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PubMed2003

How effective is surgery to cure seizures in drug-resistant temporal lobe epilepsy?

It is well recognized that two-thirds of patients with drug-resistant temporal lobe epilepsy will be free of disabling seizures with continued medical treatment after temporal resection. Seizure recurrence has been noted during a five-year follow-up in approximately one-third of these seizure-free patients mostly but not exclusively following planned complete discontinuation of antiepileptic drugs (AEDs). This leaves one-third of patients without disabling seizures and without AEDs several years after surgery. Despite improvements in seizure frequency or severity, seizures persist in another third of patients undergoing surgery. Although cure (five years without any seizures and off AEDs) is the ultimate aim of epilepsy surgery, the percentage of patients cured by surgery cannot be well defined at the moment. We need a long-term randomized controlled trial on AED discontinuation in seizure-free patients followed by long-term open extension to determine if only one in three adult patients with drug-resistant temporal lobe epilepsy is cured by surgical intervention.

Anticonvulsants↗

PubMed2006

The first invasive EEG monitoring for surgical treatment of epilepsy in Thailand.

The authors report the first invasive electroencephalography (EEG) monitoring in Thailand in a patient who had intractable left temporal lobe epilepsy. The seizure origin and functioning cortices were identified The corresponding epileptogenic zone was resected without functional deficit. The patient has become seizure free 1 year since surgery. Subdural EEG monitoring with cortical stimulation have been developed at this tertiary epilepsy center The technique provides essential evidence for the surgical decision so that the best post operative outcome can be achieved.

Adult↗

PubMed1996

Cognitive effects of resecting basal temporal language areas.

Electrical stimulation of the basal temporal region of the dominant hemisphere before partial temporal lobectomy for epilepsy sometimes produces temporary interruption of language function, but the significance of removal of this area is unknown. We evaluated the correlation between resection of the basal temporal language areas (BTLA) and certain types of postoperative language deficits. In a population of 25 patients, we mapped the inferolateral temporal lobe with cortical electrical stimulation, verifying the positions of the stimulating electrodes with three-dimensional computed tomography (CT). Eighty percent of the patients developed transient language deficits with stimulation, particularly with tests of confrontation naming and comprehension. BTLA was primarily located in the fusiform gyrus, from 1 to 9 cm from the temporal tip. At testing 6-12 months after operation, patients with BTLA resection performed worse (mean 9% decrease) than those with no BTLA resection (mean 4% improvement) on tests of confrontation naming (p = 0.03). Resection size accounted for less of the variance in decrease in confrontation naming than did resection of the BTLA. Tests of performance I.Q. (PIQ), verbal I.Q. (VIQ), or recognition memory for word and verbal learning showed no significant difference between these groups. Most patients do not have language decrease with removal of basal temporal lobe 5-6 cm from the tip, even with removal of BTLA. Some patients, however, have persistent decrease in naming.

Adolescent↗

PubMed2004

Increased expression of erythropoietin receptor on blood vessels in the human epileptogenic hippocampus with sclerosis.

Microvascular (capillary) proliferation is a readily observed, but largely ignored phenomenon of the mesial temporal lobe epilepsy (MTLE) hippocampus. Here, we report that the proliferated capillaries in surgically resected MTLE hippocampi were strongly immunoreactive for erythropoietin receptor (EPO-r). Further, we found that these capillaries were most prominent in areas of the MTLE hippocampus with extensive neuronal loss and gliosis, i.e. the CA3, CA1, and dentate hilus. High-resolution immunogold electron microscopy revealed that the capillary EPO-r was localized to the luminal and abluminal plasma membrane of endothelial cells, to endosome-like structures of these cells, and to pericapillary astrocytic end-feet. Previous studies have shown that systemically administered EPO appears in the cerebrospinal fluid in experimental animals, and the present results are consistent with the idea that EPO enters the brain via receptor-mediated endocytosis. The enrichment of EPO-r shown here suggests a highly efficient uptake of plasma EPO into the MTLE hippocampus and a possible role for this cytokine in epileptogenesis. Moreover, the presence of EPO-r in the MTLE hippocampus may provide a new vehicle for highly efficient delivery of hitherto impermeable drugs into the epileptic brain.

