Management of patients with medically intractable epilepsy and anterior temporal lobe encephaloceles

2021 ◽  
pp. 1-8
Author(s):  
Mani Ratnesh S. Sandhu ◽  
Mauricio Mandel ◽  
Hari McGrath ◽  
Layton Lamsam ◽  
Pue Farooque ◽  
...  
Keyword(s):  
Temporal Lobe ◽  
Refractory Epilepsy ◽  
Preoperative Evaluation ◽  
Intractable Epilepsy ◽  
Class Iii ◽  
Single Institution ◽  
Scalp Eeg ◽  
Surgical Data ◽  
Medically Refractory Epilepsy

OBJECTIVE Temporal lobe encephaloceles (TLENs) are a significant cause of medically refractory epilepsy, but there is little consensus regarding their workup and treatment. This study characterizes these lesions and their role in seizures and aims to standardize preoperative evaluation and surgical management. METHODS Patients with TLEN who had undergone resective epilepsy surgery from December 2015 to August 2020 at a single institution were included in the study. Medical records were reviewed for each patient to collect relevant seizure workup information including demographics, radiological findings, surgical data, and neuropsychological evaluation. RESULTS For patients who presented to the authors’ program with suspected medically intractable temporal lobe epilepsy (219 patients), TLEN was considered to be the epileptogenic focus in 5.5%. Ten patients with TLEN had undergone resection and were included in this study. Concordance between ictal scalp electroencephalography (EEG) lateralization and TLEN was found in 9/10 patients (90%), and 4/10 patients (40%) had signs suggestive of idiopathic intracranial hypertension (IIH). Surgical outcome was reported in patients with at least 12 months of follow-up (9/10). Patients with scalp EEG findings concordant with the TLEN side had a good outcome (Engel class I: 7 patients, class II: 1 patient). One patient with discordant EEG findings had a bad outcome (Engel class III). No significant neuropsychological deficits were observed after the surgery. CONCLUSIONS TLENs are epileptogenic lesions that should be screened for in patients with medically refractory epilepsy who have signs of IIH and no other lesions on MRI. Restricted resection is safe and effective in patients with scalp EEG findings concordant with TLEN.

Medial Temporal Encephalocele and Medically Intractable Epilepsy: A Tailored Inferior Temporal Lobectomy and Case Report

2019 ◽  
Vol 18 (1) ◽  
pp. E19-E22 ◽  
Author(s):  
Anthony L Mikula ◽  
Karim ReFaey ◽  
Sanjeet S Grewal ◽  
Jeffrey W Britton ◽  
Jamie J Van Gompel
Keyword(s):  
Case Report ◽  
Temporal Lobe ◽  
Refractory Epilepsy ◽  
Statistical Parametric Mapping ◽  
Intractable Epilepsy ◽  
Middle Cranial Fossa ◽  
Temporal Lobectomy ◽  
Seizure Freedom ◽  
Temporal Region ◽  
Medically Refractory Epilepsy

AbstractBACKGROUND AND IMPORTANCETemporal lobe encephaloceles are increasingly recognized as a potential cause of medically refractory epilepsy and surgical treatment has proven effective. Resection of the encephalocele and associated cortex is often sufficient to provide seizure control. However, it is difficult to determine the extent of adjacent temporal lobe that should be resected. We present a case report and our technique of a tailored inferior temporal pole resection.CLINICAL PRESENTATIONA 32-yr-old man with an 11-yr history of medically refractory epilepsy. Prolonged electroencephalography (EEG) revealed frequent left and rare right frontotemporal sharp waves. Numerous seizures were captured with EEG, all of which originated from the left temporal region. Statistical parametric mapping (SPM) subtraction ictal–interictal SPECT coregistered with magnetic resonance imaging (MRI) (SISCOM) demonstrated ictal hyperperfusion in the anterior left temporal lobe. MRI showed 2 encephaloceles in the left anterior temporal lobe with the accompanying bony defects in the floor of the middle cranial fossa apparent on the computed tomography scan. The patient underwent left temporal craniotomy with intraoperative electrocorticography, resection of the encephaloceles, and a tailored inferior temporal lobectomy (IFTL) and repair of the middle fossa defects. At 7 mo follow up he reported seizure-freedom since surgery.CONCLUSIONResection of temporal encephalocele and adjacent cortex is safe and effective procedure for select patients with medically refractory epilepsy. This video demonstrates our technique which provides a more standardized approach to the resection.

