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PubMed1996

[Temporal lobe epilepsy. Surgical treatment].

The authors report the surgical management of 32 patients with medically intractable seizures. In all cases the epileptiform focus present in the temporal region was demonstrated by electroencephalography. Our report was made up of 14 male patients and 18 female patients. Their ages ranged from 9 to 62 years. The material was divided into two groups. The first, with eighteen patients with cerebral lesion (like gliomas, arteriovenous malformation, epidermoid tumor) demonstrated on the CT scan and MR imaging underwent to lesion resection: in some cases with adjacent irritative area (guided by electrocorticography) out of eloquent zone, the removal of this irritative area was done. The second, with fourteen patients without cerebral expansive lesion; the MR imaging showed mesial temporal sclerosis in eight cases; all the patients of this group underwent to temporal lobectomy; the histopathologic exam showed temporal sclerosis in nine cases and normal brain in five. The postoperative follow-up showed better results in the cases with expansive cerebral lesion (83.4% seizure free) than the cases without that lesion (71.4% seizure free).

Adolescent↗
PubMed1997

Surgical treatment of neoplasms associated with medically intractable epilepsy.

OBJECTIVE: Surgical treatment in patients with brain tumors and medically intractable epilepsy is aimed at the removal of the neoplasm and complete seizure control. However, an adequate surgical approach is still controversial. This study was designed to analyze the factors for the optimum surgical treatment of these patients. METHODS: The clinical, electrophysiological, operative, and histopathological data of 146 consecutive patients who underwent surgery between November 1987 and May 1995 for intrinsic brain tumors and pharmacoresistant epilepsy were evaluated. RESULTS: The majority of the tumors were located in the temporal lobe (n = 116) and involved the cortical gray matter. The most frequent tumors were gangliogliomas (n = 65), pilocytic astrocytomas (n = 21), and dysembryoplastic neuroepithelial tumors (n = 19). All but three tumors (98%) were of low histopathological grade (World Health Organization Grades I or II). The biological behavior of the tumors was strikingly indolent, as indicated by a long preoperative history of chronic seizures (mean, 14 yr). In all cases, complete resection of the tumor, including the epileptogenic area (as determined by noninvasive and/or invasive recordings of the zone of seizure onset and persistent interictal activity), was intended. Complications were encountered in 11 cases (8%). However, no patient died and there was no permanent morbidity. Of the 124 patients who had postoperative follow-up examinations more than 6 months after resection, 71% were seizure-free, 11% had no more than two seizures per year, 13% showed a reduction of seizure frequency of at least 75%, and 5% had no appreciable reduction in seizure frequency. CONCLUSION: The data indicate that neoplasms associated with medically intractable epilepsy constitute a distinct clinicopathological group of tumors that arise in young hosts, involve the cortex, and exhibit indolent biological behavior for many years. Complete surgical removal of these tumors, including the epileptogenic area, can achieve excellent seizure control.

Adolescent↗
PubMedDate not supplied

Surgical treatment of children with medically intractable frontal or temporal lobe epilepsy: results and highlights of 40 years' experience.

Etiologic, pathologic, and clinical features of possible prognostic significance were studied in 118 children who underwent frontal or temporal lobe epilepsy surgery at the Montreal Neurological Institute (MNI) between 1940 and 1980 (excluding tumor cases). Mean age of seizure onset was 5.1 years (range 0-12 years), mean age at operation was 11.7 years (range 0.6-15 years), and median duration of follow-up was 15 years (range 2-31 years). Thirteen of 45 frontal surgery patients and 43 of 73 temporal surgery patients had an excellent outcome. In the frontal surgery group, this was restricted almost entirely to patients with an established etiology, particularly if this included a circumscribed resectable structural abnormality. In the temporal surgery group, a history of early, prolonged febrile seizures was usually associated with good outcome, unless there was additional evidence of extratemporal epilepsy. In the entire series, the presence of a nonresectable structural lesion or secondarily generalized seizures was associated with a poor outcome.

Child↗
PubMedDate not supplied

Extent of ictal origin in mesial temporal sclerosis patients monitored with subdural intracranial electrodes predicts outcome.

