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Radaelli G, Majolo F, Leal-Conceição E, de Souza Santos F, Escobar V, Zanirati GG, Portuguez MW, Scorza FA, da Costa JC. Left Hemisphere Lateralization of Epileptic Focus Can Be More Frequent in Temporal Lobe Epilepsy Surgical Patients with No Consensus Associated with Depression Lateralization. Dev Neurosci 2021; 43:1-8. [PMID: 33789300 DOI: 10.1159/000513537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/02/2020] [Indexed: 11/19/2022] Open
Abstract
Temporal lobe epilepsy (TLE) is considered to be the most common form of epilepsy, and it has been seen that most patients are refractory to antiepileptic drugs. A strong association of this ailment has been established with psychiatric comorbidities, primarily mood and anxiety disorders. The side of epileptogenic may contribute to depressive and anxiety symptoms; thus, in this study, we performed a systematic review to evaluate the prevalence of depression in TLE in surgical patients. The literature search was performed using PubMed/Medline, Web of Science, and PsycNet to gather data from inception until January 2019. The search strategy was related to TLE, depressive disorder, and anxiety. After reading full texts, 14 articles meeting the inclusion criteria were screened. The main method utilized for psychiatric diagnosis was Diagnostic and Statistical Manual of Mental Disorders/Structured Clinical Interview for DSM. However, most studies failed to perform the neuropsychological evaluation. For those with lateralization of epilepsy, focus mostly occurred in the left hemisphere. For individual depressive diagnosis, 9 studies were evaluated, and 5 for anxiety. Therefore, from the data analyzed in both situations, no diagnosis was representative in preoperative and postoperative cases. In order to estimate the efficacy of surgery in the psychiatry episodes and its relation to seizure control, the risk of depression and anxiety symptoms in epileptic patients need to be determined before surgical procedures. Rigorous preoperative and postoperative evaluation is essential for psychiatry conditions in patients with refractory epilepsy candidates for surgery.
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Affiliation(s)
- Graciane Radaelli
- Brain Institute of Rio Grande do Sul (BraIns), Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Fernanda Majolo
- Brain Institute of Rio Grande do Sul (BraIns), Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil.,Post-graduate Program in Biotechnology, Universidade do Vale do Taquari - Univates, Lajeado, Brazil
| | - Eduardo Leal-Conceição
- Brain Institute of Rio Grande do Sul (BraIns), Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Francisco de Souza Santos
- Brain Institute of Rio Grande do Sul (BraIns), Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Vinícius Escobar
- Brain Institute of Rio Grande do Sul (BraIns), Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Gabriele Goulart Zanirati
- Brain Institute of Rio Grande do Sul (BraIns), Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Mirna Wetters Portuguez
- Brain Institute of Rio Grande do Sul (BraIns), Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil.,School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Fulvio Alexandre Scorza
- Department of Neurology and Neurosurgery, Laboratory of Neuroscience, Federal University of São Paulo, São Paulo, Brazil.,Researcher from CNPq, Porto Alegre, Brazil
| | - Jaderson Costa da Costa
- Brain Institute of Rio Grande do Sul (BraIns), Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil.,School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil.,Researcher from CNPq, Porto Alegre, Brazil
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Can We Anticipate and Prevent the Occurrence of Iatrogenic Psychiatric Events Caused by Anti-seizure Medications and Epilepsy Surgery? Curr Top Behav Neurosci 2021; 55:281-305. [PMID: 33860467 DOI: 10.1007/7854_2021_228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Psychiatric disorders and behavioral manifestations in patients with epilepsy have complex and multifactorial etiologies. The psychotropic properties of anti-seizure medications (ASMs) and psychiatric effects of epilepsy surgery can result in iatrogenic psychiatric symptoms or episodes or can yield a therapeutic effect of underlying psychiatric disorders and have a significant impact on the patients' quality of life. The aims of this chapter are to review the available evidence of psychotropic properties of ASMs, which may be responsible for iatrogenic psychiatric symptoms and/or disorders. Moreover, the several aspects associated with the impact of epilepsy surgery on the possible improvement/development of psychiatric disorders were addressed.
