The role of intraoperative MRI in resective epilepsy surgery for peri-eloquent cortex cortical dysplasias and heterotopias in pediatric patients

OBJECTIVE Previous studies have demonstrated that an important factor in seizure freedom following surgery for lesional epilepsy in the peri-eloquent cortex is completeness of resection. However, aggressive resection of epileptic tissue localized to this region must be balanced with the competing objective of retaining postoperative neurological functioning. The objective of this study was to investigate the role of intraoperative MRI (iMRI) as a complement to existing epilepsy protocol techniques and to compare rates of seizure freedom and neurological deficit in pediatric patients undergoing resection of perieloquent lesions. METHODS The authors retrospectively reviewed the medical records of pediatric patients who underwent resection of focal cortical dysplasia (FCD) or heterotopia localized to eloquent cortex regions at the Children's National Health System between March 2005 and August 2015. Patients were grouped into two categories depending on whether they underwent conventional resection (n = 18) or iMRI-assisted resection (n = 11). Patient records were reviewed for factors including demographics, length of hospitalization, postoperative seizure freedom, postoperative neurological deficit, and need for reoperation. Postsurgical seizure outcome was assessed at the last postoperative follow-up evaluation using the Engel Epilepsy Surgery Outcome Scale. RESULTS At the time of the last postoperative follow-up examination, 9 (82%) of the 11 patients in the iMRI resection group were seizure free (Engel Class I), compared with 7 (39%) of the 18 patients in the control resection group (p = 0.05). Ten (91%) of the 11 patients in the iMRI cohort achieved gross-total resection (GTR), compared with 8 (44%) of 18 patients in the conventional resection cohort (p = 0.02). One patient in the iMRI-assisted resection group underwent successful reoperation at a later date for residual dysplasia, compared with 7 patients in the conventional resection cohort (with 2/7 achieving complete resection). Four (36%) of the patients in the iMRI cohort developed postoperative neurological deficits, compared with 15 patients (83%) in the conventional resection cohort (p = 0.02). CONCLUSIONS These results suggest that in comparison with a conventional surgical protocol and technique for resection of epileptic lesions in peri-eloquent cortex, the incorporation of iMRI led to elevated rates of GTR and postoperative seizure freedom. Furthermore, this study suggests that iMRI-assisted surgeries are associated with a reduction in neurological deficits due to intraoperative damage of eloquent cortex.

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A study of pediatric cerebral arteriovenous malformations: clinical presentation, radiological features, and long-term functional and educational outcomes with predictors of sustained neurological deficits

Journal of Neurosurgery Pediatrics ◽

10.3171/2019.2.peds18731 ◽

2019 ◽

Vol 24 (1) ◽

pp. 1-8 ◽

Cited By ~ 4

Author(s):

Vijay M. Ravindra ◽

Robert J. Bollo ◽

Ilyas M. Eli ◽

Julius Griauzde ◽

Arianna Lanpher ◽

...

Keyword(s):

Outcome Measures ◽

Neurological Deficit ◽

Functional Outcomes ◽

Arteriovenous Malformations ◽

Pediatric Patients ◽

Neurological Deficits ◽

Long Term Follow Up ◽

Eloquent Cortex

OBJECTIVELarge experiences with the treatment of pediatric arteriovenous malformations (AVMs) remain relatively rare, with limited data on presentation, treatment, and long-term functional outcomes. Because of the expected long lifespan of children, caregivers are especially interested in outcome measures that assess quality of life. The authors’ intention was to describe the long-term functional outcomes of pediatric patients who undergo AVM surgery and to identify predictors of sustained neurological deficits.METHODSThe authors analyzed a 21-year retrospective cohort of pediatric patients with intracranial AVMs treated with microsurgery at two institutions. The primary outcome was a persistent neurological deficit at last follow-up. Secondary outcome measures included modified Rankin Scale (mRS) score and independent living.RESULTSOverall, 97 patients (mean age 11.1 ± 4.5 years; 56% female) were treated surgically for intracranial AVMs (mean follow-up 77.5 months). Sixty-four patients (66%) presented with hemorrhage, and 45 patients (46%) had neurological deficits at presentation. Radiologically, 39% of lesions were Spetzler-Martin grade II. Thirty-seven patients (38%) with persistent neurological deficits at last follow-up were compared with those without deficits; there were no differences in patient age, presenting Glasgow Coma Scale score, AVM size, surgical blood loss, or duration of follow-up. Multivariate analysis demonstrated that a focal neurological deficit on presentation, AVM size > 3 cm, and lesions in eloquent cortex were independent predictors of persistent neurological deficits at long-term follow-up. Overall, 92% of the children had an mRS score ≤ 2 on long-term follow-up.CONCLUSIONSPediatric patients with AVMs treated with microsurgical resection have good functional and radiological outcomes. There is a high rate (38%) of persistent neurological deficits, which were independently predicted by preoperative deficits, AVMs > 3 cm, and lesions located in eloquent cortex. This information can be useful in counseling families on the likelihood of long-term neurological deficits after cerebral AVM surgery.