In patients with mesiotemporal sclerosis, posterior hippocampal involvement at the ictal onset is not associated with an excellent outcome. A study confirmed that ictal onset in the posterior parahippocampal gyrus is associated with a less favorable outcome compared with ictal onset in the anterior parahippocampal gyrus in patients with mesiobasal temporal lobe epilepsy who are undergoing foramen ovale recording. The authors hypothesized that involvement of the two medial contact points of posterior basal temporal subdural (SD) strip at the ictal onset, representing ictal onset in the posterior parahippocampal gyrus, may also adversely influence the surgical outcome. With this objective, the authors assessed the incidence of posterior basal temporal SD strip (the two medial contact points) involvement at the ictal onset in patients with mesiotemporal sclerosis and determined whether presence of this finding influenced surgical outcome. Thirty-six patients with mesiotemporal sclerosis underwent a single SD grid (lateral frontotemporal) and strips (three basal temporal and one orbitosubfrontal) monitoring. Based on the earliest involvement of basal temporal strips (the two medial contact points) during the seizure, patients were classified into (1) anterior and/or middle basal temporal, or (2) posterior basal temporal (with or without involvement of anterior and/or middle basal temporal) ictal onset groups. A temporal lobectomy with adequate resection of the ictal onset zone was performed in all patients. Surgical outcome was based on Engel's classification. Six of 36 (17%) patients were classified into the posterior basal temporal ictal onset group. Only two patients from the posterior basal temporal ictal onset group experienced a good outcome compared with 26 of 30 patients from anterior and/or middle basal temporal ictal onset group (P = 0.01). In patients with mesiotemporal sclerosis who were monitored with SD electrodes, involvement of the two medial contact points of posterior basal temporal strip at the ictal onset (representing ictal onset in the posterior parahippocampal gyrus) occurred in 17% of the patients. These patients might not experience an excellent surgical outcome despite including the ictal onset zone in resection. These findings may be useful in presurgical counseling of patients with mesiotemporal sclerosis who undergo intracranial SD monitoring.

Adolescent↗
PubMed2003

[Temporal lobe epilepsy associated with cystic lesion in the temporal lobe and middle cranial fossa].

Four patients out of 52 patients with temporal lobe epilepsy (TLE), who underwent epilepsy surgery in our hospital since September of 1994, had cystic lesions in the temporal lobe and middle cranial fossa. Case 1 had old hematoma cavity in the inferior temporal gyrus and chronic subdural electrode recording revealed the ictal onset zone to be localized in the ipsilateral medial temporal region. Case 2 had cystic ganglioglioma in the temporal tip, and intraoperative electrocorticography demonstrated independent paroxysmal activities from medial temporal region and temporal tip near the cyst. Both area were resected and the patients became seizure free. Case 3 and 4 had arachnoid cysts in the middle cranial fossa. Chronic subdural electrode recording revealed that the ictal onset zone was localized in the ipsilateral inferior temporal gyrus (that had microdysgenesis) in Case 3 and contralateral medial temporal region (that had hippocampal sclerosis) in Case 4, respectively. These finding suggest that co-existence of extra-axial cyst such as Case 3 and 4 is incidental and that arachnoid cyst is less epileptogenic. However, intra-axial cyst such as Case 1 and 2 is epileptogenic and complicated physiological mechanism such as kindling phenomenon or secondary epileptogenesis may effect on the hippocampus. Comprehensive presurgical evaluation including electrocorticography is needed in the surgical treatment of TLE with cystic lesion.

Adolescent↗
PubMed1999

[Pathological features of dysembryoplastic neuroepithelial tumor (DNT): study of five surgical cases with intractable epilepsies].

The dysembryoplastic neuroepithelial tumor (DNT), characterized by its favorable prognosis, must be precisely differentiated from other gliomas to prevent overtreatment by radio/chemotherapy. We studied, here, pathological features of five surgical cases of DNT with intractable epilepsies. There were two males and three females with a median age of 20.4 years (range 12-41). We evaluated lesional topography, gross appearances and microscopic findings including immunohistochemical data. One tumor was located in the temporal lobe, another two in the parietal lobe, another in the occipital lobe, and the other one in the occipito-parietal junction. The lesions were predominantly intracortical in all cases. Macroscopically, two tumors were grayish-soft, another two were yellowish-elastic, and the other one was resected as soft-mucinous fragments. Microscopically, the main glial components were oligodendrocyte-like cells (OLCs) in all cases, except for one case in which atypical glial cells were also prominent. Histopathological characteristics of the DNTs included the specific glioneuronal elements (the mixture of OLCs and neurons) in four cases, alveolar pattern (all cases), microcystic degeneration (all cases), multinodular architecture (four cases), and adjacent cortical dysplasia (all cases). Immunohistochemically, Ki-67 labelling indices ranged from 0 to 0.8%. OLCs were positive for glial fibrillary acidic protein in two cases, for S-100 protein in all cases, for synaptophysin in two cases, and for class III beta tubulin in all cases. Pathological features of our cases were characterized by its heterogeneous histological appearances and divergent cellular differentiation.