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Figueiredo NSVD, Cavalcanti MM, Gaça LB, Noffs MHDS, Sousa AVM, Alonso NB, Mazetto L, de Araújo Filho GM, Yacubian EMT, Guilhoto LM. Neuropsychological findings related to the presence of pre-surgical comorbid depression in Latin-American patients with mesial temporal lobe epilepsy and hippocampal sclerosis. Seizure 2020; 81:96-103. [PMID: 32771825 DOI: 10.1016/j.seizure.2020.07.031] [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: 01/22/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To evaluate the neuropsychological findings related to the presence of pre-surgical comorbid depression in Latin-American patients with mesial temporal lobe epilepsy (MTLE) and unilateral hippocampal sclerosis (HS). METHOD Patients with drug-resistant MTLE and unilateral, left (L-) or right (R-) HS were studied. To diagnose depression, psychiatrists with expertise in epilepsy applied a semi-structured interview based on DSM. The depression group (DG) included patients with a psychiatric diagnosis in addition to a Beck Depression Inventory (BDI) score >16 points, and the non-depression group (NDG) included those without this diagnosis and with a BDI score ≤16. We analysed two clusters of neuropsychological tests, which evaluated memory (Complex Rey Figure III, Logical Memory II and RAVLT VII) and attention plus executive functions (Stroop I/II/III and Trail Making A/B). Moreover, we calculated the z-scores (Zs) using a local control group. The DG was compared to the NDG, independently and according to the HS side, using non-parametrical analyses. Due to the multivariate analysis, the p-value was corrected by applyingpost hoc Bonferroni adjustment. RESULTS We analysed 65 patients. The NDG included 51 (78.4 %) patients, and the DG included 14 (21.5 %) patients. Pre-surgical comorbid depression occurred in eight patients with L- (n = 29) and in six patients with R-MTLE-HS (n = 36). All of these groups had similar gender, age, IQs, and years of schooling. Compared to the healthy subjects, the L-MTLE-HS patients had lower Zs in verbal episodic memory tests [Logical Memory II (p < 0.001), and RAVLT VII (p < 0.001)], and the R-MTLE-HS patients had lower scores in visual episodic memory [Complex Rey Figure III (p < 0.001)]. In the analysis of the DGvs. NDG, there were no differences in the clusters of tests of memory or in those of attention and executive functions. Moreover, when we analysed the patients according to HS side, no neuropsychological difference was observed in the DG and NDG in terms of L- and R-MTLE-HS. CONCLUSIONS The patients with MTLE and unilateral HS in this study showed no differences in memory, attention and executive functions in relation to the presence of pre-surgical comorbid depression and independently of HS side. In this series from Latin-America, this psychiatric comorbidity did not affect cognition more than epilepsy alone.
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Affiliation(s)
- Nathália Stela Visoná de Figueiredo
- Epilepsy Research and Treatment Unit, Department of Neurology and Neurosurgery, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil.
| | - Maryane Mendes Cavalcanti
- Epilepsy Research and Treatment Unit, Department of Neurology and Neurosurgery, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| | - Larissa Botelho Gaça
- Epilepsy Research and Treatment Unit, Department of Neurology and Neurosurgery, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| | - Maria Helena da Silva Noffs
- Epilepsy Research and Treatment Unit, Department of Neurology and Neurosurgery, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| | - Arthur Victor Menezes Sousa
- Epilepsy Research and Treatment Unit, Department of Neurology and Neurosurgery, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| | - Neide Barreira Alonso
- Epilepsy Research and Treatment Unit, Department of Neurology and Neurosurgery, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| | - Lenon Mazetto
- Epilepsy Research and Treatment Unit, Department of Neurology and Neurosurgery, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| | - Gerardo Maria de Araújo Filho
- Department of Psychiatry and Medical Psychology, Faculdade de Medicina de São José do Rio Preto (Famerp), São José do Rio Preto, SP, Brazil
| | - Elza Márcia Targas Yacubian
- Epilepsy Research and Treatment Unit, Department of Neurology and Neurosurgery, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| | - Laura Maria Guilhoto
- Epilepsy Research and Treatment Unit, Department of Neurology and Neurosurgery, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
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Novais F, Pestana LC, Loureiro S, Andrea M, Figueira ML, Pimentel J. Psychiatric disorders as predictors of epilepsy surgery outcome. Epilepsy Behav 2019; 100:106513. [PMID: 31639645 DOI: 10.1016/j.yebeh.2019.106513] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 08/21/2019] [Accepted: 08/21/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Our aim was to determine if a history of a mental disorder predicts a worst neurological outcome for patients undergoing epilepsy surgery. METHODS We conducted an ambispective observational study including people with refractory epilepsy who underwent resective surgery. Demographic, psychiatric, and neurological data were collected, before and one year after surgery. Presurgical interviews included a psychiatric evaluation and the determination of prevalent and lifetime psychiatric diagnosis. The one-year postsurgical outcome was classified according to the Engel Outcome Scale. Predictors of postsurgical Engel class were determined using an ordered logistic regression model. RESULTS A lifetime history of any mental disorder was a significant predictor of a higher Engel Class (p = 0.017). CONCLUSION This study shows that psychiatric lifetime diagnoses are associated with worse surgical outcome and highlighted the importance of the inclusion of these diagnoses in the evaluation of the potential success of the surgery.
