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

Abstract See Engel (doi:10.1093/awv374) for a scientific commentary on this article. 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.

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Stereotactic-EEG Guided Radiofrequency Thermocoagulation Versus Anterior Temporal Lobectomy for Mesial Temporal Lobe Epilepsy with Hippocampal Sclerosis: Study protocol for a randomized controlled trial

10.21203/rs.3.rs-56665/v1 ◽

2021 ◽

Author(s):

Yi-He Wang ◽

Si-Chang Chen ◽

Peng-Hu Wei ◽

Kun Yang ◽

Xiao-Tong Fan ◽

...

Keyword(s):

Temporal Lobe Epilepsy ◽

Temporal Lobe ◽

Hippocampal Sclerosis ◽

Controlled Trial ◽

Mesial Temporal Lobe Epilepsy ◽

Temporal Lobectomy ◽

Anterior Temporal Lobectomy ◽

Radiofrequency Thermocoagulation ◽

Mesial Temporal Lobe

Abstract Introduction: In this report, we aim to describe the design for the randomized controlled trial of Stereotactic-electroencephalogram (EEG) guided Radiofrequency Thermocoagulation versus Anterior Temporal Lobectomy for Mesial Temporal Lobe Epilepsy with Hippocampal Sclerosis (STARTS). Mesial temporal lobe epilepsy (mTLE) is a classical subtype of temporal lobe epilepsy that often requires surgical intervention. Although anterior temporal lobectomy (ATL) remains the most popular treatment for mTLE, accumulating evidence has indicated that ATL can cause tetartanopia and memory impairments. Stereotactic EEG (SEEG)-guided radiofrequency thermocoagulation (RF-TC) is a non-invasive alternative associated with lower seizure freedom but greater preservation of neurological function. In the present study, we aim to compare the safety and efficacy of SEEG-guided RF-TC and classical ATL in the treatment of mTLE. Methods and analysis: STARTS is a single-centre, two-arm, randomised controlled, parallel-group clinical trial. The study includes patients with typical mTLE over the age of 14 who have drug-resistant seizures for at least 2 years and have been determined via detailed evaluation to be surgical candidates prior to randomisation. The primary outcome measure is cognitive function at the 1-year follow-up after treatment. Seizure outcomes, visual field abnormalities after surgery, quality of life, ancillary outcomes, and adverse events will also be evaluated at 1-year follow-up as secondary outcomes. Disscussion: SEEG-guided RF-TC for mTLE remains a controversial seizure outcome but has the advantage for cognitive and visual filed protection. This is the first RCT studying cognitive outcomes and treatment results between SEEG-guided RF-TC and standard ATL for mTLE with hippocampal sclerosis. This study may provide a higher levels of clinical evidence for the treatment for mTLE. Trial registration: The STARTS protocol has been registered on the US National Institutes of Health (ClinicalTrials.gov): NCT03941613. The status of the STARTS was recruiting and the estimated study completion date was December 31, 2021.

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Seizure Freedom in Temporal Plus Epilepsy Surgery Following Stereo-Electroencephalography

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2020.26 ◽

2020 ◽

Vol 47 (3) ◽

pp. 374-381

Author(s):

Juan S. Bottan ◽

Ana Suller Marti ◽

Andrew G. Parrent ◽

Keith W. MacDougall ◽

Richard S. McLachlan ◽

...

Keyword(s):

