Trends in lobectomy/amygdalohippocampectomy over time and the impact of hospital surgical volume on hospitalization outcomes: A population-based study.

OBJECTIVE: Despite national guidelines supporting surgical referral in drug-resistant epilepsy, it is hypothesized that surgery is underutilized. We investigated the volumes of lobectomy/amygdalohippocampectomy surgeries over time and examined differences in outcomes between (1) high-volume (HV), middle-volume (MV), and low-volume (LV) hospitals and (2) Level 4 Centers versus non-Level 4 Centers. METHODS: The 2003-2014 National Inpatient Sample (the largest all-payer hospitalization database, representative of the US population) was utilized. Epilepsy was identified using a previously validated International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) case definition and surgeries using ICD-9-CM procedure codes. A hospital was considered a Level 4 Center if it performed intracranial electroencephalographic (EEG) monitoring. Tumor surgeries were excluded. Linear regression was used to perform trend tests. Weighted multivariate logistic regression was used to summarize association of surgery with outcomes. RESULTS: A total of 4,487 lobectomy/amygdalohippocampectomy surgeries were performed in children and adults with epilepsy. Lobectomy/amygdalohippocampectomy surgeries significantly decreased over time (slope: -0.24, P < .001). This declining surgical trend was greater for all resective/disconnective surgery (slope: -0.45, P < .001), and greatest when compared to all types of epilepsy surgery, for example, resection/disconnection/radiosurgery/laser interstitial thermal therapy/vagus nerve stimulation/deep brain stimulation/responsive neurostimulation/intracranial EEG (slope: -0.95, P < .001). LV compared to HV hospitals had higher odds of transfer to other facilities (13.60% vs 4.24%, odds ratio [OR] = 2.76, 95% confidence interval [CI] = 1.11-6.82). LV hospitals had higher odds of surgical complications versus MV (12.69% vs 6.80%, OR = 2.20, 95% CI = 1.01-5.09). HV hospitals incurred the least total charges. There were no differences in discharge status, adverse events, length of stay, or cost between Level 4 Centers versus non-Level 4 Centers. SIGNIFICANCE: Lobectomies/amygdalohippocampectomies are decreasing over time, suggesting ongoing underutilization. LV centers are associated with greater complication and transfer rates. Future studies are required to understand the reason for worse outcomes in LV centers and to determine whether a minimum number of surgeries must be performed to meet necessary standards.

A patient-centered approach to understanding long-term psychosocial adjustment and meaning-making, 15 to 20 years after epilepsy surgery.

OBJECTIVE: Different psychosocial trajectories have been identified following treatment with epilepsy surgery, as patients adjust to possible changes in seizure frequency and the subsequent impact on their psychosocial functioning. Qualitative research has been key to understanding this adjustment process, particularly in the short-term (2-5 years). Currently, however, there is a lack of qualitative research examining longer-term (>15 years) outcomes, precluding the same rich, detailed understanding of longer-term psychosocial outcomes. Using a grounded theory approach, we explored how patients reflected on and made sense of their adjustment trajectories, 15 to 20 years after surgery. This included the impact of surgery on their sense of self and broader psychosocial functioning. METHODS: We recruited 40 adult patients who had undergone anterior temporal lobectomy (ATL) 15 to 20 years ago (24 females; 26 left-sided). Median age at habitual seizure onset was 9.7 years (Interquartile range; IQR = 13.8), and at surgery was 31 years (IQR = 12). Median length of follow-up was 18.4 years (IQR = 4.3). Comprehensive one-on-one interviews (median time = 86 min, IQR = 28) were used to elicit patient experiences of their surgery and subsequent psychosocial outcomes. Data were analyzed using a grounded theory inductive-deductive process. RESULTS: Patient narratives revealed a common process of psychosocial change and meaning-making triggered by surgery, which was often perceived as a major turning point in life. Patients reflected on moving through an early postsurgical period (<5 years) of upheaval and psychological disequilibrium. While this period was often remembered as stressful, difficulties were softened and/or reframed in hindsight. Through this process of reframing and meaning-making, patients were able to reestablish equilibrium and a sense of normality. Differences were evident in how patients navigated the process of meaning-making, and the extent to which they felt surgery had changed their self-identity. DISCUSSION: We propose a model of postsurgical meaning-making, evident in the narratives of patients who have undergone ATL, providing a new perspective on long-term psychosocial outcomes. This model contributes to our understanding of patient well-being and quality of life, by acknowledging the active role that patients play in seeking to create their own sense of normality after epilepsy surgery.

