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Shakhatreh L, Sinclair B, McLean C, Lui E, Morokoff AP, King JA, Chen Z, Perucca P, O'Brien TJ, Kwan P. Amygdala enlargement in temporal lobe epilepsy: Histopathology and surgical outcomes. Epilepsia 2024; 65:1709-1719. [PMID: 38546705 DOI: 10.1111/epi.17968] [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: 08/17/2023] [Revised: 03/18/2024] [Accepted: 03/18/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVES Amygdala enlargement is detected on magnetic resonance imaging (MRI) in some patients with drug-resistant temporal lobe epilepsy (TLE), but its clinical significance remains uncertain We aimed to assess if the presence of amygdala enlargement (1) predicted seizure outcome following anterior temporal lobectomy with amygdalohippocampectomy (ATL-AH) and (2) was associated with specific histopathological changes. METHODS This was a case-control study. We included patients with drug-resistant TLE who underwent ATL-AH with and without amygdala enlargement detected on pre-operative MRI. Amygdala volumetry was done using FreeSurfer for patients who had high-resolution T1-weighted images. Mann-Whitney U test was used to compare pre-operative clinical characteristics between the two groups. The amygdala volume on the epileptogenic side was compared to the amygdala volume on the contralateral side among cases and controls. Then, we used a two-sample, independent t test to compare the means of amygdala volume differences between cases and controls. The chi-square test was used to assess the correlation of amygdala enlargement with (1) post-surgical seizure outcomes and (2) histopathological changes. RESULTS Nineteen patients with and 19 patients without amygdala enlargement were studied. Their median age at surgery was 38 years for cases and 39 years for controls, and 52.6% were male. There were no statistically significant differences between the two groups in their pre-operative clinical characteristics. There were significant differences in the means of volume difference between cases and controls (Diff = 457.2 mm3, 95% confidence interval [CI] 289.6-624.8; p < .001) and in the means of percentage difference (p < .001). However, there was no significant association between amygdala enlargement and surgical outcome (p = .72) or histopathological changes (p = .63). SIGNIFICANCE The presence of amygdala enlargement on the pre-operative brain MRI in patients with TLE does not affect the surgical outcome following ATL-AH, and it does not necessarily suggest abnormal histopathology. These findings suggest that amygdala enlargement might reflect a secondary reactive process to seizures in the epileptogenic temporal lobe.
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Affiliation(s)
- Lubna Shakhatreh
- Department of Neuroscience, The Central Clinical School, Monash University, Melbourne, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Australia
- Department of Neurology, Alfred Health, Melbourne, Australia
- Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Ben Sinclair
- Department of Neuroscience, The Central Clinical School, Monash University, Melbourne, Australia
| | - Catriona McLean
- Department of Anatomical Pathology, The Alfred Hospital, Melbourne, Australia
| | - Elaine Lui
- Department of Radiology, University of Melbourne, The Royal Melbourne Hospital, Melbourne, Australia
| | - Andrew P Morokoff
- Department of Surgery, University of Melbourne, The Royal Melbourne Hospital, Melbourne, Australia
| | - James A King
- Department of Surgery, University of Melbourne, The Royal Melbourne Hospital, Melbourne, Australia
| | - Zhibin Chen
- Department of Neuroscience, The Central Clinical School, Monash University, Melbourne, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Piero Perucca
- Department of Neuroscience, The Central Clinical School, Monash University, Melbourne, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Australia
- Department of Neurology, Alfred Health, Melbourne, Australia
- Bladin-Berkovic Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Melbourne, Australia
- Epilepsy Research Centre, Department of Medicine, Austin Health, The University of Melbourne, Melbourne, Australia
| | - Terence J O'Brien
- Department of Neuroscience, The Central Clinical School, Monash University, Melbourne, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Australia
- Department of Neurology, Alfred Health, Melbourne, Australia
- Department of Medicine, University of Melbourne, The Royal Melbourne Hospital, Melbourne, Australia
| | - Patrick Kwan
- Department of Neuroscience, The Central Clinical School, Monash University, Melbourne, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Australia
- Department of Neurology, Alfred Health, Melbourne, Australia
- Department of Medicine, University of Melbourne, The Royal Melbourne Hospital, Melbourne, Australia
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Hsieh JK, Pucci FG, Sundar SJ, Kondylis E, Sharma A, Sheikh SR, Vegh D, Moosa AN, Gupta A, Najm I, Rammo R, Bingaman W, Jehi L. Beyond seizure freedom: Dissecting long-term seizure control after surgical resection for drug-resistant epilepsy. Epilepsia 2023; 64:103-113. [PMID: 36281562 PMCID: PMC10100416 DOI: 10.1111/epi.17445] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 10/23/2022] [Accepted: 10/24/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE This study was undertaken to better understand the long-term palliative and disease-modifying effects of surgical resection beyond seizure freedom, including frequency reduction and both late recurrence and remission, in patients with drug-resistant epilepsy. METHODS This retrospective database-driven cohort study included all patients with >9 years of follow-up at a single high-volume epilepsy center. We included patients who underwent lobectomy, multilobar resection, or lesionectomies for drug-resistant epilepsy; we excluded patients who underwent hemispherectomies. Our main outcomes were (1) reduction in frequency of disabling seizures (at 6 months, each year up to 9 years postoperatively, and at last follow-up), (2) achievement of seizure remission (>6 months, >1 year, and longest duration), and (3) seizure freedom at last follow-up. RESULTS We included 251 patients; 234 (93.2%) achieved 6 months and 232 (92.4%) experienced 1 year of seizure freedom. Of these, the average period of seizure freedom was 10.3 years. A total of 182 (72.5%) patients were seizure-free at last follow-up (defined as >1 year without seizures), with a median 11.9 years since remission. For patients not completely seizure-free, the mean seizure frequency reduction at each time point was 76.2%, and ranged from 66.6% to 85.0%. Patients decreased their number of antiseizure medications on average by .58, and 53 (21.2%) patients were on no antiseizure medication at last follow-up. Nearly half (47.1%) of those seizure-free at last follow-up were not seizure-free immediately postoperatively. SIGNIFICANCE Patients who continue to have seizures after resection often have considerable reductions in seizure frequency, and many are able to achieve seizure freedom in a delayed manner.