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Stereoelectroencephalography in Children and Adolescents With Difficult-to-Localize Refractory Focal Epilepsy

Neurosurgery ◽

10.1227/neu.0000000000000453 ◽

2014 ◽

Vol 75 (3) ◽

pp. 258-268 ◽

Cited By ~ 50

Author(s):

Jorge Gonzalez-Martinez ◽

Jeffrey Mullin ◽

Juan Bulacio ◽

Ajay Gupta ◽

Rei Enatsu ◽

...

Keyword(s):

Children And Adolescents ◽

Pediatric Patients ◽

Focal Epilepsy ◽

Early Experience ◽

Morbidity Rate ◽

Seizure Outcome ◽

Seizure Freedom ◽

Epileptogenic Zone ◽

Eloquent Cortex

Abstract BACKGROUND: Although stereoelectroencephalography (SEEG) has been shown to be a valuable tool for preoperative decision making in focal epilepsy, there are few reports addressing the utility and safety of SEEG methodology applied to children and adolescents. OBJECTIVE: To present the results of our early experience using SEEG in pediatric patients with difficult-to-localize epilepsy who were not considered candidates for subdural grid evaluation. METHODS: Thirty children and adolescents with the diagnosis of medically refractory focal epilepsy (not considered ideal candidates for subdural grids and strip placement) underwent SEEG implantation. Demographics, electrophysiological localization of the hypothetical epileptogenic zone, complications, and seizure outcome after resections were analyzed. RESULTS: Eighteen patients (60%) underwent resections after SEEG implantations. In patients who did not undergo resections (12 patients), reasons included failure to localize the epileptogenic zone (4 patients); multifocal epileptogenic zone (4 patients); epileptogenic zone located in eloquent cortex, preventing resection (3 patients); and improvement in seizures after the implantation (1 patient). In patients who subsequently underwent resections, 10 patients (55.5%) were seizure free (Engel class I) and 5 patients (27.7%) experienced seizure improvement (Engel class II or III) at the end of the follow-up period (mean, 25.9 months; range, 12 to 47 months). The complication rate in SEEG implantations was 3%. CONCLUSION: The SEEG methodology is safe and should be considered in children/adolescents with difficult-to-localize epilepsy. When applied to highly complex and difficult-to-localize pediatric patients, SEEG may provide an additional opportunity for seizure freedom in association with a low morbidity rate.

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Multimodality management of Spetzler-Martin Grade III arteriovenous malformations

Journal of Neurosurgery ◽

10.3171/2012.3.jns111575 ◽

2012 ◽

Vol 116 (6) ◽

pp. 1279-1288 ◽

Cited By ~ 42

Author(s):

Paritosh Pandey ◽

Michael P. Marks ◽

Ciara D. Harraher ◽

Erick M. Westbroek ◽

Steven D. Chang ◽

...