Preoperative sensory aura predicts risk for seizure in temporal lobe epilepsy surgery.

BACKGROUND: Patients with temporal lobe epilepsy (TLE) often report viscerosensory and experiential auras, with substantial epilepsy localization. However, few previous studies have investigated the epileptic preoperative aura, particularly with regard to its effect on surgical outcomes in patients with drug-resistant epilepsy. OBJECTIVE: This study investigated the potential role of preoperative aura in predicting outcomes after surgery for TLE. MATERIAL AND METHODS: This study included consecutive patients diagnosed with TLE who underwent anterior temporal lobectomy (ATL) for drug-resistant TLE during the period from January 1999 to December 2017. Data pertaining to patient age at the time of surgery, sex, age at initial seizure onset, duration of epilepsy, presence of preoperative aura, comprehensive clinical semiology, side of surgery, and type of pathology were analyzed. Preoperative auras were classified as autonomic, sensory, mental and affective, or multiple manifestations. Patients were followed at 3 and 12 months after surgery and at regular intervals thereafter. RESULTS AND CONCLUSIONS: A total of 498 patients were included in the study. Positive preoperative aura was observed in 386 patients (77.51%). The correlation of each variable with seizure outcomes was analyzed, and the only variable found to correlate with seizure outcome was the presence of preoperative aura. Compared with those with negative preoperative aura, those with positive preoperative aura were 1.74-fold more likely to be seizure-free after surgery for TLE. The analysis of patient data suggested a later onset of initial seizure in those with positive preoperative aura, compared with those without (p = 0.04, 95% confidence interval (CI): 0.55-3.24). Patients with a shorter duration of disease prior to TLE surgery were more likely to achieve seizure-free status postoperatively. Preoperative sensory aura was a good predictor that a patient would be seizure-free during follow-up (p = 0.022).

Changes in description naming for common and proper nouns after left anterior temporal lobectomy.

Numerous studies have shown that surgical resection of the left anterior temporal lobe (ATL) is associated with a decline in object naming ability (Hermann et al., 1999). In contrast, few studies have examined the effects of left ATL surgery on auditory description naming (ADN) or category-specific naming. Compared with object naming, which loads heavily on visual recognition processes, ADN provides a more specific measure of concept retrieval. The present study examined ADN declines in a large group of patients who were tested before and after left ATL surgery, using a 2 × 2 × 2 factorial manipulation of uniqueness (common vs. proper nouns), taxonomic category (living vs. nonliving things), and time (pre- vs. postsurgery). Significant declines occurred across all categories but were substantially larger for proper living (PL) concepts, i.e., famous individuals. The disproportionate decline in PL noun naming relative to other conditions is consistent with the notion that the left ATL is specialized not only for retrieval of unique entity concepts, but also plays a role in processing social concepts and person-specific features.

Initiating a new national epilepsy surgery program: Experiences gathered in Georgia.

