Visual field defects after radiosurgery versus temporal lobectomy for mesial temporal lobe epilepsy: Findings of the ROSE trial.

PURPOSE: Stereotactic radiosurgery (SRS) may be an alternative to anterior temporal lobectomy (ATL) for mesial temporal lobe epilepsy (MTLE). Visual field defects (VFD) occur in 9-100% of patients following open surgery for MTLE. Postoperative VFD after minimally invasive versus open surgery may differ. METHODS: This prospective trial randomized patients with unilateral hippocampal sclerosis and concordant video-EEG findings to SRS versus ATL. Humphries perimetry was obtained at 24 m after surgery. VFD ratios (VFDR = proportion of missing homonymous hemifield with 0 = no VFD, 0.5 = complete superior quadrantanopsia) quantified VFD. Regressions of VFDR were evaluated against treatment arm and covariates. MRI evaluated effects of volume changes on VFDR. The relationships of VFDR with seizure remission and driving status 3 years after surgery were evaluated. RESULTS: No patients reported visual changes or had abnormal bedside examinations, but 49 of 54 (91%) of patients experienced VFD on formal perimetry. Neither incidence nor severity of VFDR differed significantly by treatment arm. VFDR severity was not associated with seizure remission or driving status. CONCLUSION: The nature of VFD was consistent with lesions of the optic radiations. Effective surgery (defined by seizure remission) of the mesial temporal lobe results in about a 90% incidence of typical VFD regardless of method.

Radiosurgery versus open surgery for mesial temporal lobe epilepsy: The randomized, controlled ROSE trial.

OBJECTIVE: To compare stereotactic radiosurgery (SRS) versus anterior temporal lobectomy (ATL) for patients with pharmacoresistant unilateral mesial temporal lobe epilepsy (MTLE). METHODS: This randomized, single-blinded, controlled trial recruited adults eligible for open surgery among 14 centers in the USA, UK, and India. Treatment was either SRS at 24 Gy to the 50% isodose targeting mesial structures, or standardized ATL. Outcomes were seizure remission (absence of disabling seizures between 25 and 36 months), verbal memory (VM), and quality of life (QOL) at 36-month follow-up. RESULTS: A total of 58 patients (31 in SRS, 27 in ATL) were treated. Sixteen (52%) SRS and 21 (78%) ATL patients achieved seizure remission (difference between ATL and SRS = 26%, upper 1-sided 95% confidence interval = 46%, P value at the 15% noninferiority margin = .82). Mean VM changes from baseline for 21 English-speaking, dominant-hemisphere patients did not differ between groups; consistent worsening occurred in 36% of SRS and 57% of ATL patients. QOL improved with seizure remission. Adverse events were anticipated cerebral edema and related symptoms for some SRS patients, and cerebritis, subdural hematoma, and others for ATL patients. SIGNIFICANCE: These data suggest that ATL has an advantage over SRS in terms of proportion of seizure remission, and both SRS and ATL appear to have effectiveness and reasonable safety as treatments for MTLE. SRS is an alternative to ATL for patients with contraindications for or with reluctance to undergo open surgery.

Independencia de las puntas limbicas neocorticales en epilepsia del lobulo temporal / Independence of the limbic and neocortical discharges in temporal lobe epilepsy

Han habido numerosas publicaciones relacionadas con la independencia de las crisis de descargas epilépticas en las estructuras profundas y el cuero cabelludo en pacientes sometidos a registros con electrodos profundos (candidatos potenciales para cirugía de epilepsia). La presente comunicación, es sobre una observación de registro simultáneo con electrodos profundos, electrodos epidurales y también sobre el cuero cabelludo, en una paciente de 36 años de edad con epilepsia crónica intratable, del lóbulo temporal. La actividad profunda fue registrada con electrodos de acero inoxidable en forma de trenza (de 6 contactos cada uno), insertados en la corteza fronto-orbitaria y en la región del núcleo amigdaliano. Los electrodos epidurales, fueron de plata-dorada y se colocaron a través de un orificio de trepanación a nivel de la segunda circunvolución temporal. Los registros mostraron: a) el máximo de actividad espicular en los 3 contactos más profundos del electrodo colocado en la región de la amigdala izquierda, casi sin actividad correspondiente en otras áreas; b) puntas independientes en el electrodo de la región fronto-orbitaria izquierda; c) frecuentes puntas en los electrodos epidurales, ocasionalmente sincrónicos con las descargas fronto-orbitarias y a veces sincrónicas con las puntas observadas en los electrodos del cuero cabelludo ubicados en la región temporal izquierda. Estas observaciones remarcan el caracter difuso en el origen de la actividad espicular en epilepsia del lóbulo temporal y permiten apoyar la técnica de la resección "en bloque" de amplias partes del lóbulo temporal involucrado