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Affiliation(s)
- Jason K. Hsieh
- Department of Neurosurgery, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Francesco G. Pucci
- Department of Neurosurgery, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
- Charles Shor Epilepsy Center, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Swetha J. Sundar
- Department of Neurosurgery, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Efstathios Kondylis
- Department of Neurosurgery, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Akshay Sharma
- Department of Neurosurgery, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Shehryar R. Sheikh
- Department of Neurosurgery, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Deborah Vegh
- Charles Shor Epilepsy Center, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Ahsan N. Moosa
- Charles Shor Epilepsy Center, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Ajay Gupta
- Charles Shor Epilepsy Center, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Imad Najm
- Charles Shor Epilepsy Center, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Richard Rammo
- Department of Neurosurgery, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
- Charles Shor Epilepsy Center, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - William Bingaman
- Department of Neurosurgery, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
- Charles Shor Epilepsy Center, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Lara Jehi
- Charles Shor Epilepsy Center, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
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McIntosh AM, Wynd AW, Berkovic SF. Extended follow-up after anterior temporal lobectomy demonstrates seizure recurrence 20+ years postsurgery. Epilepsia 2023; 64:92-102. [PMID: 36268808 PMCID: PMC10098858 DOI: 10.1111/epi.17440] [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: 09/11/2022] [Revised: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Anterior temporal lobectomy (ATL) for medication-resistant localized epilepsy results in ablation or reduction of seizures for most patients. However, some individuals who attain an initial extended period of postsurgical seizure freedom will experience a later seizure recurrence. In this study, we examined the prevalence and some risk factors for late recurrence in an ATL cohort with extensive regular follow-up. METHODS Included were 449 patients who underwent ATL at Austin Health, Australia, from 1978 to 2008. Postsurgical follow-up was undertaken 2-3 yearly. Seizure recurrence was tested using Kaplan-Meier analysis, log-rank test, and Cox regression. Late recurrence was qualified as a first disabling seizure >2 years postsurgery. We examined risks within the ATL cohort according to broad pathology groups and tested whether late recurrence differed for the ATL cohort compared to patients who had resections outside the temporal lobe (n = 98). RESULTS Median post-ATL follow-up was 22 years (range = .1-38.6), 6% were lost to follow-up, and 12% had died. Probabilities for remaining completely seizure-free after surgery were 51% (95% confidence interval [CI] = 53-63) at 2 postoperative years, 36% (95% CI = 32-41) at 10 years, 32% (95% CI = 27-36) at 20 years, and 30% (95% CI = 25-34) at 25 years. Recurrences were reported up to 23 years postoperatively. Late seizures occurred in all major ATL pathology groups, with increased risk in the "normal" and "distant lesion" groups (p ≤ .03). Comparison between the ATL cohort and patients who underwent extratemporal resection demonstrated similar patterns of late recurrence (p = .74). SIGNIFICANCE Some first recurrences were very late, reported decades after ATL. Late recurrences were not unique to any broad ATL pathology group and did not differ according to whether resections were ATL or extratemporal. Reports of these events by patients with residual pathology suggest that potentially epileptogenic abnormalities outside the area of resection may be implicated as one of several possible underlying mechanisms.
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Affiliation(s)
- Anne M McIntosh
- Epilepsy Research Centre, Department of Medicine (Austin Health), University of Melbourne, Melbourne, Victoria, Australia.,Bladin-Berkovic Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Melbourne, Victoria, Australia.,Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Alex W Wynd
- Epilepsy Research Centre, Department of Medicine (Austin Health), University of Melbourne, Melbourne, Victoria, Australia.,Bladin-Berkovic Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Melbourne, Victoria, Australia
| | - Samuel F Berkovic
- Epilepsy Research Centre, Department of Medicine (Austin Health), University of Melbourne, Melbourne, Victoria, Australia.,Bladin-Berkovic Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Melbourne, Victoria, Australia
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Sheikh SR, Kattan MW, Steinmetz M, Singer ME, Udeh BL, Jehi L. Cost-effectiveness of surgery for drug-resistant temporal lobe epilepsy in the US. Neurology 2020; 95:e1404-e1416. [PMID: 32641528 DOI: 10.1212/wnl.0000000000010185] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 03/16/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Surgery is an effective but costly treatment for many patients with drug-resistant temporal lobe epilepsy (DR-TLE). We aim to evaluate whether, in the United States, surgery is cost-effective compared to medical management for patients deemed surgical candidates and whether surgical evaluation is cost-effective for patients with DR-TLE in general. METHODS We use a semi-Markov model to assess the cost-effectiveness of surgery and surgical evaluation over a lifetime horizon. We use second-order Monte Carlo simulations to conduct probabilistic sensitivity analyses to estimate variation in model output. We adopt both health care and societal perspectives, including direct health care costs (e.g., surgery, antiepileptic drugs) and indirect costs (e.g., lost earnings by patients and care providers.) We compare the incremental cost-effectiveness ratio to societal willingness to pay (∼$100,000 per quality-adjusted life-year [QALY]) to determine whether surgery is cost-effective. RESULTS Epilepsy surgery is cost-effective compared to medical management in surgically eligible patients by virtue of being cost-saving ($328,000 vs $423,000) and more effective (16.6 vs 13.6 QALY) than medical management in the long run. Surgical evaluation is cost-effective in patients with DR-TLE even if the probability of being deemed a surgical candidate is only 5%. From a societal perspective, surgery becomes cost-effective within 3 years, and 89% of simulations favor surgery over the lifetime horizon. CONCLUSION For surgically eligible patients with DR-TLE, surgery is cost-effective. For patients with DR-TLE in general, referral for surgical evaluation (and possible subsequent surgery) is cost-effective. Patients with DR-TLE should be referred for surgical evaluation without hesitation on cost-effectiveness grounds.
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Affiliation(s)
- Shehryar R Sheikh
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (S.R.S.); Department of Quantitative Health Sciences (M.W.K., B.L.U.), Department of Neurological Surgery (M.S.), and Epilepsy Center (L.J.), Cleveland Clinic; and Department of Population and Quantitative Health Sciences (M.E.S.), Case Western Reserve University, Cleveland, OH
| | - Michael W Kattan
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (S.R.S.); Department of Quantitative Health Sciences (M.W.K., B.L.U.), Department of Neurological Surgery (M.S.), and Epilepsy Center (L.J.), Cleveland Clinic; and Department of Population and Quantitative Health Sciences (M.E.S.), Case Western Reserve University, Cleveland, OH
| | - Michael Steinmetz
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (S.R.S.); Department of Quantitative Health Sciences (M.W.K., B.L.U.), Department of Neurological Surgery (M.S.), and Epilepsy Center (L.J.), Cleveland Clinic; and Department of Population and Quantitative Health Sciences (M.E.S.), Case Western Reserve University, Cleveland, OH
| | - Mendel E Singer
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (S.R.S.); Department of Quantitative Health Sciences (M.W.K., B.L.U.), Department of Neurological Surgery (M.S.), and Epilepsy Center (L.J.), Cleveland Clinic; and Department of Population and Quantitative Health Sciences (M.E.S.), Case Western Reserve University, Cleveland, OH
| | - Belinda L Udeh
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (S.R.S.); Department of Quantitative Health Sciences (M.W.K., B.L.U.), Department of Neurological Surgery (M.S.), and Epilepsy Center (L.J.), Cleveland Clinic; and Department of Population and Quantitative Health Sciences (M.E.S.), Case Western Reserve University, Cleveland, OH
| | - Lara Jehi
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (S.R.S.); Department of Quantitative Health Sciences (M.W.K., B.L.U.), Department of Neurological Surgery (M.S.), and Epilepsy Center (L.J.), Cleveland Clinic; and Department of Population and Quantitative Health Sciences (M.E.S.), Case Western Reserve University, Cleveland, OH.
