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PubMed2000

Intraoperative hippocampal electrocorticography to predict the extent of hippocampal resection in temporal lobe epilepsy surgery.

OBJECT: Among the variety of surgical procedures that are performed for the treatment of medically refractory mesial temporal lobe epilepsy (TLE), no consensus exists as to how much of the hippocampus should be removed. Whether all patients require a maximal hippocampal resection has not yet been determined. METHODS: At the University of Washington, all TLE operations are performed in a tailored fashion, guided by electrocorticography (ECoG). The amount of hippocampal resection is determined intraoperatively by the extent of interictal epileptiform abnormalities on ECoG recorded from that structure, resulting in a hippocampal resection that is individualized for each patient. Using this approach, the authors prospectively observed 140 consecutive patients who underwent surgery for mesial TLE with pathological diagnoses of either mesial temporal sclerosis with neuronal loss (MTS group) or mild gliosis without neuronal loss (non-MTS group) to determine whether the extent of hippocampal resection correlates with outcome when a tailored approach is used. Additionally, the authors analyzed whether the presence of residual interictal epileptiform activity on ECoG following mesial temporal resection predicts poorer seizure control. With at least 18 months of clinical follow up, 67% of the 140 patients were seizure free or had only a single postoperative seizure. There was no correlation between the size of the hippocampal resection and seizure control in the group as a whole or when stratified by pathological subtype. Using an intraoperatively tailored strategy, individuals with a larger hippocampal resection (> 2.5 cm) were not more likely to have seizure-free outcomes than patients with smaller resections (p = 0.9). Additionally, both MTS and non-MTS patients, in whom postoperative ECoG detected residual epileptiform hippocampal (but not cortical or parahippocampal) interictal activity following surgical resection, had significantly worse seizure outcomes (p = 0.01 in the MTS group; p = 0.002 in the non-MTS group). CONCLUSIONS: Intraoperative hippocampal ECoG can predict how much hippocampus should be removed to maximize seizure-free outcome, allowing for sparing of possibly functionally important hippocampus.

Adolescent↗
PubMed1989

Results of surgical treatment in patients with bitemporal epileptiform abnormalities.

Fifty-three of 57 patients who had evidence of bitemporal epileptiform abnormalities and who required investigation with stereotactic depth electroencephalography (SDEEG) recordings to determine the site of origin of seizures underwent surgical resection for the treatment of their epilepsy. A minimum of 2 years' follow-up was available in 48 patients who underwent a temporal lobe resection. In this group, 19 patients (40%) were greatly improved, and of these 14 (29%) became seizure free and 5 (10%) had no more than 3 seizures each year. Another 22 patients (46%) showed a worthwhile reduction in seizure frequency of at least 50%. Seven patients (15%) were not significantly improved. An etiological factor of early convulsions before age 3 (usually febrile) was associated with a better outcome. Both the lack of a strong predominance for SDEEG-recorded seizures to arise in the resected temporal lobe and the presence of residual epileptiform abnormalities in the postexcision electrocorticogram were correlated with poorer results.

Adult↗
PubMed2001

Complement activation in the human brain after traumatic head injury.

The complement cascade has been suggested to be involved in the development of secondary brain injuries following brain contusions, based on animal experiments. The aim of the present study was to examine the possible involvement of the complement cascade following traumatic head injury in the human brain. Sixteen patients were included in this study, 12-77 years of age, treated at the neurointensive care unit for traumatic brain contusions. All of these patients were operated with frontal or temporal lobe resection due to intractable intracranial hypertension. The resected tissue was analyzed with regard to components related to complement activation. The time interval between accident and operation was 2-82 h. Brain tissue from three patients operated with hippocampectomy due to epilepsy, including temporal lobe resection, were used as controls. We found increased immunoreactivity for complement components C1q, C3b, and C3d and the membrane attack complex (MAC), C5b-9, in the immediate vicinity of neurons in the penumbra area of the contusion. These findings constitute histological evidence for activation of the complement cascade in the penumbra of cortical contusions in the human brain. Using in situ hybridization, we also found C3-mRNA in the penumbra, suggesting a local synthesis of complement. Furthermore, upregulation of the endogenous complement regulator clusterin was found in some neurons in the same area. We suggest that unknown compounds in the debris from injured neurons or myelin breakdown products trigger complement activation, including formation of C5b-9. Activated complement components may stimulate accumulation of inflammatory cells and formation of brain edema, as well as having membrane destructive effects by the end product MAC, thereby being mediators in the development of secondary brain damage.

Adolescent↗
PubMed1997

Differential involvement of left temporolateral and temporomesial structures in verbal declarative learning and memory: evidence from temporal lobe epilepsy.