Temporal Lobe ◽

Epilepsy Surgery ◽

Right Hemisphere ◽

Case Series ◽

Temporal Lobectomy ◽

Seizure Freedom ◽

Epileptogenic Zone ◽

Small Case Series ◽

Adjacent Structures

ABSTRACT:Background:“Temporal plus” epilepsy (TPE) is a term that is used when the epileptogenic zone (EZ) extends beyond the boundaries of the temporal lobe. Stereotactic electroencephalography (SEEG) has been essential to identify additional EZs in adjacent structures that might be part of the temporal lobe/limbic network.Objective:We present a small case series of temporal plus cases successfully identified by SEEG who were seizure-free after resective surgery.Methods:We conducted a retrospective analysis of 156 patients who underwent SEEG in 5 years. Six cases had TPE and underwent anterior temporal lobectomy (ATL) with additional extra-temporal resections.Results:Five cases had a focus on the right hemisphere and one on the left. Three cases were non-lesional and three were lesional. Mean follow-up time since surgery was 2.9 years (SD ± 1.8). Three patients had subdural electrodes investigation prior or in addition to SEEG. All patients underwent standard ATL and additional extra-temporal resections during the same procedure or at a later date. All patients were seizure-free at their last follow-up appointment (Engel Ia = 3; Engel Ib = 2; Engel Ic = 1). Pathology was nonspecific/gliosis for all six cases.Conclusion:TPE might explain some of the failures in temporal lobe epilepsy surgery. We present a small case series of six patients in whom SEEG successfully identified this phenomenon and surgery proved effective.

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Stereotactic EEG-guided radiofrequency thermocoagulation versus anterior temporal lobectomy for mesial temporal lobe epilepsy with hippocampal sclerosis: study protocol for a randomised controlled trial

Trials ◽

10.1186/s13063-021-05378-3 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Yi-He Wang ◽

Si-Chang Chen ◽

Peng-Hu Wei ◽

Kun Yang ◽

Xiao-Tong Fan ◽

...

Keyword(s):

Temporal Lobe Epilepsy ◽

Temporal Lobe ◽

Hippocampal Sclerosis ◽

Controlled Trial ◽

Mesial Temporal Lobe Epilepsy ◽

Temporal Lobectomy ◽

Anterior Temporal Lobectomy ◽

Radiofrequency Thermocoagulation ◽

Mesial Temporal Lobe ◽

Randomised Controlled

Abstract Introduction In this report, we aim to describe the design for the randomised controlled trial of Stereotactic electroencephalogram (EEG)-guided Radiofrequency Thermocoagulation versus Anterior Temporal Lobectomy for Mesial Temporal Lobe Epilepsy with Hippocampal Sclerosis (STARTS). Mesial temporal lobe epilepsy (mTLE) is a classical subtype of temporal lobe epilepsy that often requires surgical intervention. Although anterior temporal lobectomy (ATL) remains the most popular treatment for mTLE, accumulating evidence has indicated that ATL can cause tetartanopia and memory impairments. Stereotactic EEG (SEEG)-guided radiofrequency thermocoagulation (RF-TC) is a non-invasive alternative associated with lower seizure freedom but greater preservation of neurological function. In the present study, we aim to compare the safety and efficacy of SEEG-guided RF-TC and classical ATL in the treatment of mTLE. Methods and analysis STARTS is a single-centre, two-arm, randomised controlled, parallel-group clinical trial. The study includes patients with typical mTLE over the age of 14 who have drug-resistant seizures for at least 2 years and have been determined via detailed evaluation to be surgical candidates prior to randomisation. The primary outcome measure is the cognitive function at the 1-year follow-up after treatment. Seizure outcomes, visual field abnormalities after surgery, quality of life, ancillary outcomes, and adverse events will also be evaluated at 1-year follow-up as secondary outcomes. Discussion SEEG-guided RF-TC for mTLE remains a controversial seizure outcome but has the advantage for cognitive and visual field protection. This is the first RCT studying cognitive outcomes and treatment results between SEEG-guided RF-TC and standard ATL for mTLE with hippocampal sclerosis. This study may provide higher levels of clinical evidence for the treatment of mTLE. Trial registration ClinicalTrials.gov NCT03941613. Registered on May 8, 2019. The STARTS protocol has been registered on the US National Institutes of Health. The status of the STARTS was recruiting and the estimated study completion date was December 31, 2021.

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PHARMACORESISTENT TEMPORAL LOBE & EXTRA TEMPORAL EPILEPSY: OUTCOMES AFTER SURGERY.

