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Fava A, Lisi SV, Mauro L, Morace R, Ciavarro M, Gorgoglione N, Petrella G, Quarato PP, Di Gennaro G, di Russo P, Esposito V. The anterior sylvian point as a reliable landmark for the anterior temporal lobectomy in mesial temporal lobe epilepsy: technical note, case series, and cadaveric dissection. Front Med (Lausanne) 2024; 11:1352321. [PMID: 39015783 PMCID: PMC11250084 DOI: 10.3389/fmed.2024.1352321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 05/29/2024] [Indexed: 07/18/2024] Open
Abstract
Introduction Mesial temporal lobe epilepsy (MTLE) is one of the most prevalent forms of focal epilepsy in surgical series, particularly among adults. Over the decades, different surgical strategies have been developed to address drug-resistant epilepsy while safeguarding neurological and cognitive functions. Among these strategies, anterior temporal lobectomy (ATL), involving the removal of the temporal pole and mesial temporal structures, has emerged as a widely employed technique. Numerous modifications have been proposed to mitigate the risks associated with aphasia, cognitive issues, and visual field defects. Methods Our approach is elucidated through intraoperative and cadaveric dissections, complemented by neuroradiological and cadaveric measurements of key anatomical landmarks. A retrospective analysis of patients with drug-resistant MTLE who were treated using our ATL technique at IRCCS Neuromed (Pozzilli) is presented. Results A total of 385 patients were treated with our ATL subpial technique anatomically focused on the anterior Sylvian point (ASyP). The mean FU was 9.9 ± 5.4 years (range 1-24). In total, 84%of patients were free of seizures during the last follow-up, with no permanent neurological deficits. Transient defects were as follows: aphasia in 3% of patients, visual field defects in 2% of patients, hemiparesis in 2% of patients, and cognitive/memory impairments in 0.8% of patients. In cadaveric dissections, the ASyP was found at a mean distance from the temporal pole of 3.4 ± 0.2 cm (range 3-3.8) at the right side and 3.5 ± 0.2 cm (3.2-3.9) at the left side. In neuroimaging, the ASyP resulted anterior to the temporal horn tip in all cases at a mean distance of 3.2 ± 0.3 mm (range 2.7-3.6) at the right side and 3.5 ± 0.4 mm (range 2.8-3.8) at the left side. Discussion To the best of our knowledge, this study first introduces the ASyP as a reliable and reproducible cortical landmark to perform the ATL to overcome the patients' variabilities, the risk of Meyer's loop injury, and the bias of intraoperative measurements. Our findings demonstrate that ASyP can be a safe cortical landmark that is useful in MTLE surgery because it is constantly present and is anterior to risky temporal regions such as temporal horn and language networks.
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Affiliation(s)
- Arianna Fava
- IRCCS Neuromed, Pozzilli, Italy
- Laboratory of Neuroanatomy “G. Cantore”, IRCCS Neuromed, Pozzilli, Italy
- Department of Human Neurosciences, University of Rome “La Sapienza”, Rome, Italy
| | | | - Luigi Mauro
- Laboratory of Neuroanatomy “G. Cantore”, IRCCS Neuromed, Pozzilli, Italy
| | | | | | - Nicola Gorgoglione
- IRCCS Neuromed, Pozzilli, Italy
- Laboratory of Neuroanatomy “G. Cantore”, IRCCS Neuromed, Pozzilli, Italy
| | | | | | | | - Paolo di Russo
- IRCCS Neuromed, Pozzilli, Italy
- Laboratory of Neuroanatomy “G. Cantore”, IRCCS Neuromed, Pozzilli, Italy
| | - Vincenzo Esposito
- IRCCS Neuromed, Pozzilli, Italy
- Laboratory of Neuroanatomy “G. Cantore”, IRCCS Neuromed, Pozzilli, Italy
- Department of Human Neurosciences, University of Rome “La Sapienza”, Rome, Italy
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Leal-Conceição E, Muxfeldt Bianchin M, Vendramini Borelli W, Spencer Escobar V, Januário de Oliveira L, Bernardes Wagner M, Palmini A, Paglioli E, Radaelli G, Costa da Costa J, Wetters Portuguez M. Memory changes in patients with hippocampal sclerosis submitted to surgery to treat mesial temporal lobe epilepsy. Neurologia 2024; 39:399-407. [PMID: 38830719 DOI: 10.1016/j.nrleng.2021.07.007] [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: 04/06/2021] [Accepted: 07/12/2021] [Indexed: 06/05/2024] Open
Abstract
PURPOSE This study was performed with the purpose of analysing the relationship between epileptological and surgical variables and post-operative memory performance, following surgery for refractory mesial temporal lobe epilepsy (MTLE) due to hippocampal sclerosis (HS). METHODS Logical memory (LM) and visual memory (VM) scores for immediate and late follow-up of 201 patients operated for MTLE/HS were reviewed. Scores were standardized with a control group of 54 healthy individuals matched for age and education. The Reliable Change Index (RCI) was calculated to verify individual memory changes for late LM and VM scores. A multiple linear regression analysis was carried out with the RCI, using LM and VM scores as well as the clinical variables. RESULTS A total of 112 (56%) patients had right HS. The RCI of the right HS group demonstrated that 6 (7%) patients showed improvement while 5 (6%) patients showed decreased scores in late LM; for late VM, 7 (8%) patients presented improvement, and 2 (3%) patients showed poorer scores. RCI of the left HS group showed that 3 (3%) individuals showed improved scores, while scores of 5 (4%) patients worsened for late LM; for late VM, 3 (3%) patients presented higher scores and 6 (5%) showed lower scores. Left HS and advanced age at onset of the first epileptic seizure were predictors of late LM loss (p<.05). CONCLUSION Left MTLE/HS and seizure onset at advanced ages were predictive factors for the worsening of late LM. We observed poorer baseline LM function in the left HS group and improvement of LM in some patients who had resection of the right MTL. Patients in the right HS group showed a higher percentage of reliable post-operative improvement for both VM and LM scores.
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Affiliation(s)
- E Leal-Conceição
- Epilepsy Surgery Program, Neurology, Neurosurgery and Neuropsychology Services, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil; Brain Institute of Rio Grande do Sul (BraIns), PUCRS, Porto Alegre, Brazil; Faculty of Medicine, UFRGS, Porto Alegre, Brazil.
| | - M Muxfeldt Bianchin
- Neurology Services, Hospital de Clínicas, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil; Faculty of Medicine, UFRGS, Porto Alegre, Brazil
| | - W Vendramini Borelli
- Brain Institute of Rio Grande do Sul (BraIns), PUCRS, Porto Alegre, Brazil; School of Medicine, PUCRS, Porto Alegre, Brazil
| | - V Spencer Escobar
- Epilepsy Surgery Program, Neurology, Neurosurgery and Neuropsychology Services, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil; Brain Institute of Rio Grande do Sul (BraIns), PUCRS, Porto Alegre, Brazil
| | | | | | - A Palmini
- Epilepsy Surgery Program, Neurology, Neurosurgery and Neuropsychology Services, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil; Brain Institute of Rio Grande do Sul (BraIns), PUCRS, Porto Alegre, Brazil; School of Medicine, PUCRS, Porto Alegre, Brazil
| | - E Paglioli
- Epilepsy Surgery Program, Neurology, Neurosurgery and Neuropsychology Services, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil; School of Medicine, PUCRS, Porto Alegre, Brazil
| | - G Radaelli
- Brain Institute of Rio Grande do Sul (BraIns), PUCRS, Porto Alegre, Brazil; School of Medicine, PUCRS, Porto Alegre, Brazil
| | - J Costa da Costa
- Epilepsy Surgery Program, Neurology, Neurosurgery and Neuropsychology Services, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil; Brain Institute of Rio Grande do Sul (BraIns), PUCRS, Porto Alegre, Brazil; School of Medicine, PUCRS, Porto Alegre, Brazil
| | - M Wetters Portuguez
- Epilepsy Surgery Program, Neurology, Neurosurgery and Neuropsychology Services, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil; Brain Institute of Rio Grande do Sul (BraIns), PUCRS, Porto Alegre, Brazil; School of Medicine, PUCRS, Porto Alegre, Brazil
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Câmara B, Fava A, Matano F, Okano A, Ronconi D, Silva Costa B, Gadelha Figueiredo E, Chassoux F, Devaux B, Froelich S. Transuncal Selective Amygdalohippocampectomy by an Inferolateral Preseptal Endoscopic Approach Through Inferior Eyelid Conjunctival Incision: An Anatomic Study. Oper Neurosurg (Hagerstown) 2023; 25:199-208. [PMID: 37133253 DOI: 10.1227/ons.0000000000000728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/23/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Transorbital endoscopic approaches have been described for pathologies of anterior and middle fossae. Standard lateral orbitotomy gives access to mesial temporal lobe, but the axis of work is partially obscured by the temporal pole and working corridor is limited. OBJECTIVE To evaluate the usefulness of an inferolateral orbitotomy to provide a more direct corridor to perform a transuncal selective amygdalohippocampectomy. METHODS Three adult cadaveric specimens were used for a total of 6 dissections. A step-by-step description and illustration of the transuncal corridor for a selective amygdalohippocampectomy were performed using the inferolateral orbitotomy through an inferior eyelid conjunctival incision. The anatomic landmarks were demonstrated in detail. Orbitotomies and angles of work were measured from computed tomography scans, and the area of resection was illustrated by postdissection MRI. RESULTS Inferior eyelid conjunctival incision was made for exposure of the inferior orbital rim. Inferolateral transorbital approach was performed to access the transuncal corridor. Endoscopic selective amygdalohippocampectomy was performed through the entorhinal cortex without damage to the temporal neocortex or Meyer's loop. The mean horizontal diameter of the osteotomy was 14.4 mm, and the vertical one was 13.6 mm. The mean angles of work were 65° and 35.5° in the axial and sagittal planes, respectively. Complete amygdalohippocampectomy was achieved in all 6 dissections. CONCLUSION Transuncal selective amygdalohippocampectomy was feasible in cadaveric specimens using the inferolateral transorbital endoscopic approach avoiding damage to the temporal neocortex and Meyer's loop. The inferior eyelid conjunctival incision may result in an excellent cosmetic outcome.
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Affiliation(s)
- Breno Câmara
- Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
- Laboratoire de neurochirurgie expérimentale, Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Arianna Fava
- Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
- Laboratoire de neurochirurgie expérimentale, Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Fumihiro Matano
- Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
- Laboratoire de neurochirurgie expérimentale, Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Atsushi Okano
- Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
- Laboratoire de neurochirurgie expérimentale, Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Daniel Ronconi
- Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
- Laboratoire de neurochirurgie expérimentale, Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Bruno Silva Costa
- Hospital Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil
| | | | - Francine Chassoux
- Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Bertrand Devaux
- Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Sébastien Froelich
- Service de Neurochirurgie-Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
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Palmini A. More versus less: the unresolved debate on the best surgical approach to temporal lobe epilepsy with hippocampal sclerosis. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:613-615. [PMID: 37494947 PMCID: PMC10371413 DOI: 10.1055/s-0043-1771265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Affiliation(s)
- André Palmini
- Pontificia Universidade Católica do Rio Grande do Sul, Escola de Medicina, Núcleo de Neurociências Clínicas, Porto Alegre RS, Brazil
- Pontificia Universidade Católica do Rio Grande do Sul, Hospital São Lucas, Serviço de Neurologia & Programa de Cirurgia da Epilepsia, Porto Alegre RS, Brazil
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Almeida LCA, Lobato VA, Santos MDCV, Moraes ACD, Costa BS. Surgical treatment of temporal lobe epilepsy: comparative results of selective amygdalohippocampectomy versus anterior temporal lobectomy from a referral center in Brazil. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:647-655. [PMID: 37494949 PMCID: PMC10658662 DOI: 10.1055/s-0043-1771172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 04/12/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Temporal lobe epilepsy (TLE) is a high prevalence neurological disorder. Surgery has emerged as a promising treatment. OBJECTIVE The objective of this work is to compare the surgical results of anterior temporal lobectomy (ATL) versus selective amygdalohippocampectomy (SAH) in a cohort of 132 patients. METHODS We performed a retrospective study of 146 patients operated for TLE from 2008 to 2019. Initially, 13 patients were excluded from the study due to insufficient medical record data or follow-up loss. One patient was excluded from the analysis of the results due to death in the first postoperative week. We used the ILAE scale to classify seizure control after surgery. In patients with left hippocampal sclerosis, SAH was performed and in right temporal lobe epilepsy, ATL was the approach of choice. RESULTS The mean follow-up time after surgery was 57.2 months (12-137). In our data analysis, we found that the group of patients undergoing ATL had a higher prevalence of being completely seizure-free (ILAE I) (57.1% versus 31%) and a higher rate of satisfactory seizure control (88.6% versus 69.3%) p = 0,006, when compared with patients undergoing SAH. CONCLUSION The literature is still controversial about seizure control concerning the technique used due to the lack of a robust methodology. Our data analysis identified the superiority of ATL over SAH in seizure outcomes. ATL may be the best option for adequately controlling seizures with minimal additional morbidity in countries with a cost limitation for extended propaedeutics.