Keyword(s):

Neurological Deficit ◽

Arteriovenous Malformations ◽

Venous Drainage ◽

Neurological Deficits ◽

Eloquent Cortex ◽

Type 3 ◽

Grade Iii

Object Grade III arteriovenous malformations (AVMs) are diverse because of their variations in size (S), location in eloquent cortex (E), and presence of central venous drainage (V). Because they may have implications for management and outcome, the authors evaluated these variations in the present study. Methods Between 1984 and 2010, 100 patients with Grade III AVMs were treated. The AVMs were categorized by Spetzler-Martin characteristics as follows: Type 1 = S1E1V1, Type 2 = S2E1V0, Type 3 = S2E0V1, and Type 4 = S3E0V0. The occurrence of a new neurological deficit, functional status (based on modified Rankin Scale [mRS] score) at discharge and follow-up, and radiological obliteration were correlated with demographic and morphological characteristics. Results One hundred patients (49 female and 51 male; age range 5–68 years, mean 35.8 years) were evaluated. The size of AVMs was less than 3 cm in 28 patients, 3–6 cm in 71, and greater than 6 cm in 1; 86 AVMs were located in eloquent cortex and 38 had central drainage. The AVMs were Type 1 in 28 cases, Type 2 in 60, Type 3 in 11, and Type 4 in 1. The authors performed embolization in 77 patients (175 procedures), surgery in 64 patients (74 surgeries), and radiosurgery in 49 patients (44 primary and 5 postoperative). The mortality rate following the management of these AVMs was 1%. Fourteen patients (14%) had new neurological deficits, with 5 (5%) being disabling (mRS score > 2) and 9 (9%) being nondisabling (mRS score ≤ 2) events. Patients with Type 1 AVMs (small size) had the best outcome, with 1 (3.6%) in 28 having a new neurological deficit, compared with 72 patients with larger AVMs, of whom 13 (18.1%) had a new neurological deficit (p < 0.002). Older age (> 40 years), malformation size > 3 cm, and nonhemorrhagic presentation predicted the occurrence of new deficits (p < 0.002). Sex, eloquent cortex, and venous drainage did not confer any benefit. In 89 cases follow-up was adequate for data to be included in the obliteration analysis. The AVM was obliterated in 78 patients (87.6%), 69 of them (88.5%) demonstrated on angiography and 9 on MRI /MR angiography. There was no difference between obliteration rates between different types of AVMs, size, eloquence, and drainage. Age, sex, and clinical presentation also did not predict obliteration. Conclusions Multimodality management of Grade III AVMs results in a high rate of obliteration, which was not influenced by size, venous drainage, or eloquent location. However, the development of new neurological deficits did correlate with size, whereas eloquence and venous drainage did not affect the neurological complication rate. The authors propose subclassifying the Grade III AVMs according to their size (< 3 and ≥ 3 cm) to account for treatment risk.

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Resective epilepsy surgery in tuberous sclerosis complex: a nationwide multicentre retrospective study from China

Brain ◽

10.1093/brain/awz411 ◽

2020 ◽

Vol 143 (2) ◽

pp. 570-581 ◽

Cited By ~ 5

Author(s):

Shiyong Liu ◽

Tao Yu ◽

Yuguang Guan ◽

Kai Zhang ◽

Ping Ding ◽

...

Keyword(s):

Quality Of Life ◽

Tuberous Sclerosis ◽

Epilepsy Surgery ◽

Tuberous Sclerosis Complex ◽

Intelligence Quotient ◽

Influence Factors ◽

Seizure Freedom ◽

Postoperative Seizure

Abstract At least 50% of patients with tuberous sclerosis complex present with intractable epilepsy; for these patients, resective surgery is a treatment option. Here, we report a nationwide multicentre retrospective study and analyse the long-term seizure and neuropsychological outcomes of epilepsy surgery in patients with tuberous sclerosis complex. There were 364 patients who underwent epilepsy surgery in the study. Patients’ clinical data, postoperative seizure outcomes at 1-, 4-, and 10-year follow-ups, preoperative and postoperative intelligence quotients, and quality of life at 1-year follow-up were collected. The patients’ ages at surgery were 10.35 ± 7.70 years (range: 0.5–47). The percentage of postoperative seizure freedom was 71% (258/364) at 1-year, 60% (118/196) at 4-year, and 51% (36/71) at 10-year follow-up. Influence factors of postoperative seizure freedom were the total removal of epileptogenic tubers and the presence of outstanding tuber on MRI at 1- and 4-year follow-ups. Furthermore, monthly seizure (versus daily seizure) was also a positive influence factor for postoperative seizure freedom at 1-year follow-up. The presence of an outstanding tuber on MRI was the only factor influencing seizure freedom at 10-year follow-up. Postoperative quality of life and intelligence quotient improvements were found in 43% (112/262) and 28% (67/242) of patients, respectively. Influence factors of postoperative quality of life and intelligence quotient improvement were postoperative seizure freedom and preoperative low intelligence quotient. The percentage of seizure freedom in the tuberectomy group was significantly lower compared to the tuberectomy plus and lobectomy groups at 1- and 4-year follow-ups. In conclusion, this study, the largest nationwide multi-centre study on resective epilepsy surgery, resulted in improved seizure outcomes and quality of life and intelligence quotient improvements in patients with tuberous sclerosis complex. Seizure freedom was often achieved in patients with an outstanding tuber on MRI, total removal of epileptogenic tubers, and tuberectomy plus. Quality of life and intelligence quotient improvements were frequently observed in patients with postoperative seizure freedom and preoperative low intelligence quotient.

