Epilepsy and Functional Neurosurgery

This chapter covers several aspects of the management of seizures and epilepsy relevant to a general neurosurgical practice. First, all candidates should know how to manage a patient presenting with a new-onset seizure or in status epilepticus with a brain lesion or after a craniotomy. Second, they are expected to be able to explain how to perform fundamental epilepsy procedures such as a temporal lobectomy for hippocampal sclerosis or resection of an epileptogenic lesion. Third, it is useful to have a clear process in place for mapping language and motor function for the resection of tumors located in the eloquent cortex. Lastly, the thought process behind developing an appropriate plan for the surgical management of movement disorders and the technical nuances of managing such cases are discussed. Historically, surgery for pain has been a large part of general neurosurgical practice. A variety of destructive and decompressive interventions have been developed over the years, and a number of comprehensive textbooks have summarized neurosurgical involvement with management of all kinds of medically refractory pain syndromes. It is included in the core neurosurgical education curriculum and is an integral part of neurosurgical knowledge that is tested during the oral board examination. Not surprisingly, cases involving complex pain conditions that require neurosurgical interventions may show up during examinations, and it is expected that examinees are comfortable performing these interventions and able to discuss indications, surgical details, outcomes and complications. Cases include trigeminal neuralgia, cordotomy versus morphine pain pump for cancer pain and a spinal cord stimulator.

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Long-term seizure outcomes after pediatric temporal lobectomy: does brain MRI lesion matter?

Journal of Neurosurgery Pediatrics ◽

10.3171/2019.4.peds18677 ◽

2019 ◽

Vol 24 (2) ◽

pp. 200-208

Author(s):

Ravindra Arya ◽

Francesco T. Mangano ◽

Paul S. Horn ◽

Sabrina K. Kaul ◽

Serena K. Kaul ◽

...

Keyword(s):

Repeated Measures ◽

Mixed Model ◽

Linear Mixed Model ◽

Hippocampal Sclerosis ◽

Brain Mri ◽

Temporal Lobectomy ◽

Seizure Freedom ◽

Seizure Onset

OBJECTIVEThere is emerging data that adults with temporal lobe epilepsy (TLE) without a discrete lesion on brain MRI have surgical outcomes comparable to those with hippocampal sclerosis (HS). However, pediatric TLE is different from its adult counterpart. In this study, the authors investigated if the presence of a potentially epileptogenic lesion on presurgical brain MRI influences the long-term seizure outcomes after pediatric temporal lobectomy.METHODSChildren who underwent temporal lobectomy between 2007 and 2015 and had at least 1 year of seizure outcomes data were identified. These were classified into lesional and MRI-negative groups based on whether an epilepsy-protocol brain MRI showed a lesion sufficiently specific to guide surgical decisions. These patients were also categorized into pure TLE and temporal plus epilepsies based on the neurophysiological localization of the seizure-onset zone. Seizure outcomes at each follow-up visit were incorporated into a repeated-measures generalized linear mixed model (GLMM) with MRI status as a grouping variable. Clinical variables were incorporated into GLMM as covariates.RESULTSOne hundred nine patients (44 females) were included, aged 5 to 21 years, and were classified as lesional (73%), MRI negative (27%), pure TLE (56%), and temporal plus (44%). After a mean follow-up of 3.2 years (range 1.2–8.8 years), 66% of the patients were seizure free for ≥ 1 year at last follow-up. GLMM analysis revealed that lesional patients were more likely to be seizure free over the long term compared to MRI-negative patients for the overall cohort (OR 2.58, p < 0.0001) and for temporal plus epilepsies (OR 1.85, p = 0.0052). The effect of MRI lesion was not significant for pure TLE (OR 2.64, p = 0.0635). Concordance of ictal electroencephalography (OR 3.46, p < 0.0001), magnetoencephalography (OR 4.26, p < 0.0001), and later age of seizure onset (OR 1.05, p = 0.0091) were associated with a higher likelihood of seizure freedom. The most common histological findings included cortical dysplasia types 1B and 2A, HS (40% with dual pathology), and tuberous sclerosis.CONCLUSIONSA lesion on presurgical brain MRI is an important determinant of long-term seizure freedom after pediatric temporal lobectomy. Pediatric TLE is heterogeneous regarding etiologies and organization of seizure-onset zones with many patients qualifying for temporal plus nosology. The presence of an MRI lesion determined seizure outcomes in patients with temporal plus epilepsies. However, pure TLE had comparable surgical seizure outcomes for lesional and MRI-negative groups.

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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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Extratemporal ictal clinical features in hippocampal sclerosis: Their relationship to the degree of hippocampal volume loss and to the outcome of temporal lobectomy

Epilepsia ◽

10.1111/j.1528-1167.2008.01694.x ◽

2008 ◽

Vol 49 (8) ◽

pp. 1333-1339 ◽

Cited By ~ 8

Author(s):

Paolo Borelli ◽

Simon D. Shorvon ◽

John M. Stevens ◽

Shelagh J. Smith ◽

Catherine A. Scott ◽

...

Keyword(s):

Clinical Features ◽

Hippocampal Sclerosis ◽

Hippocampal Volume ◽

Temporal Lobectomy ◽

Volume Loss

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Post-operative nonketotic hyperglycemic induced focal motor status epilepticus related to treatment with corticosteroids following standard anterior temporal lobectomy

Epilepsy & Behavior Case Reports ◽

10.1016/j.ebcr.2018.09.001 ◽

2018 ◽

Vol 10 ◽

pp. 124-128 ◽

Cited By ~ 1

Author(s):

Andrew Zillgitt ◽

Abdullah Alshammaa ◽

Muhammad Salim Kahn ◽

Sarah Madani ◽

Salman Zahoor ◽

...