Adult↗

PubMed2005

Excision of visual cortex does not affect the facilitatory and inhibitory effects of a light flash prepulse on the acoustic startle reflex in the rat.

We studied the inhibitory (PPI) and facilitatory (PPF) behavioural effects of brief light flashes presented as prepulses just prior to the acoustic startle reflex (ASR) in intact rats and in rats that had a bilateral excision of visual cortex (VC). The VC-lesioned and control groups (n=5, 5) were near identical in PPF for flashes presented 5-20 ms before the ASR and near identical in PPI for flashes presented 60 ms before the ASR. These findings differ from those of a case report of a human patient following occipital cortex resection, for whom light flashes failed to produce either acoustic startle PPF or PPI if the flash were presented to the portion of the visual field in which she could not see; they differ also from data obtained in functionally decorticate rats, for which a light flash produced no startle PPI, but instead a late-appearing exaggerated PPF. In the present experiment the lesion was restricted to VC, while in contrast the occipital resection in the human patient included posterior areas of the parietal and temporal lobe, and functional decortication in the rat disengaged the entire cortex. The greater extent of these two effective surgical procedures may have been responsible for their greater behavioural effects; otherwise, the complete loss of reflex control by photic stimulation in the human patient but not in the rat may reflect the greater functional importance and anatomical complexity of the VC in humans.

Acoustic Stimulation↗

PubMed2001

Current trends in electroencephalography.

Several recent articles re-emphasize the value of clinical electrophysiology: in localizing epileptogenesis, predicting effectiveness of epilepsy surgery, and disclosing a mechanism of benign Rolandic epilepsy of childhood.A review of the role of EEG in the diagnosis of epilepsy indicated that epileptiform activity will appear in 50% of initial awake recordings of adults with epilepsy and in 85% of subjects undergoing two recordings. This contrasts with the appearance of spikes in only 4 of 1000 normal persons. Several studies focused on the value of electroencephalography in extratemporal epilepsy: 62% of patients with neocortical epilepsy had at least one localizing ictal EEG; occipital and temporal neocortical seizures were localized in a greater proportion than frontal or parietal attacks. Interictal spikes, if unifocal, always arose from the epileptogenic region in a study of their seizure localizing value. Such congruence augured for better seizure control by focal resection in two studies reviewed herein. Studies indicating the value of interictal temporal lobe spikes and scalp-recorded seizures in lateralising a temporal seizure focus are reviewed. One study found EEG to be slightly more reliable for lateralization of temporal epileptogenesis than MRI. In patients with benign Rolandic seizures, enhanced motor evoked potentials (MEPs) were obtained from transcranial magnetic stimulation when this was applied 50-80 msec after electrical stimulation of the thumb whereas this interval inhibited the MEP in normal subjects. This suggests that afferent cutaneous input abnormally and synchronously activates a large population of sensory neurons; such activation is subsequently transmitted to the motor cortex to produce the focal spikes in this condition.Finally, advances in non-invasive technology have redefined and limited the need for invasive monitoring in children with intractable seizure disorders.

Cerebral Cortex↗

PubMed2003

Long-term outcome of nonsurgical candidates with medically refractory localization-related epilepsy.