Adolescent↗
PubMed2005

Somatostatin receptor type 2 undergoes plastic changes in the human epileptic dentate gyrus.

Temporal lobe epilepsy (TLE) is characterized by hippocampal sclerosis together with profound losses and phenotypic changes of different classes of interneurons, including those expressing somatostatin (SRIF). To understand the functional significance of the plasticity of SRIF transmission in TLE, unraveling the status of SRIF receptors is, however, a prerequisite. To address this issue, we characterized expression and distribution of the major SRIF receptor, the sst2 subtype, in hippocampal tissue resected in patients with TLE using complementary neuroanatomic approaches. In patients with hippocampal sclerosis, the number of cells expressing sst2 receptor mRNA as well as sst2 receptor-binding sites and immunoreactivity decreased significantly in the CA1-3, reflecting neuronal loss. By contrast, in the dentate gyrus, sst2 receptor mRNA expression was strongly increased in the granule cell layer, and sst2 receptor-binding sites and immunoreactivity was preserved in the inner but decreased significantly in the outer molecular layer. In this latter region, pronounced changes in SRIF terminal fields were observed. Decreased receptor density in the distal dendrites of granule cells is likely to reflect downregulation of sst2 receptors in response to physiopathologic release of SRIF. Because sst2 receptors have anticonvulsant and antiepileptogenic properties, this phenomenon may contribute to the etiology of TLE seizures.

Adolescent↗
PubMed1996

Double pathology in Rasmussen's encephalitis: etiologic considerations.

In a 7-year-old girl with epilepsia partialis continua (EPC) involving the left face, arm, and leg for 1 year, serial neuroimaging studies showed progressive, brain atrophy. Because medical treatment was ineffective, she underwent a large fronto-temporal surgical resection. Neuropathological examination showed loss of lamination and dysplastic neurons, gliosis, microglial nodules, and perivascular cuffing. Such "double pathology" (dysgenesia and a chronic inflammatory process) may have implications for the pathophysiology of Rasmussen's syndrome.

Cerebral Cortex↗
PubMed2005

Reoperation of a recurrent temporal lobe epilepsy: a technical case report.

BACKGROUND: The indications for the reoperation of a recurrent temporal lobe epilepsy, the risks, and outcome have not been well documented. The invasive video electroencephalogram (EEG) monitoring and magnetic resonance imaging (MRI) techniques can reveal the residual tissues and their epileptogenic activity so that a reoperation decision can be made. CASE DESCRIPTION: A 30-year-old patient who had recurrent temporal lobe epilepsy and had undergone 2 operations at the same temporal region is presented. After both of these operations, approximately 6 months later, seizures relapsed. Postoperative neuroimaging studies showed residual mesiotemporal tissues at the operative site. The invasive video EEG monitoring revealed epileptogenic activity originating from these residual tissues. After all of these investigations, it was thought that a third operation was indicated, and the patient was operated. Postoperative course was uneventful. No postoperative deficit was observed. Pathological examination was reported as hippocampal sclerosis. He is seizure-free at his third postoperative year. CONCLUSIONS: Complete resection of epileptogenic mesiotemporal structures at the first operation can prevent the necessity for reoperation in defined cases. The MRI and invasive video EEG monitoring techniques can reveal the residual tissues and their epileptogenic activity in a recurrent epilepsy case.

Adult↗
PubMed2003

Emergency craniotomy for intraparenchymal massive hematoma after embolization of supratentorial arteriovenous malformations.