International Journal of Medical and Biomedical Studies ◽

10.32553/ijmbs.v5i6.1952 ◽

2021 ◽

Vol 5 (6) ◽

Author(s):

Govind Mangal ◽

Uday Bhaumik ◽

Giriraj Prajapati ◽

Poojan Thakor

Keyword(s):

Temporal Lobe Epilepsy ◽

Temporal Lobe ◽

Age Of Onset ◽

Hippocampal Sclerosis ◽

Temporal Lobectomy ◽

Temporal Epilepsy ◽

Post Surgery ◽

Study Population ◽

The Mean

Background: Our aim was to follow up patients postoperatively to identify seizure remission and relapse after surgery, to enable individuals considering surgery to make informed choices. Methods: Ninteen consecutive patients operated for drug resistant Temporal lobe & extra temporal lobe epilepsy between 2019 and 2020, at our centre. All the patients had at least one year post surgery follow-up. Results: The mean age of study population was 20.87 ± 10.08 years. The mean age of onset of epilepsy in study population was 14.9 ± 8 years. There were no acute post operative seizures. The most common histpathological finding was hippocampal sclerosis in 15 patients. The patients were followed up and 15 were in the class 1 of engel classification. 2 in class 2, rest had one each Conclusion: Following surgery approx half of patients were seizure free and Engel's favourable outcome was noted. The predictors of unfavourable outcome were younger age of onset and pronged duration and of epilepsy Keywords: Temporal lobe epilepsy, temporal lobectomy, amygdalohippocampectomy, outcome, extra temporal lobe epilepsy, extra temporal lobectomy

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Seizure Freedom After Epilepsy Surgery and Higher Baseline Cognition May Be Associated With a Negatively Correlated Epilepsy Network in Temporal Lobe Epilepsy

Frontiers in Neuroscience ◽

10.3389/fnins.2020.629667 ◽

2021 ◽

Vol 14 ◽

Author(s):

Elliot G. Neal ◽

Mike R. Schoenberg ◽

Stephanie Maciver ◽

Yarema B. Bezchlibnyk ◽

Fernando L. Vale

Keyword(s):

Temporal Lobe Epilepsy ◽

Temporal Lobe ◽

Epilepsy Surgery ◽

Memory Function ◽

Brain Regions ◽

Seizure Freedom ◽

Epileptogenic Zone ◽

Temporal Lobes ◽

Scalp Eeg ◽

The Brain

Background: Brain regions positively correlated with the epileptogenic zone in patients with temporal lobe epilepsy vary in spread across the brain and in the degree of correlation to the temporal lobes, thalamus, and limbic structures, and these parameters have been associated with pre-operative cognitive impairment and seizure freedom after epilepsy surgery, but negatively correlated regions have not been as well studied. We hypothesize that connectivity within a negatively correlated epilepsy network may predict which patients with temporal lobe epilepsy will respond best to surgery.Methods: Scalp EEG and resting state functional MRI (rsfMRI) were collected from 19 patients with temporal lobe epilepsy and used to estimate the irritative zone. Using patients’ rsfMRI, the negatively correlated epilepsy network was mapped by determining all the brain voxels that were negatively correlated with the voxels in the epileptogenic zone and the spread and average connectivity within the network was determined.Results: Pre-operatively, connectivity within the negatively correlated network was inversely related to the spread (diffuseness) of that network and positively associated with higher baseline verbal and logical memory. Pre-operative connectivity within the negatively correlated network was also significantly higher in patients who would go on to be seizure free.Conclusion: Patients with higher connectivity within brain regions negatively correlated with the epilepsy network had higher baseline memory function, narrower network spread, and were more likely to be seizure free after surgery.

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Relation of Structural and Functional Changes in Auditory and Visual Pathways after Temporal Lobe Epilepsy Surgery

Behavioral Sciences ◽

10.3390/bs8100092 ◽

2018 ◽

Vol 8 (10) ◽

pp. 92

Author(s):

Margarita Báez-Martín ◽

Lilia Morales-Chacón ◽

Iván García-Maeso ◽

Bárbara Estupiñán-Díaz ◽

María García-Navarro ◽

...