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Affiliation(s)
- Filipa Novais
- Department of Neurosciences and Mental Health, Psychiatry Department, Hospital de Santa Maria (CHULN), Portugal; Faculdade de Medicina, Universidade de Lisboa, Portugal.
| | - Luís Câmara Pestana
- Department of Neurosciences and Mental Health, Psychiatry Department, Hospital de Santa Maria (CHULN), Portugal; Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - Susana Loureiro
- Department of Neurosciences and Mental Health, Psychiatry Department, Hospital de Santa Maria (CHULN), Portugal; Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - Mafalda Andrea
- Department of Neurosciences and Mental Health, Psychiatry Department, Hospital de Santa Maria (CHULN), Portugal
| | - Maria Luísa Figueira
- Department of Neurosciences and Mental Health, Psychiatry Department, Hospital de Santa Maria (CHULN), Portugal; Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - José Pimentel
- Department of Neurosciences and Mental Health, Neurology Department, Hospital de Santa Maria (CHULN), Portugal; Faculdade de Medicina, Universidade de Lisboa, Portugal
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Abstract
BACKGROUND This is an updated version of the original Cochrane review, published in 2015.Focal epilepsies are caused by a malfunction of nerve cells localised in one part of one cerebral hemisphere. In studies, estimates of the number of individuals with focal epilepsy who do not become seizure-free despite optimal drug therapy vary between at least 20% and up to 70%. If the epileptogenic zone can be located, surgical resection offers the chance of a cure with a corresponding increase in quality of life. OBJECTIVES The primary objective is to assess the overall outcome of epilepsy surgery according to evidence from randomised controlled trials.Secondary objectives are to assess the overall outcome of epilepsy surgery according to non-randomised evidence, and to identify the factors that correlate with remission of seizures postoperatively. SEARCH METHODS For the latest update, we searched the following databases on 11 March 2019: Cochrane Register of Studies (CRS Web), which includes the Cochrane Epilepsy Group Specialized Register and the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid, 1946 to March 08, 2019), ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). SELECTION CRITERIA Eligible studies were randomised controlled trials (RCTs) that included at least 30 participants in a well-defined population (age, sex, seizure type/frequency, duration of epilepsy, aetiology, magnetic resonance imaging (MRI) diagnosis, surgical findings), with an MRI performed in at least 90% of cases and an expected duration of follow-up of at least one year, and reporting an outcome related to postoperative seizure control. Cohort studies or case series were included in the previous version of this review. DATA COLLECTION AND ANALYSIS Three groups of two review authors independently screened all references for eligibility, assessed study quality and risk of bias, and extracted data. Outcomes were proportions of participants achieving a good outcome according to the presence or absence of each prognostic factor of interest. We intended to combine data with risk ratios (RRs) and 95% confidence intervals (95% CIs). MAIN RESULTS We identified 182 studies with a total of 16,855 included participants investigating outcomes of surgery for epilepsy. Nine studies were RCTs (including two that randomised participants to surgery or medical treatment (99 participants included in the two trials received medical treatment)). Risk of bias in these RCTs was unclear or high. Most of the remaining 173 non-randomised studies followed a retrospective design. We assessed study quality using the Effective Public Health Practice Project (EPHPP) tool and determined that most studies provided moderate or weak evidence. For 29 studies reporting multivariate analyses, we used the Quality in Prognostic Studies (QUIPS) tool and determined that very few studies were at low risk of bias across domains.In terms of freedom from seizures, two RCTs found surgery (n = 97) to be superior to medical treatment (n = 99); four found no statistically significant differences between anterior temporal lobectomy (ATL) with or without corpus callosotomy (n = 60), between subtemporal or transsylvian approach to selective amygdalohippocampectomy (SAH) (n = 47); between ATL, SAH and parahippocampectomy (n = 43) or between 2.5 cm and 3.5 cm ATL resection (n = 207). One RCT found total hippocampectomy to be superior to partial hippocampectomy (n = 70) and one found ATL to be superior to stereotactic radiosurgery (n = 58); and another provided data to show that for Lennox-Gastaut syndrome, no significant differences in seizure outcomes were evident between those treated with resection of the epileptogenic zone and those treated with resection of the epileptogenic zone plus corpus