PURPOSE: Epilepsy surgery can result in complete seizure remission rates of upto 80% in patients with mesial temporal sclerosis and unilateral seizures. The seizure-free rate after surgery for patients with extratemporal nonlesional epilepsy has ranged between 30% and 40%. Some patients with medically refractory localization-related epilepsy cannot be offered surgical resection because of inadequate localization of the epileptogenic zone, documentation of bilateral ictal onsets, or functionally important areas of cortex that prohibit resection. The short-term rate of complete remission with medications in temporal lobe epilepsy is poor. Less is known about remission rates in patients who are not surgical candidates. In this study, we evaluated the outcome of medical treatment in patients with medically refractory partial epilepsy who were evaluated for possible epilepsy surgery but deemed to be inadequate surgical candidates. METHODS: A retrospective chart review and telephone survey with a self-rating questionnaire were completed for all patients who underwent epilepsy surgery evaluation but were not ultimately offered surgical treatment at the University of Michigan from 1990 through 1998. We assessed changes in seizure frequency and type, imaging characteristics, ictal recordings, interim medication history, and subjective changes in quality of life. RESULTS: Thirty-four subjects were available for follow-up study, at an average of >4 years after surgical evaluation. A significant reduction in seizure frequency was noted at the time of follow-up compared with that at the time of surgical evaluation. Of patients, 21% achieved seizure remission and remained seizure free for an average of 2.5 years. Four of the seven seizure-free patients attributed their remission to new antiepileptic drugs (AEDs). On a global self-rating item, 15 of 34, or 44%, felt more or much more satisfied with their lives, and 41% felt their quality of life was stable. CONCLUSIONS: A surprisingly large number of patients we surveyed, with refractory partial epilepsy not eligible for surgical management, reported reduced seizure frequency at follow-up, and 21% were seizure free. Our findings suggest that the long-term prognosis in patients with refractory partial epilepsy who are not surgical candidates may be more positive than might be generally expected.

Adult↗

PubMed1993

[Stereotactically-guided microsurgery in cerebral processes].

Stereotaxy-guided microsurgery offers significant advantages in the treatment of deep-seated cerebral lesions, or in lesions that cannot reliably be localized because of their small size or lack of evident landmarks. We report our experience with 16 stereotaxy-guided microsurgical procedures performed with the Leksell or the Lerch stereotactic system. Small superficial lesions were operated on in 6 patients and deep-seated subcortical lesions in 10 patients. The lesion size ranged from 10 to 50 mm and the depth of the lesions varied between 5 and 65 mm. A trans-sulcus approach was chosen in patients with cavernomas and a transcortical or transtumoral one in patients presenting with cerebral tumors. In no patient was a new postoperative neurologic deficit found, i.e. 12 patients had neither a pre- nor a postoperative deficit. 2 patients (with central lesions) of 4 presenting with preoperative deficits showed an impressive recovery, while in the other 2 patients with lesions in the dominant temporal lobe the neurologic deficit remained unchanged. Stereotaxy-guided microsurgery allows safe resection of small or deep-seated cerebral lesions without postoperative morbidity in our series.

Adult↗

PubMedDate not supplied

Pigmented villonodular tenosynovitis of the temporomandibular joint.

A case report of pigmented villonodular tenosynovitis involving the temporomandibular joint is presented. The lesion had destroyed the ascending ramus and condyle of the mandible, anterior cartilaginous wall of the external auditory meatus, and a large part of the squamous portion of the temporal bone. Surgery included resection of a portion of the mandible, temporal squama, and dura of the temporal lobe with replacement by a fascia temporalis graft. Four years postoperatively, the patient is free of any evidence of recurrent disease. A discussion of the differential diagnosis of an infratemporal mass, natural history, and pathology of pigmented villonodular tenosynovitis are discussed herein.

Diagnosis, Differential↗

PubMedDate not supplied

[Hypothalamic hamartomas: control of seizures after partial removal in one case].