Keyword(s):

Temporal Lobe Epilepsy ◽

Temporal Lobe ◽

Epilepsy Surgery ◽

Visual Pathway ◽

Visual Pathways ◽

Temporal Lobectomy ◽

Epileptogenic Zone ◽

Drug Resistant ◽

Anatomical Connectivity ◽

Anatomical Connection

Auditory and visual pathways may be affected as a consequence of temporal lobe epilepsy surgery because of their anatomical relationships with this structure. The purpose of this paper is to correlate the results of the auditory and visual evoked responses with the parameters of tractography of the visual pathway, and with the state of connectivity between respective thalamic nuclei and primary cortices in both systems after the surgical resection of the epileptogenic zone in drug-resistant epileptic patients. Tractography of visual pathway and anatomical connectivity of auditory and visual thalamus-cortical radiations were evaluated in a sample of eight patients. In general, there was a positive relationship of middle latency response (MLR) latency and length of resection, while a negative correlation was found between MLR latency and the anatomical connection strength and anatomical connection probability of the auditory radiations. In the visual pathway, significant differences between sides were found with respect to the number and length of tracts, which was lower in the operated one. Anatomical connectivity variables and perimetry (visual field defect index) were particularly correlated with the latency of P100 wave which was obtained by quadrant stimulation. These results demonstrate an indirect functional modification of the auditory pathway and a direct traumatic lesion of the visual pathway after anterior temporal lobectomy in patients with drug resistant epilepsy.

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Gamma Knife radiosurgery for recurrent or residual seizures after anterior temporal lobectomy in mesial temporal lobe epilepsy patients with hippocampal sclerosis: long-term follow-up results of more than 4 years

Journal of Neurosurgery ◽

10.3171/2014.12.jns141280 ◽

2015 ◽

Vol 123 (6) ◽

pp. 1375-1382 ◽

Cited By ~ 4

Author(s):

Eun Mi Lee ◽

Joong Koo Kang ◽

Sang Joon Kim ◽

Seok Ho Hong ◽

Tae Sung Ko ◽

...

Keyword(s):

Temporal Lobe ◽

Hippocampal Sclerosis ◽

Gamma Knife Radiosurgery ◽

Mesial Temporal Lobe Epilepsy ◽

Temporal Lobectomy ◽

Seizure Outcome ◽

Anterior Temporal Lobectomy ◽

Mesial Temporal Lobe ◽

Signal Changes

OBJECTGamma Knife radiosurgery (GKRS) has proven efficacy in the treatment of drug-resistant mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) and is comparable to conventional resective surgery. It may be effective as an alternative treatment to reoperation after failed temporal lobe surgery in patients with MTLE-HS. The purpose of this study was to investigate the efficacy of GKRS in patients with unilateral MTLE-HS who did not achieve seizure control or had recurrent seizures after anterior temporal lobectomy (ATL).METHODSTwelve patients (8 males; mean age 35.50 ± 9.90 years) with MTLE-HS who underwent GKRS after failed ATL (Engel Classes III–IV) were included. GKRS targets included the remnant tissue or adjacent regions of the previously performed ATL with a marginal dose of 24–25 Gy at the 50% isodose line in all patients. Final seizure outcome was assessed using Engel’s modified criteria during the final 2 years preceding data analysis. A comparison between signal changes on follow-up MRI and clinical outcome was performed.RESULTSAll patients were followed up for at least 4 years with a mean duration of 6.18 ± 1.77 years (range 4–8.8 years) after GKRS. At the final assessment, 6 of 12 patients were classified as seizure free (Engel Class Ia, n = 3; Ic, n = 2; and Id, n = 1) and 6 patients were classified as not seizure free (Engel Class II, n = 1; III, n = 2; and IV, n = 3). Neither initial nor late MRI signal changes after GKRS statistically correlated with surgical outcome. Clinical seizure outcome did not differ significantly with initial or late MRI changes after GKRS.CONCLUSIONSGKRS can be considered an alternative option when the patients with MTLE-HS who had recurrent or residual seizures after ATL refuse a second operation.

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Outcome after seizure recurrence on antiepileptic drug withdrawal following temporal lobectomy

Neurology ◽

10.1212/wnl.0000000000005820 ◽

2018 ◽

Vol 91 (3) ◽

pp. e208-e216 ◽

Cited By ~ 7

Author(s):

Chaturbhuj Rathore ◽

Malcolm K. Jeyaraj ◽

Gopal K. Dash ◽

Pandurang Wattamwar ◽

Neeraj Baheti ◽

...