Surgery is the most effective therapeutic approach for medically refractory epilepsies and a safe and cost-efficient treatment in terms of long-term expenses of direct, indirect, and intangible costs. Georgia is a Caucasian low- to middle-income country with a remarkable effort to deal with epileptic diseases, but without an appropriate epilepsy surgery program. To address the needs for such a service in this country, two joint German-Georgian projects were initiated in 2017 and 2019. In the framework of these projects, a productive exchange program involving German and Georgian experts was undertaken in the past two years. This program included training and mentoring for Georgian clinical colleagues, as well as joint case conferences and workshops with the aim of optimizing presurgical diagnostics and preparing for an epilepsy surgery program in Georgia. Finally, a postsurgical medium- and long-term follow-up scheme was organized as the third component of this comprehensive approach. As a result of our efforts, the first patients underwent anterior temporal lobectomy and all of them remain seizure-free up to the present day. Hence, epilepsy surgery is not only feasible, but also already available in Georgia. In this report, we aim to share our experiences in the initiation and implementation of surgical epilepsy intervention in Georgia and illustrate our recent endeavor and achievements.

The impact of cerebrovascular risk factors on postoperative memory decline in patients with left temporal lobe epilepsy.

Cerebrovascular risk factors (CVRFs) and comorbid cardiovascular and metabolic disease have been linked to accelerated cognitive aging and dementia in the general population; however, the contribution of these comorbidities to the risk of post anterior temporal lobectomy (ATL) memory decline has been unexamined. We explored the effects of CVRFs on postoperative verbal memory decline in a cohort of 22 patients with left temporal lobe epilepsy (LTLE) who completed pre- and one-year postsurgical neuropsychological testing. Diagnoses of interest included preoperative cardiovascular and metabolic disorders, as well as CVRFs [pulse pressure proxy, body mass index (BMI), and fasting glucose]. Twenty-three percent of patients had a history of cardiovascular disease, 9% of metabolic disorders, and 38% had a BMI indicating overweight or obese status. Higher preoperative BMI and glucose were associated with greater decline in verbal memory. The association between BMI and memory decline remained significant after controlling for age and left hippocampal volume. These findings suggest that modifiable health-related risk factors, including CVRFs, may impact the risk of postoperative cognitive decline, and that BMI in particular could be an important factor to consider and/or target for intervention early in clinical care to protect cognitive health.

Anterior Temporal Lobectomy Impairs Neural Classification of Body Emotions in Right Superior Temporal Sulcus and Reduces Emotional Enhancement in Distributed Brain Areas without Affecting Behavioral Classification.

Humans with amygdalar lesions show proportional reductions of the emotional response to facial expressions in the fusiform face area as well as deficits in emotion recognition from facial expressions. While processing of bodily expressions shares many similarities with facial expressions, there is no substantial evidence that lesions of the amygdala result in similar behavioral and neural sequelae. We combined behavioral assessment with functional neuroimaging in a group of male and female humans with unilateral anterior temporal lobe (ATL) resections, including the amygdala (right: n = 10; left: n = 10) and 12 matched controls. The objective was to assess whether the amygdala is crucial for the recognition of body expressions and for modulatory effects on distant areas during perception of body expressions. The behavioral results revealed normal performance in both patient groups on emotion categorization of body expressions. The neuroimaging results showed that ATL patients displayed no enhanced activations in right fusiform body area and left extrastriate body area and that left ATL patients additionally displayed no enhanced activations in right posterior superior temporal sulcus and right extrastriate body area, respectively. Multivoxel pattern analysis revealed altered categorization capacity between emotional and neutral stimuli in right posterior superior temporal sulcus in right ATL patients. In addition, we also found emotional enhancement in frontal, parietal, occipital, and cingulate regions in controls. Together, our data show that the amygdala and ATLs are not necessary for recognition of dynamic body expressions, but suggest that amygdala lesions affect body emotion processing in distant brain areas.SIGNIFICANCE STATEMENT For humans, information from emotional expressions of others is crucial to support social interactions. The majority of emotion studies has focused on facial expressions; however, in daily life, we also use information from body postures and body movement. Visual processing of body expressions relies on a brain network, including body-specific visual areas and visuomotor areas. Even though the importance of the amygdala and its modulatory effects on distant brain regions have been documented, it remains unclear whether the amygdala plays a crucial role in emotional body processing. By combining behavioral and neuroimaging data in patients with amygdalar lesions, we provide further evidence for its modulatory effect on distant areas during the perception of body expressions.