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Outcome after resective epilepsy surgery in the elderly

Journal of Neurosurgery ◽

10.3171/2021.4.jns204013 ◽

2021 ◽

pp. 1-10

Author(s):

Attila Rácz ◽

Kathryn Menne ◽

Valeri Borger ◽

Kevin G. Hampel ◽

Hartmut Vatter ◽

...

Keyword(s):

Elderly Patients ◽

Epilepsy Surgery ◽

Seizure Control ◽

Surgical Complication ◽

The Elderly ◽

Neurological Deficits ◽

Control Group ◽

Chi Square ◽

Postoperative Seizure

OBJECTIVE The objective of this study was to compare complications, seizures, and neuropsychological outcomes after resective epilepsy surgery in patients ≥ 60 years of age who underwent operations to younger and matched controls. METHODS Charts of 2243 patients were screened for operated patients in the authors’ center between 2000 and 2015. Patients with available postsurgical follow-up data who were operated on at the age of 60 years or older and matched (by gender, histopathology, and side of surgery) controls who were between 20 and 40 years of age at the time of surgery were included. Outcomes regarding postoperative seizure control were scored according to the Engel classification and group comparisons were performed by using chi-square statistics. RESULTS Data of 20 older patients were compared to those of 60 younger controls. Postoperative seizure control was favorable in the majority of the elderly patients (Engel classes I and II: 75% at 12 months, 65% at last follow-up), but the proportion of patients with favorable outcome tended to be larger in the control group (Engel classes I and II: 90% at 12 months, p = 0.092; 87% at last follow-up, p = 0.032, chi-square test). The surgical complication rate was higher in the elderly population (65% vs 27%, p = 0.002), but relevant persistent deficits occurred in 2 patients of each group only. Neuropsychological and behavioral assessments displayed considerable preoperative impairment and additional postoperative worsening, particularly of verbal skills, memory (p < 0.05), and mood in the elderly. CONCLUSIONS The overall favorable postsurgical outcome regarding seizure control and the moderate risk of disabling persistent neurological deficits in elderly patients supports the view that advanced age should not be a barrier per se for resective epilepsy surgery and underscores the importance of an adequate presurgical evaluation and of referral of elderly patients to presurgical assessment.

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Intraoperative MRI–guided resection of focal cortical dysplasia in pediatric patients: technique and outcomes

Journal of Neurosurgery Pediatrics ◽

10.3171/2015.10.peds15512 ◽

2016 ◽

Vol 17 (6) ◽

pp. 672-678 ◽

Cited By ~ 13

Author(s):

Matthew F. Sacino ◽

Cheng-Ying Ho ◽

Jonathan Murnick ◽

Tammy Tsuchida ◽

Suresh N. Magge ◽

...