OBJECTIVE: We sought to evaluate the efficacy of emergency craniotomy for patients with massive hematoma secondary to endovascular embolization of supratentorial arteriovenous malformations (AVMs) and to investigate relevant factors affecting outcome. METHODS: Within the past 15 years, 605 patients with intracranial AVMs have undergone 1066 endovascular embolizations at our institution. Of these, 24 patients experienced intracranial hemorrhage during or after the procedure. Fourteen patients were demonstrated to have massive intraparenchymal hematomas and deteriorated to a comatose state (Glasgow Come Scale score < or =6). Twelve patients underwent craniotomy within 170 minutes of being diagnosed with intraparenchymal hemorrhage. The surgical procedures performed were hematoma evacuation with total (6 patients) or partial (2 patients) resection of the AVM or hematoma evacuation only (4 patients). The clinical records of these 12 patients were analyzed retrospectively. RESULTS: Nine patients recovered to a favorable condition (good recovery, four patients; moderately disabled, five patients), one patient remained in a persistent vegetative state, and two patients died. The interval between hemorrhage and emergency craniotomy was significantly shorter in patients with favorable outcomes than in those with poor clinical outcomes. Advanced age and a larger volume of intraoperative blood loss were the factors relevant to poor outcome. Temporal lobe location of the AVM and incomplete embolization tended to correlate to poor clinical outcome, but this correlation was not statistically significant. The sizes of the AVM and the hematoma did not correlate to patient outcome. There was no difference in outcomes with regard to the surgical procedure performed. CONCLUSION: In patients with massive postembolization hematomas, emergency craniotomy should be performed as soon as possible to achieve a favorable outcome. Cooperation among interventional neuroradiologists, intensive care physicians, and neurosurgeons is essential to manage AVM patients with critical postembolization hemorrhage. There is no need to persist in performing simultaneous total resection of the AVM at the emergency craniotomy.

Adult↗
PubMed2002

Factors predictive of suboptimal seizure control following selective amygdalohippocampectomy.

OBJECT: Selective amygdalohippocampectomy (SelAH) is used in the treatment of mesial temporal lobe epilepsy (MTLE). The goal of this study was to determine factors predictive of poor postoperative seizure control (Engel Class III or IV) following SelAH. METHODS: A retrospective study was conducted of 27 patients with poor seizure control postoperatively (Engel III/IV group), in comparison with 27 patients who were free from seizures after surgery (Engel I/II group). The results of electroencephalography, magnetic resonance (MR) imaging, and pathological studies were reviewed, and volumetric MR image analysis was used to compare the extent of the mesial structures that had been resected. In 56% of patients in the Engel III/IV group, significant bitemporal abnormalities were displayed on preoperative EEG studies, compared with 24% of patients in the Engel I/II group (p < 0.05). An analysis of preoperative MR images disclosed five patients (19%) in the Engel III/IV group and no patient in the Engel I/II group with normal hippocampal volumes bilaterally. Thirteen patients in the Engel III/IV group subsequently underwent either extension of the SelAH (six cases) or a corticoamygdalohippocampectomy (seven patients). Three patients from the former and one patient from the latter subgroup subsequently became seizure free (four patients total [34%]). The remaining nine patients did not improve despite the fact that they had undergone near-total resection of mesial structures. CONCLUSIONS: The majority of patients receiving suboptimal seizure control following SelAH did not meet the criteria for unilateral MTLE, based on EEG, MR imaging, and/or histopathological studies. These patients were therefore unlikely to benefit from additional resection of mesial structures. With the benefits of modern imaging, and by strict adherence to selection criteria, SelAH can be predicted to yield excellent postoperative seizure control for nearly all patients with unilateral MTLE. There remains a subpopulation, however, that meets the criteria for MTLE, but does not become free from seizure following SelAH.

Adult↗
PubMedDate not supplied

[Dysembryoplastic neuroepithelial tumors].

