Surgery for focal epilepsy in the older patient.

Eight of the 237 patients who received a surgical procedure for intractable partial epilepsy at the Mayo Clinic during a 3-year period were 50 years of age or older. All patients had disabling partial seizures of several years in duration that were refractory to antiepileptic drug medication. A neuroimaging-identified epileptogenic lesion prompted referral for surgical treatment in three patients. The only clinically significant morbidity associated with surgery in the eight patients was a transient exacerbation of an aphasia in a patient who underwent a left frontal corticectomy. All eight patients had a favorable seizure outcome, and three patients postoperatively are seizure free. Epilepsy surgery may be an appropriate alternate therapy for select patients in the sixth decade of life or older with medically refractory partial seizures.

Gadolinium-DTPA-enhanced magnetic resonance imaging in intractable partial epilepsy.

We performed magnetic resonance imaging (MRI), before and after the administration of gadolinium-DTPA (Gd-DTPA), in 23 patients with medically refractory partial epilepsy who subsequently had surgical treatment for their seizure disorder. In most patients, 61%, unenhanced and enhanced MRI studies were negative. In 26% the unenhanced image was positive, and the abnormality enhanced with Gd-DTPA. In 13% the unenhanced MR image was positive, but the abnormality did not enhance with Gd-DTPA. Gd-DTPA does not appear to increase the diagnostic yield of MRI in the presurgical evaluation of patients with partial epilepsy if the unenhanced MRIs are normal.

MRI hippocampal volumes and memory function before and after temporal lobectomy.

We investigated the relationship between preoperative MRI hippocampal volumes and clinical neuropsychological memory test data obtained before and after temporal lobectomy and amygdalohippocampectomy for intractable epilepsy in 44 left (LTL) and 36 right (RTL) temporal lobectomy patients. In LTL patients, the difference (right minus left hippocampal volume) between hippocampal volumes (DHF) was significantly (p < 0.001) correlated (r = 0.61) with postoperative verbal memory change as measured by a delayed memory percent retention score from the Wechsler Memory Scale-Revised, Logical Memory subtest. DHF was also positively associated with postoperative memory for abstract geometric designs in LTL patients (r = 0.49, p < 0.005). Resection of a relatively nonatrophic left hippocampus was associated with poorer verbal and visual memory outcome. In RTL patients, larger right adjusted (for total intracranial volume) hippocampal volume was associated with decline in visual-spatial learning, but not memory, following surgery. MRI hippocampal volume data appear to provide meaningful information in evaluating the risk for memory impairment following temporal lobectomy.

Stereotactic resection of intra-axial cerebral lesions in partial epilepsy.

We performed a retrospective study of stereotactic resections of intra-axial brain mass lesions in 30 patients with intractable partial epilepsy. The most common pathologic alterations observed were vascular malformations (11 lesions) and glial neoplasms (11 lesions). The locations of the lesions included the postcentral gyrus in five patients, the precentral gyrus in five, and the deep-seated left posterior temporal region in four, all of which were sites that may have precluded standard craniotomy and cortical resection. Of the 30 medically refractory patients, 26 had at least an 80% reduction in seizure activity at a mean duration of follow-up of 22 months postoperatively. Nineteen of 22 patients with at least 1 year (mean, 28 months) of follow-up and 13 of 15 patients with at least 2 years (mean, 34 months) of follow-up had favorable surgical outcomes. "Lesionectomy" may allow pathologic examination of intracranial lesions and may produce a worthwhile reduction in seizure activity in some patients with intractable partial epilepsy.

Quantitative MRI hippocampal volumes: association with onset and duration of epilepsy, and febrile convulsions in temporal lobectomy patients.