callosotomy (n = 43). We judged evidence from the nine RCTs to be of moderate to very low quality due to lack of information reported about the randomised trial design and the restricted study populations.Of the 16,756 participants included in this review who underwent a surgical procedure, 10,696 (64%) achieved a good outcome from surgery; this ranged across studies from 13.5% to 92.5%. Overall, we found the quality of data in relation to recording of adverse events to be very poor.In total, 120 studies examined between one and eight prognostic factors in univariate analysis. We found the following prognostic factors to be associated with a better post-surgical seizure outcome: abnormal pre-operative MRI, no use of intracranial monitoring, complete surgical resection, presence of mesial temporal sclerosis, concordance of pre-operative MRI and electroencephalography, history of febrile seizures, absence of focal cortical dysplasia/malformation of cortical development, presence of tumour, right-sided resection, and presence of unilateral interictal spikes. We found no evidence that history of head injury, presence of encephalomalacia, presence of vascular malformation, and presence of postoperative discharges were prognostic factors of outcome.Twenty-nine studies reported multi-variable models of prognostic factors, and showed that the direction of association of factors with outcomes was generally the same as that found in univariate analyses.We observed variability in many of our analyses, likely due to small study sizes with unbalanced group sizes and variation in the definition of seizure outcome, the definition of prognostic factors, and the influence of the site of surgery AUTHORS' CONCLUSIONS: Study design issues and limited information presented in the included studies mean that our results provide limited evidence to aid patient selection for surgery and prediction of likely surgical outcomes. Future research should be of high quality, follow a prospective design, be appropriately powered, and focus on specific issues related to diagnostic tools, the site-specific surgical approach, and other issues such as extent of resection. Researchers should investigate prognostic factors related to the outcome of surgery via multi-variable statistical regression modelling, where variables are selected for modelling according to clinical relevance, and all numerical results of the prognostic models are fully reported. Journal editors should not accept papers for which study authors did not record adverse events from a medical intervention. Researchers have achieved improvements in cancer care over the past three to four decades by answering well-defined questions through the conduct of focused RCTs in a step-wise fashion. The same approach to surgery for epilepsy is required.
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Affiliation(s)
- Siobhan West
- Royal Manchester Children's HospitalDepartment of Paediatric NeurologyHathersage RoadManchesterUKM13 0JH
| | - Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Jennifer Cotton
- The Clatterbridge Cancer Centre NHS Foundation TrustWirralUK
| | - Sacha Gandhi
- NHS Ayrshire and ArranDepartment of General SurgeryAyrUKKA6 6DX
| | - Jennifer Weston
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
| | - Ajay Sudan
- Royal Manchester Children's HospitalDepartment of Paediatric NeurologyHathersage RoadManchesterUKM13 0JH
| | - Roberto Ramirez
- Royal Manchester Children's HospitalHospital RoadPendleburyManchesterUKM27 4HA
| | - Richard Newton
- Royal Manchester Children's HospitalDepartment of Paediatric NeurologyHathersage RoadManchesterUKM13 0JH
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Pope RA, Thompson PJ, Rantell K, Stretton J, Wright MA, Foong J. Frontal lobe dysfunction as a predictor of depression and anxiety following temporal lobe epilepsy surgery. Epilepsy Res 2019; 152:59-66. [DOI: 10.1016/j.eplepsyres.2019.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 03/05/2019] [Accepted: 03/09/2019] [Indexed: 11/26/2022]
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Lebedeva AV, Avedisova AS, Kustov GV, Gersamiya AG, Kaymovskiy IL, Rider FK, Trifonov IS, Pashnin EV, Malkhasyan EA, Guekht AB, Krylov VV. [Prognosis for surgical treatment of pharmacoresistant epilepsy: the role of mental and cognitive disorders]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 118:27-36. [PMID: 30698541 DOI: 10.17116/jnevro201811810227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This review focuses on the role of mental and cognitive disorders in the prognosis for surgical treatment of pharmacoresistant epilepsy. The authors analyze historical aspects of the surgical treatment of epilepsy and present current data on the prognosis of operative intervention with respect to seizure control, cognitive functioning, and psychiatric disorders. The psychiatrist's role in the structure of preoperative and postoperative management of patients is considered.