OBJECTIVE: To describe a patient with intractable seizures and hypothalamic hamartoma that was only partially resected with complete control of seizures and improvement in behavior after surgery. CLINICAL CASE: He had gelastic seizures from the first months of life associated with hypothalamic hamartoma. We used magnetic resonance spectroscopy to localize and measure the lesion in the temporal lobes and in the hamartoma. The relative intensity of N-acetylaspartate to creatine (NAA/Cr) and NAA/choline (Ch) were not significantly different from normal control subjects for either temporal lobes, whereas the ratio NAA/Ch was decreased and the ratio NAA/Cr was highly increased in the hamartoma. Despite only partial resection of the hamartoma, seizures have been completely controlled and the patient has recovered normal social and work activity and is ending a normal life, that follow three years after surgery. CONCLUSIONS: These findings suggest that gelastic seizures associated with hypothalamic hamartoma are generated within the hamartoma itself, and that it is possible to control epilepsy and to improve intellectual and social problems with only partial resection of the mass.

Adult↗

PubMed1993

Short-term cognitive changes after unilateral temporal lobectomy or unilateral amygdalo-hippocampectomy for the relief of temporal lobe epilepsy.

Forty two patients who had unilateral temporal lobe surgery (either temporal lobectomy or amygdalo-hippocampectomy) were evaluated using a selection of cognitive tests before and soon after surgery, to examine whether the amygdalo-hippocampectomy produces less cognitive impairment than the standard en bloc resection. On specific indices of cognitive functioning an amygdalo-hippocampectomy rather than a temporal lobectomy, undertaken on the temporal lobe thought to mediate that particular function, produced less impairment, in terms of change in cognitive function resulting from the operation. An amygdalo-hippocampectomy carried out on the temporal lobe not thought to mediate such skills, however, resulted in less improvement or more deterioration in these functions than a temporal lobectomy, except in the case of delayed prose recall, where a right amygdalo-hippocampectomy led to more improvement than a right temporal lobectomy. Overall there were few scores which distinguished between the different surgical procedures for cognitive outcome.

Adult↗

PubMed2003

Category-specific naming deficit identified by intraoperative stimulation mapping and postoperative neuropsychological testing. Case report.

Category-specific naming deficits and differential brain activation patterns have been reported in patients naming living as opposed to nonliving objects. The authors report on a case in which they used preoperative functional magnetic resonance (fMR) imaging, intraoperative electrocortical stimulation mapping (ESM), and postoperative neuropsychological testing to map language function. Using the latter two modalities, the authors identified a specific locus for category-specific naming in the posterior inferior temporal lobe, presumably a part of the basal temporal language area. Preoperative fMR imaging findings revealed the presence of a language area in the inferior temporal lobe; intraoperative ESM results indicated that this cortical area may be category specific for living objects; and after resection of the area, the results of postoperative neuropsychological testing confirmed that the patient made significantly more errors while naming living objects compared with nonliving ones (p < 0.001), independent of the effects of word frequency and with an intact system of object recognition and comprehension. These authors are the first to identify a specific and well-localized area of category-specific naming in the inferior temporal lobe and to demonstrate congruence of intraoperative and postoperative category-specific naming deficits. They also emphasize the roles of preoperative and intraoperative testing in predicting clinical outcomes.

Adult↗

PubMed1998

In vivo [11C]flumazenil-PET correlates with ex vivo [3H]flumazenil autoradiography in hippocampal sclerosis.

By using [11C]flumazenil-positron emission tomography ([11C]FMZ-PET), we have previously shown that reductions of central benzodiazepine receptors (cBZRs) are restricted to the hippocampus in mesial temporal lobe epilepsy (mTLE) caused by unilateral hippocampal sclerosis (HS). Receptor autoradiographic studies on resected hippocampal specimens from the same patients demonstrated loss of cBZRs that was over and above loss of neurons in the CA1 subregion. Here, we report the first direct comparison of in vivo cBZR binding with [11C]FMZ-PET and ex vivo binding using [3H]FMZ autoradiography. We applied a magnetic resonance imaging-based method for partial volume effect correction to the PET images of [11C]FMZ volume of distribution ([11C]FMZ Vd) obtained in 10 patients with refractory mTLE due to unilateral, histologically verified HS. Saturation autoradiography was performed on the hippocampal specimens obtained from the same patients, allowing calculation of receptor availability ([3H]FMZ Bmax). After correction for partial volume effect, [11C]FMZ Vd in the body of the epileptogenic hippocampus was reduced by a mean of 42.1% compared with normal controls. [3H]FMZ Bmax, determined autoradiographically from the same hippocampal tissue, was reduced by a mean of 42.7% compared with control hippocampi. Absolute in vivo and ex vivo measurements of cBZR binding for the body of the hippocampus were significantly correlated in each individual. Our study demonstrates that reduction of available cBZR on remaining neurons in HS can be reliably detected in vivo by using [11C]FMZ-PET after correction for partial volume effect.