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Arifin MT, Bakhtiar Y, Andar EBPS, Kurnia B H, Priambada D, Risdianto A, Kusnarto G, Tsaniadi K, Bunyamin J, Hanaya R, Arita K, Bintoro AC, Iida K, Kurisu K, Askoro R, Briliantika SP, Muttaqin Z. Surgery for Radiologically Normal-Appearing Temporal Lobe Epilepsy in a Centre with Limited Resources. Sci Rep 2020; 10:8144. [PMID: 32424296 PMCID: PMC7235248 DOI: 10.1038/s41598-020-64968-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/27/2020] [Indexed: 11/08/2022] Open
Abstract
Approximately 26-30% of temporal lobe epilepsy (TLE) cases display a normal-appearing magnetic resonance image (MRI) leading to difficulty in determining the epileptogenic focus. This causes challenges in surgical management, especially in countries with limited resources. The medical records of 154 patients with normal-appearing MRI TLE who underwent epilepsy surgery between July 1999 and July 2019 in our epilepsy centre in Indonesia were examined. The primary outcome was the Engel classification of seizures. Anterior temporal lobectomy was performed in 85.1% of the 154 patients, followed by selective amygdalo-hippocampectomy and resection surgery. Of 82 patients (53.2%), Engel Class I result was reported in 69.5% and Class II in 25.6%. The median seizure-free period was 13 (95% CI,12.550-13.450) years, while the seizure-free rate at 5 and 12 years follow-up was 96.3% and 69.0%, respectively. Patients with a sensory aura had better seizure-free outcome 15 (11.575-18.425) years. Anterior temporal lobectomy and selective amygdala-hippocampectomy gave the same favourable outcome. Despite the challenges of surgical procedures for normal MRI TLE, our outcome has been favourable. This study suggests that epilepsy surgery in normal MRI TLE can be performed in centres with limited resources.
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Affiliation(s)
- Muhamad Thohar Arifin
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Jl Prof. Soedarto, Tembalang, Semarang, Jawa Tengah, Indonesia.
| | - Yuriz Bakhtiar
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Jl Prof. Soedarto, Tembalang, Semarang, Jawa Tengah, Indonesia
| | - Erie B P S Andar
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Jl Prof. Soedarto, Tembalang, Semarang, Jawa Tengah, Indonesia
| | - Happy Kurnia B
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Jl Prof. Soedarto, Tembalang, Semarang, Jawa Tengah, Indonesia
| | - Dody Priambada
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Jl Prof. Soedarto, Tembalang, Semarang, Jawa Tengah, Indonesia
| | - Ajid Risdianto
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Jl Prof. Soedarto, Tembalang, Semarang, Jawa Tengah, Indonesia
| | - Gunadi Kusnarto
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Jl Prof. Soedarto, Tembalang, Semarang, Jawa Tengah, Indonesia
| | - Krisna Tsaniadi
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Jl Prof. Soedarto, Tembalang, Semarang, Jawa Tengah, Indonesia
| | - Jacob Bunyamin
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Jl Prof. Soedarto, Tembalang, Semarang, Jawa Tengah, Indonesia
| | - Ryosuke Hanaya
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Kazunori Arita
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Aris Catur Bintoro
- Department of Neurology, Faculty of Medicine, Diponegoro University, Jl Prof. Soedarto Tembalang, Semarang, Jawa Tengah, Indonesia
| | - Koji Iida
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | | | - Rofat Askoro
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Jl Prof. Soedarto, Tembalang, Semarang, Jawa Tengah, Indonesia
| | - Surya P Briliantika
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Jl Prof. Soedarto, Tembalang, Semarang, Jawa Tengah, Indonesia
| | - Zainal Muttaqin
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Jl Prof. Soedarto, Tembalang, Semarang, Jawa Tengah, Indonesia
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Luan L, Sun Y, Yang K. Surgical strategy for temporal lobe epilepsy with dual pathology and incomplete evidence from EEG and neuroimaging. Exp Ther Med 2018; 16:4886-4892. [PMID: 30546403 DOI: 10.3892/etm.2018.6774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 08/02/2018] [Indexed: 11/06/2022] Open
Abstract
Coexistence of hippocampal sclerosis (HS) and a temporal neocortical lesion, including focal cortical dysplasia, vascular malformations or benign primary brain tumors, is defined as dual pathology. In the majority of cases, the complete evidence based on electroencephalogram (EEG) and magnetic resonance imaging (MRI) for each of the dual pathological lesions is difficult to obtain. As a result, patients with dual pathology are poor surgical candidates due to potential incomplete resection of the epileptogenic zone. The current study retrospectively reviewed 24 patients with potential dual pathology and incomplete EEG and MRI evidence, aiming to provide novel surgical strategies. The results revealed a significantly worse seizure-free outcome for patients with incomplete EEG and MRI data compared with patients who received a clear diagnosis of dual pathology based on complete test results (11.1 vs. 60.0%; P<0.05). Notably, satisfying surgical (seizure-free) outcomes were still achieved in 60% of patients with unclear EEGs to locate the onset zone and clear MRI scans identifying the sclerotic hippocampus and nearby neocortical lesions, which could be resected together. In patients with multiple epileptogenic onsets or with widespread epileptic discharges, the hippocampus should be spared from resection due to concern for potential postsurgical mood or memory disorders. In conclusion, patients with resection of the sclerotic hippocampus and neocortical lesion had improved seizure-free outcomes compared with patients who received individual lesion resection. The current study aimed to provide a novel surgical strategy for neurosurgeons treating epileptic patients with dual pathology.
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Affiliation(s)
- Lan Luan
- Department of Neurosurgery, The Second Hospital of Dalian Medical University, Dalian, Liaoning 116000, P.R. China
| | - Yuqiang Sun
- Department of Neurosurgery, The Central Hospital of Harbin, Harbin, Heilongjiang 150000, P.R. China
| | - Kang Yang
- Department of Neurosurgery, The Second Hospital of Dalian Medical University, Dalian, Liaoning 116000, P.R. China
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Brown MG, Drees C, Nagae LM, Thompson JA, Ojemann S, Abosch A. Curative and palliative MRI-guided laser ablation for drug-resistant epilepsy. J Neurol Neurosurg Psychiatry 2018; 89:425-433. [PMID: 29084870 DOI: 10.1136/jnnp-2017-316003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/15/2017] [Accepted: 09/18/2017] [Indexed: 12/30/2022]
Abstract
Epilepsy is a common neurological disorder occurring in 3% of the US adult population. It is characterised by seizures resulting from aberrant hypersynchronous neural activity. Approximately one-third of newly diagnosed epilepsy cases fail to become seizure-free in response to antiseizure drugs. Optimal seizure control, in cases of drug-resistant epilepsy, often requires neurosurgical intervention targeting seizure foci, such as the temporal lobe. Advances in minimally invasive ablative surgical approaches have led to the development of MRI-guided laser interstitial thermal therapy (LITT). For refractory epilepsy, this surgical intervention offers many advantages over traditional approaches, including real-time lesion monitoring, reduced morbidity, and in some reports increased preservation of cognitive and language processes. We review the use of LITT for epileptic indications in the context of its application as a curative (seizure freedom) or palliative (seizure reduction) measure for both lesional and non-lesional forms of epilepsy. Furthermore, we address the use of LITT for a variety of extratemporal lobe epilepsies. Finally, we describe clinical outcomes, limitations and future applications of LITT for epilepsy.