The relationships between preoperatively acquired MRI-based hippocampal volumes (HV), seizure disorder onset and duration, and early childhood febrile convulsions were investigated retrospectively with data from 72 left and 56 right temporal lobectomy patients. Patients with lesional pathology and heterotopic abnormalities were excluded. Age at development of spontaneous seizures unprovoked by an acute illness defined age of seizure disorder onset. Age of onset was subtracted from age at neurosurgery to determine duration. MRI variables included in this study were the right and left HV divided by total intracranial volume (RAHV, LAHV), and the right-left hippocampal difference (DHF). Partial correlations were used to better isolate relationships with onset of recurrent seizures corrected for age at surgery, and age at neurosurgery corrected for age of recurrent seizure onset. Partial correlations between age at neurosurgery and volume were not significant in either group. LAHV (r = 0.42, P < 0.0003) and DHF (r = -0.49, P < 0.0001) were correlated with age of onset in the left lobectomy group. Correlations in the right lobectomy group were not significant. The presence of a febrile convulsion was associated with smaller LAHV (F(1,70) = 10.54, P < 0.002) and larger DHF (F(1,70) = 11.36, P < 0.002) in left temporal lobectomy patients. The presence of a febrile convulsion in the right temporal group was associated with a slightly smaller DHF (F(1,56) = 5.90, P < 0.02), and slightly smaller RAHV (F(1,56) = 4.49, P < 0.04). These data suggest that hippocampal atrophy remains stable over the duration of temporal lobe onset seizure disorders, and is associated with early onset of recurrent seizures in left temporal patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Intractable frontal lobe epilepsy: pathological and MRI features.

The clinical, pathological, and at least one year follow-up of 48 patients with intractable frontal lobe partial epilepsy who underwent surgical treatment for their seizure disorder were reviewed. The group consisted of 27 males and 21 females. Preoperative magnetic resonance imaging (MRI) was normal (26 patients), demonstrated focal frontal lobe (16 patients) or multilobar signal abnormalities (6 patients). Postoperatively patients were divided into one of four groups based upon the degree of seizure activity (Class I: seizure free, Class IV: little to no improvement, Classes II/III: intermediate). Eight patients with tumors (low grade gliomas) were Class I (N = 6) or Class II (N = 2) postoperatively. The remaining six patients with focal, completely resected pathological lesions (e.g. tubers, contusions, etc.) also had Class I or Class II outcomes. Of the 31 patients with the pathological diagnosis of gliosis, the outcome was dependent on the MRI appearance. Preoperative MRI scans of these patients were normal (N = 23), or had focal frontal lobe (N = 2) or multilobar (N = 6) abnormalities. The gliosis patients with unilateral frontal MRI lesions had a good outcome (Class I or II) while those with multilobar MRI abnormalities were all Class IV. Successful outcome correlated strongly with both focal frontal lobe MRI and pathological abnormalities in contrast to the less favorable results seen in patients with normal head MRI scans and gliosis or no pathological abnormality on pathological examination. Multilobar MRI abnormalities invariably had the poorest outcome of all patient groups. Thus presurgical MRI is an important tool and predictor of surgical outcome in patients with frontal lobe epilepsy.

MRI in the presurgical evaluation of patients with frontal lobe epilepsy and children with temporal lobe epilepsy: pathologic correlation and prognostic importance.

We performed magnetic resonance imaging (MRI) using a high-field strength magnet (1.5 T) in two series of 53 patients with intractable partial epilepsy of frontal lobe or temporal lobe origin who subsequently received ablative surgery for their seizure disorder. In the first series of patients the pathologic correlation and prognostic importance of an MRI-identified lesion in the frontal lobe were assessed. Twenty-five percent of the patients with negative MRI studies and 67% of patients with neuroimaging abnormalities restricted to the frontal lobe, were seizure-free at a minimum duration of follow-up of 1 year. None of the patients with a multilobar MRI-detected abnormality was seizure-free postoperatively. In the second study the sensitivity and specificity of MRI-based hippocampal volumetry was determined in pediatric patients with partial epilepsy of temporal lobe origin unrelated to foreign-tissue pathology. Hippocampal formation atrophy in the epileptic temporal lobe was identified in 63% of patients. The sensitivity and specificity of hippocampal volumetry was 100% in patients with mesial temporal sclerosis. The presence of an MRI-detected epileptogenic lesion in the frontal lobe and hippocampal formation atrophy in the temporal lobe may correlate with the underlying pathology and affect the identification of potential candidates for epilepsy surgery.

Neurocognitive efficiency following left temporal lobectomy: standard versus limited resection.