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Affiliation(s)
| | - Vanessa Alves Lobato
- Santa Casa de Misericórdia de Belo Horizonte, Departamento de Neurologia e
Neurocirurgia, Belo Horizonte MG, Brazil.
| | | | - Aline Curcio de Moraes
- Santa Casa de Misericórdia de Belo Horizonte, Departamento de Neurologia e
Neurocirurgia, Belo Horizonte MG, Brazil.
| | - Bruno Silva Costa
- Santa Casa de Misericórdia de Belo Horizonte, Departamento de Neurologia e
Neurocirurgia, Belo Horizonte MG, Brazil.
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Krámská L, Šroubek J, Česák T, Vojtěch Z. One-year neuropsychological outcome after temporal lobe epilepsy surgery in large Czech sample: Search for factors contributing to memory decline. Surg Neurol Int 2022; 13:248. [PMID: 35855171 PMCID: PMC9282793 DOI: 10.25259/sni_335_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 05/20/2022] [Indexed: 11/05/2022] Open
Abstract
Background: Assessment of cognitive functions is an integral part of the evaluation the efficacy of temporal resections. We studied postoperative neuropsychological changes and factors contributing to worse memory outcomes in patients who experienced a significant decline using reliable change indices. Methods: We prospectively studied 110 patients in whom we indicated anteromesial temporal resection (AMTR) and 46 patients who underwent selective amygdalohippocampectomy (SAHE). We administrated Wechsler Adult Intelligence Scale-Revised, Wechsler Memory Scale-Revised, and the Verbal Fluency Test before and 1 year after the operation. Results: At a group level, we did not observe any statistically significant changes in global, verbal, and visual MQ in either the AMTR or the SAHE group. At an individual level, we found a mean decrease of verbal MQ after left-sided AMTR by −4.43 points (P = 0.01). We detected no significant differences between the left and right side of surgery in the SAHE group. In patients with significant postoperative memory decline, we found either pre-existing extrahippocampal deficits/postoperative complications or incomplete hippocampal resection or a combination of these factors. Conclusion: In addition to the side of surgery, structural integrity and functional adequacy of resected hippocampus and volume of resected tissue and preoperative extrahippocampal lesions/postoperative complications also contribute to postoperative memory decline after temporal lobe epilepsy surgery.
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Affiliation(s)
- Lenka Krámská
- Department of Clinical Psychology, Na Homolce Hospital, Prague, Czech Republic
- Department of Neurology, Epilepsy Center, Na Homolce Hospital, Prague, Czech Republic
| | - Jan Šroubek
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
- Department of Neurosurgery, University Hospital, Hradec Kralove, Czech Republic
| | - Tomáš Česák
- Department of Neurosurgery, University Hospital, Hradec Kralove, Czech Republic
| | - Zdeněk Vojtěch
- Department of Neurology, Epilepsy Center, Na Homolce Hospital, Prague, Czech Republic
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Haslund-Vinding JL, BalslevJørgensen M, Engelmann CM, Ziebell M, Elklit A. Right temporal lobe epilepsy surgery activates suppressed post-traumatic stress disorder 31 years after a robbery. Acta Neurochir (Wien) 2022; 164:549-554. [PMID: 34988707 DOI: 10.1007/s00701-021-05091-9] [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: 06/25/2021] [Accepted: 12/14/2021] [Indexed: 11/01/2022]
Abstract
Hippocampus and amygdala play central roles in the development of post-traumatic stress disorder (PTSD). Changes in neurological structures due to surgery leading to PTSD have previously been reported. In this case, we present a patient that develops PTSD right after epilepsy surgery in the right temporal lobe. The case adds knowledge to the mechanisms of storage of PTSD memories. A 56-year-old male suffering from refractory temporal lobe epilepsy was treated with an anteromesial temporal lobe resection on the right side. A few weeks after the surgery, he developed strong PTSD symptoms. They included flashbacks from a robbery he was subjected to three decades ago when he was 25 years old. In addition, he suffered from hypervigilance, irritability, and avoidance behavior. Psychotherapy eventually eased his symptoms. No previous disorders were recorded. No psychiatry symptoms were present before surgery. This case is one of few reports on the sudden occurrence of PTSD after epilepsy-surgery in the form of right-sided anteromesial temporal lobe resection. The disorder may not have been detected if not included in the Danish Epilepsy-Surgery-Protocol, among them both the pre-surgery psychiatric management and in the post-operative monitoring.
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Abstract
Temporal lobe epilepsy (TLE) is the most common cause of refractory epilepsy amenable for surgical treatment and seizure control. Surgery for TLE is a safe and effective strategy. The seizure-free rate after surgical resection in patients with mesial or neocortical TLE is about 70%. Resective surgery has an advantage over stereotactic radiosurgery in terms of seizure outcomes for mesial TLE patients. Both techniques have similar results for safety, cognitive outcomes, and associated costs. Stereotactic radiosurgery should therefore be seen as an alternative to open surgery for patients with contraindications for or with reluctance to undergo open surgery. Laser interstitial thermal therapy (LITT) has also shown promising results as a curative technique in mesial TLE but needs to be more deeply evaluated. Brain-responsive stimulation represents a palliative treatment option for patients with unilateral or bilateral MTLE who are not candidates for temporal lobectomy or who have failed a prior mesial temporal lobe resection. Overall, despite the expansion of innovative techniques in recent years, resective surgery remains the reference treatment for TLE and should be proposed as the first-line surgical modality. In the future, ultrasound therapies could become a credible therapeutic option for refractory TLE patients.
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Affiliation(s)
- Bertrand Mathon
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Paris, France; Sorbonne University, Paris, France; Paris Brain Institute, Paris, France
| | - Stéphane Clemenceau
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Paris, France
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Velasco AL, Saucedo-Alvarado PE, Alejandre-Sánchez M, Guzmán-Jiménez DE, González-Garcia I, Velasco F. New Horizons in Temporal Lobe Seizure Control. J Clin Neurophysiol 2021; 38:478-484. [PMID: 34261115 DOI: 10.1097/wnp.0000000000000715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY In patients with mesial temporal lobe epilepsy, high-frequency, low-amplitude electrical stimulation (ES) was applied during 3 weeks through contacts of intracranial electrodes that defined the epileptogenic zone. This subacute ES induced cessation of spontaneous seizures, decreased the number of EEG interictal spikes, caused a 10-fold increase in threshold to induce postdischarges, and showed a profound decrease in regional blood flow of the stimulated area in SPECT studies. Autoradiography analysis of surgical specimens from these patients demonstrated increased expression of benzodiazepine receptors and in gamma-aminobutyric acid content, particularly in the parahippocampal cortex. These observations provided evidence of a gamma-aminobutyric acid-mediated antiepileptic effect induced by ES. Several reports of long-term hippocampal ES through internalized neurostimulators have confirmed the antiepileptic effect on mesial temporal lobe-initiated seizures, with preservation of neuropsychological performance, in particular memory functions. The experience of the authors is that the response is optimal in patients without hippocampal sclerosis evidenced by MRI, whereas it is less significant and delayed in patients with hippocampal sclerosis. Other studies reported the best result stimulating through the contacts in the subiculum, the transition between the hippocampus and parahippocampal cortex, that usually escapes to the hippocampal sclerosis. Currently, the effect of ES directed at the subiculum and the parahippocampal cortex in patients with hippocampal sclerosis is under investigation.
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Affiliation(s)
- Ana L Velasco
- Unit for Stereotactic and Functional Neurosurgery, Epilepsy Clinic, Hospital General de México, Mexico City, Mexico
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Pitskhelauri DI, Kudieva ES, Melikyan AG, Vlasov PA, Kamenetskaya MI, Zaitsev OS, Kozlova AB, Eliseeva NM, Shishkina LV, Danilov GV, Nagorskaya IA, Sanikidze AZ, Melnikova-Pitskhelauri TV, Pronin IN, Konovalov AN. [Surgical treatment of drug-resistant epilepsy following hippocampal sclerosis]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:31-40. [PMID: 34714001 DOI: 10.17116/neiro20218505131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Surgery is an effective approach for drug-resistant temporal lobe epilepsy following hippocampal sclerosis. There is still no clear and unanimous opinion about advantages and disadvantages of certain surgical technique. MATERIAL AND METHODS There were 103 surgical interventions in 101 patients. Females prevailed (1.45:1). Age of patients ranged from 16 to 56 years (median 28). Anteromedial temporal lobectomy and selective amygdaloghippocampectomy were performed in 49 (47.6%) and 54 (52.4%) patients, respectively. In the latter group, 30 patients were operated via a 14-mm burr hole-subtemporal approach. Postoperative outcomes were assessed using the Engel grading system. The follow-up period ranged from 2 to 8 years (median 4 years). RESULTS By the 2nd year, Engel class I was observed in 74 (72%) patients, Engel II, III and IV - in 20 (19.4%), 6 (5.8%) and 3 (2.9%) patients, respectively. Engel class I was achieved after anteromedial temporal lobectomy in 68% of cases, selective amygdaloghippocampectomy via standard approaches in 75% of cases, amygdaloghippocampectomy via subtemporal burr hole approach - in 80% of cases. Neurocognitive impairments after anteromedial lobectomy and selective amygdaloghippocampectomy were similar. At the same time, mental disorders de novo prevailed in the group of anteromedial lobectomy (p<0.05). There were no severe visual field disorders after subtemporal burr-hole access. In other cases, these disorders occurred in 36.2% of patients (p<0.05). There were 8 (7.8%) postoperative complications: 5 (10.2%) - after anterior temporal lobectomy, 3 (5.5%) - after selective surgeries via standard approaches. There were no complications after burr-hole surgery. CONCLUSION Selective amygdaloghippocampectomy is not inferior to anteromedial lobectomy. Moreover, this procedure is associated with a lower risk of complications and adverse events.
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Affiliation(s)
| | - E S Kudieva
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - P A Vlasov
- Burdenko Neurosurgical Center, Moscow, Russia.,Center for Epileptology and Neurology, Moscow, Russia
| | | | - O S Zaitsev
- Burdenko Neurosurgical Center, Moscow, Russia.,Privolzhskiy Research Medical University, Nizhniy Novgorod, Russia
| | - A B Kozlova
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | | - G V Danilov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | | | | - I N Pronin
- Burdenko Neurosurgical Center, Moscow, Russia
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Shah A, Lunawat A, Jhawar SS, Goel A, Goel A. White Fiber Correlates of Amygdalohippocampectomy Through the Middle Temporal Gyrus Approach. World Neurosurg 2021; 157:e156-e165. [PMID: 34619404 DOI: 10.1016/j.wneu.2021.09.116] [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: 08/08/2021] [Revised: 09/26/2021] [Accepted: 09/27/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The white fiber and gross anatomy relevant for performing amygdalohippocampectomy through the middle temporal gyrus approach for mesial temporal sclerosis has been depicted by white fiber dissection. METHODS Three previously frozen and formalin fixed cerebral hemispheres were studied. The Klingler method of fiber dissection was used to study the anatomy. The primary tools used were hand-made wooden spatulas, forceps, and microscissors. The anatomy of the amygdala and hippocampus and the landmarks for performing the disconnection during epilepsy surgery are presented. The white fibers at risk during the middle temporal gyrus approach were studied. RESULTS The white fiber tracts at risk during the middle temporal gyrus approach for epilepsy surgery are the fibers of the inferior frontooccipital fasciculus, temporal extension of the anterior commissure, Meyer loop of the optic radiation, and uncinate fasciculus. On the basis of our anatomic dissections, we present a novel entry point into the temporal horn, potentially minimizing injury to the fibers of the sagittal stratum. We also propose novel landmarks to perform the amygdala disconnection in mesial temporal sclerosis. CONCLUSIONS The middle temporal gyrus is a commonly used approach to perform temporal lobectomy and amygdalohippocampectomy for patients with mesial temporal sclerosis. The anatomy relevant to the approach as presented will aid while performing epilepsy surgery.