Efficacy and safety of corpus callosotomy after vagal nerve stimulation in patients with drug-resistant epilepsy

2018 ◽  
Vol 128 (1) ◽  
pp. 277-286 ◽  
Author(s):  
Jennifer Hong ◽  
Atman Desai ◽  
Vijay M. Thadani ◽  
David W. Roberts
Keyword(s):  
Nerve Stimulation ◽  
Refractory Epilepsy ◽  
Case Series ◽  
Vagal Nerve ◽  
Vagal Nerve Stimulation ◽  
Class Iii ◽  
Corpus Callosotomy ◽  
Few Data ◽  
Medically Refractory Epilepsy

OBJECTIVEVagal nerve stimulation (VNS) and corpus callosotomy (CC) have both been shown to be of benefit in the treatment of medically refractory epilepsy. Recent case series have reviewed the efficacy of VNS in patients who have undergone CC, with encouraging results. There are few data, however, on the use of CC following VNS therapy.METHODSThe records of all patients at the authors' center who underwent CC following VNS between 1998 and 2015 were reviewed. Patient baseline characteristics, operative details, and postoperative outcomes were analyzed.RESULTSTen patients met inclusion criteria. The median follow-up was 72 months, with a minimum follow-up of 12 months (range 12–109 months). The mean time between VNS and CC was 53.7 months. The most common reason for CC was progression of seizures after VNS. Seven patients had anterior CC, and 3 patients returned to the operating room for a completion of the procedure. All patients had a decrease in the rate of falls and drop seizures; 7 patients experienced elimination of drop seizures. Nine patients had an Engel Class III outcome, and 1 patient had a Class IV outcome. There were 3 immediate postoperative complications and 1 delayed complication. One patient developed pneumonia, 1 developed transient mutism, and 1 had persistent weakness in the nondominant foot. One patient presented with a wound infection.CONCLUSIONSThe authors demonstrate that CC can help reduce seizures in patients with medically refractory epilepsy following VNS, particularly with respect to drop attacks.

scholarly journals Corpus callosotomy performed with laser interstitial thermal therapy

2019 ◽  
pp. 1-9 ◽  
Author(s):  
Jarod L. Roland ◽  
Syed Hassan A. Akbari ◽  
Afshin Salehi ◽  
Matthew D. Smyth
Keyword(s):  
Refractory Epilepsy ◽  
Effective Means ◽  
Thermal Therapy ◽  
Class Iii ◽  
Corpus Callosotomy ◽  
Invasive Approach ◽  
Laser Interstitial Thermal Therapy ◽  
Less Invasive ◽  
Medically Refractory Epilepsy

OBJECTIVECorpus callosotomy is a palliative procedure that is effective at reducing seizure burden in patients with medically refractory epilepsy. The procedure is traditionally performed via open craniotomy with interhemispheric microdissection to divide the corpus callosum. Concerns for morbidity associated with craniotomy can be a deterrent to patients, families, and referring physicians for surgical treatment of epilepsy. Laser interstitial thermal therapy (LITT) is a less invasive procedure that has been widely adopted in neurosurgery for the treatment of tumors. In this study, the authors investigated LITT as a less invasive approach for corpus callosotomy.METHODSThe authors retrospectively reviewed all patients treated for medically refractory epilepsy by corpus callosotomy, either partial or completion, with LITT. Chart records were analyzed to summarize procedural metrics, length of stay, adverse events, seizure outcomes, and time to follow-up. In select cases, resting-state functional MRI was performed to qualitatively support effective functional disconnection of the cerebral hemispheres.RESULTSTen patients underwent 11 LITT procedures. Five patients received an anterior two-thirds LITT callosotomy as their first procedure. One patient returned after LITT partial callosotomy for completion of callosotomy by LITT. The median hospital stay was 2 days (IQR 1.5–3 days), and the mean follow-up time was 1.0 year (range 1 month to 2.86 years). Functional outcomes are similar to those of open callosotomy, with the greatest effect in patients with a significant component of drop attacks in their seizure semiology. One patient achieved an Engel class II outcome after anterior two-thirds callosotomy resulting in only rare seizures at the 18-month follow-up. Four others were in Engel class III and 5 were Engel class IV. Hemorrhage occurred in 1 patient at the time of removal of the laser fiber, which was placed through the bone flap of a prior open partial callosotomy.CONCLUSIONSLITT appears to be a safe and effective means for performing corpus callosotomy. Additional data are needed to confirm equipoise between open craniotomy and LITT for corpus callosotomy.