Keyword(s):

Status Epilepticus ◽

Temporal Lobectomy ◽

Anterior Temporal Lobectomy

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Neurocysticercosis as a probable risk factor for hippocampal sclerosis

Arquivos de Neuro-Psiquiatria ◽

10.1590/0004-282x20180130 ◽

2018 ◽

Vol 76 (11) ◽

pp. 783-790 ◽

Cited By ~ 4

Author(s):

Gagandeep Singh ◽

Josemir W. Sander

Keyword(s):

Hippocampal Sclerosis ◽

Taenia Solium ◽

Population Based ◽

Temporal Lobectomy ◽

Epileptogenic Zone ◽

Drug Resistant ◽

Common Risk Factors ◽

Longitudinal Imaging ◽

Drug Resistant Epilepsy ◽

Pathology Reports

ABSTRACT Neurocysticercosis is one of the most common risk factors for epilepsy but its association with drug-resistant epilepsy remains uncertain. Conjectures of an association with drug-resistant epilepsy have been fueled by reports of an association between calcific neurocysticercosis lesions (CNL) and hippocampal sclerosis (HS) from specialized epilepsy centers in Taenia solium-endemic regions. The debate arising from these reports is whether the association is causal. Evidence for the association is not high quality but sufficiently persuasive to merit further investigation with longitudinal imaging studies in population-based samples from geographically-diverse regions. The other controversial point is the choice of a surgical approach for drug-resistant epilepsy associated with CNL-HS. Three approaches have been described: standard anteromesial temporal lobectomy, lesionectomy involving a CNL alone and lesionectomy with anteromesial temporal lobectomy (for dual pathology); reports of the latter two approaches are limited. Presurgical evaluation should consider possibilities of delineating the epileptogenic zone/s in accordance with all three approaches.

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How Different Are the Patients With Bilateral Hippocampal Sclerosis From the Unilateral Ones Clinically?

Clinical EEG and Neuroscience ◽

10.1177/1550059416653900 ◽

2016 ◽

Vol 48 (3) ◽

pp. 209-216 ◽

Cited By ~ 4

Author(s):

Ebru Nur Vanli-Yavuz ◽

Betul Baykan ◽

Serra Sencer ◽

Altay Sencer ◽

Isin Baral-Kulaksizoglu ◽

...

Keyword(s):

Mental Retardation ◽

Status Epilepticus ◽

Epilepsy Surgery ◽

Hippocampal Sclerosis ◽

Control Group ◽

High Signal ◽

Binary Logistic Regression Analysis ◽

Laboratory Findings ◽

Patients With Epilepsy ◽

Febrile Status Epilepticus

Purpose. There is a lack of knowledge on consecutive patients with epilepsy associated with bilateral hippocampal sclerosis (BHS). We aimed to investigate the differentiating features of BHS in comparison with unilateral HS (UHS). Method. We investigated our database for patients with epilepsy fulfilling the major magnetic resonance imaging criteria for BHS; namely, presence of bilateral atrophy and high signal changes on T2 and FLAIR series in the hippocampi. UHS patients seen in past 2 years were included as the control group. Clinical, EEG, and other laboratory findings, data on treatment response and epilepsy surgery were investigated from their files. Results. A total of 124 patients (31 with BHS and 93 with UHS; 49 right-sided and 44 left-sided) were included. We found that 16.1% of the BHS and 18.3% of the UHS groups were not drug-refractory. A binary logistic regression analysis performed with significant clinical features disclosed that history of febrile status epilepticus, mental retardation, and status epilepticus were statistically more common in BHS group. Moreover, diagnosis of psychosis established by an experienced psychiatrist and slowing of the EEG background activity were both found significantly more frequent in BHS. 66.67% of the operated BHS patients showed benefit from epilepsy surgery. Conclusions. BHS is a heterogeneous group, showing significant differences such as increased frequencies of mental retardation, status epilepticus, febrile status epilepticus and psychosis, in comparison to UHS. In all, 16.1% of the BHS cases showed a benign course similar to the UHS group and some patients with drug-resistant epilepsy may show benefit from epilepsy surgery.

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Nonconvulsive status epilepticus associated with Alzheimer’s disease mimicking symptomatic focal epilepsy following the resection of a frontal parasagittal meningioma

Surgical Neurology International ◽

10.25259/sni_709_2020 ◽

2020 ◽

Vol 11 ◽

pp. 469

Author(s):

Keisuke Abe ◽

Nobutaka Mukae ◽

Takato Morioka ◽

Yuhei Sangatsuda ◽

Ayumi Sakata ◽

...

Keyword(s):

Alzheimer’S Disease ◽

Alzheimer's Disease ◽

Status Epilepticus ◽

Focal Epilepsy ◽

Nonconvulsive Status Epilepticus ◽

Histopathological Diagnosis ◽

Epileptogenic Lesion ◽

Consciousness Disorder ◽

Impaired Awareness ◽

The Right

Background: Epilepsies are frequent in patients with Alzheimer’s disease (AD); however, epilepsies in AD can easily go unrecognized because they usually present as focal impaired awareness seizures or nonconvulsive status epilepticus (NCSE) and can overlap with other symptoms of AD. Case Description: We performed an epilepsy surgery in a 69-year-old woman with progressive cognitive impairment and consciousness disorder, who was diagnosed with focal NCSE related to the resected meningioma in the right frontal parasagittal region. Intraoperative electrocorticography revealed localized periodic paroxysmal discharges with beta and gamma activities in the neighboring cortex where the meningioma existed. The histopathological diagnosis of AD was first made from the resected epileptogenic cortex. Conclusion: Even when there is a suspected epileptogenic lesion that could cause focal NCSE, AD should be ruled out in elderly patients with progressive cognitive decline.

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