INTRODUCTION: The dysembryoplastic neuroepithelial tumors tend to occur in young patients, with partial complex partial seizures which is refractory to medical treatment. These are stable lesions, with defined histological features, specially with clinical data corroboration. CLINICAL CASES: The clinical, imagiological, operative, and histopathological data of six patients with proved dysembryoplastic neuroepithelial tumors were reviewed. All patients had seizures with age at onset ranged from 7 to 27 years. Five lesions were located in the temporal lobe and one in the parietal lobe. Common features included cortical to subcortical location, low density in CT-scan, very low signal intensity on T1-weighted images and high signal on T2-weighted images. Calcification occurred in two lesions, and three showed contrast enhancement. Complete resection of the tumor was performed in three cases, and subtotal resection in other three cases. Pathological features included oligodendroglial-like cells, glioneural component, and few cases showed dysplastic cortical disorganization. The postoperative period of follow-up ranged from 2 to 18 months. Four patients were seizure free, two of which had subtotal resection of the lesion. The remaining two patients maintained seizures. CONCLUSIONS: The clinical, imagiological and histopathological data of the six cases presented are generally compatible with those of the reports reviewed by the authors. The imagiological features are nonspecific. Surgical treatment permits histological diagnosis and epilepsy control.

Adolescent↗
PubMed2005

Epilepsy surgery in children and adolescence; Phramongkutklao College of Medicine's experience.

OBJECTIVES: To evaluate the safety and efficacy of epilepsy surgery in children and adolescence at Comprehensive Epilepsy Center, Phramongkutklao College of Medicine. MATERIAL AND METHOD: Children and adolescents, who underwent epilepsy surgery at Comprehensive Epilepsy Center, Phramongkutklao College of Medicine were identified from the epilepsy surgery database. The following parameters were evaluated: age at surgery, duration of seizure prior to surgery, presurgical work up, presurgical as well as postsurgical neurological/ seizure status and neuropathology (if applicable). All follow-up data were obtained through clinic visits. RESULTS: Fifteen children who underwent epilepsy surgery between January 1, 2003 and March 31, 2005 were identified. Age at surgery ranged from 2.5 years to 19 years (mean age=8.2 years). Seizure duration prior to surgery ranged from 1 year to 17 years (mean=4.7 years). Eight patients (53%) had partial seizures and underwent excisional procedures [5 temporal lobectomy, 2 left frontal corticectomy, and 1 left functional hemispherectomy]. Seven patients (47%) had generalized seizures and underwent anterior 2/3 corpus callosotomy. Pathological information was available for all 8 cases with partial epilepsy. Four out of eight cases with pathological information demonstrated cortical dysplasia, four revealed hippocampal sclerosis, and two patients had dysembryoplastic neuroepithelial tumor (DNET). At follow-up, all 5 patients with temporal lobectomy and a child who underwent functional hemispherectomy were seizure free (follow up period 3-31 months). Two children with extratemporal resective surgery [left frontal corticectomy] showed remarkable improvement with rare breakthrough seizures (follow up period= 3 and 19 months respectively). Four out of seven patients with corpus collosotomy had worthwhile improvement of seizures (follow up period=4-19 months), while another two children were seizure free during short-termed follow up postoperatively (follow up period=1 and 2 months). All patients did not have significant neurological deterioration or worsening of seizure after the surgery. CONCLUSION: Resective epilepsy surgery in Thai pediatric populations in the authors' experience seems to be safe and effective in selected patients. Most children who underwent callosotomy had a significant reduction in intensity and frequency of tonic, atonic, and tonic-clonic seizures. Dual pathology was common in refractory temporal lobe epilepsy with hippocampal sclerosis. Although the study sample was small, it did advocate several larger studies with the same findings.

Adolescent↗
PubMed2005

The effects on cognitive performance of tailored resection in surgery for nonlesional mesiotemporal lobe epilepsy.