Decreased memory and learning efficiency may follow left temporal lobectomy. Debate exists as to whether the acquired deficit is related to the size of the surgical resection. This study addresses this question by comparing changes in cognitive performance to the extent of resection of both mesial temporal structures and lateral cortex. The authors retrospectively reviewed 47 right-handed patients who underwent left temporal lobectomy for medically intractable seizures. To examine the effects of the extent of mesial resection, the patients were divided into two groups: those with resection at the anterior 1 to 2 cm of mesial structures versus those with resection greater than 2 cm. To examine the effects of the extent of lateral cortical resection, patients were again divided into two groups: those with lateral cortex resections of 4 cm or less versus those with resections greater than 4 cm. Statistical analyses showed no difference in cognitive outcome between the groups defined by the extent of mesial resection. Likewise, no difference in cognitive outcome was seen between the groups defined by the extent of lateral cortical resection. Associated data analyses did, however, reveal a negative correlation of cognitive change with patient age at seizure onset. These results showed that the neurocognitive consequences of extended mesial resections were similar to those of limited mesial resections, and that the neurocognitive consequences of extended lateral cortical resections were similar to those of limited lateral cortical resections. The risk of cognitive impairment depends more on age at seizure onset than on the extent of mesial or lateral resection.

Traditional and computerized assessment procedures applied to the evaluation of memory change after temporal lobectomy.

After establishing that 40 temporal lobectomy patients (20 right, 20 left) demonstrated the same pattern of memory compromise as has been reported in prior studies, we examined the sensitivity of computerized tests of everyday memory skills to the cognitive change associated with temporal resection. Multiple cognitive deficits occur after left, but not after right, temporal lobectomies. Memory impairment after surgery is not limited to traditionally structured memory tests but is also evident on tasks designed to simulate activities of daily life.

Identification of the epileptic focus: magnetic resonance imaging.

Magnetic resonance imaging (MRI) is the most sensitive and specific structural imaging technique available to demonstrate focal epileptogenic lesions in patients with intractable partial epilepsy. MRI may be useful in the selection of candidates for surgical treatment of epilepsy. The studies may also assist in the implantation of depth electrodes and in the stereotactic resection of epileptogenic lesions. More recent applications of this neuroimaging modality in the surgical treatment of epilepsy include pre-operative hippocampal formation of volume measurements and postoperative quantitative determinations of cortical resections.

Long-term follow-up of stereotactic lesionectomy in partial epilepsy: predictive factors and electroencephalographic results.

We performed an extended follow-up study assessing the efficacy of stereotactic lesionectomy in 23 patients with foreign-tissue lesions and intractable partial epilepsy. Sixteen lesions involved functional or eloquent cortex as determined by anatomic localization. By definition, the surgical objective in these patients was excision of the lesion, and not the surrounding cerebral cortex. The mean duration of follow-up was 48.5 months (range 26-69 months). Seventeen patients (74%) had a significant reduction in seizures (greater than or equal to 90%) after lesionectomy. Thirteen patients (56%) had a class I operative outcome (seizure-free, single seizure episode, or auras only). Five of these patients were successfully discontinued from antiepileptic drug (AED) therapy. Patients with temporal lobe lesions were statistically less likely to be rendered seizure-free (p less than 0.05). Age at operation, duration of epilepsy, and underlying pathology were not significant predictors of seizure outcome. The anatomic distribution of extracranial EEG recorded epileptiform activity did not appear to be an important determinant of outcome. The absence of interictal epileptiform activity in the 3-month postoperative EEG correlated with a significant reduction in seizures. Long-term follow-up indicates that lesionectomy may be effective in select patients with medically refractory partial seizure disorders.

Magnetic resonance imaging-based volume studies in temporal lobe epilepsy: pathological correlations.

We performed a prospective study correlating magnetic resonance imaging volume measurements of the hippocampal formation with histopathology in 24 patients with intractable partial epilepsy who subsequently underwent an anterior temporal lobectomy for their seizure disorder. Patients with mass lesions verified pathologically were excluded from this study. In 71% of patients, quantitative hippocampal formation atrophy correctly lateralized the temporal lobe of seizure origin; in 29%, the volume study was indeterminant. The severity of the pathological alterations in the hippocampus correlated with the hippocampal formation volume determination. Mesial temporal sclerosis was identified in the surgically excised temporal lobe in 15 patients. The magnetic resonance imaging volume studies indicated hippocampal atrophy in the temporal lobe resected in 14 of the 15 patients. Magnetic resonance imaging-based volume measurements of the hippocampal formation increase the diagnostic yield of magnetic resonance imaging scanning in patients with intractable partial epilepsy related to mesial temporal sclerosis.