scholarly journals Resistant Temporal Lobe Epilepsy: Initial Steps into a Bigger Epilepsy Surgery Program

2020 ◽  
Author(s):  
Anant Mehrotra ◽  
Suyash Singh ◽  
Soumen Kanjilal ◽  
Gagandeep Attri ◽  
Kamlesh Rangari ◽  
...  
Keyword(s):  
Temporal Lobe ◽  
Medial Temporal Lobe ◽  
Refractory Epilepsy ◽  
Single Photon ◽  
Photon Emission ◽  
Cerebrospinal Fluid Leak ◽  
Emission Computed Tomography ◽  
Mesial Temporal Sclerosis ◽  
Medically Refractory Epilepsy

Abstract Background Among the patients of drug-resistant epilepsy, a subset which has focal impaired seizures localizes to the temporal lobe region (TLE). A majority of these cases are surgically amenable with anterior-medial temporal lobe resection or “lesionectomy.” Objective In India, there is scarcity of “specialized centers” providing “comprehensive epilepsy care” and this dearth is further worse in populous states. In this article, we share our single center, observational, and retrospective experience of TLE in background of limited resources and utmost requirement. Methodology Our study is a retrospective analysis medically refractory epilepsy patients (2016–2019). Patients with medically refractory epilepsy were selected based upon our noninvasive protocol (clinical semiology, interictal scalp electroencephalography (EEG), long-term video EEG monitoring data, and magnetic resonance injury [MRI]). The follow-up was noted from the last out-patient visit record or through telephonic conversation (International League Against Epilepsy score). Results Of 23 cases of TLE (n = 7, mesial temporal sclerosis; n = 16 temporal lobe like cavernomas, tumors, or arterio-venous malformations). Single photon emission computed tomography/positron emission tomography (SPECT/PET) was performed in five cases (three cases of ictal/interictal SPECT and two cases of PET scan) where there was discordance between EEG/clinical and MRI. The median follow-up was of 19 months with 18 cases being seizure free. Five cases were fully off the antiepileptic drug (AEDs) while in 15 cases, the AEDs dosages or the number were reduced. Average number of AEDs reduced from 2.9 in preoperative period to 1.2 postoperatively. Two cases had quadrantanopia and one case of cerebrospinal fluid leak. Conclusion A multidisciplinary and holistic approach is required for best patient care. The results of our initial surgical experience are encouraging.

Consequences of mesial temporal sparing temporal lobe surgery in medically refractory epilepsy

2021 ◽  
Vol 115 ◽  
pp. 107642
Author(s):  
Lilach Goldstein ◽  
Mitra Dehghan Harati ◽  
Kathryn Devlin ◽  
Joseph Tracy ◽  
Maromi Nei ◽  
...  
Keyword(s):  
Temporal Lobe ◽  
Refractory Epilepsy ◽  
Medically Refractory Epilepsy

A historical cohort of temporal lobe surgery for medically refractory epilepsy: a systematic review and meta-analysis to guide future nonrandomized controlled trial studies