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Affiliation(s)
- Mesha-Gay Brown
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Cornelia Drees
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Lidia M Nagae
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - John A Thompson
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Steven Ojemann
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Aviva Abosch
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado, USA
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8
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Smith ZZ, Benison AM, Bercum FM, Dudek FE, Barth DS. Progression of convulsive and nonconvulsive seizures during epileptogenesis after pilocarpine-induced status epilepticus. J Neurophysiol 2018; 119:1818-1835. [PMID: 29442558 DOI: 10.1152/jn.00721.2017] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Although convulsive seizures occurring during pilocarpine-induced epileptogenesis have received considerable attention, nonconvulsive seizures have not been closely examined, even though they may reflect the earliest signs of epileptogenesis and potentially guide research on antiepileptogenic interventions. The definition of nonconvulsive seizures based on brain electrical activity alone has been controversial. Here we define and quantify electrographic properties of convulsive and nonconvulsive seizures in the context of the acquired epileptogenesis that occurs after pilocarpine-induced status epilepticus (SE). Lithium-pilocarpine was used to induce the prolonged repetitive seizures characteristic of SE; when SE was terminated with paraldehyde, seizures returned during the 2-day period after pilocarpine treatment. A distinct latent period ranging from several days to >2 wk was then measured with continuous, long-term video-EEG. Nonconvulsive seizures dominated the onset of epileptogenesis and consistently preceded the first convulsive seizures but were still present later. Convulsive and nonconvulsive seizures had similar durations. Postictal depression (background suppression of the EEG) lasted for >100 s after both convulsive and nonconvulsive seizures. Principal component analysis was used to quantify the spectral evolution of electrical activity that characterized both types of spontaneous recurrent seizures. These studies demonstrate that spontaneous nonconvulsive seizures have electrographic properties similar to convulsive seizures and confirm that nonconvulsive seizures link the latent period and the onset of convulsive seizures during post-SE epileptogenesis in an animal model. Nonconvulsive seizures may also reflect the earliest signs of epileptogenesis in human acquired epilepsy, when intervention could be most effective. NEW & NOTEWORTHY Nonconvulsive seizures usually represent the first bona fide seizure following a latent period, dominate the early stages of epileptogenesis, and change in severity in a manner consistent with the progressive nature of epileptogenesis. This analysis demonstrates that nonconvulsive and convulsive seizures have different behavioral outcomes but similar electrographic signatures. Alternatively, epileptiform spike-wave discharges fail to recapitulate several key seizure features and represent a category of electrical activity separate from nonconvulsive seizures in this model.
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Affiliation(s)
- Zachariah Z Smith
- Department of Psychology and Neuroscience, University of Colorado , Boulder, Colorado
| | - Alexander M Benison
- Department of Psychology and Neuroscience, University of Colorado , Boulder, Colorado
| | - Florencia M Bercum
- Department of Psychology and Neuroscience, University of Colorado , Boulder, Colorado
| | - F Edward Dudek
- Department of Neurosurgery, University of Utah School of Medicine , Salt Lake City, Utah
| | - Daniel S Barth
- Department of Psychology and Neuroscience, University of Colorado , Boulder, Colorado
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Kang JY, Sperling MR. Magnetic Resonance Imaging-Guided Laser Interstitial Thermal Therapy for Treatment of Drug-Resistant Epilepsy. Neurotherapeutics 2017; 14:176-181. [PMID: 27905093 PMCID: PMC5233636 DOI: 10.1007/s13311-016-0498-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Surgery is the most effective treatment for drug-resistant epilepsy. Long-term studies demonstrate that about 60% to 80% of patients become seizure-free after anterior temporal lobectomy and a majority of patients (about 95%) report significant seizure reduction after surgery. In the last few years, there has been significant advances in minimally invasive surgical techniques to treat drug-resistant epilepsy. These minimally invasive procedures have significant advantages over open surgery in that they produce less immediate discomfort and disability, while allowing for greater preservation of functional tissue. Laser interstitial thermal therapy (LiTT) is an example of such a procedure. Recent advances in imaging, surgical navigation, and real-time thermal monitoring have made LiTT safer and easier to implement, offering an effective and powerful neurosurgical tool for drug-resistant epilepsy. This article will review the technical considerations, uses, and potential future directions for LiTT in drug-resistant epilepsy.
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Affiliation(s)
- Joon Y Kang
- Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Meyer 2-147, Baltimore, MD, 21287, USA.
| | - Michael R Sperling
- Thomas Jefferson University Hospital, 900 Walnut Street Suite 200, Philadelphia, PA, 19107, USA
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Moura LMVR, Eskandar EN, Hassan M, Salinas J, Cole AJ, Hoch DB, Cash SS, Hsu J. Anterior temporal lobectomy for older adults with mesial temporal sclerosis. Epilepsy Res 2016; 127:358-365. [PMID: 27760412 DOI: 10.1016/j.eplepsyres.2016.09.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 09/07/2016] [Accepted: 09/29/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare postoperative seizure-free survival between older and younger adults. METHODS A retrospective cohort of 107 temporal lobe epilepsy patients with a diagnosis of mesial temporal sclerosis (MTS) received anterior temporal lobectomy (ATL) between 1993 and 2014. We divided the lower three quartiles (younger) and top quartile (older, all 47+ years) of patients, then reviewed patient registry and electronic medical records to determine time to first self-reported seizure after ATL, the primary outcome (mean=3.5years of follow-up, SD=3.6). We also assessed Engel classifications, intraoperative and postoperative treatment complications, and social disability. We used Cox proportional hazard models to assess the association between individual traits and time of seizure recurrence. RESULTS During follow-up, 35/107 (32.7%) patients had post-operative seizure(s). After adjustment for potential confounders there were no significant differences in the probability of post-operative seizures between the older and younger groups, though we had limited precision (hazard ratio of 0.67 [0.28-1.59]), (p=0.36). There were more treatment complications and disability in older patients (18% vs. 1.3% for any complications, 84.62% vs. 58.23% for driving disability, and 84.6% vs. 60.7% for work disability, p<0.05). CONCLUSION Older patients appear to have more complications after ATL, compared with younger patients. Age, however, does not appear to have a large independent association with seizure recurrence.
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Affiliation(s)
- Lidia M V R Moura
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, United States.