A wealth of animal and human research has pointed to a significant involvement of the temporal lobes in memory processing, and yet the different functional roles of temporal cortical vs. mesial structures remain unclear. We studied verbal declarative memory, by using a word list paradigm that differentiates among learning (immediate recall), memory (delayed recall), and recognition, in epilepsy patients being considered for surgical resection of the left temporal lobe. Verbal memory was evaluated preoperatively and during the recording of intracranial event related potentials and postoperatively after selective hippocampectomy, temporal cortical lesionectomy, or anterior two-thirds en bloc temporal lobe resection procedures. Preoperative differences in verbal memory performance as a function of differences in underlying neuropathology, concurrent event-related potentials, and specific patterns of postoperative memory impairments lead to converging evidence that verbal declarative memory relies on a synergistic interaction of at least two functionally distinct brain systems. Material-specific data acquisition, or working memory, is mediated by neocortical temporal structures, whereas long-term consolidation/retrieval is particularly mediated by temporomesial structures. In contrast to the left temporal neocortex, the function of the temporomesial system appears to be material nonspecific. Apparently, its preferential involvement in verbal memory is due to its close interaction with overlying neocortical structures that are specialized for language processing.

Adult↗
PubMed2004

Analysis of different types of resection for pediatric patients with temporal lobe epilepsy.

OBJECTIVE: Resection strategies for the treatment of temporal lobe epilepsy (TLE) are a matter of discussion. Few data on the significance of resection type are available for pediatric patients with TLE. METHODS: Data for a series of 89 children who were surgically treated for TLE were analyzed. A first cohort of patients were mainly surgically treated with anterior temporal lobectomies. For a second cohort, resections were preoperatively "tailored" to the lesion and presumed epileptogenic area. RESULTS: The follow-up period was 46 months (range, 14-118 mo). Seventy-seven patients (87%) attained satisfactory seizure control (82% Engel Class I and 5% Class II). For 12 patients (13%), seizure control was unsatisfactory (8% Class III and 5% Class IV). Anterior temporal lobectomies resulted in 94% satisfactory seizure control (33 patients), whereas the success rates were only 74% (20 patients) for amygdalohippocampectomy (AH) (P = 0.023) and 77% (13 patients) for lesionectomy plus hippocampectomy (not significant). All patients who underwent purely lateral temporal lesionectomies became seizure-free (14 patients). Logistic regression revealed the factors of AH (P = 0.021) and left-side surgery (P = 0.017) as significant predictors of unsatisfactory seizure control. Satisfactory seizure control was not dependent on the histopathological diagnoses. There was a low rate of verbal memory deterioration after left-side operations. Neuropsychological deterioration was rare after right temporal resections. Attentional and contralateral functions improved after surgery. CONCLUSION: Surgery for the treatment of juvenile TLE is successful and safe, but the resection type may influence outcomes. Results after AHs were disappointing, probably because of difficulties in precise localization of the epileptogenic focus among children. Neuropsychological results demonstrated minimal rates of deterioration and significant improvements in contralateral functions. Surgical treatment of juvenile TLE should be encouraged, but the use of especially left AH should possibly be restricted.

Adolescent↗
PubMed1999

Surgical treatment of epilepsy--clinical, radiological and histopathological findings in 139 children and adults.

The present study relates clinical and radiological data to histopathological diagnoses in the first 139 patients (children and adults) in the Göteborg Epilepsy Surgery series. Temporal lobe resections were most common (54.0%) followed by frontal lobe (18.0%) and multilobar resections (11.5%). All histopathological specimens were re-evaluated in connection with this study. Parenchymal malformations and atrophic-gliotic lesions were the most common histopathological findings. Microdysgenesis was more common than major malformations (24.5% versus 11.5%). When the MRI scans were blindly re-evaluated the MRI findings correlated with histopathological diagnosis in all of the vascular malformations, in 77.8% of the tumours, in 76.5% of the cases with hippocampal sclerosis but only in 28.6% of the major cortical development malformations. Hemispherectomies carried the best seizure outcome prognosis followed by temporal lobe resections (75.0% versus 57.3% seizure free 2 years after surgery). Vascular malformations carried the best, and microdysgenesis the worst prognosis (76.9% versus 39.4% seizure free).

Adolescent↗
PubMed2001

[Dutch Collaborative Epilepsy Surgery Program: reduction of seizures, operative complications and tapering of medication in 338 patients, 1973-1998].