Adult↗

PubMed1988

Microdysgenesis in resected temporal neocortex: incidence and clinical significance in focal epilepsy.

Fifty patients underwent superficial temporal lobectomy for intractable temporal lobe epilepsy. Total cure rate was 52%, and significant improvement was achieved in 88%. Cytoarchitectural changes in gray and white tissue were analyzed under light microscopy. Neuronal dysgenesis was correlated with the duration of seizure disorder, age of onset, and other etiologic factors, and with clinical outcome. Temporal lobes from 33 neurologically normal autopsy brains which were age- and sex-matched with patients were examined as controls. Severe neuronal ectopia (greater than 8 neurons/2 mm2 white matter) was present in 42% of patients with epilepsy and in none of controls. There was neuronal clustering in 28% of those with epilepsy, and Chaslin's (subpial) gliosis in 38%. Controls did not have these changes. The presence of severe neuronal ectopia and clustering was predictive of a favorable clinical outcome following surgery (p less than 0.05). No correlation was found between microdysgenesis and other factors. These findings suggest that the presence of neuronal dysgenesis may be of significance in the clinical outcome following surgery, and that the abnormal tissue may be important as a morphologic substrate for seizures in some patients.

Adolescent↗

PubMed1996

Subtemporal transparahippocampal amygdalohippocampectomy for surgical treatment of mesial temporal lobe epilepsy. Technical note.

Amygdalohippocampectomy (AH) is an accepted surgical option for treatment of medically refractory mesial temporal lobe epilepsy. Operative approaches to the amygdala and hippocampus that previously have been reported include: the sylvian fissure, the superior temporal sulcus, the middle temporal gyrus, and the fusiform gyrus. Regardless of the approach, AH permits not only extirpation of an epileptogenic focus in the amygdala and anterior hippocampus, but interruption of pathways of seizure spread via the entorhinal cortex and the parahippocampal gyrus. The authors report a modification of a surgical technique for AH via the parahippocampal gyrus, in which excision is limited to the anterior hippocampus, amygdala and parahippocampal gyrus while preserving the fusiform gyrus and the rest of the temporal lobe. Because transparahippocampal AH avoids injury to the fusiform gyrus and the lateral temporal lobe, it can be performed without intracarotid sodium amobarbital testing of language dominance and language mapping. Thus the operation would be particularly suitable for pediatric patients in whom intraoperative language mapping before resection is difficult.

Amygdala↗

PubMed1999

Nontumoral occipitotemporal epilepsy: localizing findings and surgical outcome.