| | - Emad N Eskandar
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Mursal Hassan
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Joel Salinas
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Andrew J Cole
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Daniel B Hoch
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Sydney S Cash
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, United States
| | - John Hsu
- Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA 02114, United States; Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, United States
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Jin H, Li W, Dong C, Wu J, Zhao W, Zhao Z, Ma L, Ma F, Chen Y, Liu Q. Hippocampal deep brain stimulation in nonlesional refractory mesial temporal lobe epilepsy. Seizure 2016; 37:1-7. [DOI: 10.1016/j.seizure.2016.01.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 01/28/2016] [Accepted: 01/29/2016] [Indexed: 11/28/2022] Open
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Rosenow F, Klein KM, Hamer HM. Non-invasive EEG evaluation in epilepsy diagnosis. Expert Rev Neurother 2015; 15:425-44. [DOI: 10.1586/14737175.2015.1025382] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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13
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Electrical stimulation of hippocampus for the treatment of refractory temporal lobe epilepsy. Brain Res Bull 2014; 109:13-21. [DOI: 10.1016/j.brainresbull.2014.08.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 08/21/2014] [Accepted: 08/28/2014] [Indexed: 01/21/2023]
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Kim J, Kim CH, Chung CK. Longitudinal changes in seizure outcomes after resection of cerebral cavernous malformations in patients presenting with seizures: a long-term follow-up of 46 patients. Acta Neurochir (Wien) 2014; 156:1539-47; discussion 1546-7. [PMID: 24829156 DOI: 10.1007/s00701-014-2121-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 04/30/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Seizure is the most common presentation in patients with cerebral cavernous malformations (CCMs). Although many articles have documented seizure outcomes after resection of CCM, few have conducted long-term follow-ups; thus, the fluctuating seizure outcomes have been neglected. The purpose of this study is to describe long-term postoperative seizure outcomes in patients with CCM and to compare seizure outcomes between patients with sporadic seizures and those with chronic seizures. METHODS Forty-six patients with CCM presenting with seizures underwent surgery. The male-to-female ratio was 1:1, and the average age at initial seizure onset was 27.6 years. The mean preoperative seizure duration was 42.7 months. Patients were divided into two groups: a chronic group (N = 20) and a sporadic group (N = 26) according to seizure frequency and duration. The mean postoperative follow-up duration was 96.3 months, and the postoperative seizure outcomes were checked annually based upon Engel's classification. RESULTS After the first year of follow-up, 80.8 % of the sporadic group and 75.0 % of the chronic group were evaluated as Engel class I. These rates increased to 100.0 % and 90.0 %, respectively, at the eighth year of follow-up. Overall, 29 (63.0 %) of the 46 patients experienced changes in seizure outcomes over the follow-up period. Despite their delayed improvements, the chronic group showed less favorable outcomes throughout follow-up (p = 0.025). CONCLUSIONS Long-term follow-up is indispensable for accurately assessing postoperative seizure outcomes because these outcomes change continuously. We recommend earlier surgery to achieve seizure-free status in patients with CCM. However, even in the chronic group, surgery is recommended, considering the overall delayed improvement.
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Temporal lobe surgery in medically refractory epilepsy: A comparison between populations based on MRI findings. Seizure 2014; 23:20-4. [DOI: 10.1016/j.seizure.2013.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 08/12/2013] [Accepted: 09/06/2013] [Indexed: 11/20/2022] Open
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Goellner E, Bianchin MM, Burneo JG, Parrent AG, Steven DA. Timing of early and late seizure recurrence after temporal lobe epilepsy surgery. Epilepsia 2013; 54:1933-41. [DOI: 10.1111/epi.12389] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Eduardo Goellner
- Epilepsy Program; Department of Clinical Neurological Sciences; Western University; London Health Sciences Centre; London Ontario Canada
- Hospital Mãe de Deus; Porto Alegre Rio Grande do Sul Brazil
- Postgraduate Program in Medical Sciences; Federal University of Rio Grande do Sul; Porto Alegre Rio Grande do Sul Brazil
| | - Marino M. Bianchin
- Postgraduate Program in Medical Sciences; Federal University of Rio Grande do Sul; Porto Alegre Rio Grande do Sul Brazil
| | - Jorge G. Burneo
- Epilepsy Program; Department of Clinical Neurological Sciences; Western University; London Health Sciences Centre; London Ontario Canada
| | - Andrew G. Parrent
- Epilepsy Program; Department of Clinical Neurological Sciences; Western University; London Health Sciences Centre; London Ontario Canada
| | - David A. Steven
- Epilepsy Program; Department of Clinical Neurological Sciences; Western University; London Health Sciences Centre; London Ontario Canada
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Sainju RK, Wolf BJ, Bonilha L, Martz G. Relationship of number of seizures recorded on video-EEG to surgical outcome in refractory medial temporal lobe epilepsy. ARQUIVOS DE NEURO-PSIQUIATRIA 2013; 70:694-9. [PMID: 22990726 DOI: 10.1590/s0004-282x2012000900009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Accepted: 05/28/2012] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Surgical planning for refractory medial temporal lobe epilepsy (rMTLE) relies on seizure localization by ictal electroencephalography (EEG). Multiple factors impact the number of seizures recorded. We evaluated whether seizure freedom correlated to the number of seizures recorded, and the related factors. METHODS We collected data for 32 patients with rMTLE who underwent anterior temporal lobectomy. Primary analysis evaluated number of seizures captured as a predictor of surgical outcome. Subsequent analyses explored factors that may seizure number. RESULTS Number of seizures recorded did not predict seizure freedom. More seizures were recorded with more days of seizure occurrence (p<0.001), seizure clusters (p≤0.011) and poorly localized seizures (PLSz) (p=0.004). Regression modeling showed a trend for subjects with fewer recorded poorly localized seizures to have better surgical outcome (p=0.052). CONCLUSIONS Total number of recorded seizures does not predict surgical outcome. Patients with more PLSz may have worse outcome.
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Affiliation(s)
- Rup Kamal Sainju
- Division of Neurology, Department of Neurosciences, Medical University of South Carolina (MUSC), Charleston, SC 29425, USA.
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Comparison of MRI features and surgical outcome among the subtypes of focal cortical dysplasia. Seizure 2012; 21:789-94. [DOI: 10.1016/j.seizure.2012.09.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 09/07/2012] [Accepted: 09/13/2012] [Indexed: 11/21/2022] Open
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Vale FL, Effio E, Arredondo N, Bozorg A, Wong K, Martinez C, Downes K, Tatum WO, Benbadis SR. Efficacy of temporal lobe surgery for epilepsy in patients with negative MRI for mesial temporal lobe sclerosis. J Clin Neurosci 2012; 19:101-6. [DOI: 10.1016/j.jocn.2011.08.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 08/01/2011] [Accepted: 08/13/2011] [Indexed: 10/14/2022]
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Evaluating the feasibility of measures of motor threshold and cortical silent period as predictors of outcome after temporal lobe epilepsy surgery. Seizure 2011; 20:775-8. [DOI: 10.1016/j.seizure.2011.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Revised: 07/17/2011] [Accepted: 07/18/2011] [Indexed: 11/19/2022] Open
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Fong JS, Jehi L, Najm I, Prayson RA, Busch R, Bingaman W. Seizure outcome and its predictors after temporal lobe epilepsy surgery in patients with normal MRI. Epilepsia 2011; 52:1393-401. [DOI: 10.1111/j.1528-1167.2011.03091.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Alfstad KÅ, Lossius MI, Røste GK, Mowinckel P, Scheie D, Borota OC, Larsson PG, Nakken KO. Acute postoperative seizures after epilepsy surgery - a long-term outcome predictor? Acta Neurol Scand 2011; 123:48-53. [PMID: 20199515 DOI: 10.1111/j.1600-0404.2010.01343.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The prognostic value of acute postoperative seizures (APS) after epilepsy surgery is much debated. This study evaluated APS, defined as seizures in the first week post-surgery, as a predictor of long-term seizure outcome, and investigated the utility of other potential outcome predictors. MATERIALS AND METHODS Medical records of 48 patients with temporal and extra-temporal epilepsy surgery were studied. Forty patients had lesional surgery. All had at least 2 year postoperative follow-up. RESULTS At 2 year follow-up, 25 patients (53%) were seizure free. Univariate analysis showed that APS (P = 0.048), using ≥ six AEDs prior to surgery (P = 0.03), pathological postoperative EEG (P = 0.043) and female gender (P = 0.012) were associated with seizure recurrence. CONCLUSIONS Univariate analysis indicate that APS, a high number of AEDs used prior to surgery, and pathological postoperative EEG are possible predictors of seizure recurrence after epilepsy surgery. Only gender retained significance in the multivariate analysis.
