated on with AHCo. METHOD Since 2007, 35 patients (22 females) aged 20-61 years (mean: 42 years) were operated on with the AHCo technique, 17 patients on the left side and 18 on the right. Of these patients, 21 (14 females) have been followed up > 5 years (5 to 7.5 years, mean 6.5 years). We compare the present results with those observed shortly after surgery and with the patients operated on with AHC. FINDINGS In all 21 cases, the diagnosis was mesial temporal lobe sclerosis (histology confirmed in 20), 11 on the left side and 10 on the right. Epilepsy results after 5 years were good/very good in 18 patients (85.7%), with Engel class IA-B in 15 (71.4%) and II in 3 (14.3%), and bad in 3 patients, with Engel Class III in 2 (9.5%) and class IV in 1 (4.8%). Concerning morbidity, one patient had hemiparesis (hypertensive capsular hemorrhage 24 h after surgery), two verbal memory worsening, two quadrantanopia and three late depression that was reversed with medication. Comparatively, the AHC long-term results were 87% Engel class I, 8% Engel class II and 5% Engel class III-IV. The morbidity was equally small. CONCLUSIONS The good/very good results of AHCo 5 years after surgery are 86%, which is not distinct from the AHC results. So AHCo seems to be effective and potentially safer than AHC in long-term follow-up.
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Affiliation(s)
- Antonio Gonçalves-Ferreira
- Department of Neurosurgery, Refractory Epilepsy Reference Center, Department of Neurosciences, University Hospital Santa Maria (CHLN-EPE), Lisbon, Portugal.
| | - Alexandre Rainha-Campos
- Department of Neurosurgery, Refractory Epilepsy Reference Center, Department of Neurosciences, University Hospital Santa Maria (CHLN-EPE), Lisbon, Portugal
| | - Ana Franco
- Department of Neurology, EEG Laboratory, Refractory Epilepsy Reference Center, Department of Neurosciences, University Hospital Santa Maria (CHLN-EPE), Lisbon, Portugal
| | - Jose Pimentel
- Department of Neurology, Neuropathology Laboratory, Refractory Epilepsy Reference Center, Department of Neurosciences, University Hospital Santa Maria (CHLN-EPE), Lisbon, Portugal
| | - Carla Bentes
- Department of Neurology, EEG Laboratory, Refractory Epilepsy Reference Center, Department of Neurosciences, University Hospital Santa Maria (CHLN-EPE), Lisbon, Portugal
| | - Ana-Rita Peralta
- Department of Neurology, EEG Laboratory, Refractory Epilepsy Reference Center, Department of Neurosciences, University Hospital Santa Maria (CHLN-EPE), Lisbon, Portugal
| | - Carlos Morgado
- Department of Neurological Imaging, Refractory Epilepsy Reference Center, Department of Neurosciences, University Hospital Santa Maria (CHLN-EPE), Lisbon, Portugal
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Surgical treatment for mesial temporal lobe epilepsy associated with hippocampal sclerosis. Rev Neurol (Paris) 2015; 171:315-25. [DOI: 10.1016/j.neurol.2015.01.561] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 01/01/2015] [Accepted: 01/30/2015] [Indexed: 02/07/2023]
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Sánchez JJG, Rincon-Torroella J, Prats-Galino A, Notaris MD, Berenguer J, Rodríguez EF, Benet A. New endoscopic route to the temporal horn of the lateral ventricle: surgical simulation and morphometric assessment. J Neurosurg 2014; 121:751-9. [DOI: 10.3171/2014.5.jns132309] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The temporal horn of the lateral ventricle is a complex structure affected by specific pathological conditions. Current approaches to the temporal horn involve a certain amount of corticotomy and white matter disruption. Surgeons therefore set aside anterior temporal lobectomy as a last resource and avoid it in the dominant hemisphere. The authors propose a minimally invasive endoscopic intraventricular approach to the temporal horn and describe a standardized analysis and technical assessment of the feasibility of this approach.
Methods
To determine the best trajectory, angulation, and entry point to the temporal horn of the lateral ventricle, the authors evaluated 50 cranial MRI studies (100 temporal lobes) from healthy patients. They studied and systematized the neurosurgical endoscopic anatomy. They also simulated the proposed approach in 9 cadaveric specimens (18 approaches).
Results
Mean scalp entry point coordinates (± SD) were 2.7 ± 0.28 cm lateral to the inion and 5.6 ± 0.41 cm superior to the inion. The mean total distance from the uncal recess to the scalp (± SD) was 10.64 ± 0.6 cm. The mean total intraparenchymal distance crossed by the endoscope was 3.76 ± 0.36 cm. The approach was successfully completed in all studied specimens.