Keyword(s):

Temporal Lobe Epilepsy ◽

Antiepileptic Drug ◽

Temporal Lobe ◽

Mesial Temporal Lobe Epilepsy ◽

Temporal Lobectomy ◽

Seizure Recurrence ◽

Anterior Temporal Lobectomy ◽

Long Term Outcome ◽

Mesial Temporal Lobe

ObjectiveTo study the long-term outcome following seizure recurrence on antiepileptic drug (AED) withdrawal after anterior temporal lobectomy for mesial temporal lobe epilepsy.MethodsWe 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.ResultsThree 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.ConclusionPatients 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.

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Endfolium sclerosis in temporal lobe epilepsy diagnosed preoperatively by 3-tesla magnetic resonance imaging

Journal of Neurosurgery ◽

10.3171/2008.11.jns081109 ◽

2009 ◽

Vol 110 (6) ◽

pp. 1124-1126 ◽

Cited By ~ 9

Author(s):

Masaki Iwasaki ◽

Nobukazu Nakasato ◽

Hiroyoshi Suzuki ◽

Teiji Tominaga

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Temporal Lobe Epilepsy ◽

Temporal Lobe ◽

Temporal Lobectomy ◽

Preoperative Imaging ◽

Seizure Freedom ◽

Resonance Imaging ◽

Anterior Temporal Lobectomy ◽

The Right

A 34-year-old man presented with intractable temporal lobe epilepsy. Three-tesla magnetic resonance imaging revealed increased T2 signal intensity and volume loss limited to the CA4 region of the right hippocampus. A right anterior temporal lobectomy and amygdalohippocampectomy were performed. Histological examination of the hippocampus disclosed severe neuron loss limited to the CA4 region, consistent with the preoperative imaging, which is a pattern known as endfolium sclerosis. Close inspection of the internal hippocampal anatomy with high-field MR imaging is useful in patients with temporal lobe epilepsy, because endfolium sclerosis may be associated with less chance of seizure freedom after temporal lobectomy.

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Neurocognitive and Seizure Outcomes of Selective Amygdalohippocampectomy versus Anterior Temporal Lobectomy for Mesial Temporal Lobe Epilepsy

Epilepsy Research and Treatment ◽

10.1155/2014/306382 ◽

2014 ◽

Vol 2014 ◽

pp. 1-8 ◽

Cited By ~ 9

Author(s):

Alireza Mansouri ◽

Aria Fallah ◽

Mary Pat McAndrews ◽

Melanie Cohn ◽

Diana Mayor ◽

...

Keyword(s):

Temporal Lobe Epilepsy ◽

Temporal Lobe ◽

Mesial Temporal Lobe Epilepsy ◽

Temporal Lobectomy ◽

Anterior Temporal Lobectomy ◽

Selective Amygdalohippocampectomy ◽

Significant Difference ◽

Mesial Temporal Lobe ◽

Neuropsychological Outcomes

Objective. To report our institutional seizure and neuropsychological outcomes for a series of patients with mesial temporal lobe epilepsy (mTLE) undergoing anterior temporal lobectomy (ATL) or selective amygdalohippocampectomy (SelAH) between 2004 and 2011. Methods. A retrospective study of patients with mTLE was conducted. Seizure outcome was reported using time-to-event analysis. Cognitive outcome was reported using the change principal in component factor scores, one each, for intellectual abilities, visuospatial memory, and verbal memory. The Boston Naming Test was used for naming assessment. Language dominant and nondominant resections were compared separately. Student’s t-test was used to assess statistical significance. Results. Ninety-six patients (75 ATL, 21 SelAH) were included; fifty-four had complete neuropsychological follow-up. Median follow-up was 40.5 months. There was no statistically significant difference in seizure freedom or any of the neuropsychological outcomes, although there was a trend toward greater postoperative decline in naming in the dominant hemisphere group following ATL. Conclusion. Seizure and neuropsychological outcomes did not differ for the two surgical approaches which is similar to most prior studies. Given the theoretical possibility of SelAH sparing language function in patients with epilepsy secondary to mesial temporal sclerosis and the limited high-quality evidence creating equipoise, a multicenter randomized clinical trial is warranted.

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