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Affiliation(s)
- Abhidha Shah
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai
| | - Aditya Lunawat
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai
| | - Sukhdeep Singh Jhawar
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai
| | - Aimee Goel
- Department of Neurosurgery, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Atul Goel
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai; Department of Neurosurgery, Lilavati Hospital and Research Center, Bandra, Mumbai.
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12
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Leal-Conceição E, Muxfeldt Bianchin M, Vendramini Borelli W, Spencer Escobar V, Januário de Oliveira L, Bernardes Wagner M, Palmini A, Paglioli E, Radaelli G, Costa da Costa J, Wetters Portuguez M. Memory changes in patients with hippocampal sclerosis submitted to surgery to treat mesial temporal lobe epilepsy. Neurologia 2021. [DOI: 10.1016/j.nrl.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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13
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Ali R, Englot DJ, Yu H, Naftel R, Haas KF, Konrad PE. Experience From 211 Transcortical Selective Amygdalohippocampectomy Procedures: Relevant Surgical Anatomy and Review of the Literature. Oper Neurosurg (Hagerstown) 2021; 21:181-188. [PMID: 34228100 DOI: 10.1093/ons/opab206] [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: 06/07/2020] [Accepted: 04/27/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Selective amygdalohippocampectomy (SelAH) is designed to treat medically refractory mesial temporal lobe epilepsy with reduced morbidity compared to standard anterior temporal lobectomy. At our institution, we perform SelAH via a transcortical approach via small corticectomy in the middle temporal gyrus. OBJECTIVE To discuss the surgical anatomy and nuances of SelAH, share our institutional experience, and perform a review of literature. METHODS Institutional experience was recorded by collecting demographic and outcome data from 1999 to 2017 under an Institutional Review Board protocol in a prospective manner using a REDCap database. RESULTS A total of 211 SelAH procedures were performed at our institution between 1999 and 2017. Of these patients, 54% (113/211) were females. The average age at surgery was 39.4 yr. Two-year Engel outcome data were available for 168 patients, of which 73% (123/168) had Engel I outcomes. Engel II outcomes were reported in 16.6% (28/168), III in 4.7% (8/168), and IV in 5.3% (9/168). Our review of literature showed that this is comparable to the seizure freedom rates reported by other groups. We then reviewed our surgical methodology based on operative reports and created illustrations of the surgical anatomy of temporal lobe approach. These illustrations were compared with postoperative magnetic resonance imaging to provide a better 3D understanding of the complex architecture of mesial temporal structures. CONCLUSION SelAH is a minimally invasive, safe, and effective approach for the treatment of medically refractory epilepsy with good surgical outcomes and low morbidity. We feel that mastering the complex anatomy of this approach helps achieve successful outcomes.
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Affiliation(s)
- Rushna Ali
- Department of Neurosciences, Spectrum Health Medical Group, Grand Rapids, Michigan, USA
| | - Dario J Englot
- Department of Neurosurgery, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Hong Yu
- Department of Neurosurgery, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Robert Naftel
- Department of Neurosurgery, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Kevin F Haas
- Department of Neurology, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Peter E Konrad
- Department of Neurosurgery, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
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14
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Kohlhase K, Zöllner JP, Tandon N, Strzelczyk A, Rosenow F. Comparison of minimally invasive and traditional surgical approaches for refractory mesial temporal lobe epilepsy: A systematic review and meta-analysis of outcomes. Epilepsia 2021; 62:831-845. [PMID: 33656182 DOI: 10.1111/epi.16846] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 01/29/2021] [Accepted: 01/29/2021] [Indexed: 01/10/2023]
Abstract
Magnetic resonance-guided laser interstitial laser therapy (MRgLITT) and radiofrequency ablation (RFA) represent two minimally invasive methods for the treatment of drug-refractory mesial temporal lobe epilepsy (mTLE). We performed a systematic review and a meta-analysis to compare outcomes and complications between MRgLITT, RFA, and conventional surgical approaches to the temporal lobe (i.e., anterior temporal lobe resection [ATL] or selective amygdalohippocampectomy [sAHE]). Forty-three studies (13 MRgLITT, 6 RFA, and 24 surgery studies) involved 554, 123, 1504, and 1326 patients treated by MRgLITT, RFA, ATL, or sAHE, respectively. Engel Class I (Engel-I) outcomes were achieved after MRgLITT in 57% (315/554, range = 33.3%-67.4%), RFA in 44% (54/123, range = 0%-67.2%), ATL in 69% (1032/1504, range = 40%-92.9%), and sAHE in 66% (887/1326, range = 21.4%-93.3%). Meta-analysis revealed no significant difference in seizure outcome between MRgLITT and RFA (Q = 2.74, p = .098), whereas ATL and sAHE were both superior to MRgLITT (ATL: Q = 8.92, p = .002; sAHE: Q = 4.33, p = .037) and RFA (ATL: Q = 6.42, p = .0113; sAHE: Q = 5.04, p = .0247), with better outcome in patients at follow-up of 60 months or more. Mesial hippocampal sclerosis (mTLE + hippocampal sclerosis) was associated with significantly better outcome after MRgLITT (Engel-I outcome in 64%; Q = 8.55, p = .0035). The rate of major complications was 3.8% for MRgLITT, 3.7% for RFA, 10.9% for ATL, and 7.4% for sAHE; the differences did not show statistical significance. Neuropsychological deficits occurred after all procedures, with left-sided surgeries having a higher rate of verbal memory impairment. Lateral functions such as naming or object recognition may be more preserved in MRgLITT. Thermal therapies are effective techniques but show a significantly lower rate of Engel-I outcome in comparison to ATL and sAHE. Between MRgLITT and RFA there were no significant differences in Engel-I outcome, whereby the success of treatment seems to depend on the approach used (e.g., occipital approach). MRgLITT shows a similar rate of complications compared to RFA, whereas patients undergoing MRgLITT may experience fewer major complications compared to ATL or sAHE and might have a more beneficial neuropsychological outcome.
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Affiliation(s)
- Konstantin Kohlhase
- Department of Neurology, Epilepsy Center Frankfurt Rhine-Main, University Hospital Frankfurt, Frankfurt am Main, Germany.,Landes-Offensive zur Entwicklung wissenschaftlich-ökonomischer Exzellen, Center for Personalized and Translational Epilepsy Research, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Johann Philipp Zöllner
- Department of Neurology, Epilepsy Center Frankfurt Rhine-Main, University Hospital Frankfurt, Frankfurt am Main, Germany.,Landes-Offensive zur Entwicklung wissenschaftlich-ökonomischer Exzellen, Center for Personalized and Translational Epilepsy Research, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Nitin Tandon
- Department of Neurosurgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Adam Strzelczyk
- Department of Neurology, Epilepsy Center Frankfurt Rhine-Main, University Hospital Frankfurt, Frankfurt am Main, Germany.,Landes-Offensive zur Entwicklung wissenschaftlich-ökonomischer Exzellen, Center for Personalized and Translational Epilepsy Research, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Department of Neurology, Epilepsy Center Frankfurt Rhine-Main, University Hospital Frankfurt, Frankfurt am Main, Germany.,Landes-Offensive zur Entwicklung wissenschaftlich-ökonomischer Exzellen, Center for Personalized and Translational Epilepsy Research, Goethe University Frankfurt, Frankfurt am Main, Germany
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15
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de Souza JPSAS, Pimentel-Silva LR, Ayub G, Nogueira MH, Zanao T, Yasuda CL, Campos BM, Rogerio F, Tedeschi H, Cendes F, Ghizoni E. Transsylvian amygdalohippocampectomy for mesial temporal lobe epilepsy: Comparison of three different approaches. Epilepsia 2021; 62:439-449. [PMID: 33449366 DOI: 10.1111/epi.16816] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study's objective was to compare the transinsular (TI-AH), transuncus (TU-AH), and temporopolar (TP-AH) amygdalohippocampectomy approaches regarding seizure control, temporal stem (TS) damage, and neurocognitive decline. METHODS We included 114 consecutive patients with unilateral hippocampal sclerosis (HS) who underwent TI-AH, TU-AH, or TP-AH between 2002 and 2017. We evaluated seizure control using Engel classification. We used diffusion tensor imaging and postoperative Humphrey perimetry to assess the damage of the TS. We also performed pre- and postoperative memory performance and intelligence quotient (IQ). RESULTS There were no significant differences in the proportion of patients free of disabling seizures (Engel IA+IB) among the three surgical approaches in the survival analysis. However, more patients were free of disabling seizures (Engel IA+IB) at 2 years of postsurgical follow-up with TP-AH (69.5%) and TI-AH (76.7%) as compared to the TU-AH (43.5%) approach (p = .03). The number of fibers of the inferior fronto-occipital fasciculus postoperatively was reduced in the TI-AH group compared with the TU-AH and TP-AH groups (p = .001). The rate of visual field defects was significantly higher with TI-AH (14/19, 74%) in comparison to the TU-AH (5/15, 33%) and TP-AH (13/40, 32.5%) approaches (p = .008). Finally, there was a significant postoperative decline in verbal memory in left-sided surgeries (p = .019) and delayed recall for both sides (p < .001) regardless of the surgical approach. However, TP-AH was the only group that showed a significant improvement in visual memory (p < .001) and IQ (p < .001) for both right- and left-sided surgeries. SIGNIFICANCE The TP-AH group had better short-term seizure control than TU-AH, a lower rate of visual field defects than TI-AH, and improved visual memory and IQ compared to the other groups. Our findings suggest that TP-AH is a better surgical approach for temporal lobe epilepsy with HS than TI-AH and TU-AH.
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Affiliation(s)
| | | | - Gabriel Ayub
- Department of Ophthalmology, University of Campinas, Campinas, Brazil
| | | | - Tamires Zanao
- Neuroimaging Laboratory, University of Campinas, Campinas, Brazil
| | - Clarissa L Yasuda
- Neuroimaging Laboratory, University of Campinas, Campinas, Brazil.,Department of Neurology, University of Campinas, Campinas, Brazil
| | - Brunno M Campos
- Neuroimaging Laboratory, University of Campinas, Campinas, Brazil
| | - Fabio Rogerio
- Department of Neuropathology, University of Campinas, Campinas, Brazil
| | - Helder Tedeschi
- Department of Neurology, University of Campinas, Campinas, Brazil
| | - Fernando Cendes
- Neuroimaging Laboratory, University of Campinas, Campinas, Brazil.,Department of Neurology, University of Campinas, Campinas, Brazil
| | - Enrico Ghizoni
- Neuroimaging Laboratory, University of Campinas, Campinas, Brazil.,Department of Neurology, University of Campinas, Campinas, Brazil
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16
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Zilli J, Kressin M, Schänzer A, Kampschulte M, Schmidt MJ. Partial cortico-hippocampectomy in cats, as therapy for refractory temporal epilepsy: A descriptive cadaveric study. PLoS One 2021; 16:e0244892. [PMID: 33449929 PMCID: PMC7810294 DOI: 10.1371/journal.pone.0244892] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 12/17/2020] [Indexed: 11/18/2022] Open
Abstract
Cats, similar to humans, are known to be affected by hippocampal sclerosis (HS), potentially causing antiepileptic drug (AED) resistance. HS can occur as a consequence of chronic seizure activity, trauma, inflammation, or even as a primary disease. In humans, temporal lobe resection is the standardized therapy in patients with refractory temporal lobe epilepsy (TLE). The majority of TLE patients are seizure free after surgery. Therefore, the purpose of this prospective cadaveric study is to establish a surgical technique for hippocampal resection in cats as a treatment for AED resistant seizures. Ten cats of different head morphology were examined. Pre-surgical magnetic resonance imaging (MRI) and computed tomography (CT) studies of the animals’ head were carried out to complete 3D reconstruction of the head, brain, and hippocampus. The resected hippocampal specimens and the brains were histologically examined for tissue injury adjacent to the hippocampus. The feasibility of the procedure, as well as the usability of the removed specimen for histopathological examination, was assessed. Moreover, a micro-CT (mCT) examination of the brain of two additional cats was performed in order to assess temporal vasculature as a reason for possible intraoperative complications. In all cats but one, the resection of the temporal cortex and the hippocampus were successful without any evidence of traumatic or vascular lesions in the surrounding neurovascular structures. In one cat, the presence of mechanical damage (a fissure) of the thalamic surface was evident in the histopathologic examination of the brain post-resection. All hippocampal fields and the dentate gyrus were identified in the majority of the cats via histological examination. The study describes a new surgical approach (partial temporal cortico-hippocampectomy) offering a potential treatment for cats with clinical and diagnostic evidence of temporal epilepsy which do not respond adequately to the medical therapy.