Binding deficits in visual short-term memory in patients with temporal lobe lobectomy.

Classical views of the medial temporal lobe (MTL) have established that it plays a crucial role in long-term memory (LTM). Here we demonstrate, in a sample of patients who have undergone anterior temporal lobectomy for the treatment of pharmacoresistant epilepsy, that the MTL additionally plays a specific, causal role in short-term memory (STM). Patients (n=22) and age-matched healthy control participants (n=26) performed a STM task with a sensitive continuous report measure. This paradigm allowed us to examine recall memory for object identity, location and object-location binding, independently on a trial-by-trial basis. Our findings point to a specific involvement of MTL in object-location binding, but, crucially, not retention of either object identity or location. Therefore the MTL appears to perform a specific computation: binding disparate features that belong to a memory. These results echo findings from previous studies, which have identified a role for the MTL in relational binding for LTM, and support the proposal that MTL regions perform such a function for both STM and LTM, independent of the retention duration. Furthermore, these findings and the methodology employed here may provide a simple, sensitive and clinically valuable means to test memory dysfunuction in MTL disorders.

Complications after Anterior Temporal Lobectomy for Medically Intractable Epilepsy: A Systematic Review and Meta-Analysis.

BACKGROUND: The efficacy of surgery in the management of patients with longstanding temporal lobe epilepsy has been established. Anterior temporal lobectomy (ATL) is the most frequently implemented procedure. However, there is an obvious need to assess its perioperative safety. OBJECTIVE: We conducted a meta-analysis to estimate the postoperative mortality (Q1) and morbidity (Q2) associated with ATL for medically intractable epilepsy. In addition, we tried to identify the most frequent complications after ATL and assess their relative frequency (Q3) in children and adults. METHODS: Fixed- and random-effects model meta-analysis was conducted to assess the proportion estimate for each outcome individually. RESULTS: The postoperative mortality and cumulative morbidity were estimated to be as high as 0.01 (95% CI: 0.01, 0.02) and 0.17 (95% CI: 0.12, 0.24), respectively. Psychiatric disorders were the most common postoperative complications after ATL, with an estimated frequency as high as 0.07 (95% CI: 0.04, 0.10), followed by visual field defects (0.06; 0.03, 0.11), and cognitive disorders (0.05; 0.02, 0.10). Less frequent complications included hemiparesis and language disorders (0.03; 0.01, 0.06), infections (0.03; 0.02, 0.04), hemorrhage (0.02; 0.01, 0.05), cranial nerve deficits (0.03; 0.02, 0.05), extra-axial fluid collections (0.02; 0.01, 0.03), and medical complications (0.02; 0.01, 0.03). CONCLUSIONS: Even though the mortality after ATL is minimal, the overall morbidity cannot be ignored. Psychiatric disturbances, visual field defects, and cognitive disorders are the most common postoperative complications, and should be considered during the preoperative planning and consultation.

Histopathologic subtype of hippocampal sclerosis and episodic memory performance before and after temporal lobectomy for epilepsy.