We describe a syndrome of medically intractable occipitotemporal epilepsy of nontumoral developmental origin and its treatment by surgery. From our epilepsy surgery database of 1988 to 1996, we selected all patients without neoplasm who had at least two characteristics localizing to the occipital lobe (clinical symptoms, interictal focus, ictal onset, or a lesion on magnetic resonance imaging scanning) and one to the temporal lobe (interictal spikes or seizure onset). We discuss seizure characteristics, electroencephalographic (EEG), magnetic resonance imaging, positron emission tomographic, and single-photon emission computed tomographic findings, pathological findings, surgical approach, outcome from resective surgery, and implications for pathophysiology. Sixty-nine percent of our 16 patients with occipitotemporal syndrome had neuronal migration disorder, suggesting a developmental etiology of this entity. Initial signs or symptoms suggested occipital lobe seizure onset in 13 of 16 patients. On scalp EEG, interictal spikes were localized to the temporal lobe in 9 and to the occipital lobe in 1; seizure onset was poorly localized. Intracranial EEG localized seizure onset to the area of temporo-occipital junction in 77% of patients. Positron emission tomography and single-photon emission computed tomography showed occipital and temporal or widespread deficits, and neuropsychological performance was diffusely abnormal. Surgical results were best with occipital and temporal resections, but sometimes satisfactory after occipital resection even with temporal (ipsilateral) EEG findings. Temporal resection with hippocampectomy uniformly failed to control seizures. An often refractory, probably developmental epileptic syndrome with regional occipitotemporal distribution can be diagnosed by a specific constellation of findings, which has implications for treatment and pathophysiology.

Adolescent↗

PubMed1998

Two-staged resection of a left frontal astrocytoma involving the operculum and insula using intraoperative neurophysiological monitoring--case report.

A 29-year-old right-handed male with a 12-year education presented with a 2-month history of generalized epileptic activity. Neuroradiological imaging demonstrated a large lesion in the left frontal lobe involving the insulooperculum and in the temporal tip. Neurological and neuropsychological examination revealed no abnormality. Two-staged total resection of a left frontal large astrocytoma involving the insulooperculum was achieved, with preservation of the speech and motor functions. The prefrontal area was resected en bloc under general anesthesia. To avoid vascular damage including the lenticulostriate arteries, the sylvian and the interhemispheric fissures were thoroughly opened. The tumor was apparently located in the anatomical Broca's area. Eighteen days later, the residual tumor was totally resected with no language deficit after identifying the motor-speech cortex, which was displaced from the usual location, by direct cortical stimulation under local anesthesia. The medially extended insular tumor was then resected stepwise with frequent neurological monitoring with the patient awake. Surgery for intraaxial insuloopercular lesions in the dominant hemisphere carries a high risk of speech and motor deficit. This staged operation enables maximum tumor resection of dominant-side large frontal gliomas involving the insuloopercular region, with preservation of both motor and speech functions.

Adult↗

PubMedDate not supplied

[Focal cortical dysplasia and refractory epilepsy. Surgical treatment].

INTRODUCTION: Focal cortical dysplasia (FCD) is an unusual cause of refractory epilepsy, in which the morbid anatomy is characterized by cortical laminar dysplasia and the presence of balloon like cells. CLINICAL CASE: A 36 year old woman who had had drug-resistant epilepsy since the age of 9 years old, with daily complex partial seizures and seizures in which she fell to the ground. After many therapeutic trials, at the age of 29 years she had a callostomy as palliative treatment for the seizures in which she fell and was completely cured of these. The complex partial seizures increased in frequency, in spite of high doses of multiple drugs, so the possibility of resective surgery was considered. A surface EEG with predominant lateralization and localization to the left temporal lobe, ictal and interictal cerebral SPECT, PET and MR were done. The findings were comparable with two foci of dysplasia in the left cerebral hemisphere, one superior parietal and the other posterior basal temporal in situation. Finally, video-EEG monitoring with foramen ovale electrodes showed ictal activity starting in the left posterior temporal regions and with rapid homolateral anteromesial diffusion. A left temporal lobectomy and amigdalohippocampectomy was done with resection of a posterior basal temporal lesion. This reduced the number of seizures by 90%, with minimal dysnomy as a sequel. The findings on morbid anatomical study were compatible with a FCD. CONCLUSIONS: FCD is a cause of refractory epilepsy which may benefit from surgical treatment, with excellent results, after suitable pre-operative surgical evaluation and planning, including hippocampal evaluation since there is a high incidence of associated mesial sclerosis.

Adult↗