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Affiliation(s)
- Jessica Zilli
- Department of Veterinary Clinical Sciences, Small Animal Clinic, Justus-Liebig-University, Giessen, Germany
- * E-mail:
| | - Monika Kressin
- Institute for Veterinary Anatomy, Histology and Embryology, Justus-Liebig-University, Giessen, Germany
| | - Anne Schänzer
- Institute of Neuropathology, Justus-Liebig-University, Giessen, Germany
| | | | - Martin J. Schmidt
- Department of Veterinary Clinical Sciences, Small Animal Clinic, Justus-Liebig-University, Giessen, Germany
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17
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Xu K, Wang X, Guan Y, Zhao M, Zhou J, Zhai F, Wang M, Li T, Luan G. Comparisons of the seizure-free outcome and visual field deficits between anterior temporal lobectomy and selective amygdalohippocampectomy: A systematic review and meta-analysis. Seizure 2020; 81:228-235. [DOI: 10.1016/j.seizure.2020.07.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 11/24/2022] Open
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18
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Liu S, Parvizi J. Cognitive refractory state caused by spontaneous epileptic high-frequency oscillations in the human brain. Sci Transl Med 2020; 11:11/514/eaax7830. [PMID: 31619544 DOI: 10.1126/scitranslmed.aax7830] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/21/2019] [Accepted: 09/09/2019] [Indexed: 12/31/2022]
Abstract
Epileptic brain tissue is often considered physiologically dysfunctional, and the optimal treatment of many patients with uncontrollable seizures involves surgical removal of the epileptic tissue. However, it is unclear to what extent the epileptic tissue is capable of generating physiological responses to cognitive stimuli and how cognitive deficits ensuing surgical resections can be determined using state-of-the-art computational methods. To address these unknowns, we recruited six patients with nonlesional epilepsies and identified the epileptic focus in each patient with intracranial electrophysiological monitoring. We measured spontaneous epileptic activity in the form of high-frequency oscillations (HFOs), recorded stimulus-locked physiological responses in the form of physiological high-frequency broadband activity, and explored the interaction of the two as well as their behavioral correlates. Across all patients, we found abundant normal physiological responses to relevant cognitive stimuli in the epileptic sites. However, these physiological responses were more likely to be "seized" (delayed or missed) when spontaneous HFOs occurred about 850 to 1050 ms before, until about 150 to 250 ms after, the onset of relevant cognitive stimuli. Furthermore, spontaneous HFOs in medial temporal lobe affected the subjects' memory performance. Our findings suggest that nonlesional epileptic sites are capable of generating normal physiological responses and highlight a compelling mechanism for cognitive deficits in these patients. The results also offer clinicians a quantitative tool to differentiate pathological and physiological high-frequency activities in epileptic sites and to indirectly assess their possible cognitive reserve function and approximate the risk of resective surgery.
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Affiliation(s)
- Su Liu
- Laboratory of Behavioral and Cognitive Neuroscience, Department of Neurology and Neurological Sciences, Stanford University, CA 94305, USA
| | - Josef Parvizi
- Laboratory of Behavioral and Cognitive Neuroscience, Department of Neurology and Neurological Sciences, Stanford University, CA 94305, USA.
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19
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Lee AT, Burke JF, Chunduru P, Molinaro AM, Knowlton R, Chang EF. A historical cohort of temporal lobe surgery for medically refractory epilepsy: a systematic review and meta-analysis to guide future nonrandomized controlled trial studies. J Neurosurg 2020; 133:71-78. [PMID: 31252393 DOI: 10.3171/2019.4.jns183235] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 04/08/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Recent trials for temporal lobe epilepsy (TLE) highlight the challenges of investigating surgical outcomes using randomized controlled trials (RCTs). Although several reviews have examined seizure-freedom outcomes from existing data, there is a need for an overall seizure-freedom rate estimated from level I data as investigators consider other methods besides RCTs to study outcomes related to new surgical interventions. METHODS The authors performed a systematic review and meta-analysis of the 3 RCTs of TLE in adults and report an overall surgical seizure-freedom rate (Engel class I) composed of level I data. An overall seizure-freedom rate was also collected from level II data (prospective cohort studies) for validation. Eligible studies were identified by filtering a published Cochrane meta-analysis of epilepsy surgery for RCTs and prospective studies, and supplemented by searching indexed terms in MEDLINE (January 1, 2012-April 1, 2018). Retrospective studies were excluded to minimize heterogeneity in patient selection and reporting bias. Data extraction was independently reverified and pooled using a fixed-effects model. The primary outcome was overall seizure freedom following surgery. The historical benchmark was applied in a noninferiority study design to compare its power to a single-study cohort. RESULTS The overall rate of seizure freedom from level I data was 72.4% (55/76 patients, 3 RCTs), which was nearly identical to the overall seizure-freedom rate of 71.7% (1325/1849 patients, 18 studies) from prospective cohorts (z = 0.134, p = 0.89; z-test). Seizure-freedom rates from level I and II studies were consistent over the years of publication (R2 < 0.01, p = 0.73). Surgery resulted in markedly improved seizure-free outcomes compared to medical management (RR 10.82, 95% CI 3.93-29.84, p < 0.01; 2 RCTs). Noninferiority study designs in which the historical benchmark was used had significantly higher power at all difference margins compared to using a single cohort alone (p < 0.001, Bonferroni's multiple comparison test). CONCLUSIONS The overall rate of seizure freedom for temporal lobe surgery is approximately 70% for medically refractory epilepsy. The small sample size of the RCT cohort underscores the need to move beyond standard RCTs for epilepsy surgery. This historical seizure-freedom rate may serve as a useful benchmark to guide future study designs for new surgical treatments for refractory TLE.
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Affiliation(s)
| | | | | | | | - Robert Knowlton
- 2Department of Neurology, University of California, San Francisco, San Francisco, California
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20
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Liao CH, Chen SC, Yu HY, Lin CF, Chou CC, Lee CC, Lin CJ, Hsu SPC, Shih YH. Procedure-Related Temporal Infarct After Retractorless Transsylvian Selective Amygdalohippocampectomy and Impact on 2-Year Epilepsy Outcome. Oper Neurosurg (Hagerstown) 2020; 18:430-437. [PMID: 31369110 DOI: 10.1093/ons/opz192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 04/16/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Selective amygdalohippocampectomy (SAH) is designed to treat patients with mesial temporal lobe epilepsy (MTLE). OBJECTIVE To determine the volume and impact of temporal lobe infarction after retractorless transsylvian SAH (en bloc resection of the hippocampus) that have not been reported. METHODS A retrospective analysis of patients treated with retractorless transsylvian SAH. Infarctions were detected by magnetic resonance imaging (MRI) within the first week after the operation. Neuropsychological testing was performed preoperatively and 6 mo later. Seizure outcome was evaluated 2 yr after epilepsy surgery. RESULTS Between 2010 and 2014, a total of 30 patients were included in this study. Analysis of postoperative MRI showed the following: (1) mean removal volume of the hippocampus-parahippocampus was 5.72 cm3, and (2) mean volumes of temporal and insular infarctions were 1.71 and 0.25 cm3, respectively. Twenty-five patients (83.3%) were free of disabling seizures (Engel class I) at 2 yr of outcome. Neuropsychological testing revealed improvement in Perceptual Organization Index (P = .036) and verbal paired associates II (P = .014) after the operation. Neither infarction volume nor removal volume was related to epilepsy outcome in linear regression model. CONCLUSION Transsylvian SAH has comparable seizure outcomes but bears inherent risks of vasospasm/vascular injury. Immediate postoperative small infarction volume around resection cavity or along surgical corridor was noticed after retractorless transsylvian SAH, which did not cause neuropsychological deteriorations, in contrast to previous study with the use of self-sustaining rigid retraction system. Further study should be performed to compare procedure-related infarctions and their impacts on neuropsychological outcomes in different selective approaches.
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Affiliation(s)
- Chih-Hsiang Liao
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shao-Ching Chen
- Division of General Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Hsiang-Yu Yu
- School of Medicine, National Yang Ming University, Taipei, Taiwan.,Division of Epilepsy, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chun-Fu Lin
- Division of General Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Chien-Chen Chou
- School of Medicine, National Yang Ming University, Taipei, Taiwan.,Division of Epilepsy, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Chia Lee
- Division of General Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang Ming University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Sanford P C Hsu
- Division of General Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Yang-Hsin Shih
- Division of General Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming University, Taipei, Taiwan
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21
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Giacomini L, de Souza JPSA, Formentin C, de Campos BM, Todeschini AB, de Oliveira E, Tedeschi H, Joaquim AF, Cendes F, Ghizoni E. Temporal lobe structural evaluation after transsylvian selective amygdalohippocampectomy. Neurosurg Focus 2020; 48:E14. [DOI: 10.3171/2020.1.focus19937] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 01/29/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEMesial temporal lobe epilepsy (MTLE) is the most common type of focal epilepsy in adolescents and adults, and in 65% of cases, it is related to hippocampal sclerosis (HS). Selective surgical approaches to the treatment of MTLE have as their main goal resection of the amygdala and hippocampus with minimal damage to the neocortex, temporal stem, and optic radiations (ORs). The object of this study was to evaluate late postoperative imaging findings on the temporal lobe from a structural point of view.METHODSThe authors conducted a retrospective evaluation of all patients with refractory MTLE who had undergone transsylvian selective amygdalohippocampectomy (SAH) in the period from 2002 to 2015. A surgical group was compared to a control group (i.e., adults with refractory MTLE with an indication for surgical treatment of epilepsy but who did not undergo the surgical procedure). The inferior frontooccipital fasciculus (IFOF), uncinate fasciculus (UF), and ORs were evaluated on diffusion tensor imaging analysis. The temporal pole neocortex was evaluated using T2 relaxometry.RESULTSFor the IFOF and UF, there was a decrease in anisotropy, voxels, and fibers in the surgical group compared with those in the control group (p < 0.001). An increase in relaxometry time in the surgical group compared to that in the control group (p < 0.001) was documented, suggesting gliosis and neuronal loss in the temporal pole.CONCLUSIONSSAH techniques do not seem to totally preserve the temporal stem or even spare the neocortex of the temporal pole. Therefore, although the transsylvian approaches have been considered to be anatomically selective, there is evidence that the temporal pole neocortex suffers structural damage and potentially functional damage with these approaches.
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Affiliation(s)
- Leonardo Giacomini
- Departments of 1Neurosurgery and
- 3Department of Neurosurgery, Hospital 9 de Julho, São Paulo, Brazil
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22
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23
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Bauman K, Devinsky O, Liu AA. Temporal lobe surgery and memory: Lessons, risks, and opportunities. Epilepsy Behav 2019; 101:106596. [PMID: 31711868 PMCID: PMC6885125 DOI: 10.1016/j.yebeh.2019.106596] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 10/04/2019] [Accepted: 10/04/2019] [Indexed: 11/19/2022]
Abstract
Careful study of the clinical outcomes of temporal lobe epilepsy (TLE) surgery has greatly advanced our knowledge of the neuroanatomy of human memory. After early cases resulted in profound amnesia, the critical role of the hippocampus and associated medial temporal lobe (MTL) structures to declarative memory became evident. Surgical approaches quickly changed to become unilateral and later, to be more precise, potentially reducing cognitive morbidity. Neuropsychological studies following unilateral temporal lobe resection (TLR) have challenged early models, which simplified the lateralization of verbal and visual memory function. Diagnostic tests, including intracarotid sodium amobarbital procedure (WADA), structural magnetic resonance imaging (MRI), and functional neuroimaging (functional MRI (fMRI), positron emission tomography (PET), and single-photon emission computed tomography (SPECT)), can more accurately lateralize and localize epileptogenic cortex and predict memory outcomes from surgery. Longitudinal studies have shown that memory may even improve in seizure-free patients. From 70 years of experience with epilepsy surgery, we now have a richer understanding of the clinical, neuroimaging, and surgical predictors of memory decline-and improvement-after TLR. "Special Issue: Epilepsy & Behavior's 20th Anniversary".