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Affiliation(s)
- A V Lebedeva
- Moscow Research and Clinical Center for Neuropsychiatry of the Healthcare Department, Moscow, Russia; Pirogov Russian National Research Medical University, Moscow, Russia
| | - A S Avedisova
- Moscow Research and Clinical Center for Neuropsychiatry of the Healthcare Department, Moscow, Russia; Serbsky Federal Medical Research Center for Psychiatry and Narcology, Moscow, Russia
| | - G V Kustov
- Moscow Research and Clinical Center for Neuropsychiatry of the Healthcare Department, Moscow, Russia
| | - A G Gersamiya
- Moscow Research and Clinical Center for Neuropsychiatry of the Healthcare Department, Moscow, Russia
| | | | - F K Rider
- Moscow Research and Clinical Center for Neuropsychiatry of the Healthcare Department, Moscow, Russia
| | - I S Trifonov
- Evdokimov Moscow State University of Medical Dentisitry, Moscow, Russia
| | - E V Pashnin
- Moscow Research and Clinical Center for Neuropsychiatry of the Healthcare Department, Moscow, Russia
| | - E A Malkhasyan
- Moscow Research and Clinical Center for Neuropsychiatry of the Healthcare Department, Moscow, Russia
| | - A B Guekht
- Moscow Research and Clinical Center for Neuropsychiatry of the Healthcare Department, Moscow, Russia; Pirogov Russian National Research Medical University, Moscow, Russia
| | - V V Krylov
- Evdokimov Moscow State University of Medical Dentisitry, Moscow, Russia; Sklifosovsky Research Institute of Emergensy Medicine, Moscow, Russia
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Presurgical depression and anxiety are not associated with worse epilepsy surgery outcome five years postoperatively. Epilepsy Behav 2018; 83:7-12. [PMID: 29631157 DOI: 10.1016/j.yebeh.2018.01.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 01/29/2018] [Accepted: 01/29/2018] [Indexed: 01/25/2023]
Abstract
PURPOSE Anxiety and depression have been associated with poor seizure control after epilepsy surgery. This study explored the effect of presurgical anxiety or depression on two- and five-year seizure control outcomes. METHODS Adult subjects were enrolled between 1996 and 2001 in a multicenter prospective study to evaluate outcomes of resective epilepsy surgery. A Poisson regression was used to analyze the association of depression and anxiety with surgical outcome, while adjusting for gender, age, ethnicity, number of years with seizures, and presence of mesial temporal sclerosis. RESULTS The relative risk (RR) of presurgical depression on two-year seizure-free outcome in this cohort is 1.12 (95% confidence interval (CI), 0.84-1.49) and 1.06 (CI, 0.73-1.55) on five-year seizure free outcome. The RR of presurgical anxiety on two-year seizure outcome is 0.73 (CI, 0.50-1.07) and 0.70 (CI, 0.43-1.17) on five-year seizure outcome. When including Engel classes I and II, the RRs of presurgical depression, anxiety, or both two years after surgery were 0.96 (p=0.59), 0.73 (p<0.05), and 0.97 (p=0.70), respectively, and they were 0.97 (p=0.82), 0.84 (p=0.32), and 0.89 (p=0.15), respectively, five years after surgery. Only presurgical anxiety was associated with worse epilepsy surgery outcome two year after surgery but not at five years postsurgery. Depression was not a risk factor for poor epilepsy surgical outcome in the long term. CONCLUSION These findings from a prospective study that utilized a standardized protocol for psychiatric and seizure outcome assessment suggest that presurgical mood disorders have no substantial impact on postsurgical seizure outcome for up to five years after surgery.