OBJECTIVE: The International League Against Epilepsy (ILAE) proposed a classification system for hippocampal sclerosis (HS) based on location and extent of hippocampal neuron loss. The literature debates the usefulness of this classification system when studying memory in people with temporal lobe epilepsy (TLE) and determining memory outcome after temporal lobe resection (TLR). This study further explores the relationship between HS ILAE subtypes and episodic memory performance in patients with TLE and examines memory outcomes after TLR. METHODS: This retrospective study identified 213 patients with TLE who underwent TLR and had histopathological evidence of HS (HS ILAE type 1a = 92; type 1b = 103; type 2 = 18). Patients completed the Wechsler Memory Scale-3rd Edition prior to surgery, and 78% of patients had postoperative scores available. Linear regressions examined differences in preoperative memory scores as a function of pathology classification, controlling for potential confounders. Fisher's exact tests were used to compare pathology subtypes on the magnitude of preoperative memory impairment and the proportion of patients who experienced clinically meaningful postoperative memory decline. RESULTS: Individuals with HS ILAE type 2 demonstrated better preoperative verbal memory performance than patients with HS ILAE type 1; however, individual data revealed verbal and visual episodic memory impairments in many patients with HS ILAE type 2. The base rate of postoperative memory decline was similar among all 3 pathology groups. SIGNIFICANCE: This is the largest reported overall sample and the largest subset of patients with HS ILAE type 2. Group data suggest that patients with HS ILAE type 2 perform better on preoperative memory measures, but individually there were no differences in the magnitude of memory impairment. Following surgery, there were no statistically significant differences between groups in the proportion of patients who declined. Future research should focus on quantitative measurements of hippocampal neuronal loss, and multicenter collaboration is encouraged.

Brain network alterations of mesial temporal lobe epilepsy with cognitive dysfunction following anterior temporal lobectomy.

The aims of this study were to investigate the brain network connectivity alterations of intractable unilateral mesial temporal lobe epilepsy (MTLE) with cognitive dysfunction before and after anterior temporal lobectomy (ATL) using resting-state functional magnetic resonance imaging (rs-fMRI) study and to further observe the correlation between the brain network connectivity with cognitive performance. Fourteen patients with unilateral left MTLE before and after ATL were compared with thirty healthy controls (HCs) on functional connectivity (FC) between resting-state networks (RSNs). The correlation between the neuropsychological tests of patients and abnormal FC was further investigated. When compared with the HCs, patients before surgery showed significantly changed FC between special RSNs. No difference of FC was found between each RSN when patients were compared with the HCs after surgery. Compared with patients before surgery, patients after surgery showed significantly decreased FC between RSNs. Abnormal FC between RSNs significantly correlated with Montreal Cognitive Assessment (MoCA) scores. Our study suggested that dynamic alterations of RSN after ATL in unilateral MTLE may be closely related with seizure generating. However, unchanged FC between RSN before and after ATL may be closely related with cognitive performance. The present findings may help us understand the feature of brain network alterations in patients with left MTLE who became seizure-free following ATL.

Temporal plus epilepsy is a major determinant of temporal lobe surgery failures.

Reasons for failed temporal lobe epilepsy surgery remain unclear. Temporal plus epilepsy, characterized by a primary temporal lobe epileptogenic zone extending to neighboured regions, might account for a yet unknown proportion of these failures. In this study all patients from two epilepsy surgery programmes who fulfilled the following criteria were included: (i) operated from an anterior temporal lobectomy or disconnection between January 1990 and December 2001; (ii) magnetic resonance imaging normal or showing signs of hippocampal sclerosis; and (iii) postoperative follow-up ≥ 24 months for seizure-free patients. Patients were classified as suffering from unilateral temporal lobe epilepsy, bitemporal epilepsy or temporal plus epilepsy based on available presurgical data. Kaplan-Meier survival analysis was used to calculate the probability of seizure freedom over time. Predictors of seizure recurrence were investigated using Cox proportional hazards model. Of 168 patients included, 108 (63.7%) underwent stereoelectroencephalography, 131 (78%) had hippocampal sclerosis, 149 suffered from unilateral temporal lobe epilepsy (88.7%), one from bitemporal epilepsy (0.6%) and 18 (10.7%) from temporal plus epilepsy. The probability of Engel class I outcome at 10 years of follow-up was 67.3% (95% CI: 63.4-71.2) for the entire cohort, 74.5% (95% CI: 70.6-78.4) for unilateral temporal lobe epilepsy, and 14.8% (95% CI: 5.9-23.7) for temporal plus epilepsy. Multivariate analyses demonstrated four predictors of seizure relapse: temporal plus epilepsy (P < 0.001), postoperative hippocampal remnant (P = 0.001), past history of traumatic or infectious brain insult (P = 0.022), and secondary generalized tonic-clonic seizures (P = 0.023). Risk of temporal lobe surgery failure was 5.06 (95% CI: 2.36-10.382) greater in patients with temporal plus epilepsy than in those with unilateral temporal lobe epilepsy. Temporal plus epilepsy represents a hitherto unrecognized prominent cause of temporal lobe surgery failures. In patients with temporal plus epilepsy, anterior temporal lobectomy appears very unlikely to control seizures and should not be advised. Whether larger resection of temporal plus epileptogenic zones offers greater chance of seizure freedom remains to be investigated.