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Affiliation(s)
- K Å Alfstad
- National Centre for Epilepsy, Rikshospitalet University Hospital, Oslo, Norway.
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23
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Buckingham SE, Chervoneva I, Sharan A, Zangaladze A, Mintzer S, Skidmore C, Nei M, Evans J, Pequignot E, Sperling MR. Latency to first seizure after temporal lobectomy predicts long-term outcome. Epilepsia 2010; 51:1987-93. [DOI: 10.1111/j.1528-1167.2010.02721.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Interictal spikes are widely accepted diagnostically as a sign of epilepsy, but reasons for the presence of interictal activity in the epileptic brain are unknown. Interictal spikes are easily generated in normal brain by pharmacologically reducing inhibition, and experimental studies of acquired epilepsy indicate that spikes precede seizures. These data lead to the hypothesis that interictal spikes are correlated with epilepsy because they play a fundamental role in epileptogenesis following brain injury. Spikes may guide sprouting axons back to their network of origin, increase and sustain the strength of the synapses formed by sprouted axons, and alter the balance of ion channels in the epileptic focus, such that seizures become possible. This hypothesis has implications that are testable: altering spiking or the calcium signals generated by spikes should alter epileptogenesis and spikes should precede seizures in brain-injured human patients.
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Affiliation(s)
- Kevin J Staley
- Pediatrics andNeurology, The Children'sHospital, University of Colorado, USA
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25
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Jehi L, Sarkis R, Bingaman W, Kotagal P, Najm I. When is a postoperative seizure equivalent to “epilepsy recurrence” after epilepsy surgery? Epilepsia 2010; 51:994-1003. [DOI: 10.1111/j.1528-1167.2010.02556.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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26
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Kelemen A, Fogarasi A, Borbély C, Szűcs A, Fabó D, Jakus R, Rásonyi G, Halász P. Nonmanipulative proximal upper extremity automatisms lateralize contralaterally in temporal lobe epilepsy. Epilepsia 2010; 51:214-20. [DOI: 10.1111/j.1528-1167.2009.02277.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kim DW, Lee SK, Nam H, Chu K, Chung CK, Lee SY, Choe G, Kim HK. Epilepsy with dual pathology: Surgical treatment of cortical dysplasia accompanied by hippocampal sclerosis. Epilepsia 2009; 51:1429-35. [DOI: 10.1111/j.1528-1167.2009.02403.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ramos E, Benbadis S, Vale FL. Failure of temporal lobe resection for epilepsy in patients with mesial temporal sclerosis: results and treatment options. J Neurosurg 2009; 110:1127-34. [PMID: 19249930 DOI: 10.3171/2009.1.jns08638] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The purpose of this study was to identify the causes of failed temporal lobe resection in patients with mesial temporal sclerosis (MTS) and the role of repeat surgery for seizure control. METHODS This is a retrospective study of 105 patients who underwent temporal lobe resection for MTS with unilateral electroencephalographic findings. The mean follow-up duration was 36 months (range 24-84 months). Surgeries were all performed by the senior author (F.L.V.). RESULTS Following initial surgical intervention, 97 patients (92%) improved to Engel Class I or II (Group A), and 8 (8%) did not have significant improvement (Engel Class III or IV; Group B). These 8 patients were restudied using video-electroencephalography (EEG) and MR imaging. All major surgical failures occurred within 1 year after initial intervention. Reevaluation demonstrated 3 patients (37.5%) with contralateral temporal EEG findings. Five patients (62.5%) had evidence of ipsilateral recurrent discharges. Four patients underwent extended neocortical resection along the previous resection cavity. Their outcomes ranged from Engel Class I to Class III. Only 1 patient (12.5%) who failed to improve after initial surgery was found to have incomplete resection of mesial structures. This last patient underwent reoperation to complete the resection and improved to Engel Class I. CONCLUSIONS Failure of temporal lobe resection for MTS is multifactorial. The cause of failure lies in the pathological substrate of the epileptogenic area. Complete seizure control cannot be predicted solely by conventional preoperative workup. Initial surgical failures from temporal lobe resection often benefit from reevaluation, because reoperation may be beneficial in selected patients. Based on this work, the authors have proposed a management and treatment algorithm for these patients.
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Affiliation(s)
- Edwin Ramos
- Department of Neurological Surgery, University of South Florida College of Medicine, Tampa, Florida, USA
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Bell GS, Gaitatzis A, Bell CL, Johnson AL, Sander JW. Suicide in people with epilepsy: how great is the risk? Epilepsia 2009; 50:1933-42. [PMID: 19453718 DOI: 10.1111/j.1528-1167.2009.02106.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Suicide is more common in populations with epilepsy, but estimates vary concerning the magnitude of the risk. We aimed to estimate the risk using meta-analysis. METHODS A literature search identified 74 articles (76 cohorts of people with epilepsy) in whom the number of deaths by suicide in people with epilepsy and the number of person-years at risk could be estimated. Standardized mortality ratios (SMRs) with 95% confidence intervals (CIs) were calculated for each cohort, for groups of cohorts, and for the total population. RESULTS The overall SMR was 3.3 (95% CI 2.8-3.7) based on 190 observed deaths by suicide compared with 58.4 expected. The SMR was significantly increased in people with incident or newly diagnosed epilepsy in the community (SMR 2.1), in populations with mixed prevalence and incidence cases (SMR 3.6), in those with prevalent epilepsy (SMR 4.8), in people in institutions (SMR 4.6), in people seen in tertiary care clinics (SMR 2.28), in people with temporal lobe epilepsy (SMR 6.6), in those following temporal lobe excision (SMR 13.9), and following other forms of epilepsy surgery (SMR 6.4). The SMR was significantly low overall in two community-based studies of people with epilepsy and developmental disability. DISCUSSION We confirm that the risk of suicide is increased in most populations of people with epilepsy. Psychiatric comorbidity has been demonstrated to be a risk factor for suicide in the general population and in people with epilepsy, and such comorbidity should thus be identified and treated.
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Affiliation(s)
- Gail S Bell
- Department of Clinical & Experimental Epilepsy, UCL Institute of Neurology, and National Hospital for Neurology and Neurosurgery, UCL Hospitals NHS Foundation Trust, London, United Kingdom
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Abstract
Epilepsy is a chronic neurological disorder that affects 0.5-1% of the population. Up to one-third of patients will have incompletely controlled seizures or debilitating side effects of anticonvulsant medications. Although some of these patients may be candidates for resection, many are not. The desire to find alternative treatments for epilepsy has led to a resurgence of interest in the use of deep brain stimulation (DBS), which has been used quite successfully in movement disorders. Small pilot studies and open-label trials have yielded results that may support the use of DBS in selected patients with refractory seizures. Because of the diversity of regions involved with seizure initiation and propagation, a variety of targets for stimulation have been examined. Moreover, stimulation parameters such as amplitude, frequency, pulse duration, and continuous versus intermittent on vary from one study to the next. More studies are necessary to determine if there is an appropriate population of seizure patients for DBS, the optimal target, and the most efficacious stimulation parameters.