2020 ◽  
Vol 133 (1) ◽  
pp. 71-78 ◽  
Author(s):  
Anthony T. Lee ◽  
John F. Burke ◽  
Pranathi Chunduru ◽  
Annette M. Molinaro ◽  
Robert Knowlton ◽  
...  
Keyword(s):  
Systematic Review ◽  
Temporal Lobe ◽  
Epilepsy Surgery ◽  
Refractory Epilepsy ◽  
Meta Analysis ◽  
Small Sample ◽  
Seizure Freedom ◽  
Level I ◽  
Study Designs ◽  
Medically Refractory Epilepsy

OBJECTIVERecent trials for temporal lobe epilepsy (TLE) highlight the challenges of investigating surgical outcomes using randomized controlled trials (RCTs). Although several reviews have examined seizure-freedom outcomes from existing data, there is a need for an overall seizure-freedom rate estimated from level I data as investigators consider other methods besides RCTs to study outcomes related to new surgical interventions.METHODSThe authors performed a systematic review and meta-analysis of the 3 RCTs of TLE in adults and report an overall surgical seizure-freedom rate (Engel class I) composed of level I data. An overall seizure-freedom rate was also collected from level II data (prospective cohort studies) for validation. Eligible studies were identified by filtering a published Cochrane meta-analysis of epilepsy surgery for RCTs and prospective studies, and supplemented by searching indexed terms in MEDLINE (January 1, 2012–April 1, 2018). Retrospective studies were excluded to minimize heterogeneity in patient selection and reporting bias. Data extraction was independently reverified and pooled using a fixed-effects model. The primary outcome was overall seizure freedom following surgery. The historical benchmark was applied in a noninferiority study design to compare its power to a single-study cohort.RESULTSThe overall rate of seizure freedom from level I data was 72.4% (55/76 patients, 3 RCTs), which was nearly identical to the overall seizure-freedom rate of 71.7% (1325/1849 patients, 18 studies) from prospective cohorts (z = 0.134, p = 0.89; z-test). Seizure-freedom rates from level I and II studies were consistent over the years of publication (R2< 0.01, p = 0.73). Surgery resulted in markedly improved seizure-free outcomes compared to medical management (RR 10.82, 95% CI 3.93–29.84, p < 0.01; 2 RCTs). Noninferiority study designs in which the historical benchmark was used had significantly higher power at all difference margins compared to using a single cohort alone (p < 0.001, Bonferroni’s multiple comparison test).CONCLUSIONSThe overall rate of seizure freedom for temporal lobe surgery is approximately 70% for medically refractory epilepsy. The small sample size of the RCT cohort underscores the need to move beyond standard RCTs for epilepsy surgery. This historical seizure-freedom rate may serve as a useful benchmark to guide future study designs for new surgical treatments for refractory TLE.

scholarly journals Magnetic Resonance Thermometry-Guided Stereotactic Laser Ablation of Cavernous Malformations in Drug-Resistant Epilepsy: Imaging and Clinical Results

2015 ◽  
Vol 12 (1) ◽  
pp. 39-48 ◽  
Author(s):  
D Jay McCracken ◽  
Jon T Willie ◽  
Brad A Fernald ◽  
Amit M Saindane ◽  
Daniel L Drane ◽  
...  
Keyword(s):  
Laser Ablation ◽  
Magnetic Resonance ◽  
Minimally Invasive ◽  
Real Time ◽  
Refractory Epilepsy ◽  
Acute Hemorrhage ◽  
Cavernous Malformations ◽  
Remote Imaging ◽  
Medically Refractory Epilepsy