Conclusions
In this study, the endoscopic intraventricular approach to the temporal horn is standardized. The morphometric analysis makes this approach anatomically feasible and replicable. This approach provides minimally invasive endoscopic access to the uncal recess, amygdala, hippocampus, fornix, and paraventricular temporal lobe structures. The following essential strategies enabled access to and maneuverability inside the temporal horn: tailored preoperative planning of the trajectory and use of anatomical and radiological references, constant irrigation, and an angled endoscopic lens. Safety assessment and novel instruments and techniques may be proposed to advance this very promising route to pathological changes in the temporal lobe.
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Affiliation(s)
- Jose Juan González Sánchez
- 1Departments of Neurosurgery and
- 3Department of Neurosurgery, Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California
| | | | - Alberto Prats-Galino
- 5Laboratory of Surgical Neuroanatomy, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Matteo de Notaris
- 5Laboratory of Surgical Neuroanatomy, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Joan Berenguer
- 2Radiology, Hospital Clinic i Provincial de Barcelona, Barcelona, Spain
| | | | - Arnau Benet
- 3Department of Neurosurgery, Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California
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Taylor PN, Kaiser M, Dauwels J. Structural connectivity based whole brain modelling in epilepsy. J Neurosci Methods 2014; 236:51-7. [PMID: 25149109 DOI: 10.1016/j.jneumeth.2014.08.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Revised: 08/06/2014] [Accepted: 08/06/2014] [Indexed: 11/30/2022]
Abstract
Epilepsy is a neurological condition characterised by the recurrence of seizures. During seizures multiple brain areas can behave abnormally. Rather than considering each abnormal area in isolation, one can consider them as an interconnected functional 'network'. Recently, there has been a shift in emphasis to consider epilepsy as a disorder involving more widespread functional brain networks than perhaps was previously thought. The basis for these functional networks is proposed to be the static structural brain network established through the connectivity of the white matter. Additionally, it has also been argued that time varying aspects of epilepsy are of crucial importance and as such computational models of these dynamical properties have recently advanced. We describe how dynamic computer models can be combined with static human in vivo connectivity obtained through diffusion weighted magnetic resonance imaging. We predict that in future the use of these two methods in concert will lead to predictions for optimal surgery and brain stimulation sites for epilepsy and other neurological disorders.
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Affiliation(s)
| | - Marcus Kaiser
- School of Computing Science, Newcastle University, UK; Institute of Neuroscience, Newcastle University, UK
| | - Justin Dauwels
- School of Electrical & Electronic Engineering, Nanyang Technological University, Singapore
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Massager N, Tugendhaft P, Depondt C, Coppens T, Drogba L, Benmebarek N, De Witte O, Van Bogaert P, Legros B. Long-term outcome of surgical disconnection of the epileptic zone as an alternative to resection for nonlesional mesial temporal epilepsy. J Neurol Neurosurg Psychiatry 2013; 84:1378-83. [PMID: 23599386 DOI: 10.1136/jnnp-2012-304083] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Pharmacoresistant epilepsy can be treated by either resection of the epileptic focus or functional isolation of the epileptic focus through complete disconnection of the pathways of propagation of the epileptic activity. OBJECTIVE To evaluate long-term seizure outcome and complications of temporal lobe disconnection (TLD) without resection for mesial temporal lobe epilepsy (MTLE). METHODS Data of 45 patients operated on for intractable MTLE using a functional disconnection procedure have been studied. Indication of TLD surgery was retained after a standard preoperative evaluation of refractory epilepsy and using the same criteria as for standard temporal resection. RESULTS Mean follow-up duration was 3.7 years. At the last follow-up, 30 patients (67%) were completely seizure-free (Engel-Ia/International League Against Epilepsy class 1) and 39 patients (87%) remained significantly improved (Engel-I or -II) by surgery. Actuarial outcome displays a 77.7% probability of being seizure-free and an 85.4% probability of being significantly improved at 5 years. No patient died after surgery and no subdural haematoma or hygroma occurred. Permanent morbidity included hemiparesis, hemianopia and oculomotor paresis found in three, five and one patient, respectively, after TLD. CONCLUSIONS TLD is acceptable alternative surgical technique for patients with intractable MTLE. The results of TLD are in the range of morbidity and long-term seizure outcome rates after standard surgical resection. We observed a slightly higher rate of complications after TLD in comparison with usual rates of morbidity of resection procedures. TLD may be used as an alternative to resection and could reduce operating time and the risks of subdural collections.