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Affiliation(s)
- Thomas L Ellis
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.
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Guarnieri R, Walz R, Hallak JEC, Coimbra E, de Almeida E, Cescato MP, Velasco TR, Alexandre V, Terra VC, Carlotti CG, Assirati JA, Sakamoto AC. Do psychiatric comorbidities predict postoperative seizure outcome in temporal lobe epilepsy surgery? Epilepsy Behav 2009; 14:529-34. [PMID: 19186216 DOI: 10.1016/j.yebeh.2009.01.002] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Revised: 01/04/2009] [Accepted: 01/10/2009] [Indexed: 10/21/2022]
Abstract
Clinical and demographic presurgical variables may be associated with unfavorable postsurgical neurological outcome in patients with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS). However, few reports include preoperative psychiatric disorders as a factor predictive of long-term postsurgical MTLE-HS neurological outcome. We used Engel's criteria to follow 186 postsurgical patients with MTLE-HS for an average of 6 years. DSM-IV criteria and psychiatric comorbidity criteria specific to epilepsy (interictal dysphoric disorder, postictal and interictal psychosis) were used to assess presurgical psychiatric disorders. Kaplan-Meier event-free survival and adjusted hazard ratios were estimated with unconditional logistic regression. Seventy-seven (41.4%) patients had a preoperative Axis I psychiatric diagnosis. Thirty-six patients had depression, 11 interictal dysphoric disorder, 14 interictal psychosis, 6 postictal psychosis, and 10 anxiety disorders. Twenty-three (12.4%) patients had Axis II personality disorders. Regarding seizure outcome, preoperative anxiety disorders (P=0.009) and personality disorders (P=0.003) were positively correlated with Engel class 1B (remaining auras) or higher. These findings emphasize the importance of presurgical psychiatric evaluation, counseling, and postsurgical follow-up of patients with epilepsy and psychiatric disorders.
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Affiliation(s)
- Ricardo Guarnieri
- Centro de Cirurgia de Epilepsia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
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Yeon JY, Kim JS, Choi SJ, Seo DW, Hong SB, Hong SC. Supratentorial cavernous angiomas presenting with seizures: surgical outcomes in 60 consecutive patients. Seizure 2008; 18:14-20. [PMID: 18656386 DOI: 10.1016/j.seizure.2008.05.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2007] [Revised: 05/19/2008] [Accepted: 05/23/2008] [Indexed: 11/17/2022] Open
Abstract
The aim of this study is to determine surgical outcomes and factors affecting seizure outcomes in patients who harbor supratentorial cavernous angiomas presenting with seizures. Sixty patients were classified into the intractable epilepsy group (n=22) and the sporadic seizure group (n=38) and then managed differently in accordance with our guidelines. Patients exhibiting sporadic seizures were treated by lesionectomy, except for patients harboring mesial temporal lesions. We performed lesionectomy, extended lesionectomy, standard temporal lobectomy and tailored resection on 33, 9, 9 and 9 patients, respectively. Finally, 72.7% (16/22) of patients with intractable epilepsy and 89.5% (34/38) of patients with sporadic seizures achieved Engel Class I outcomes. A long duration of illness was somewhat related to a poor outcome in patients with intractable epilepsy, yet this was not true of patients with sporadic seizures. Other factors which included age at onset, size of the lesions and locations were not related to seizure outcomes. The role of residual hemosiderin is yet to be discovered. A lesionectomy alone can be considered a reasonable approach for those patients who exhibit sporadic seizures and have an extra-temporal or neo-temporal lesion. In patients with intractable epilepsy and/or mesial temporal lesions, a more invasive approach could achieve the better seizure outcome.
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Affiliation(s)
- Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, 50 IL-Won Dong, Kang-Nam Ku, Seoul, Republic of Korea
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Uijl SG, Leijten FSS, Arends JBAM, Parra J, van Huffelen AC, Moons KGM. Prognosis after temporal lobe epilepsy surgery: the value of combining predictors. Epilepsia 2008; 49:1317-23. [PMID: 18557776 DOI: 10.1111/j.1528-1167.2008.01695.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE Although several independent predictors of seizure freedom after temporal lobe epilepsy surgery have been identified, their combined predictive value is largely unknown. Using a large database of operated patients, we assessed the combined predictive value of previously reported predictors included in a single multivariable model. METHODS The database comprised a cohort of 484 patients who underwent temporal lobe surgery for drug-resistant epilepsy. Good outcome was defined as Engel class 1, one year after surgery. Previously reported independent predictors were tested in this cohort. To be included in our final prediction model, predictors had to show a multivariable p-value of <0.20. RESULTS The final multivariable model included predictors obtained from the patient's history (absence of tonic-clonic seizures, absence of status epilepticus), magnetic resonance imaging [MRI; ipsilateral mesial temporal sclerosis (MTS), space occupying lesion], video electroencephalography (EEG; absence of ictal dystonic posturing, concordance between MRI and ictal EEG), and fluorodeoxyglucose positron emission tomography (FDG-PET; unilateral temporal abnormalities), that were related to seizure freedom in our data. The model showed an expected receiver-operating characteristic curve (ROC) area of 0.63 [95% confidence interval (CI) 0.57-0.68] for new patient populations. Intracranial monitoring and surgery-related parameters (including histology) were not important predictors of seizure freedom. Among patients with a high probability of seizure freedom, 85% were seizure-free one year after surgery; however, among patients with a high risk of not becoming seizure-free, still 40% were seizure-free one year after surgery. CONCLUSION We could only moderately predict seizure freedom after temporal lobe epilepsy surgery. It is particularly difficult to predict who will not become seizure-free after surgery.
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Affiliation(s)
- Sabine G Uijl
- Department of Clinical Neurophysiology, Rudolf Magnus Institute of Neuroscience and University Medical Center Utrecht, Utrecht, The Netherlands.
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Boon P, Vonck K, De Herdt V, Van Dycke A, Goethals M, Goossens L, Van Zandijcke M, De Smedt T, Dewaele I, Achten R, Wadman W, Dewaele F, Caemaert J, Van Roost D. Deep brain stimulation in patients with refractory temporal lobe epilepsy. Epilepsia 2007; 48:1551-60. [PMID: 17726798 DOI: 10.1111/j.1528-1167.2007.01005.x] [Citation(s) in RCA: 237] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE This pilot study prospectively evaluated the efficacy of long-term deep brain stimulation (DBS) in medial temporal lobe (MTL) structures in patients with MTL epilepsy. METHODS Twelve consecutive patients with refractory MTL epilepsy were included in this study. The protocol included invasive video-EEG monitoring for ictal-onset localization and evaluation for subsequent stimulation of the ictal-onset zone. Side effects and changes in seizure frequency were carefully monitored. RESULTS Ten of 12 patients underwent long-term MTL DBS. Two of 12 patients underwent selective amygdalohippocampectomy. After mean follow-up of 31 months (range, 12-52 months), one of 10 stimulated patients are seizure free (>1 year), one of 10 patients had a >90% reduction in seizure frequency; five of 10 patients had a seizure-frequency reduction of > or =50%; two of 10 patients had a seizure-frequency reduction of 30-49%; and one of 10 patients was a nonresponder. None of the patients reported side effects. In one patient, MRI showed asymptomatic intracranial hemorrhages along the trajectory of the DBS electrodes. None of the patients showed changes in clinical neurological testing. Patients who underwent selective amygdalohippocampectomy are seizure-free (>1 year), AEDs are unchanged, and no side effects have occurred. CONCLUSIONS This open pilot study demonstrates the potential efficacy of long-term DBS in MTL structures that should now be further confirmed by multicenter randomized controlled trials.