Abstract BACKGROUND Surgery is indicated for cerebral cavernous malformations (CCMs) that cause medically refractory epilepsy. Real-time magnetic resonance thermography (MRT)-guided stereotactic laser ablation (SLA) is a minimally invasive approach to treating focal brain lesions. SLA of CCM has not previously been described. OBJECTIVE To describe MRT-guided SLA, a novel approach to treating CCM-related epilepsy, with respect to feasibility, safety, imaging, and seizure control in 5 consecutive patients. METHODS Five patients with medically refractory epilepsy undergoing standard presurgical evaluation were found to have corresponding lesions fulfilling imaging characteristics of CCM and were prospectively enrolled. Each underwent stereotactic placement of a saline-cooled cannula containing an optical fiber to deliver 980-nm diode laser energy via twist drill craniostomy. MR anatomic imaging was used to evaluate targeting before ablation. MR imaging provided evaluation of targeting and near real-time feedback regarding the extent of tissue thermocoagulation. Patients maintained seizure diaries, and remote imaging (6-21 months postablation) was obtained in all patients. RESULTS Imaging revealed no evidence of acute hemorrhage following fiber placement within presumed CCM. MRT during treatment and immediate postprocedure imaging confirmed the desired extent of ablation. We identified no adverse events or neurological deficits. Four of 5 (80%) patients achieved freedom from disabling seizures after SLA alone (Engel class 1 outcome), with follow-up ranging 12 to 28 months. Reimaging of all subjects (6-21 months) indicated lesion diminution with surrounding liquefactive necrosis, consistent with the surgical goal of extended lesionotomy. CONCLUSION Minimally invasive MRT-guided SLA of epileptogenic CCM is a potentially safe and effective alternative to open resection. Additional experience and longer follow-up are needed.

scholarly journals Surgical Outcomes and EEG Prognostic Factors After Stereotactic Laser Amygdalohippocampectomy for Mesial Temporal Lobe Epilepsy

2021 ◽  
Vol 12 ◽  
Author(s):  
Shasha Wu ◽  
Naoum P. Issa ◽  
Maureen Lacy ◽  
David Satzer ◽  
Sandra L. Rose ◽  
...  
Keyword(s):  
Temporal Lobe Epilepsy ◽  
Temporal Lobe ◽  
Surgical Outcomes ◽  
Mesial Temporal Lobe Epilepsy ◽  
Seizure Freedom ◽  
Seizure Recurrence ◽  
Factors Associated ◽  
Scalp Eeg ◽  
Mesial Temporal Lobe

Objective: To assess the seizure outcomes of stereotactic laser amygdalohippocampectomy (SLAH) in consecutive patients with mesial temporal lobe epilepsy (mTLE) in a single center and identify scalp EEG and imaging factors in the presurgical evaluation that correlate with post-surgical seizure recurrence.Methods: We retrospectively reviewed the medical and EEG records of 30 patients with drug-resistant mTLE who underwent SLAH and had at least 1 year of follow-up. Surgical outcomes were classified using the Engel scale. Univariate hazard ratios were used to evaluate the risk factors associated with seizure recurrence after SLAH.Results: The overall Engel class I outcome after SLAH was 13/30 (43%), with a mean postoperative follow-up of 48.9 ± 17.6 months. Scalp EEG findings of interictal regional slow activity (IRSA) on the side of surgery (HR = 4.05, p = 0.005) and non-lateralizing or contra-lateralizing seizure onset (HR = 4.31, p = 0.006) were negatively correlated with postsurgical seizure freedom. Scalp EEG with either one of the above features strongly predicted seizure recurrence after surgery (HR = 7.13, p &lt; 0.001) with 100% sensitivity and 71% specificity.Significance: Understanding the factors associated with good or poor surgical outcomes can help choose the best candidates for SLAH. Of the variables assessed, scalp EEG findings were the most clearly associated with seizure outcomes after SLAH.

Vagal nerve stimulation for the treatment of medically refractory epilepsy: a review of the current literature

2012 ◽  
Vol 32 (3) ◽  
pp. E12 ◽  
Author(s):  
David E. Connor ◽  
Menarvia Nixon ◽  
Anil Nanda ◽  
Bharat Guthikonda
Keyword(s):  
Nerve Stimulation ◽  
Refractory Epilepsy ◽  
Epileptiform Activity ◽  
Vagal Nerve ◽  
Vagal Nerve Stimulation ◽  
Class I ◽  
Class Iii ◽  
Surgical Evaluation ◽  
Pediatric Populations ◽  
Medically Refractory Epilepsy