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Affiliation(s)
- Nicolas Massager
- Department of Neurosurgery, Clinic of Stereotactic and Functional Neurosurgery, ULB-Hôpital Erasme, , Brussels, Belgium
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Quirico-Santos T, Nascimento Mello A, Casimiro Gomes A, de Carvalho LP, de Souza JM, Alves-Leon S. Increased metalloprotease activity in the epileptogenic lesion--Lobectomy reduces metalloprotease activity and urokinase-type uPAR circulating levels. Brain Res 2013; 1538:172-81. [PMID: 24095794 DOI: 10.1016/j.brainres.2013.09.044] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 09/25/2013] [Accepted: 09/26/2013] [Indexed: 01/08/2023]
Abstract
Inflammation influences the pathogenesis of seizures by boosting neuronal degeneration of temporal lobe epilepsy with hippocampal sclerosis (TLE-HS). This work aimed to determine the activity of metalloproteases (MMPs) in brain tissue fragments of TLE-HS patients and the effect of lobectomy on circulating inflammatory biomarkers. Surgical fragments (n=4) from epileptogenic focus (EF) e perilesion area (PL), and control hippocampus from autopsy (n=5) were processed for glial protein (GFAP), activated microglia (IB4) immunohistochemistry, and metalloprotease activity (MMP-2, -9). Perilesional area showed GFAP positive cells with morphology of activate astrocyte and reactive gliosis nearby the lesion. In the lesion foci, astrocytes had altered cytoarchitecture with disorganized stroma suggestive of necrosis, and numerous mononuclear cells with few projections and morphological characteristics of activate microglia. Analysis of MMP-9 and MMP-2 in the sera before and after hippocampectomy confirmed the inflammatory pattern of TLE-HS, with high MMP-9 activity; high MMP-9/TIMP-1 and urokinase uPAR plasma levels before lobectomy but low after surgery. Maintenance of MMP-2 activity indicates persistent tissue remodeling in both groups. The present work shows that patients with chronic and medically intractable TLE-HS that undergone amigdalo-hippocampectomy for removal of epileptogenic lesion had a clinical enduring benefit of lack seizure recurrence for up to a year, and consistent reduction of proteases (MMP-9 and uPAR) activation that participate as important inflammatory epileptogenic inducers.
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Affiliation(s)
- Thereza Quirico-Santos
- Department of Cellular and Molecular Biology, Fluminense Federal University, Niteroi, Rio de Janeiro 24020-141, Brazil.
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Gonçalves-Ferreira A, Campos AR, Herculano-Carvalho M, Pimentel J, Bentes C, Peralta AR, Morgado C. Amygdalohippocampotomy: surgical technique and clinical results. J Neurosurg 2013; 118:1107-13. [PMID: 23432145 DOI: 10.3171/2013.1.jns12727] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The removal of mesial temporal structures, namely amygdalohippocampectomy, is the most efficient surgical procedure for the treatment of epilepsy. However, disconnection of the epileptogenic zones, as in temporal lobotomy or, for different purposes, hemispherotomy, have shown equivalent results with less morbidity. Thus, authors of the present study began performing selective amygdalohippocampotomy in cases of refractory mesial temporal lobe epilepsy (TLE) to treat mesial temporal lobe sclerosis (MTLS). METHOD The authors conducted a retrospective analysis of all cases of amygdalohippocampotomy collected in a database between November 2007 and March 2011. RESULTS Since 2007, 21 patients (14 males and 7 females), ages 20-58 years (mean 41 years), all with TLE due to MTLS, were treated with selective ablation of the lateral amygdala plus perihippocampal disconnection (anterior one-half to two-thirds in dominant hemisphere), the left side in 11 cases and the right in 10. In 20 patients the follow-up was 2 or more years (range 24-44 months, average 32 months). Clinical outcome for epilepsy 2 years after surgery (20 patients) was good/very good in 19 patients (95%) with an Engel Class I (15 patients [75%]) or II outcome (4 patients [20%]) and bad in 1 patient (5%) with an Engel Class IV outcome (extratemporal focus and later reoperation). Surgical morbidity included hemiparesis (capsular hypertensive hemorrhage 24 hours after surgery, 1 patient), verbal memory worsening (2 patients), and quadrantanopia (permanent in 2 patients, transient in 1). Late psychiatric depression developed in 3 cases. Operative time was reduced by about 30 minutes (15%) on average with this technique. CONCLUSIONS Amygdalohippocampotomy is as effective as amygdalohippocampectomy to treat MTLS and is a potentially safer, time-saving procedure.
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