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Affiliation(s)
- Kristie Bauman
- NYU Langone Health, Department of Neurology, 222 East 41st Street 9th Floor, New York, NY 10017, United States of America
| | - Orrin Devinsky
- NYU Langone Health, Department of Neurology, 222 East 41st Street 9th Floor, New York, NY 10017, United States of America; NYU Comprehensive Epilepsy Center, 223 East 34th Street, New York, NY 10016, United States of America
| | - Anli A Liu
- NYU Langone Health, Department of Neurology, 222 East 41st Street 9th Floor, New York, NY 10017, United States of America; NYU Comprehensive Epilepsy Center, 223 East 34th Street, New York, NY 10016, United States of America.
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24
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Liu X, Wu S, Daif A, Sun T, Chauhan V, Issa NP, Rose S, Tao JX. Clinical implications of scalp ictal EEG pattern in patients with temporal lobe epilepsy. Clin Neurophysiol 2019; 130:1604-1610. [DOI: 10.1016/j.clinph.2019.05.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/13/2019] [Accepted: 05/18/2019] [Indexed: 11/16/2022]
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25
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Sheikh SR, Nair D, Gross RE, Gonzalez‐Martinez J. Tracking a changing paradigm and the modern face of epilepsy surgery: A comprehensive and critical review on the hunt for the optimal extent of resection in mesial temporal lobe epilepsy. Epilepsia 2019; 60:1768-1793. [DOI: 10.1111/epi.16310] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/13/2019] [Accepted: 07/14/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Shehryar R. Sheikh
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland Ohio
| | - Dileep Nair
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland Ohio
- Epilepsy Center Cleveland Clinic Foundation Cleveland Ohio
| | | | - Jorge Gonzalez‐Martinez
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland Ohio
- Epilepsy Center Cleveland Clinic Foundation Cleveland Ohio
- Department of Neurosurgery Cleveland Clinic Foundation Cleveland Ohio
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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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Comparing the Wada Test and Functional MRI for the Presurgical Evaluation of Memory in Temporal Lobe Epilepsy. Curr Neurol Neurosci Rep 2019; 19:31. [PMID: 31044310 DOI: 10.1007/s11910-019-0945-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW The usefulness of the Wada test (WT) predicting memory impairment from temporal lobe epilepsy (TLE) surgery has been debated, and it has progressively been replaced by functional MRI (fMRI). We review the current role of WT and fMRI in the presurgical assessment of TLE, and how novel surgical techniques might improve cognitive outcomes. RECENT FINDINGS fMRI's ability to predict global amnesia has not been assessed. Although WT can produce false-positive results, it is still indicated in patients at risk for developing global amnesia: those with significant bilateral or contralateral memory deficits. In the current review, WT exhibited no added value, beyond preclinical data, for predicting material-specific memory impairment, whereas fMRI was reliable for either verbal or non-verbal memory decline. Abnormal functional connectivity on resting state fMRI (rs-fMRI) between the posterior cingulate and the hippocampus may be a predictor of postsurgical memory outcomes. Restricted resections to the pathogenic tissue, stereotactic laser, radiosurgery, and SEEG-guided thermos-coagulation were associated with better cognitive outcome. fMRI should be used routinely in the presurgical workup of TLE to predict verbal and/or non-verbal memory decline, whereas WT may be indicated when there is a high risk of postsurgical global amnesia. Rs-fMRI is a promising tool for the presurgical workup of TLE, and more restricted resections are recommended to enhance cognitive outcomes.
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Jain P, Tomlinson G, Snead C, Sander B, Widjaja E. Systematic review and network meta-analysis of resective surgery for mesial temporal lobe epilepsy. J Neurol Neurosurg Psychiatry 2018; 89:1138-1144. [PMID: 29769251 DOI: 10.1136/jnnp-2017-317783] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 03/05/2018] [Accepted: 04/22/2018] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of anterior temporal lobectomy (ATL) versus selective amygdalohippocampectomy (SAH) on seizure-free outcome in patients with temporal lobe epilepsy, using both direct and indirect evidence from the literature. METHODS MEDLINE, Embase and Cochrane databases were searched for original research articles and systematic reviews comparing ATL versus SAH, and ATL or SAH versus medical management (MM). The outcome was seizure freedom at 12 months of follow-up or longer. Direct pairwise meta-analyses were conducted, followed by a random-effect Bayesian network meta-analysis (NMA) combining direct and indirect evidence. RESULTS Twenty-eight articles were included (18 compared ATL vs SAH, 1 compared ATL vs SAH vs MM, 8 compared ATL vs MM, and 1 compared SAH vs MM). Direct pairwise meta-analyses showed no significant differences in seizure-free outcome of ATL versus SAH (OR 1.14, 95% CI 0.93 to 1.39; p=0.201), but the odds of seizure-free outcome were higher for ATL versus MM (OR 29.16, 95% CI 10.44 to 81.50; p<0.00001), and SAH versus MM (OR 28.42, 95% CI 10.17 to 79.39; p<0.00001). NMA also showed that the odds of seizure-free outcome were no different in ATL versus SAH (OR 1.15, 95% credible interval (CrI) 0.84-1.15), but higher for ATL versus MM (OR 27.22, 95% CrI 15.38-27.22), and SAH versus MM (OR 23.57, 95% CrI 12.67-23.57). There were no significant differences between direct and indirect comparisons (all p>0.05). CONCLUSION Direct evidence, indirect evidence and NMA did not identify a difference in seizure-free outcome of ATL versus SAH.
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Affiliation(s)
- Puneet Jain
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - George Tomlinson
- Toronto Health Economics and Technology Assessment (THETA), University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Carter Snead
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Beate Sander
- Toronto Health Economics and Technology Assessment (THETA), University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Elysa Widjaja
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
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Tao JX, Wu S, Lacy M, Rose S, Issa NP, Yang CW, Dorociak KE, Bruzzone M, Kim J, Daif A, Choi J, Towle VL, Warnke PC. Stereotactic EEG-guided laser interstitial thermal therapy for mesial temporal lobe epilepsy. J Neurol Neurosurg Psychiatry 2018; 89:542-548. [PMID: 29183959 DOI: 10.1136/jnnp-2017-316833] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 10/28/2017] [Accepted: 11/08/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine the outcomes of combined stereo-electroencephalography-guided and MRI-guided stereotactic laser interstitial thermal therapy (LITT) in the treatment of patients with drug-resistant mesial temporal lobe epilepsy (mTLE). METHODS We prospectively assessed the surgical and neuropsychological outcomes in 21 patients with medically refractory mTLE who underwent LITT at the University of Chicago Medical Center. We further compared the surgical outcomes in patients with and without mesial temporal sclerosis (MTS). RESULTS Of the 21 patients, 19 (90%) underwent Invasive EEG study and 11 (52%) achieved freedom from disabling seizures with a mean duration of postoperative follow-up of 24±11 months after LITT. Eight (73%) of 11 patients with MTS achieved freedom from disabling seizures, whereas 3 (30 %) of 10 patients without MTS achieved freedom from disabling seizures. Patients with MTS were significantly more likely to become seizure-free, as compared with those without MTS (P=0.002). There was no significant difference in total ablation volume and the percentage of the ablated amygdalohippocampal complex between seizure-free and non-seizure-free patients. Presurgical and postsurgical neuropsychological assessments were obtained in 10 of 21 patients. While there was no group decline in any neuropsychological assessment, a significant postoperative decline in verbal memory and confrontational naming was observed in individual patients. CONCLUSIONS MRI-guided LITT is a safe and effective alternative to selective amygdalohippocampectomy and anterior temporal lobectomy for mTLE with MTS. Nevertheless, its efficacy in those without MTS seems modest. Large multicentre and prospective studies are warranted to further determine the efficacy and safety of LITT.
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Affiliation(s)
- James X Tao
- Department of Neurology, The University of Chicago, Chicago, Illinois, USA
| | - Shasha Wu
- Department of Neurology, The University of Chicago, Chicago, Illinois, USA
| | - Maureen Lacy
- Department of Psychiatry, The University of Chicago, Chicago, Illinois, USA
| | - Sandra Rose
- Department of Neurology, The University of Chicago, Chicago, Illinois, USA
| | - Naoum P Issa
- Department of Neurology, The University of Chicago, Chicago, Illinois, USA
| | - Carina W Yang
- Department of Radiology, The University of Chicago, Chicago, Illinois, USA
| | | | - Maria Bruzzone
- Department of Neurology, The University of Chicago, Chicago, Illinois, USA
| | - Jisoon Kim
- Department of Neurology, The University of Chicago, Chicago, Illinois, USA
| | - Ahmad Daif
- Department of Neurology, The University of Chicago, Chicago, Illinois, USA
| | - Jason Choi
- Department of Neurosurgery, The University of Chicago, Chicago, Illinois, USA
| | - Vernon L Towle
- Department of Neurology, The University of Chicago, Chicago, Illinois, USA
| | - Peter C Warnke
- Department of Neurosurgery, The University of Chicago, Chicago, Illinois, USA
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In Reply to "Selective Amygdalohippocampectomy for Mesial Temporal Sclerosis: Special Considerations in Geniuses". World Neurosurg 2018; 111:431-432. [PMID: 29499601 DOI: 10.1016/j.wneu.2017.12.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 12/11/2017] [Indexed: 11/23/2022]
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Salem NA, El-Shamarka M, Khadrawy Y, El-Shebiney S. New prospects of mesenchymal stem cells for ameliorating temporal lobe epilepsy. Inflammopharmacology 2018; 26:963-972. [PMID: 29470694 DOI: 10.1007/s10787-018-0456-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 02/09/2018] [Indexed: 12/29/2022]
Abstract
Temporal lobe epilepsy (TLE) is present in 30% of epileptic patients and does not respond to conventional treatments. Bone marrow derived mesenchymal stem cells (BMSCs) induce endogenous neural stem cells, inhibit neurodegeneration, and promote brain self-repair mechanisms. The present study addresses the feasibility of BMSCs transplantation against pilocarpine-induced TLE experimentally. BMSCs were injected either intravenously (IV) or in hippocampus bilaterally (IC). Increased cell count of BMSCs was achieved via IC route. BMSCs treatment ameliorated the pilocarpine-induced neurochemical and histological changes, retained amino acid neurotransmitters to the normal level, downregulated the immunoreactivity to insulin growth factor-1 receptor, synaptophysin, and caspase-3 and reduced oxidative insult and inflammatory markers detected in epileptic model. It is worth noting that BMSCs IC-administered showed more pronounced effects than those administered via IV route. BMSCs transplantation presents a promise for TLE treatment that has to be elucidated clinically.
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Affiliation(s)
- Neveen A Salem
- Biochemistry Department, Faculty of Science, Al Faisalia, King Abdulaziz University, Jeddah, Saudi Arabia. .,Medical Research Division, Narcotics, Ergogenic Aids and Poisons Department, National Research Centre, El-Bohouth Street, Dokki, Giza, 12622, Egypt.
| | - Marwa El-Shamarka
- Medical Research Division, Narcotics, Ergogenic Aids and Poisons Department, National Research Centre, El-Bohouth Street, Dokki, Giza, 12622, Egypt
| | - Yasser Khadrawy
- Medical Research Division, Physiology Department, NRC, Cairo, Egypt
| | - Shaimaa El-Shebiney
- Medical Research Division, Narcotics, Ergogenic Aids and Poisons Department, National Research Centre, El-Bohouth Street, Dokki, Giza, 12622, Egypt
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32
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Surgical Considerations of Intractable Mesial Temporal Lobe Epilepsy. Brain Sci 2018; 8:brainsci8020035. [PMID: 29461485 PMCID: PMC5836054 DOI: 10.3390/brainsci8020035] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 02/14/2018] [Accepted: 02/15/2018] [Indexed: 11/30/2022] Open
Abstract
Surgery of temporal lobe epilepsy is the best opportunity for seizure freedom in medically intractable patients. The surgical approach has evolved to recognize the paramount importance of the mesial temporal structures in the majority of patients with temporal lobe epilepsy who have a seizure origin in the mesial temporal structures. For those individuals with medically intractable mesial temporal lobe epilepsy, a selective amygdalohippocampectomy surgery can be done that provides an excellent opportunity for seizure freedom and limits the resection to temporal lobe structures primarily involved in seizure genesis.