Object The authors conducted a study to evaluate the published results of vagal nerve stimulation (VNS) for medically refractory seizures according to evidence-based criteria. Methods The authors performed a review of available literature published between 1980 and 2010. Inclusion criteria for articles included more than 10 patients evaluated, average follow-up of 1 or more years, inclusion of medically refractory epilepsy, and consistent preoperative surgical evaluation. Articles were divided into 4 classes of evidence according to criteria established by the American Academy of Neurology. Results A total of 70 publications were reviewed, of which 20 were selected for review based on inclusion and exclusion criteria. There were 2 articles that provided Class I evidence, 7 that met criteria for Class II evidence, and 11 that provided Class III evidence. The majority of evidence supports VNS usage in partial epilepsy with a seizure reduction of 50% or more in the majority of cases and freedom from seizure in 6%–27% of patients who responded to stimulation. High stimulation with a gradual increase in VNS stimulation over the first 6 weeks to 3 months postoperatively is well supported by Class I and II data. Predictors of positive response included absence of bilateral interictal epileptiform activity and cortical malformations. Conclusions Vagal nerve stimulation is a safe and effective alternative for adult and pediatric populations with epilepsy refractory to medical and other surgical management.

scholarly journals Magnetic resonance imaging–guided laser interstitial thermal therapy as treatment for intractable insular epilepsy in children

2017 ◽  
Vol 20 (6) ◽  
pp. 575-582 ◽  
Author(s):  
M. Scott Perry ◽  
David J. Donahue ◽  
Saleem I. Malik ◽  
Cynthia G. Keator ◽  
Angel Hernandez ◽  
...  
Keyword(s):  
Epilepsy Surgery ◽  
Medical Center ◽  
Surgical Techniques ◽  
Intractable Epilepsy ◽  
Vascular Supply ◽  
Thermal Therapy ◽  
Attractive Alternative ◽  
Class Iii ◽  
Laser Interstitial Thermal Therapy

OBJECTIVESeizure onset within the insula is increasingly recognized as a cause of intractable epilepsy. Surgery within the insula is difficult, with considerable risks, given the rich vascular supply and location near critical cortex. MRI-guided laser interstitial thermal therapy (LiTT) provides an attractive treatment option for insular epilepsy, allowing direct ablation of abnormal tissue while sparing nearby normal cortex. Herein, the authors describe their experience using this technique in a large cohort of children undergoing treatment of intractable localization-related epilepsy of insular onset.METHODSThe combined epilepsy surgery database of Cook Children’s Medical Center and Dell Children’s Hospital was queried for all cases of insular onset epilepsy treated with LiTT. Patients without at least 6 months of follow-up data and cases preoperatively designated as palliative were excluded. Patient demographics, presurgical evaluation, surgical plan, and outcome were collected from patient charts and described.RESULTSTwenty patients (mean age 12.8 years, range 6.1–18.6 years) underwent a total of 24 LiTT procedures; 70% of these patients had normal findings on MRI. Patients underwent a mean follow-up of 20.4 months after their last surgery (range 7–39 months), with 10 (50%) in Engel Class I, 1 (5%) in Engel Class II, 5 (25%) in Engel Class III, and 4 (20%) in Engel Class IV at last follow-up. Patients were discharged within 24 hours of the procedure in 15 (63%) cases, in 48 hours in 6 (24%) cases, and in more than 48 hours in the remaining cases. Adverse functional effects were experienced following 7 (29%) of the procedures: mild hemiparesis after 6 procedures (all patients experienced complete resolution or had minimal residual dysfunction by 6 months), and expressive language dysfunction after 1 procedure (resolved by 3 months).CONCLUSIONSTo their knowledge, the authors present the largest cohort of pediatric patients undergoing insular surgery for treatment of intractable epilepsy. The patient outcomes suggest that LiTT can successfully treat intractable seizures originating within the insula and offers an attractive alternative to open resection. This is the first description of LiTT applied to insular epilepsy and represents one of only a few series describing the use of LiTT in children. The results indicate that seizure reduction after LiTT compares favorably to that after conventional open surgical techniques.

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