Keyword(s):

Pediatric Patients ◽

Focal Cortical Dysplasia ◽

Cortical Dysplasia ◽

Seizure Freedom ◽

Surgical Decision ◽

Intraoperative Detection ◽

The Mean ◽

Postoperative Seizure ◽

Surgical Decision Making

OBJECTIVE Previous meta-analysis has demonstrated that the most important factor in seizure freedom following surgery for focal cortical dysplasia (FCD) is completeness of resection. However, intraoperative detection of epileptogenic dysplastic cortical tissue remains a challenge, potentially leading to a partial resection and the need for reoperation. The objective of this study was to determine the role of intraoperative MRI (iMRI) in the intraoperative detection and localization of FCD as well as its impact on surgical decision making, completeness of resection, and seizure control outcomes. METHODS The authors retrospectively reviewed the medical records of pediatric patients who underwent iMRI-assisted resection of FCD at the Children's National Health System between January 2014 and April 2015. Data reviewed included demographics, length of surgery, details of iMRI acquisition, postoperative seizure freedom, and complications. Postsurgical seizure outcome was assessed utilizing the Engel Epilepsy Surgery Outcome Scale. RESULTS Twelve consecutive pediatric patients (8 females and 4 males) underwent iMRI-guided resection of FCD lesions. The mean age at the time of surgery was 8.8 years ± 1.6 years (range 0.7 to 18.8 years), and the mean duration of follow up was 3.5 months ± 1.0 month. The mean age at seizure onset was 2.8 years ± 1.0 year (range birth to 9.0 years). Two patients had Type 1 FCD, 5 patients had Type 2A FCD, 2 patients had Type 2B FCD, and 3 patients had FCD of undetermined classification. iMRI findings impacted intraoperative surgical decision making in 5 (42%) of the 12 patients, who then underwent further exploration of the resection cavity. At the time of the last postoperative follow-up, 11 (92%) of the 12 patients were seizure free (Engel Class I). No patients underwent reoperation following iMRI-guided surgery. CONCLUSIONS iMRI-guided resection of FCD in pediatric patients precluded the need for repeat surgery. Furthermore, it resulted in the achievement of complete resection in all the patients, leading to a high rate of postoperative seizure freedom.

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Epilepsy Surgery in Children and Adolescents

Neurology International Open ◽

10.1055/s-0043-102834 ◽

2017 ◽

Vol 1 (02) ◽

pp. E86-E97

Author(s):

Georgia Ramantani ◽

Josef Zentner

Keyword(s):

Children And Adolescents ◽

Epilepsy Surgery ◽

Focal Cortical Dysplasia ◽

Neurological Deficits ◽

Epilepsy Syndrome ◽

Seizure Freedom ◽

Epileptogenic Zone ◽

Presurgical Evaluation ◽

Effective Treatment Option ◽

Postoperative Seizure

AbstractEpilepsy surgery has been established in recent years as an effective treatment option for children and adolescents with pharmacoresistant structural epilepsies. Thanks to advances in neurosurgery, anesthesia and intensive care, epilepsy surgery is also possible in infants with excellent results. Epilepsy surgery should be considered in children with structural epilepsies and presurgical evaluation should be initiated at the latest when the criteria for pharmacoresistance are met. Focal cortical dysplasia and glioneuronal tumors are the most common etiologies in pediatric cohorts. Postoperative seizure-freedom depends on completeness of resection. In childhood, multilobular and hemispheric interventions predominate, whereas adults commonly undergo temporal resections. The extent of resections decreases with age. Younger children often require larger resections, but have higher capacities to compensate for neurological deficits, due to functional plasticity. Postoperative seizure freedom depends on the epilepsy syndrome, underlying etiology and accurate demarcation of the epileptogenic zone. Postoperatively, two-thirds of the children remain seizure-free in the long-term. Significant improvements in cognitive development are observed with seizure control. In addition to the development of non-invasive methods for presurgical evaluation, it is crucial to reduce the latency between the establishment of pharmacoresistance, presurgical evaluation and surgical treatment in suitable candidates. Multicentric studies with longer observation intervals are urgently needed in order to identify predictors of seizure freedom and favorable developmental trajectories, to facilitate the selection of optimal candidates and to improve counseling of patients and their families.