PURPOSE: Mesiotemporal lobe epilepsy (MTLE) can be treated with different surgical approaches. In tailored resections, neocortex is removed beyond "standard" margins when spikes are present in the electrocorticogram. We hypothesized that these larger resections are justified because spiking neocortex is dysfunctional. This would imply that in patients with spikes (a) postoperative cognitive performance is not affected, and (b) preoperative performance is worse than without spikes. METHODS: We studied 80 operated-on MTLE patients with pathologically confirmed nonlesional hippocampal sclerosis. All patients were left-sided language dominant and underwent cognitive tests 6 months pre- and postoperatively. A repeated measures analysis of variance (ANOVA) was performed, looking for within- and between-subjects interactions with presence of intraoperative neocortical spikes. RESULTS: Intraoperatively, neocortical spikes were present in 61% of patients. Improved postoperative cognitive outcome was seen only in left-sided patients with spikes. Their performance IQ (PIQ) increased by 8.1 points (95% confidence interval, 3.8-12.3; p = 0.02), and visual naming latency by 12.8 s (95% CI, 2.1-23.5; p = 0.07). Conversely, in left-sided patients without spikes, naming latency declined by 7.5 s (95% CI, -2.3-17.2; p = 0.07). Preoperative scores were comparable except for a 15.3-point (95% CI, 0.1-30.5; p = 0.02) lower VIQ in left-sided patients without spikes. CONCLUSIONS: Tailoring does not harm cognitive performance and is, in left-sided MTLE, associated with postoperative improvement. Left-sided MTLE without neocortical spikes has lower verbal scores, which tend to decline after standard resection and may represent a special pathophysiologic entity.

Adult↗
PubMed2001

Magnetic resonance spectroscopic imaging in temporal lobe epilepsy: neuronal dysfunction or cell loss?

BACKGROUND: Magnetic resonance spectroscopy (MRS) has demonstrated consistent metabolic abnormalities in temporal lobe epilepsy. The reason for decreases in N-acetylated compounds are thought to be related to neuronal hippocampal cell loss as observed in hippocampal sclerosis. However, mounting evidence suggest that the N-acetylated compound decreases may be functional and reversible. OBJECTIVE: To establish whether the metabolic changes measured by MRS correlate to hippocampal cell loss in temporal lobe epilepsy. SUBJECTS AND METHODS: We prospectively performed quantitative hippocampal MR imaging volumetry and MRS imaging in 33 patients with intractable mesial temporal lobe epilepsy who were undergoing surgery. A neuronal-glial ratio of cornu ammonis and fascia dentata was obtained and correlated while validating the pathologic analysis by comparisons with specimens of age-matched autopsy control-case hippocampus (n = 14). RESULTS: The neuronal-glial ratio of the patient group was statistically significantly lower than in the control group for the cornu ammonis region (P<.001). Correlations of hippocampal volumes with cornu ammonis and neuronal-glial ratios revealed a significant interdependence (P<.01). However, correlations of the resected hippocampal creatine-N-acetylated compound ratio with the cornu ammonis or fascia dentata neuronal-glial ratios showed no significant interdependence (P>.8). CONCLUSIONS: Our findings support the concept that the metabolic dysfunction measured by MRS imaging and the hippocampal volume loss detected by MR imaging volumetry do not have the same neuropathologic basis. These findings suggest that the MRS imaging metabolic measures reflect neuronal and glial dysfunction rather than neuronal cell loss as previously assumed.

Adolescent↗
PubMed1981

Surface and deep EEG correlates of surgical outcome in temporal lobe epilepsy.

Interictal and ictal EEG characteristics derived from limited surface montages and medial temporal lobe sites were compared with long-term seizure relief following anterior temporal lobectomy in 52 epileptics. Patients were classified into one of four surgical outcome groups, ranging from seizure free to no clinical improvement. For each patient, interictal records were analyzed according to deep and surface spike characteristics and background activity. Ictal records were analyzed according to the proportion of episodes initiated in a unilateral or bilaterally synchronous fashion, the proportion of surface or deep onsets, the variability of onset location, and the morphology of seizures onsets. Interictal EEG variables that correlates with surgical outcome included: (a) various types of bilaterally synchronous surface/deep spikes; (b) diffuse background slowing; (c) sharp waves; and (d) the presence of multiple independent deep spike patterns in the lobe chosen for resection. Relevant ictal EEG variables included: (a) episodes initiated in a bilaterally synchronous fashion; (b) variability in seizure onset location; (c) the proportion of precisely focal onsets from deep sites; (d) the proportion of surface onsets; and (e) the proportion of onsets from the side chosen for resection. Multivariate analysis of these data with linear, stepwise, discriminate analysis and adaptive, nonlinear, distribution-free pattern recognition demonstrated that: (a) both interictal and ictal EEG characteristics can independently predict surgical outcome at levels significantly better than chance; (b) ictal and interictal EEG data contain nonredundant information for making such predictions; and (c) nonlinear pattern recognition techniques are capable of deriving the most accurate rules for predicting the effects of surgery.

Adolescent↗