Costs Associated with Laser Interstitial Thermal Therapy Are Lower Than Anterior Temporal Lobectomy for Treatment of Temporal Lobe Epilepsy.

BACKGROUND: Laser interstitial thermal therapy (LITT) is a minimally invasive alternative to anterior temporal lobectomy (ATL) for treatment of temporal lobe epilepsy. It has gained popularity as familiarity with technique increases and outcomes are better characterized. There has been no direct cost comparison between the 2 techniques in literature to date. The current study directly compares hospital costs associated with LITT with those of ATL patients and analyzes the factors potentially responsible for those costs. METHODS: Patients who underwent ATL (27) and LITT (15) were retrospectively reviewed for total hospital costs along with demographic, surgical, and postoperative factors potentially affecting cost. T-tests were used to compare costs and independent linear regressions, and hierarchical regressions were used to examine predictors of cost for each procedure. RESULTS: Mean hospital costs of admission for single-trajectory LITT ($104,929.88) were significantly less than for ATL ($134,980.04) (P = 0.001). In addition, length of stay, anesthesia costs, operative room costs, and postoperative hospitalization costs were all significantly lower in LITT. CONCLUSIONS: Given the minimally invasive nature of LITT, it is associated with shorter length of stay and lower hospital costs than ATL in the first head-to-head comparison of procedural costs in literature to date. Long-term efficacy as it relates to these costs associated with LITT and ATL should be further investigated to better characterize the utility of LITT in temporal lobe epilepsy patients.

The place for surgical treatment for AVM involving the temporal lobe.

OBJECTIVE: The objective of this study was to analyze preoperative symptoms and late clinical outcomes in patients who underwent surgical treatment of arterio-venous malformations (AVMs) of the temporal lobe, including those involving the Sylvian fissure (SF) and the lateral wall of the inferior ventricular horns-with special respect to postoperative hemiparesis and visual field defects (VFD). METHODS: Between 1990 and 2007, 44 patients (n = 22 women, n = 22 men) with a mean age of 41 (12-67) years were operated on an AVM of the temporal lobe. All data had been collected prospectively. Patients' charts, as well as surgical reports and outpatient files, were analyzed. Thirteen patients showed an involvement of the SF, and six were localized partially in the lateral wall of the temporal horn. Eight AVMs were located in the temporo-mesial region. Fourteen patients had an AVM located mainly within the visual pathway. In 24 cases, the AVM was located in the dominant hemisphere. The AVMs were classified by the Spetzler-Martin grading system (SM). Visual fields were assessed in all patients pre- and postoperatively by independent ophthalmological examiners. RESULTS: The initial symptoms leading to the diagnosis of the AVM were seizures in 20 cases (45%), headache without hemorrhage in six cases (14%), incidental finding in five cases (11%), and tinnitus in two cases (5%). Hemorrhage had occurred in 15 cases (34%). Based on SM, 7 AVMs were grade I, 17 grade II, 17 grade III, and 3 grade IV. Preoperatively, seven patients presented with a VFD and two with a hemiparesis. Postoperatively, 8 of 44 (18%) patients presented with a new hemiparesis, remaining permanent in 3 of 44 (7%). In two of these patients, the AVMs were localized temporo-mesially (n = 2/8, 25%). Seven patients (19%) showed a new significant postoperative VFD, and in addition, three patients had worsening of their preexisting VFD (3/7, 43%). Postoperative angiography verified complete AVM occlusion in 43 of 44 (98%) cases. One patient needed reoperation for residual AVM; hence, in all patients, complete occlusion before discharge was achieved. CONCLUSION: Treatment of temporal lobe AVMs is demanding due to their close spatio-anatomical relationship with important neurovascular structures and the optic radiation. In this surgically treated series, morbidity for a new permanent hemiparesis was 7% and preservation of the visual field could be achieved in almost 90% of all cases. This is a calculable risk for most patients that renders microsurgical resection a justifiable option, even in light of other treatment modalities. The risk for new permanent motor deficits is elevated in temporo-mesial AVMs, and these patients have to be advised accordingly for surgical treatment.