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Foged MT, Vinter K, Stauning L, Kjær TW, Ozenne B, Beniczky S, Paulson OB, Madsen FF, Pinborg LH. Verbal learning and memory outcome in selective amygdalohippocampectomy versus temporal lobe resection in patients with hippocampal sclerosis. Epilepsy Behav 2018; 79:180-187. [PMID: 29306849 DOI: 10.1016/j.yebeh.2017.12.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 12/07/2017] [Accepted: 12/08/2017] [Indexed: 11/16/2022]
Abstract
PURPOSE With the advent of new very selective techniques like thermal laser ablation to treat drug-resistant focal epilepsy, the controversy of resection size in relation to seizure outcome versus cognitive deficits has gained new relevance. The purpose of this study was to test the influence of the selective amygdalohippocampectomy (SAH) versus nonselective temporal lobe resection (TLR) on seizure outcome and cognition in patients with mesial temporal lobe epilepsy (MTLE) and histopathological verified hippocampal sclerosis (HS). METHODS We identified 108 adults (>16years) with HS, operated between 1995 and 2009 in Denmark. Exclusion criteria are the following: Intelligence below normal range, right hemisphere dominance, other native languages than Danish, dual pathology, and missing follow-up data. Thus, 56 patients were analyzed. The patients were allocated to SAH (n=22) or TLR (n=34) based on intraoperative electrocorticography. Verbal learning and verbal memory were tested pre- and postsurgery. RESULTS Seizure outcome did not differ between patients operated using the SAH versus the TLR at 1year (p=0.951) nor at 7years (p=0.177). Verbal learning was more affected in patients resected in the left hemisphere than in the right (p=0.002). In patients with left-sided TLR, a worsening in verbal memory performance was found (p=0.011). Altogether, 73% were seizure-free for 1year and 64% for 7years after surgery. CONCLUSION In patients with drug-resistant focal MTLE, HS and no magnetic resonance imaging (MRI) signs of dual pathology, selective amygdalohippocampectomy results in sustained seizure freedom and better memory function compared with patients operated with nonselective temporal lobe resection.
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Affiliation(s)
- Mette Thrane Foged
- Neurobiology Research Unit, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, 28 Juliane Maries Vej, 3rd Floor, Building 6931, DK-2100 Copenhagen, Denmark
| | - Kirsten Vinter
- Epilepsy Clinic, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, 8 Ester Møllers Vej, 1.th Floor, Entrance 85, DK-2100 Copenhagen, Denmark
| | - Louise Stauning
- Department of Neuropsychology, Danish Epilepsy Centre, 1 Kolonivej, DK-4293 Dianalund, Denmark
| | - Troels W Kjær
- Centre of Neurophysiology, Zealand University Hospital, 11 Vestermarksvej, Ground Floor, DK-4000 Roskilde, Denmark
| | - Brice Ozenne
- Department of Public Health, Section of Biostatistics, University of Copenhagen, 5 Øster Farimagsgade, DK-1014 Copenhagen, Denmark
| | - Sándor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Centre, 1 Kolonivej, DK-4293 Dianalund, Denmark; Department of Clinical Neurophysiology, Aarhus University, 44 Nørrebrogade, Ground Floor, Entrance 10, DK-8000 Aarhus C, Denmark
| | - Olaf B Paulson
- Neurobiology Research Unit, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, 28 Juliane Maries Vej, 3rd Floor, Building 6931, DK-2100 Copenhagen, Denmark
| | - Flemming Find Madsen
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, 7 Inge Lehmanns Vej, 9.th Floor, Entrance 2, DK-2100 Copenhagen, Denmark
| | - Lars H Pinborg
- Neurobiology Research Unit, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, 28 Juliane Maries Vej, 3rd Floor, Building 6931, DK-2100 Copenhagen, Denmark; Epilepsy Clinic, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, 8 Ester Møllers Vej, 1.th Floor, Entrance 85, DK-2100 Copenhagen, Denmark.
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Mathon B, Bielle F, Samson S, Plaisant O, Dupont S, Bertrand A, Miles R, Nguyen-Michel VH, Lambrecq V, Calderon-Garcidueñas AL, Duyckaerts C, Carpentier A, Baulac M, Cornu P, Adam C, Clemenceau S, Navarro V. Predictive factors of long-term outcomes of surgery for mesial temporal lobe epilepsy associated with hippocampal sclerosis. Epilepsia 2017; 58:1473-1485. [DOI: 10.1111/epi.13831] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Bertrand Mathon
- Department of Neurosurgery; AP-HP; La Pitié-Salpêtrière-Charles Foix University Hospital; Paris France
- Sorbonne University; UPMC University of Paris 06; Paris France
| | - Franck Bielle
- Sorbonne University; UPMC University of Paris 06; Paris France
- Department of Neuropathology; AP-HP; La Pitié-Salpêtrière-Charles Foix University Hospital; Paris France
| | - Séverine Samson
- Epileptology Unit; AP-HP; La Pitié-Salpêtrière-Charles Foix University Hospital; Paris France
- PSITEC Laboratory (EA 4072); University of Lille 3; Lille France
| | - Odile Plaisant
- Epileptology Unit; AP-HP; La Pitié-Salpêtrière-Charles Foix University Hospital; Paris France
- ANCRE; URDIA EA 4465; Paris Descartes University; Sorbonne Paris Cité University; Paris France
| | - Sophie Dupont
- Sorbonne University; UPMC University of Paris 06; Paris France
- Epileptology Unit; AP-HP; La Pitié-Salpêtrière-Charles Foix University Hospital; Paris France
- Rehabilitation Unit; AP-HP; La Pitié-Salpêtrière-Charles Foix University Hospital; Paris France
- Brain and Spine Institute (ICM; INSERM; UMRS 1127; CNRS; UMR 7225); Paris France
| | - Anne Bertrand
- Sorbonne University; UPMC University of Paris 06; Paris France
- Brain and Spine Institute (ICM; INSERM; UMRS 1127; CNRS; UMR 7225); Paris France
- Department of Neuroradiology; AP-HP; La Pitié-Salpêtrière-Charles Foix University Hospital; Paris France
- Inria Paris; Aramis Project Team; Paris France
| | - Richard Miles
- Brain and Spine Institute (ICM; INSERM; UMRS 1127; CNRS; UMR 7225); Paris France
| | - Vi-Huong Nguyen-Michel
- Epileptology Unit; AP-HP; La Pitié-Salpêtrière-Charles Foix University Hospital; Paris France
| | - Virginie Lambrecq
- Sorbonne University; UPMC University of Paris 06; Paris France
- Epileptology Unit; AP-HP; La Pitié-Salpêtrière-Charles Foix University Hospital; Paris France
- Brain and Spine Institute (ICM; INSERM; UMRS 1127; CNRS; UMR 7225); Paris France
| | - Ana Laura Calderon-Garcidueñas
- Department of Neuropathology; AP-HP; La Pitié-Salpêtrière-Charles Foix University Hospital; Paris France
- Institute of Forensic Medicine; Veracruzana University; Boca del Río Mexico
| | - Charles Duyckaerts
- Sorbonne University; UPMC University of Paris 06; Paris France
- Department of Neuropathology; AP-HP; La Pitié-Salpêtrière-Charles Foix University Hospital; Paris France
| | - Alexandre Carpentier
- Department of Neurosurgery; AP-HP; La Pitié-Salpêtrière-Charles Foix University Hospital; Paris France
- Sorbonne University; UPMC University of Paris 06; Paris France
- Brain and Spine Institute (ICM; INSERM; UMRS 1127; CNRS; UMR 7225); Paris France
| | - Michel Baulac
- Sorbonne University; UPMC University of Paris 06; Paris France
- Epileptology Unit; AP-HP; La Pitié-Salpêtrière-Charles Foix University Hospital; Paris France
- Brain and Spine Institute (ICM; INSERM; UMRS 1127; CNRS; UMR 7225); Paris France
| | - Philippe Cornu
- Department of Neurosurgery; AP-HP; La Pitié-Salpêtrière-Charles Foix University Hospital; Paris France
- Sorbonne University; UPMC University of Paris 06; Paris France
| | - Claude Adam
- Epileptology Unit; AP-HP; La Pitié-Salpêtrière-Charles Foix University Hospital; Paris France
- Brain and Spine Institute (ICM; INSERM; UMRS 1127; CNRS; UMR 7225); Paris France
| | - Stéphane Clemenceau
- Department of Neurosurgery; AP-HP; La Pitié-Salpêtrière-Charles Foix University Hospital; Paris France
- Brain and Spine Institute (ICM; INSERM; UMRS 1127; CNRS; UMR 7225); Paris France
| | - Vincent Navarro
- Sorbonne University; UPMC University of Paris 06; Paris France
- Epileptology Unit; AP-HP; La Pitié-Salpêtrière-Charles Foix University Hospital; Paris France
- Brain and Spine Institute (ICM; INSERM; UMRS 1127; CNRS; UMR 7225); Paris France
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Krámská L, Vojtěch Z, Lukavský J, Stará M, Malíková H. Five-Year Neuropsychological Outcome after Stereotactic Radiofrequency Amygdalohippocampectomy for Mesial Temporal Lobe Epilepsy: Longitudinal Study. Stereotact Funct Neurosurg 2017; 95:149-157. [DOI: 10.1159/000468527] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 03/02/2017] [Indexed: 11/19/2022]
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Clinical and Imaging Evaluation of Transuncus Selective Amygdalohippocampectomy. World Neurosurg 2017; 100:665-674. [DOI: 10.1016/j.wneu.2016.11.056] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/11/2016] [Accepted: 11/12/2016] [Indexed: 11/17/2022]
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Waseem H, Vivas AC, Vale FL. MRI-guided laser interstitial thermal therapy for treatment of medically refractory non-lesional mesial temporal lobe epilepsy: Outcomes, complications, and current limitations: A review. J Clin Neurosci 2017; 38:1-7. [DOI: 10.1016/j.jocn.2016.12.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 12/04/2016] [Indexed: 11/28/2022]
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Girgis F, Greil ME, Fastenau PS, Sweet J, Lüders H, Miller JP. Resection of Temporal Neocortex During Multiple Hippocampal Transections for Mesial Temporal Lobe Epilepsy Does not Affect Seizure or Memory Outcome. Oper Neurosurg (Hagerstown) 2017; 13:711-717. [DOI: 10.1093/ons/opx031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 01/31/2017] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Multiple hippocampal transection (MHT) is a surgical treatment for mesial temporal lobe epilepsy associated with improved postoperative neuropsychological outcomes compared with lobectomy.
OBJECTIVE
To determine whether resection of the amygdala and anterior temporal neocortex during MHT affects postoperative seizure/memory outcome.
METHODS
Seventeen patients with normal magnetic resonance imaging and stereo-electroencephalogram-proven drug-resistant dominant mesial temporal lobe epilepsy were treated with MHT. Nine patients underwent MHT alone (MHT–) and 8 patients underwent MHT plus removal of the amygdala and anterior 4.5 cm of temporal neocortex lateral to the fusiform gyrus (MHT+). Verbal and visual-spatial memory were assessed in all patients preoperatively and in 14 patients postoperatively using the Wechsler Memory Scale. Postoperative seizure control was assessed at 12 months for all patients.
RESULTS
Overall, 11 of 17 patients (64.7%) were Engel class 1 at 1 year (6/9 MHT–, 5/8 MHT+, P = .38), and 10 of 14 patients (71.4%) had no significant postoperative decline in either verbal or visual memory (6/8 MHT–, 4/6 MHT+, P = .42). Verbal memory declined in 2 of 8 MHT– and 1 of 6 MHT+ patients, and visual memory declined in 1 of 8 MHT– and 2 of 6 MHT+ patients. Two patients had improved visual memory postoperatively, both in the MHT+ group.
CONCLUSION
MHT on the dominant side is associated with high rates of seizure freedom and favorable memory preservation outcomes regardless of the extent of neocortical resection. Preservation of the temporal neocortex and amygdala during MHT does not appear to decrease the risk of postoperative memory decline, nor does it alter seizure outcome.