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Outcomes of cingulate epilepsy surgery: insights from an institutional and patient-level systematic review and meta-analysis

Journal of Neurosurgery ◽

10.3171/2021.8.jns211558 ◽

2021 ◽

pp. 1-10

Author(s):

Panagiotis Kerezoudis ◽

Rohin Singh ◽

Gregory A. Worrell ◽

Jamie J. Van Gompel

Keyword(s):

Epilepsy Surgery ◽

Literature Search ◽

Anterior Cingulate ◽

Postoperative Outcomes ◽

Cochrane Library ◽

Rank Test ◽

Seizure Freedom ◽

Low Grade ◽

Cingulate Gyrus

OBJECTIVE Due to their deep and medial location, range of seizure semiologies, and poor localization on ictal electroencephalography (EEG), cingulate gyrus seizures can be difficult to diagnose and treat. The aim of this study was to review the available evidence on postoperative outcomes after cingulate epilepsy surgery. METHODS A comprehensive literature search of the PubMed/MEDLINE, Ovid Embase, Ovid Scopus, and Cochrane Library databases was conducted to identify studies that investigated postoperative outcomes of patients with cingulate epilepsy. Seizure freedom at the last follow-up (at least 12 months) was the primary endpoint. The literature search was supplemented by the authors’ institutional series (4 patients). RESULTS Twenty-one studies were identified, yielding a total of 105 patients (68 with lesional epilepsy [65%]). Median age at surgery was 23 years, and 56% of patients were male. Median epilepsy duration was 7.5 years. Invasive EEG recording was performed on 69% of patients (53% of patients with lesional epilepsy and 97% of those with nonlesional epilepsy, p < 0.001). The most commonly resected region was the anterior cingulate (55%), followed by the posterior (17%) and middle (14%) cingulate. Lesionectomy alone was performed in 9% of patients. Additional extracingulate treatment was performed in 54% of patients (53% of patients with lesional epilepsy vs 57% of those with nonlesional epilepsy, p = 0.87). The most common pathology was cortical dysplasia (54%), followed by low-grade neoplasm (29%) and gliosis (8%). Seizure freedom was noted in 72% of patients (median follow-up 24 months). A neurological deficit was noted in 27% of patients (24% had temporary deficit), with the most common deficit being motor weakness (13%) followed by supplementary motor area syndrome (9.5%). Univariate survival analysis revealed significantly greater probability of seizure freedom in patients with lesional epilepsy (p = 0.015, log-rank test). CONCLUSIONS Surgical treatment of drug-resistant focal epilepsy originating from the cingulate gyrus is safe, leads to low rates of permanent adverse effects, and leads to high rates of long-term seizure freedom in carefully selected patients. These data may serve as a benchmark for surgical counseling of patients with cingulate epilepsy.

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Epilepsziasebészeti beavatkozások eredményei a Pécsi Epilepszia Centrumban 2005 és 2016 között

Orvosi Hetilap ◽

10.1556/650.2019.31321 ◽

2019 ◽

Vol 160 (7) ◽

pp. 270-278 ◽

Cited By ~ 1

Author(s):

Katalin Nóra Lőrincz ◽

Beáta Bóné ◽

Márton Tóth ◽

Réka Horváth ◽

Norbert Kovács ◽

...

Keyword(s):

Quality Of Life ◽

Epilepsy Surgery ◽

Employment Status ◽

Postoperative Outcome ◽

Seizure Freedom ◽

Neurologic Disease ◽

Exact Test ◽

Epileptic Patients

Abstract: Introduction: Epilepsy as a chronic, severe neurologic disease significantly influences the quality of life of the epileptic patients. In candidates well selected for surgery, the seizure freedom is realistically achievable, and the quality of life can be further improved with complex individual rehabilitation. Aim: We aimed to evaluate the postoperative outcome of patients who underwent epilepsy surgery between 2005 and 2016 at the Epilepsy Center at Pécs. Method: We evaluated seizure status at regular follow-up visits after surgery and the quality of life using questionnaires focusing on employment and social status. Results: 76% of the 72 patients who underwent surgical resection for epilepsy were free from disabling seizures , and 10% had rare disabling seizures (almost seizure-free), 7% experienced worthwhile improvement and 7% had no worthwhile improvement. Comparing the employment status of patients free from disabling seizures to patients not free from disabling seizures, we found that the employment status is significantly influenced by seizure freedom (p<0.01, Fisher’s exact test). While 67% of seizure-free patients were employed, only 19% of patients not free from disabling seizures were hired. Conclusion: Our results resemble the international tendencies and success rate, proving epilepsy surgery as an available, valid and effective treatment in well selected patients. Orv Hetil. 2019; 160(7): 270–278.