EEG scalp electrode projection onto three-dimensional surface rendered images of the brain.

A technique is described for generating magnetic resonance-based, surface rendered images of the brain with electroencephalographic (EEG) scalp electrode positions projected onto the cortical surface. This technique (EEG electrode projection) was used in 10 patients who subsequently underwent surgery for medically intractable frontal lobe epilepsy. In most cases of intractable epilepsy, successful surgery entails the resection of electrophysiologically abnormal cortical tissue rather than an identifiable mass lesion. EEG electrode projection is a unique and useful surgical tool because it provides images that spatially correlate the surface anatomy of the brain and the electrophysiologic abnormality recorded at the scalp. Excellent correlation was found between cortical topography delineated by the surface rendered images and cortical anatomy at surgery. Agreement between EEG electrode projection and electrocorticography as to the location of the electrophysiologic abnormality increases confidence that appropriate cortical areas have been identified for resection. The technique provides new and unique insight into important anatomic-electrophysiologic relationships and aids in formulation of surgical strategy.

Temporal lobe seizures: lateralization with MR volume measurements of the hippocampal formation.

A retrospective magnetic resonance (MR) imaging study was performed in 41 right-handed patients with presumed mesial sclerosis who underwent surgery for medically intractable, complex partial seizures of temporal lobe origin. The ability of each of five different MR imaging-based tests to lateralize the seizure disorder was determined. In order of decreasing usefulness the tests were (a) hippocampal formation (HF) volume measurements, (b) visual grading of MR images for unilateral HF atrophy, (c) anterior temporal lobe (ATL) volume measurements, (d) visual grading of MR images for unilateral ATL atrophy, and (e) evidence of unilateral medial temporal lobe signal intensity abnormalities on long repetition time MR images. A right-side minus left-side volume (designated DHF) was obtained to quantify unilateral HF atrophy with a single number. Patients with right-sided seizures had a median DHF of -0.4 cm3, while those with left-sided seizures had a median DHF of 0.8 cm3, consistent with atrophy of the HF ipsilateral to the seizure disorder. Conservative volumetric threshold values (-0.2 cm3 and 0.6 cm3), separating individual DHF measurements into right-side abnormal, indeterminate, and left-side abnormal, allowed DHF measurements to be 76% sensitive and 100% specific for correct seizure lateralization.

Magnetic resonance image-based hippocampal volumetry: correlation with outcome after temporal lobectomy.

We developed a magnetic resonance imaging (MRI)-based technique for measuring the volume of the hippocampal formation. In this study, the relationship between volumes of the hippocampal formation and outcome (i.e., postoperative seizure control) after anterior temporal lobectomy for intractable epilepsy was analyzed in 50 consecutive patients in whom the surgical specimen did not contain an epileptogenic mass lesion. Outcome was classified as either satisfactory or unsatisfactory. A significant relationship was found between outcome and volume of the operated hippocampal formation (p = 0.012), as well as a derived volumetric measure (nonoperated minus operated volume of the hippocampal formation) (p = 0.004). The association between outcome and nonoperated volume was borderline (p = 0.057). Thirty-four (97%) of 35 patients in whom the volumetric study and electroencephalography (EEG) concordantly lateralized the seizure disorder had satisfactory postoperative seizure control. Conversely, only 7 (42%) of 12 patients in whom the volume study was nonlateralizing and 1 (33%) of 3 in whom the EEG and volume study were discordant has a satisfactory outcome. We regard our MRI-based study of hippocampal formation volume as a noninvasive surrogate for the identification of moderate or severe mesial temporal sclerosis. The technique is a useful adjunct in a multidisciplinary, preoperative epilepsy evaluation when T2-weighted MRIs do not reveal an epileptogenic mass lesion. The reasons for the usefulness of this imaging technique are: (1) It is an independent source of information on seizure lateralization, (2) it will provide information as to expected postoperative outcome, and (3) it may aid in appropriately selecting patients for invasive preoperative monitoring studies.