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Affiliation(s)
- Fady Girgis
- Department of Neurosurgery, University Hospital Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Madeline E Greil
- Department of Neurosurgery, University Hospital Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Philip S Fastenau
- Department of Neurology, University Hospital Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jennifer Sweet
- Department of Neurosurgery, University Hospital Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Hans Lüders
- Department of Neurology, University Hospital Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jonathan P Miller
- Department of Neurosurgery, University Hospital Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
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DaCosta JC, Portuguez MW, Marinowic DR, Schilling LP, Torres CM, DaCosta DI, Carrion MJM, Raupp EF, Machado DC, Soder RB, Lardi SL, Garicochea B. Safety and seizure control in patients with mesial temporal lobe epilepsy treated with regional superselective intra‐arterial injection of autologous bone marrow mononuclear cells. J Tissue Eng Regen Med 2017; 12:e648-e656. [DOI: 10.1002/term.2334] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 07/29/2016] [Accepted: 09/26/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Jaderson C. DaCosta
- Brain Institute of Rio Grande do Sul (BraIns)Pontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
- Biomedical Research InstitutePontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
- Postgraduate Program in Medicine and Health SciencesPontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
- School of MedicinePontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
- São Lucas HospitalPontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
| | - Mirna W. Portuguez
- Brain Institute of Rio Grande do Sul (BraIns)Pontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
- Biomedical Research InstitutePontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
- Postgraduate Program in Medicine and Health SciencesPontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
- School of MedicinePontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
- São Lucas HospitalPontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
| | - Daniel R. Marinowic
- Brain Institute of Rio Grande do Sul (BraIns)Pontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
- Biomedical Research InstitutePontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
| | - Lucas P. Schilling
- Brain Institute of Rio Grande do Sul (BraIns)Pontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
- Postgraduate Program in Medicine and Health SciencesPontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
- São Lucas HospitalPontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
| | - Carolina M. Torres
- São Lucas HospitalPontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
| | - Danielle I. DaCosta
- Brain Institute of Rio Grande do Sul (BraIns)Pontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
- Postgraduate Program in Medicine and Health SciencesPontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
- São Lucas HospitalPontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
| | - Maria Júlia M. Carrion
- Postgraduate Program in Medicine and Health SciencesPontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
| | | | - Denise C. Machado
- Biomedical Research InstitutePontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
- Postgraduate Program in Medicine and Health SciencesPontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
- School of MedicinePontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
| | - Ricardo B. Soder
- Brain Institute of Rio Grande do Sul (BraIns)Pontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
- School of MedicinePontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
| | - Silvia L. Lardi
- School of MedicinePontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
| | - Bernardo Garicochea
- Postgraduate Program in Medicine and Health SciencesPontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
- School of MedicinePontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
- São Lucas HospitalPontifical Catholic University of Rio Grande do Sul Porto Alegre RS Brazil
- Teaching and Research Oncology CenterHospital Sírio Libanes São Paulo SP Brazil
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40
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Comprehensive preoperative work-up and surgical treatment of low grade tumor/benign lesion related temporal lobe epilepsy. J Clin Neurosci 2017; 39:203-208. [PMID: 28202379 DOI: 10.1016/j.jocn.2017.01.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 01/22/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Generally low-grade tumor/benign lesion related temporal lobe epilepsy (LGT/BL-TLE) is considered easier to treat and has better prognosis when compared to non-lesional TLE. However, multiple disputes exist in surgical management of this epilepsy entity. This study aims to discuss comprehensive preoperative work-up, surgical strategies and outcome of it. METHODS A retrospective review of sixty LGT/BL-TLE cases which underwent comprehensive preoperative work-up and then resective surgeries was conducted. Surgical strategies were categorized into limited and expanded resections. Surgical efficacy was evaluated using Engel grading after telephone or clinic follow-up and compared statistically. RESULTS Preoperative work-up includes magnetic resonance imaging (MRI), conventional electroencephalography, semiology evaluation, positron emission tomography (PET) and 256-channel dense-array electroencephalography source imaging (256-ch dESI). In aspect of concordance with epileptic lesions demonstrated on MRI, 256-ch dESI was more accurate than PET (72.7% vs. 39.4%) (p<0.05). Limited resections were performed in 28 cases while expanded resections in 32 cases. Altogether the surgical efficacy was: Engel grade I 86.7%, I+II 95.0%. Comparison of surgical outcome showed neither the outcome between limited and expanded resection nor the outcome between mesial and neocortical TLE (mTLE & nTLE) undergoing limited resections was significantly different (p>0.05). CONCLUSIONS For LGT/BL-TLE, most surgical strategies can be made preoperatively after comprehensive work-up rather than intraoperatively. Limited and expanded strategies yield similar surgical outcome in either nTLE or mTLE as long as comprehensive work-up supports the strategy and the epileptic lesion is totally removed. 256-ch dESI which can visualize both structural and electrophysiological lesions may be contributable to surgical planning of this entity.
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Schmeiser B, Wagner K, Schulze-Bonhage A, Elger CE, Steinhoff BJ, Wendling AS, Mader I, Prinz M, Scheiwe C, Zentner J. Transsylvian Selective Amygdalohippocampectomy for Mesiotemporal Epilepsy: Experience with 162 Procedures. Neurosurgery 2017; 80:454-464. [DOI: 10.1093/neuros/nyw089] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 11/22/2016] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND: Mesial temporal lobe epilepsy (MTLE) is one of the most common forms of epilepsy refractory to medical therapy. Among different surgical approaches, selective amygdalohippocampectomy has gained increasing interest for its rationale of isolated removal of the epileptogenic mesiotemporal area.
OBJECTIVE: To summarize our experience with surgical treatment of MTLE in 162 patients using the transsylvian approach and to analyze possible effects of length of hippocampal resection and postoperative gliosis on seizure and cognitive outcome.
METHODS: Clinical, radiological, histopathological and neuropsychological findings of 162 patients with MTLE who were operated by the senior author between 1993 and 2012 were retrospectively evaluated. Postoperative follow-up mounted up to 240 months (59 ± 56 months). Seizure outcome was available in 156 patients with minimum follow-up of 3 months. Extent of hippocampal resection was evaluated in 70 and postoperative gliosis in 62 of the 92 patients. Results were then correlated with seizure and cognitive outcome.
RESULTS: Of 134 patients with a follow-up of at least 1 year, 85 (63.4%) remained completely seizure free (Engel Ia) and 118 (88.0%) had a worthwhile improvement after surgery (Engel I+II). There was no perioperative death. Permanent morbidity was encountered in 4 patients (2.5%). Neither the extent of hippocampal resection nor postoperative gliosis correlated with seizure outcome or postoperative memory performance.
CONCLUSION: Transsylvian selective amygdalohippocampectomy can be recommended as an adequate procedure for the surgical treatment of mesiotemporal epilepsy with favorable epileptological results and acceptable morbidity.
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Affiliation(s)
- Barbara Schmeiser
- Department of Neurosurgery, University Hospital Freiburg, Freiburg, Germany
| | - Kathrin Wagner
- Department of Epileptology, University Hospital Freiburg, Freiburg, Germany
| | | | | | | | | | - Irina Mader
- Department of Neuroradiology, Univers-ity Hospital Freiburg, Freiburg, Germany
| | - Marco Prinz
- Department of Neuropathology, University Hospital Freiburg, Freiburg, Germany
| | - Christian Scheiwe
- Department of Neurosurgery, University Hospital Freiburg, Freiburg, Germany
| | - Josef Zentner
- Department of Neurosurgery, University Hospital Freiburg, Freiburg, Germany
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Kishima H, Kato A, Oshino S, Tani N, Maruo T, Khoo HM, Yanagisawa T, Edakawa K, Kobayashi M, Tanaka M, Hosomi K, Hirata M, Yoshimine T. Navigation-assisted trans-inferotemporal cortex selective amygdalohippocampectomy for mesial temporal lobe epilepsy; preserving the temporal stem. Neurol Res 2017; 39:223-230. [PMID: 28067149 DOI: 10.1080/01616412.2016.1275458] [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] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Selective amygdalohippocampectomy (SAH) can be used to obtain satisfactory seizure control in patients with mesial temporal lobe epilepsy (MTLE). Several SAH procedures have been reported to achieve satisfactory outcomes for seizure control, but none yield fully satisfactory outcomes for memory function. We hypothesized that preserving the temporal stem might play an important role. To preserve the temporal stem, we developed a minimally invasive surgical procedure, 'neuronavigation-assisted trans-inferotemporal cortex SAH' (TITC-SAH). METHODS TITC-SAH was performed in 23 patients with MTLE (MTLE on the language-non-dominant hemisphere, n = 11). The inferior horn of the lateral ventricle was approached via the inferior or middle temporal gyrus along the inferior temporal sulcus under neuronavigation guidance. The hippocampus was dissected in a subpial manner and resected en bloc together with the parahippocampal gyrus. Seizure control at one year and memory function at 6 months postoperatively were evaluated. RESULTS One year after TITC-SAH, 20 of the 23 patients were seizure-free (ILAE class 1), 2 were class 2, and 1 was class 3. Verbal memory improved significantly in 13 patients with a diagnosis of hippocampal sclerosis, for whom WMS-R scores were available both pre- and post-operatively. Improvements were seen regardless of whether the SAH was on the language-dominant or non-dominant hemisphere. No major complication was observed. CONCLUSION Navigation-assisted TITC-SAH performed for MTLE offers a simple, minimally invasive procedure that appears to yield excellent outcomes in terms of seizure control and preservation of memory function, because this procedure does not damage the temporal stem. TITC-SAH should be one of the feasible surgical procedures for MTLE. ABBREVIATIONS SAH: Amygdalohippocampectomy; MTLE: Mesial temporal lobe epilepsy (MTLE); TITC-SAH: Ttrans-inferotemporal cortex SAH; ILAE: International League Against Epilepsy (ILAE); MRI: Magnetic resonance imaging; EEG: Electroencephalography (EEG); FDG-PET: 8F-fluorodeoxyglucose (FDG)-positron emission tomography; ECoG: Electrocorticography; MEG: Magnetoencephalography; IMZ-SPECT: N-isopropyl-p(123I)-iodoamphetamine single photon emission computed tomography; WMS-R: Wechsler Memory Scale-Revised.