Circulating Levels of Thrombospondin-1 and Thrombospondin-2 in Patients with Temporal Lobe Epilepsy Before and After Surgery.

AIM: To measure the serum levels of strong angiostatic and synaptogenetic molecules thrombospondin-1 (TSP-1) and thrombospondin-2 (TSP-2) in patients with temporal lobe epilepsy (TLE) before and after surgery. MATERIAL AND METHODS: In this prospective study, 20 patients operated for TLE and 20 healthy subjects were included. Serum levels of TSP-1 and TSP-2 were measured using enzyme-linked immunosorbent assay (ELISA). RESULTS: Our findings showed that both groups had higher serum levels of both molecules "before" surgery than 10 days ?after? SURGERY: However, a significant difference was noted between ?before? and "after" surgery regarding TSP-1 (p=0.00001). Although a marked decrease was found "after" surgery with respect to TSP-2, the difference did not reach statistical significance (p=0.22). In patients with TLE, serum levels of both molecules ?before? surgery were found to be significantly higher than in healthy controls (TSP-1, p=0.00001; TSP-2, p=0.007). CONCLUSION: Serum levels of TSP-1 and TSP-2 are determined to be higher in patients with TLE than in healthy subjects, and the resection of epileptogenic tissues decreases the serum levels of these molecules. Future studies should involve a higher number of patients with serial serum levels of TSP-1 and TSP-2 at the long-term follow-up to correlate with seizure outcome.

Surgery for temporal lobe epilepsy associated with mesial temporal sclerosis in the older patient: a long-term follow-up.

PURPOSE: To assess the outcomes from temporal lobectomy for hippocampal sclerosis in patients 50 years or older. Controversy exists as to the suitability of older patients for epilepsy surgery, with most of the previous studies demonstrating a correlation between increasing age and poor outcome. However, the inclusion of temporal lobe epilepsy of multiple etiologies has confounded many previous studies of this age group. METHODS: Twenty-one patients aged 50 years or older (mean 54.9 years) at the time of surgery were included in the study group. All patients had a pathologic diagnosis of hippocampal sclerosis. A retrospective analysis was performed comparing seizure outcomes following a standardized anterior temporal lobectomy with those from 103 patients younger than 50 (mean age 34.7 years) operated upon over the same time period. The mean follow-up period for the study was 9.57 years. RESULTS: Twenty of the 21 patients in the older group (95.2%) had a satisfactory seizure outcome (Engel classes I and II) compared with 90.3% of the younger patients. There was no statistically significant difference in the outcomes between the two groups (p = 0.719). Across both groups of patients combined, there was no significant difference between the mean age in the patients with a satisfactory seizure outcome compared to those with an unsatisfactory outcome (38.3 vs. 34.7 years, p = 0.213). DISCUSSION: Patients 50 years or older with intractable seizures from hippocampal sclerosis have seizure outcomes following temporal lobectomy that are comparable to young patients over the long term. Older patients should not be denied treatment on the basis of age.

Selective amygdalohippocampectomy: the trans-middle temporal gyrus approach.