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Koch-Stoecker SC, Bien CG, Schulz R, May TW. Psychiatric lifetime diagnoses are associated with a reduced chance of seizure freedom after temporal lobe surgery. Epilepsia 2017; 58:983-993. [PMID: 28378900 DOI: 10.1111/epi.13736] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2017] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To examine whether psychiatric comorbidity is a predictor of long-term seizure outcome following temporal lobe epilepsy surgery. METHODS A sample of 434 adult patients who received temporal lobe resection to treat epilepsy between 1991 and 2009 and were psychiatrically assessed before surgery were followed for 2 years to assess seizure outcome. Stepwise multivariate logistic regression analyses were used to assess the impact of psychiatric variables on complete seizure freedom (Engel class IA), and freedom from disabling seizures (Engel class I). Lifetime histories of three psychiatric syndromes (PS: psychosis; depression; other) and five personality disorders (PD: DSM-IV Clusters A, B, and C; organic personality disorder; other) were considered as predictors, complemented by age at onset, duration of epilepsy, type of lesion (mesiotemporal sclerosis vs. other), and year of surgery. RESULTS Seizure-freedom rates were significantly higher (p < 0.001) in patients with no history of PS or PD (N = 138; Engel class IA: 61.6%; Engel class I: 87.7%) than in those with any PS or PD (N = 296; Engel class IA: 39.5%; Engel class I: 58.8%). Particularly low seizure-freedom rates were found in patients with a diagnosis of psychosis (N = 32, Engel class IA: 21.9%; Engel class I: 40.6%), organic PD (N = 48, Engel class IA: 25.0%; Engel class I: 35.4%) or a double diagnosis of PS plus PD (N = 97; Engel class IA: 27.8%; Engel class I: 45.5%). No other variables emerged as significant risk factors in multivariate logistic regression analyses. SIGNIFICANCE Patients with and without psychiatric comorbidities can benefit from temporal lobe epilepsy surgery; however, psychiatric comorbidities are negatively associated with postoperative seizure-freedom rates. Surgical outcome is related to the type and extent of preoperative psychiatric morbidity, which underscores the prognostic value of presurgical psychiatric evaluation. The data support the argument that there are common pathogenetic mechanisms underlying both epilepsy and psychiatric conditions.
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Affiliation(s)
- Steffi C Koch-Stoecker
- Department of Psychiatry and Psychotherapy, Evangelical Clinic Bethel, Bielefeld, Germany
| | | | - Reinhard Schulz
- Epilepsy Center Bethel, Krankenhaus Mara, Bielefeld, Germany
| | - Theodor W May
- Society for Epilepsy Research, Epilepsy Center Bethel, Bielefeld, Germany
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Abstract
BACKGROUND Focal epilepsies are caused by a malfunction of nerve cells localised in one part of one cerebral hemisphere. In studies, estimates of the number of individuals with focal epilepsy who do not become seizure-free despite optimal drug therapy vary according to the age of the participants and which focal epilepsies are included, but have been reported as at least 20% and in some studies up to 70%. If the epileptogenic zone can be located surgical resection offers the chance of a cure with a corresponding increase in quality of life. OBJECTIVES The primary objective is to assess the overall outcome of epilepsy surgery according to evidence from randomised controlled trials.The secondary objectives are to assess the overall outcome of epilepsy surgery according to non-randomised evidence and to identify the factors that correlate to remission of seizures postoperatively. SEARCH METHODS We searched the Cochrane Epilepsy Group Specialised Register (June 2013), the Cochrane Central Register of Controlled Trials (CENTRAL 2013, Issue 6), MEDLINE (Ovid) (2001 to 4 July 2013), ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) for relevant trials up to 4 July 2013. SELECTION CRITERIA Eligible studies were randomised controlled trials (RCTs), cohort studies or case series, with either a prospective and/or retrospective design, including at least 30 participants, a well-defined population (age, sex, seizure type/frequency, duration of epilepsy, aetiology, magnetic resonance imaging (MRI) diagnosis, surgical findings), an MRI performed in at least 90% of cases and an expected duration of follow-up of at least one year, and reporting an outcome relating to postoperative seizure control. DATA COLLECTION AND ANALYSIS Three groups of two review authors independently screened all references for eligibility, assessed study quality and risk of bias, and extracted data. Outcomes were proportion of participants achieving a good outcome according to the presence or absence of each prognostic factor of interest. We intended to combine data with risk ratios (RR) and 95% confidence intervals. MAIN RESULTS We identified 177 studies (16,253 participants) investigating the outcome of surgery for epilepsy. Four studies were RCTs (including one that randomised participants to surgery or medical treatment). The risk of bias in the RCTs was unclear or high, limiting our confidence in the evidence that addressed the primary review objective. Most of the remaining 173 non-randomised studies had a retrospective design; they were of variable size, were conducted in a range of countries, recruited a wide demographic range of participants, used a wide range of surgical techniques and used different scales used to measure outcomes. We performed quality assessment using the Effective Public Health Practice Project (EPHPP) tool and determined that most studies provided moderate or weak evidence. For 29 studies reporting multivariate analyses we used the Quality in Prognostic Studies (QUIPS) tool and determined that very few studies were at low risk of bias across the domains.In terms of freedom from seizures, one RCT found