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Affiliation(s)
- Haruhiko Kishima
- a Department of Neurosurgery , Osaka University Graduate School of Medicine , Suita, Osaka , Japan.,b Epilepsy Center , Osaka University Hospital , Suita , Japan
| | - Amami Kato
- c Department of Neurosurgery , Kinki University School of Medicine , Osaka-sayama , Japan
| | - Satoru Oshino
- a Department of Neurosurgery , Osaka University Graduate School of Medicine , Suita, Osaka , Japan.,b Epilepsy Center , Osaka University Hospital , Suita , Japan
| | - Naoki Tani
- b Epilepsy Center , Osaka University Hospital , Suita , Japan.,d Department of Neurosurgery , Osaka General Medical Center , Osaka , Japan
| | - Tomoyuki Maruo
- b Epilepsy Center , Osaka University Hospital , Suita , Japan.,e Department of Neurosurgery , Otemae Hospital , Osaka-sayama , Japan
| | - Hui Ming Khoo
- a Department of Neurosurgery , Osaka University Graduate School of Medicine , Suita, Osaka , Japan.,b Epilepsy Center , Osaka University Hospital , Suita , Japan
| | - Takufumi Yanagisawa
- a Department of Neurosurgery , Osaka University Graduate School of Medicine , Suita, Osaka , Japan.,b Epilepsy Center , Osaka University Hospital , Suita , Japan.,f Global Center for Medical Engineering and Informatics Division of Clinical Neuroengineering , Osaka University , Osaka , Japan
| | - Kotaro Edakawa
- a Department of Neurosurgery , Osaka University Graduate School of Medicine , Suita, Osaka , Japan.,b Epilepsy Center , Osaka University Hospital , Suita , Japan
| | - Maki Kobayashi
- a Department of Neurosurgery , Osaka University Graduate School of Medicine , Suita, Osaka , Japan.,b Epilepsy Center , Osaka University Hospital , Suita , Japan
| | - Masataka Tanaka
- a Department of Neurosurgery , Osaka University Graduate School of Medicine , Suita, Osaka , Japan.,b Epilepsy Center , Osaka University Hospital , Suita , Japan
| | - Koichi Hosomi
- a Department of Neurosurgery , Osaka University Graduate School of Medicine , Suita, Osaka , Japan.,b Epilepsy Center , Osaka University Hospital , Suita , Japan
| | - Masayuki Hirata
- a Department of Neurosurgery , Osaka University Graduate School of Medicine , Suita, Osaka , Japan.,b Epilepsy Center , Osaka University Hospital , Suita , Japan.,f Global Center for Medical Engineering and Informatics Division of Clinical Neuroengineering , Osaka University , Osaka , Japan
| | - Toshiki Yoshimine
- f Global Center for Medical Engineering and Informatics Division of Clinical Neuroengineering , Osaka University , Osaka , Japan
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Bozkurt B, da Silva Centeno R, Chaddad-Neto F, da Costa MDS, Goiri MAA, Karadag A, Tugcu B, Ovalioglu TC, Tanriover N, Kaya S, Yagmurlu K, Grande A. Transcortical selective amygdalohippocampectomy technique through the middle temporal gyrus revisited: An anatomical study laboratory investigation. J Clin Neurosci 2016; 34:237-245. [DOI: 10.1016/j.jocn.2016.05.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 05/16/2016] [Accepted: 05/25/2016] [Indexed: 11/26/2022]
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Muzumdar D, Patil M, Goel A, Ravat S, Sawant N, Shah U. Mesial temporal lobe epilepsy – An overview of surgical techniques. Int J Surg 2016; 36:411-419. [DOI: 10.1016/j.ijsu.2016.10.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 10/16/2016] [Accepted: 10/18/2016] [Indexed: 12/29/2022]
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Kawamura MJ, Ruskin DN, Masino SA. Metabolic Therapy for Temporal Lobe Epilepsy in a Dish: Investigating Mechanisms of Ketogenic Diet using Electrophysiological Recordings in Hippocampal Slices. Front Mol Neurosci 2016; 9:112. [PMID: 27847463 PMCID: PMC5088211 DOI: 10.3389/fnmol.2016.00112] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 10/17/2016] [Indexed: 11/13/2022] Open
Abstract
The hippocampus is prone to epileptic seizures and is a key brain region and experimental platform for investigating mechanisms associated with the abnormal neuronal excitability that characterizes a seizure. Accordingly, the hippocampal slice is a common in vitro model to study treatments that may prevent or reduce seizure activity. The ketogenic diet is a metabolic therapy used to treat epilepsy in adults and children for nearly 100 years; it can reduce or eliminate even severe or refractory seizures. New insights into its underlying mechanisms have been revealed by diverse types of electrophysiological recordings in hippocampal slices. Here we review these reports and their relevant mechanistic findings. We acknowledge that a major difficulty in using hippocampal slices is the inability to reproduce precisely the in vivo condition of ketogenic diet feeding in any in vitro preparation, and progress has been made in this in vivo/in vitro transition. Thus far at least three different approaches are reported to reproduce relevant diet effects in the hippocampal slices: (1) direct application of ketone bodies; (2) mimicking the ketogenic diet condition during a whole-cell patch-clamp technique; and (3) reduced glucose incubation of hippocampal slices from ketogenic diet–fed animals. Significant results have been found with each of these methods and provide options for further study into short- and long-term mechanisms including Adenosine triphosphate (ATP)-sensitive potassium (KATP) channels, vesicular glutamate transporter (VGLUT), pannexin channels and adenosine receptors underlying ketogenic diet and other forms of metabolic therapy.
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Affiliation(s)
| | - David N Ruskin
- Department of Psychology and Neuroscience Program, Trinity College Hartford, CT, USA
| | - Susan A Masino
- Department of Psychology and Neuroscience Program, Trinity College Hartford, CT, USA
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Schmeiser B, Hammen T, Steinhoff B, Zentner J, Schulze-Bonhage A. Long-term outcome characteristics in mesial temporal lobe epilepsy with and without associated cortical dysplasia. Epilepsy Res 2016; 126:147-56. [DOI: 10.1016/j.eplepsyres.2016.07.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 07/27/2016] [Accepted: 07/29/2016] [Indexed: 10/21/2022]
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Abstract
This article reviews the current topics in the field of epilepsy surgery. Each type of epilepsy is associated with a different set of questions and goals. In mesial temporal lobe epilepsy (MTLE) with hippocampal sclerosis (HS), postoperative seizure outcome is satisfactory. A recent meta-analysis revealed superior seizure outcome after anterior temporal lobectomy compared with selective amygdalohippocampectomy; in terms of cognitive outcome; however, amygdalohippocampectomy may be beneficial. In temporal lobe epilepsy with normal magnetic resonance imaging (MRI), postoperative seizure outcome is not as favorable as it is in MTLE with HS; further improvement of seizure outcome in these cases is necessary. Focal cortical dysplasia is the most common substrate in intractable neocortical epilepsy, especially in children, as well as in MRI-invisible neocortical epilepsy. Postoperative seizure-free outcome is approximately 60–70%; further diagnostic and therapeutic improvement is required. Regarding diagnostic methodology, an important topic currently under discussion is wideband electroencephalogram (EEG) analysis. Although high-frequency oscillations and ictal direct current shifts are considered important markers of epileptogenic zones, the clinical significance of these findings should be clarified further. Regarding alternatives to surgery, neuromodulation therapy can be an option for patients who are not amenable to resective surgery. In addition to vagus nerve stimulation, intracranial stimulation such as responsive neurostimulation or anterior thalamic stimulation is reported to have a modest seizure suppression effect. Postoperative management such as rehabilitation and antiepileptic drug (AED) management is important. It has been reported that postoperative rehabilitation improves postoperative employment status. Pre- and post-operative comprehensive care is mandatory for postoperative improvement of quality of life.
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Affiliation(s)
- Naotaka Usui
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders
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48
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Gül G, Yandim Kuşcu D, Özerden M, Kandemir M, Eren F, Tuğcu B, Keskinkiliç C, Kayrak N, Kirbaş D. Cognitive Outcome after Surgery in Patients with Mesial Temporal Lobe Epilepsy. Noro Psikiyatr Ars 2016; 54:43-48. [PMID: 28566958 DOI: 10.5152/npa.2016.13802] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 01/28/2016] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The aim of the present study was to evaluate the neuropsychological outcomes of patients with medically intractable unilateral mesial temporal lobe epilepsy (MTLE) due to hippocampal sclerosis (HS) treated either by anterior temporal lobectomy (ATL) or selective amygdalohippocampectomy (SAH). METHODS This was a retrospective study where 67 patients who had undergone surgery for MTLE were evaluated. Thirty-two patients underwent ATL and 35 underwent SAH. All patients underwent a detailed neuropsychological evaluation before and 1 year after surgery. RESULTS The verbal memory outcome was unchanged after left-sided surgery, whereas learning capacity increased after right-sided surgery (p=0.038). The visual memory outcome improved after right-sided surgery. Improvement of executive functions, particularly in the resistance of interference pattern in the Stroop Test, shortened 5th card time (p=0.000), and decreased corrections (p=0.003), after right-sided surgery and increased attention (p=0.027) after left-sided surgery were observed. After both surgery types, although statistically insignificant, there was a marked decrease in incorrect answers in the Stroop Test, which also showed an improvement in the resistance of interference pattern. Moreover, there was a significant decrease in switching errors with word pairs in the Verbal Fluency Test (p=0.008) after right-sided surgery. When the two sides were compared, we observed that the recall phase of the verbal memory worsened (p=0.018); however, the recognition phase improved (p=0.015) after left-sided surgery. Additionally, the short-term visual memory was better for both sides (p=0.035). CONCLUSION Our results showed that patients with left MTLE were not worsened in verbal memory, but despite improved recognition, they have some problems in recalling information and only a minor improvement in attention. Patients with right MTLE improved in their verbal learning capacity, visual memory, and resistance of interference pattern 1 year after surgery. It was thus shown that while epilepsy surgery is associated with some negative cognitive changes, it may also improve some cognitive functions.
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Affiliation(s)
- Günay Gül
- Clinic of 3 Neurology, Bakırköy Psychiatric and Neurological Diseases Training and Research Hospital, İstanbul, Turkey
| | | | - Mesude Özerden
- Clinic of 3 Neurology, Bakırköy Psychiatric and Neurological Diseases Training and Research Hospital, İstanbul, Turkey
| | - Melek Kandemir
- Clinic of of Neurology, Bayındır Hospital, İstanbul, Turkey
| | - Fulya Eren
- Clinic of 3 Neurology, Bakırköy Psychiatric and Neurological Diseases Training and Research Hospital, İstanbul, Turkey
| | - Bekir Tuğcu
- Clinic of Neurosurgery, Bakırköy Psychiatric and Neurological Diseases Training and Research Hospital, İstanbul, Turkey
| | - Cahit Keskinkiliç
- Neuropsychology Laboratory, Bakırköy Psychiatric and Neurological Diseases Training and Research Hospital, İstanbul, Turkey
| | - Nalan Kayrak
- Department of Neurology, Private Practice, İstanbul, Turkey
| | - Dursun Kirbaş
- Department of Neurology, İstanbul University Institute of Forensic Medicine, İstanbul, Turkey
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Roessler K, Hofmann A, Sommer B, Grummich P, Coras R, Kasper BS, Hamer HM, Blumcke I, Stefan H, Nimsky C, Buchfelder M. Resective surgery for medically refractory epilepsy using intraoperative MRI and functional neuronavigation: the Erlangen experience of 415 patients. Neurosurg Focus 2016; 40:E15. [DOI: 10.3171/2015.12.focus15554] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Intraoperative overestimation of resection volume in epilepsy surgery is a well-known problem that can lead to an unfavorable seizure outcome. Intraoperative MRI (iMRI) combined with neuronavigation may help surgeons avoid this pitfall and facilitate visualization and targeting of sometimes ill-defined heterogeneous lesions or epileptogenic zones and may increase the number of complete resections and improve seizure outcome.
METHODS
To investigate this hypothesis, the authors conducted a retrospective clinical study of consecutive surgical procedures performed during a 10-year period for epilepsy in which they used neuronavigation combined with iMRI and functional imaging (functional MRI for speech and motor areas; diffusion tensor imaging for pyramidal, speech, and visual tracts; and magnetoencephalography and electrocorticography for spike detection). Altogether, there were 415 patients (192 female and 223 male, mean age 37.2 years; 41% left-sided lesions and 84.9% temporal epileptogenic zones). The mean preoperative duration of epilepsy was 17.5 years. The most common epilepsy-associated pathologies included hippocampal sclerosis (n = 146 [35.2%]), long-term epilepsy-associated tumor (LEAT) (n = 67 [16.1%]), cavernoma (n = 45 [10.8%]), focal cortical dysplasia (n = 31 [7.5%]), and epilepsy caused by scar tissue (n = 23 [5.5%]).
RESULTS
In 11.8% (n = 49) of the surgeries, an intraoperative second-look surgery (SLS) after incomplete resection verified by iMRI had to be performed. Of those incomplete resections, LEATs were involved most often (40.8% of intraoperative SLSs, 29.9% of patients with LEAT). In addition, 37.5% (6 of 16) of patients in the diffuse glioma group and 12.9% of the patients with focal cortical dysplasia underwent an SLS. Moreover, iMRI provided additional advantages during implantation of grid, strip, and depth electrodes and enabled intraoperative correction of electrode position in 13.0% (3 of 23) of the cases. Altogether, an excellent seizure outcome (Engel Class I) was found in 72.7% of the patients during a mean follow-up of 36 months (range 3 months to 10.8 years). The greatest likelihood of an Engel Class I outcome was found in patients with cavernoma (83.7%), hippocampal sclerosis (78.8%), and LEAT (75.8%). Operative revisions that resulted from infection occurred in 0.3% of the patients, from hematomas in 1.6%, and from hydrocephalus in 0.8%. Severe visual field defects were found in 5.2% of the patients, aphasia in 5.7%, and hemiparesis in 2.7%, and the total mortality rate was 0%.
CONCLUSIONS
Neuronavigation combined with iMRI was beneficial during surgical procedures for epilepsy and led to favorable seizure outcome with few specific complications. A significantly higher resection volume associated with a higher chance of favorable seizure outcome was found, especially in lesional epilepsy involving LEAT or diffuse glioma.
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Affiliation(s)
| | | | | | | | | | | | - Hajo M. Hamer
- 3Neurology, Epilepsy Centre, University Hospital Erlangen; and
| | | | - Hermann Stefan
- 3Neurology, Epilepsy Centre, University Hospital Erlangen; and
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