The most common surgical procedure for the mesial temporal lobe is the standard anterior temporal resection or what is commonly called the anterior temporal lobectomy. There are, however, a number of other more selective procedures for removal of the mesial temporal lobe structures (amygdala, hippocampus, and parahippocampal gyrus) that spare much of the lateral temporal neocortex. Included in these procedures collectively referred to as selective amygdalohippocampectomy are the transsylvian, subtemporal, and transcortical (trans-middle temporal gyrus) selective amygdalohippocampectomy. In this manuscript the author reviews some of the surgical details of the trans-middle temporal gyrus approach to the mesial temporal structures.

Outcome after seizure recurrence on antiepileptic drug withdrawal following temporal lobectomy.

OBJECTIVE: To study the long-term outcome following seizure recurrence on antiepileptic drug (AED) withdrawal after anterior temporal lobectomy for mesial temporal lobe epilepsy. METHODS: We retrospectively studied the AED profile of patients who had a minimum of 5 years of postoperative follow-up after anterior temporal lobectomy for mesial temporal lobe epilepsy. Only those patients with hippocampal sclerosis or normal MRI were included. AED withdrawal was initiated at 3 months in patients on ≥2 drugs and at 1 year for patients on a single drug. RESULTS: Three hundred eighty-four patients with median postoperative follow-up of 12 years (range, 7-17 years) were included. Of them, 316 patients (82.3%) were seizure-free during the terminal 1 year. AED withdrawal was attempted in 326 patients (84.9%). At last follow-up, AEDs were discontinued in 207 patients (53.9%). Seizure recurrence occurred in 92 patients (28.2%) on attempted withdrawal. After a median postrecurrence follow-up of 7 years, 79 (86%) of them were seizure-free during the terminal 2 years. AEDs could be stopped in 17 patients (18.5%) and doses were reduced in another 57 patients (62%). Patients with febrile seizures, normal postoperative EEG at 1 year, and duration of epilepsy of <20 years (FND20 score) had 17% risk of seizure recurrence on attempted AED withdrawal. We also formulated a score to predict the chances of AED freedom for the whole cohort. CONCLUSION: Patients with seizure recurrence on AED withdrawal have good outcome with 86% becoming seizure-free and 18% becoming drug-free after initial recurrence. A FND20 score helps in predicting recurrence on AED withdrawal.

Temporal trends in pre-surgical evaluations and epilepsy surgery in the U.S. from 1998 to 2009.

OBJECTIVE: To analyze trends in utilization of pre-surgical evaluations including video-EEG (VEEG) monitoring, intracranial EEG (IEEG) monitoring, and epilepsy surgery from 1998 to 2009 in the U.S. METHODS: Data from the Nationwide Inpatient Sample were used to identify admissions for pre-surgical evaluations and surgery. Surgical treatment of epilepsy was identified by the presence of primary ICD-9-CM procedure codes 01.52 (hemispherectomy), 01.53 (lobectomy), or 01.59 (other excision of the brain, including amygdalohippocampectomy). We calculated annual rates of pre-surgical evaluations and surgery based on published estimates of prevalence of epilepsy in the U.S. In addition, we examined variations by region and hospital characteristics, and conducted multivariable analysis to detect temporal trends, adjusting for changes in the population. Sensitivity analysis was also conducted using different algorithms to identify the study population and outcomes. RESULTS: We detected an increase in the rate of hospitalizations related to intractable epilepsy. Similarly, we noted a significant increase in hospitalizations for VEEG monitoring, but not in IEEG monitoring or in surgery. Multivariable analysis and sensitivity analysis confirmed these results. In addition, there was a significant increase in the proportion of pre-surgical evaluations and surgery performed in non-teaching hospitals. CONCLUSIONS: Despite the increase in VEEG monitoring, the availability of guideline and evidences demonstrating benefits of epilepsy surgery was not associated with a greater employment of surgery over time. Nevertheless, access to pre-surgical evaluations and epilepsy surgery is no longer limited to large medical centers.