surgery to be superior to medical treatment, two RCTs found no statistically significant difference between anterior temporal lobectomy (ATL) with or without corpus callosotomy or between 2.5 cm or 3.5 cm ATL resection, and one RCT found total hippocampectomy to be superior to partial hippocampectomy. We judged the evidence from the four RCTs to be of moderate to very low quality due to the lack of information reported about the randomised trial design and the restricted study populations.Of the 16,253 participants included in this review, 10,518 (65%) achieved a good outcome from surgery; this ranged across studies from 13.5% to 92.5%. Overall, we found the quality of data in relation to the recording of adverse events to be very poor.In total, 118 studies examined between one and eight prognostic factors in univariate analysis. We found the following prognostic factors to be associated with a better post-surgical seizure outcome: an abnormal pre-operative MRI, no use of intracranial monitoring, complete surgical resection, presence of mesial temporal sclerosis, concordance of pre-operative MRI and electroencephalography (EEG), history of febrile seizures, absence of focal cortical dysplasia/malformation of cortical development, presence of tumour, right-sided resection and presence of unilateral interictal spikes. We found no evidence that history of head injury, presence of encephalomalacia, presence of vascular malformation or presence of postoperative discharges were prognostic factors of outcome. We observed variability between studies for many of our analyses, likely due to the small study sizes with unbalanced group sizes, variation in the definition of seizure outcome, definition of the prognostic factor and the influence of the site of surgery, all of which we observed to be related to postoperative seizure outcome. Twenty-nine studies reported multivariable models of prognostic factors and the direction of association of factors with outcome was generally the same as found in the univariate analyses. However, due to the different multivariable analysis approaches and selective reporting of results, meaningful comparison of multivariate analysis with univariate meta-analysis is difficult. AUTHORS' CONCLUSIONS The study design issues and limited information presented in the included studies mean that our results provide limited evidence to aid patient selection for surgery and prediction of likely surgical outcome. Future research should be of high quality, have a prospective design, be appropriately powered and focus on specific issues related to diagnostic tools, the site-specific surgical approach and other issues such as the extent of resection. Prognostic factors related to the outcome of surgery should be investigated via multivariable statistical regression modelling, where variables are selected for modelling according to clinical relevance and all numerical results of the prognostic models are fully reported. Protocols should include pre- and postoperative measures of speech and language function, cognition and social functioning along with a mental state assessment. Journal editors should not accept papers where adverse events from a medical intervention are not recorded. Improvements in the development of cancer care over the past three to four decades have been achieved by answering well-defined questions through the conduct of focused RCTs in a step-wise fashion. The same approach to surgery for epilepsy is required.
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Affiliation(s)
- Siobhan West
- Department of Paediatric Neurology, Royal Manchester Children's Hospital, Hathersage Road, Manchester, UK, M13 0JH
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Szilágyi T, Száva I, Metz EJ, Mihály I, Orbán-Kis K. Untangling the pathomechanisms of temporal lobe epilepsy—The promise of epileptic biomarkers and novel therapeutic approaches. Brain Res Bull 2014; 109:1-12. [DOI: 10.1016/j.brainresbull.2014.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 08/11/2014] [Accepted: 08/14/2014] [Indexed: 12/30/2022]
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Hecimovic H, Santos J, Price JL, Sheline YI, Mintun MA, Snyder AZ, Christensen JJ, Carter J, Vahle V, Gilliam FG. Severe hippocampal atrophy is not associated with depression in temporal lobe epilepsy. Epilepsy Behav 2014; 34:9-14. [PMID: 24667480 PMCID: PMC4009341 DOI: 10.1016/j.yebeh.2014.02.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 02/19/2014] [Accepted: 02/27/2014] [Indexed: 11/19/2022]
Abstract
Depression in temporal lobe epilepsy (TLE) is common, is a strong predictor of subjective disability, and may have unique pathophysiological characteristics. Previous studies showed that reduced hippocampal volume is associated with significant depressive symptoms in patients with TLE. We utilized regions of interest analysis of high-resolution brain MRI and a reliable and valid measure of depressive symptoms to evaluate 28 consecutive adult subjects with video-EEG-confirmed TLE. Regions of interest were based on prior human and animal studies of mood and behavioral dysfunction. Forty-three percent of the entire group had significant symptoms of depression, defined by a Beck Depression Inventory (BDI) score of greater than 15. Total hippocampal volumes were significantly smaller in the group with BDI<15, (p<0.007). None of the subjects in the quartile with the smallest left hippocampal volume had a BDI score greater than 15 compared with 57% of the subjects in the upper three quartiles (p<0.008). No other limbic brain structures (amygdala, subcallosal gyrus, subgenual gyrus, gyrus rectus), or total cerebral volume were associated with depressive symptoms. Adequate hippocampal integrity may be necessary to maintain depression symptoms in mesial temporal lobe epilepsy. This finding also supports the possibility of a unique mechanism for depression in mesial temporal lobe epilepsy, such as hyperexcitable neuronal influence on the limbic network.