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Affiliation(s)
- Paul Boon
- Reference Center for Refractory Epilepsy, Laboratory for Clinical and Experimental Neurophysiology, Department of Neurology, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium.
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Kral T, von Lehe M, Podlogar M, Clusmann H, Süssmann P, Kurthen M, Becker A, Urbach H, Schramm J. Focal cortical dysplasia: long term seizure outcome after surgical treatment. J Neurol Neurosurg Psychiatry 2007; 78:853-6. [PMID: 17287239 PMCID: PMC2117728 DOI: 10.1136/jnnp.2006.105361] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Studies of long term outcome after epilepsy surgery for cortical malformations are rare. In this study, we report our experience with surgical treatment and year to year long term outcome for a subgroup of patients with focal cortical dysplasia (FCD). METHODS We retrospectively analysed the records of 49 patients (females n = 26; males n = 23; mean age 25 (11) years) with a mean duration of epilepsy of 18 years (range 1-45). Preoperative MRI, histological results based on the Palmini classification and clinical year to year follow-up according to the International League Against Epilepsy (ILAE) classification were available in all patients. RESULTS 98% of patients had a lesion on preoperative MRI. In addition to lobectomy (n = 9) or lesionectomy (n = 40), 14 patients had multiple subpial transections of the eloquent cortex. The resected tissue was classified as FCD type II b in 41 cases with an extratemporal (88%) and FCD type II a in 8 cases with a temporal localisation (100%). After a mean follow-up of 8.1 (4.5) years, 37 patients (76%) were seizure free, a subgroup of 23 patients (47%) had been completely seizure free since surgery (ILAE class 1a) and 4 patients (8%) had only auras (ILAE class 2). Over a 10 year follow-up, the proportion of satisfactory outcomes decreased, mainly within the first 3 years. During long term follow-up, 48% stopped antiepileptic drug treatment, 34% received a driver's license and 57% found a job or training. CONCLUSION Surgical treatment of epilepsy with FCD is not only successful in the short term but also has a satisfying long term outcome which remains constant after 3 years of follow-up but is not associated with better employment status or improvement in daily living.
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Affiliation(s)
- T Kral
- Department of Neurosurgery, University of Bonn, Medical Centre, Sigmund Freud Strasse 25, 53105 Bonn, Germany.
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RamachandranNair R, Ochi A, Benifla M, Rutka JT, Snead OC, Otsubo H. Benign epileptiform discharges in Rolandic region with mesial temporal lobe epilepsy: MEG, scalp and intracranial EEG features. Acta Neurol Scand 2007; 116:59-64. [PMID: 17587257 DOI: 10.1111/j.1600-0404.2006.00759.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM OF THE STUDY To report benign epileptiform discharges (BEDs) in the Rolandic region, coexisting in a pediatric patient with intractable localization-related epilepsy, secondary to hippocampal sclerosis. METHODS We describe the clinical features, MRI, scalp video EEG, magnetoencephalography (MEG) and intracranial video EEG findings, and surgical outcome in a 9-year-old boy with BEDs and intractable complex partial seizures. RESULTS MRI showed left hippocampal sclerosis. Scalp video EEG interictally demonstrated left temporal spike and sharply contoured slow waves, and right fronto-centro-temporal spike and waves. Ictal scalp video EEG showed left temporal rhythmic sharp waves after the clinical onset of epigastric aura, followed by staring. MEG showed interictal dipoles in the bilateral Rolandic regions with a uniform orientation and right hemispheric predominance. Intracranial video EEG, with bilateral mesial temporal depth and fronto-temporo-parietal strip electrodes, interictally showed polyspikes and slow waves with superimposed low-amplitude fast waves in the left mesial and posterior lateral temporal regions, and spike and waves in the bilateral fronto-parietal regions. Ictal onset was marked by low-amplitude fast waves in the left mesial and posterior lateral temporal regions. He underwent left anterior temporal lobectomy with hippocampectomy. Pathology was hippocampal sclerosis. Predominant right fronto-centro-temporal spike and waves and MEG right Rolandic dipoles persisted after surgery. He was seizure-free 14 months after surgery. CONCLUSION This is the first report on MEG and intracranial video EEG features of BEDs in the Rolandic region, coexisting with hippocampal sclerosis. Persistence of contralateral benign MEG Rolandic dipoles after surgery indicates that BEDs are coincidental in mesial temporal lobe epilepsy. MEG identified Rolandic dipoles, although was unable to localize the deep and focal epileptogenic dipoles from the hippocampal sclerosis.
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Affiliation(s)
- R RamachandranNair
- Division of Neurology, Department of Paediatrics, Hospital for sick Children, Toronto, Ontario, Canada.
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Shorvon S, Luciano AL. Prognosis of chronic and newly diagnosed epilepsy: revisiting temporal aspects. Curr Opin Neurol 2007; 20:208-12. [PMID: 17351493 DOI: 10.1097/wco.0b013e3280555175] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose is to review recent papers on the prognosis of epilepsy, with an emphasis on the importance of considering the temporal aspects of epilepsy. RECENT FINDINGS The review considers five specific points: What is the chance of spontaneous remission without treatment (i.e. what is the natural history of untreated epilepsy)? What is the prognosis of epilepsy in newly diagnosed patients and how effective is therapy in previously drug-naïve patients? Does delaying treatment make long-term prognosis worse? Is the prognosis of chronic established epilepsy inevitably bad? Refractory epilepsy, pharmaco-resistance and the influence of time. SUMMARY This paper reviews the recent evidence that has provided data about temporal aspects of prognosis in epilepsy and confirms the importance of taking a synoptical view of prognosis, incorporating temporal aspects, in making clinical prognostic predictions.
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Shorvon S. The treatment of chronic epilepsy: a review of recent studies of clinical efficacy and side effects. Curr Opin Neurol 2007; 20:159-63. [PMID: 17351485 DOI: 10.1097/wco.0b013e3280555186] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
BACKGROUND Epilepsy surgery is cost-effective and dependent on patient selection, localization and meticulous technique. We report the use of a new robotic system in this surgery for the first time. METHODS The brain is imaged for both image guidance and robotic application. The robot uses CT-visible reflective fiducials. Registration is performed by image-guided surgery (IGS) system and the robot. The robot is used to insert depth electrodes for intra-operative epileptic focus localization and to localize the temporal horn. RESULTS This technique was used in three patients; the catheter tip was found in the temporal horn in all cases and saved considerable operating time compared to previous experience. CONCLUSION It is therefore feasible to use the robot to localize the temporal horn and place depth electrodes during epilepsy surgery with greater precision and consistency and potential time savings.
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Affiliation(s)
- M S Eljamel
- Department of Neurosurgery, Ninewells Hospital and Medical School, Dundee, UK.
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