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Results of Epilepsy Surgery: Still So Much to Learn

Epilepsy Currents ◽

10.1111/j.1535-7511.2006.00105.x ◽

2006 ◽

Vol 6 (3) ◽

pp. 80-82

Author(s):

Donna C. Bergen

Keyword(s):

Temporal Lobe Epilepsy ◽

Epilepsy Surgery ◽

Disease Duration ◽

Seizure Freedom ◽

Hippocampal Atrophy ◽

Younger Age ◽

Seizure Relapse ◽

Clonic Seizures

Predicting Long-Term Seizure Outcome after Resective Epilepsy Surgery: The Multicenter Study Spencer SS, Berg AT, Vickrey BG, Sperling MR, Bazil CW, Shinnar S, Langfitt JT, Walczak TS, Pacia SV Neurology 2005;65(6):912–918 Background In a seven-center prospective observational study of resective epilepsy surgery, the authors examined probability and predictors of entering 2-year remission and the risk of subsequent relapse. Methods Patients aged 12 years and over were enrolled at time of referral for epilepsy surgery, and underwent standardized evaluation, treatment, and follow-up procedures. The authors defined seizure remission as 2 years completely seizure-free after hospital discharge with or without auras, and relapse as any seizures after 2-year remission. The authors examined type of surgery, seizure, clinical and demographic variables, and localization study results with respect to prediction of seizure remission or relapse, using χ2 and proportional hazards analysis. Results Of 396 operated patients, 339 were followed over 2 years, and 223 (66%) experienced 2-year remission, not significantly different between medial temporal (68%) and neocortical (50%) resections. In multivariable models, only absence of generalized tonic–clonic seizures and presence of hippocampal atrophy were significantly and independently associated with remission, and only in the medial temporal resection group. Fifty-five patients relapsed after 2-year remission, again not significantly different between medial temporal (25%) and neocortical (19%) resections. Only delay to remission predicted relapse, and only in medial temporal patients. Conclusion Hippocampal atrophy and a history of absence of generalized tonic clonic seizures were the sole predictors of 2-year remission, and only for medial temporal resections. Antiepileptic Drug Withdrawal after Successful Surgery for Intractable Temporal Lobe Epilepsy Kim YD, Heo K, Park SC, Huh K, Chang JW, Choi JU, Chung SS, Lee BI Epilepsia 2005;46(2):251–257 Purpose To investigate the prognosis related to antiepileptic drug (AED) discontinuation after successful surgery for intractable temporal lobe epilepsy. Methods The clinical courses after temporal lobectomies (TLs) were retrospectively analyzed in 88 consecutive patients. All the patients had TLs as the only surgical procedure, and they had been followed up for longer than 3 years. AED discontinuation was attempted if the patient had been seizure free without aura for ≥1 year during the follow-up period. Results Sixty-six (75%) patients achieved complete seizure freedom for ≥1 year; 28 patients were seizure free immediately after surgery (immediate success); and 38 patients became seizure free after some period of recurrent seizures (delayed success). AED discontinuation was attempted in 60 (91%) of 66 patients with a successful outcome. In 13 (22%) patients, seizure relapse developed during AED reduction ( n = 60), and in 7 (12%) patients after discontinuation of AEDs ( n = 38). The seizure recurrence rate was not different between the immediate- and delayed-success groups. Among 20 patients with seizure relapse related to AED tapering, 9 (45%) of them regained seizure freedom after reinstitution of AED treatment, and AEDs were eventually discontinued in 6 of them. Seizures that recurred after complete AED discontinuation had a better prognosis than did the seizures that recurred during AED reduction (seizure freedom in 86% vs 23%). At the final assessment, 54 (61%) patients had been seizure free ≥1 year; 37 without AEDs and 17 with AEDs. The successful discontinuation of AEDs was more frequent for patients with a younger age at the time of surgery and for those patients with shorter disease duration. Conclusions Our results suggest that seizure freedom without aura at ≥1 year is a reasonable indication for the attempt at AED discontinuation. The subsequent control of recurrent seizures was excellent, especially if seizures relapsed after the complete discontinuation of AEDs. Younger age at the time of surgery and a shorter disease duration seem to affect successful AED discontinuation for a long-term period.

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