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Affiliation(s)
| | - Juan Santos
- Departamento de Psiquiatría, Universidad Maimónides, Buenos Aires, Argentina
| | - Joseph L Price
- Department of Anatomy and Neurobiology, Washington University, St. Louis, MO, USA
| | - Yvette I Sheline
- Department of Neurology, Washington University, St. Louis, MO, USA; Department of Psychiatry, Washington University, St. Louis, MO, USA; Department of Radiology, Washington University, St. Louis, MO, USA
| | - Mark A Mintun
- Department of Psychiatry, Washington University, St. Louis, MO, USA; Department of Radiology, Washington University, St. Louis, MO, USA
| | - Abraham Z Snyder
- Department of Radiology, Washington University, St. Louis, MO, USA
| | | | - Jewell Carter
- Department of Neurology, Washington University, St. Louis, MO, USA
| | - Victoria Vahle
- Department of Neurology, Washington University, St. Louis, MO, USA
| | - Frank G Gilliam
- Department of Neurology, Penn State University, Hershey, PA, USA
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Helmstaedter C, Aldenkamp AP, Baker GA, Mazarati A, Ryvlin P, Sankar R. Disentangling the relationship between epilepsy and its behavioral comorbidities - the need for prospective studies in new-onset epilepsies. Epilepsy Behav 2014; 31:43-7. [PMID: 24333577 DOI: 10.1016/j.yebeh.2013.11.010] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 11/04/2013] [Accepted: 11/09/2013] [Indexed: 12/20/2022]
Abstract
It has been long recognized that there is more to epilepsy than seizures. The prevalence of such neurobehavioral abnormalities as cognitive and mood disorders, autism spectrum disorder, and attention deficit and hyperactivity disorder (ADHD) is significantly higher among patients with epilepsy than in the general population. A long-held view that comorbidities of epilepsy represent mere epiphenomena of seizures has undergone substantial transformation during the past decade, as emerging clinical evidence and experimental evidence suggest the involvement of specific neurobiological mechanisms in the evolution of neurobehavioral deficits in patients with epilepsy. Developmental aspects of both epilepsy and its comorbidities, as well as the frequently reported reciprocal connection between these disorders, both add other dimensions to the already complex problem. In light of progress in effective seizure management in many patients with epilepsy, the importance of neurobehavioral comorbidities has become acute, as the latter are frequently more detrimental to patients' quality of life compared with seizures. This calls for a serious increase in efforts to effectively predict, manage, and ideally cure these comorbidities. Coordinated multicenter clinical, translational, and basic research studies focusing on epidemiology, neuropsychology, neurophysiology, imaging, genetics, epigenetics, and pharmacology of neurobehavioral comorbidities of epilepsy are absolutely instrumental for ensuring tangible progress in the field. Clinical research should focus more on new-onset epilepsy and put particular emphasis on longitudinal studies in large cohorts of patients and groups at risk, while translational research should primarily focus on the development of valid preclinical systems which would allow investigating the fundamental mechanism of epilepsy comorbidities. The final goal of the described research efforts would lie in producing an armamentarium of evidence-based diagnostic tools and therapeutic interventions which would at minimum mitigate and at maximum prevent or abolish neurobehavioral comorbidities of epilepsy and, thus, improve the quality of life of those patients with epilepsy who suffer from the said comorbidities.
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Affiliation(s)
| | - A P Aldenkamp
- Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands; Dept of Neurology Maastricht University Medical Centre, Faculty of Electrical Engineering, University of Technology, Eindhoven, The Netherlands
| | - G A Baker
- Division of Neurosciences, University of Liverpool, Liverpool, UK
| | - A Mazarati
- Department of Pediatrics, Neurology Division, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1752, USA
| | - Ph Ryvlin
- Department of Functional Neurology and Epileptology, Neurological Hospital, CTRS-INSERM IDEE, Institut Des Epilepsies de l'Enfant et de l'adolescent, Hospices Civils de Lyon, INSERM U821, Universite Claude Bernard Lyon 1, Lyon, France
| | - R Sankar
- Department of Pediatrics, Neurology Division, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1752, USA
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