OBJECTIVE: To determine the results of surgical treatment in patients with drug-resistant epilepsy, referred to the Dutch Epilepsy Surgery Program, who were treated in the University Medical Centre Utrecht, the Netherlands, in the period January 1973-December 1998. DESIGN: Retrospective descriptive. METHOD: A total of 338 patients were operated on; 269 underwent temporal lobe resection, 41 extratemporal resection, 12 a functional hemispherectomy and 10 callosotomy. Six patients were treated with vagus nerve stimulation. For seven of the patients no follow-up data was available. RESULTS: After a minimum follow-up of 1 year class I or class II results (in accordance with the University of California in Los Angeles classification (UCLA) where class I = seizure-free and class II < or = 3 seizures per year) were obtained in 91% of patients who underwent temporal lobe resections, 67% of patients who underwent extratemporal resections, 81% of patients who underwent functional hemispherectomy and 10% of patients who underwent anterior callosotomy. In five of these patients an improvement in their behaviour occurred. Of the 6 patients who underwent vagus nerve stimulation only I experienced a beneficial seizure reduction (UCLA class III). Transient physical complications occurred in 4% of the patients treated and permanent damage in 1%. Postoperative psychiatric complications occurred almost exclusively following temporal resections; in 11% of which 7% de novo. After 4 postoperative years this had decreased to 5%. In a group of 143 patients who were seizure-free for 2 or more years, post-surgery medication was tapered in 75 cases, stopped in 33 cases and remained unchanged in 35 cases. The relapse rate following a tapering or stopping of the medication was 30% and with unchanged medication 17%. Although the majority of patients were once again seizure-free upon restarting the medication, a significant number continued to experience seizures. CONCLUSION: For a number of carefully selected epilepsy patients with intractable seizures, surgery is a successful treatment with few serious complications.

Anticonvulsants↗
PubMed2003

Early and late cognitive changes following temporal lobe surgery for epilepsy.

OBJECTIVE: To evaluate early and late postoperative cognitive changes in adult patients who had a standardized temporal lobe resection for control of intractable complex partial seizures and to relate quality of life measures at the long-term follow-up to seizure control and a verbal memory skill. METHODS: Patients in this longitudinal study had intractable epilepsy and had cognitive tests at the initial surgical evaluation, 1 year later, and at a long-term follow-up (at least >9 years later). Mean follow-up was 12.8 years. Participants were 44 patients who had an en bloc left (LTL) or right (RTL) temporal lobe resection and 8 nonsurgical patients with epilepsy. RESULTS: Patients with LTL surgery showed selective early decreases in verbal memory. At the long-term follow-up, further decreases in verbal memory and visual memory scores were seen for all patient groups. In general, the nonmemory scores remained stable over time. LTL surgery and initial high scores were predictors of verbal memory decreases seen at the early follow-up. Late memory declines were predicted by higher 1-year scores. LTL surgery was an additional predictor of late decline on a verbal memory task sensitive to the integrity of the left hippocampus. Higher quality of life scores of patients at the long-term follow-up were associated with both better seizure control and a higher everyday verbal memory skill: prose recall. CONCLUSIONS: Surgery-induced verbal memory deficits following LTL surgery continue 13 years after surgery. Late, possibly age-related, declines in multiple memory scores are seen in patients with temporal lobe surgery and nonsurgical patients with epilepsy. Patients with LTL surgery may be at risk for a more rapid decline in selective verbal memory skills. Evaluations of treatments for intractable epilepsy that compromise memory functions should consider the further quality of life impact of late age-related memory declines.

Adult↗
PubMed1999

Cognitive consequences of coexisting temporal lobe developmental malformations and hippocampal sclerosis.

OBJECTIVE: To characterize patterns of cognitive functioning in a well-defined group of patients with MRI-identified coexisting left temporal lobe developmental malformations (TLDM) and mesial temporal sclerosis (MTS), and to examine neuropsychological outcome in this dual-pathology group following epilepsy surgery. METHODS: Cognitive functioning in patients with left TLDM and MTS (n = 15) was compared with patients with isolated left MTS (n = 40). TLDM and MTS were identified by high-quality MRI protocol. Patients were administered a battery of neuropsychology tests as part of their presurgical workup for possible epilepsy surgery. Unilateral temporal lobe resection was performed on 10 of the dual-pathology patients and 34 of the isolated MTS patients. Postoperative cognitive performance was also assessed. RESULTS: Both groups displayed impairments in verbal and visual memory, language, and academic achievement. Performance on measures of psychometric intelligence, executive function, and attention were not impaired and were similar between groups. Presence of dual pathology was associated with a significantly less efficient verbal encoding strategy on the word list learning task. Postoperatively, declines were noted for both groups across tasks of verbal memory and language. Groups were not different significantly in terms of neuropsychological outcome after surgery. CONCLUSION: Patients with coexisting TLDM and MTS have impaired cognitive functioning similar to MTS patients-in particular, with regard to episodic memory and language deficits. Temporal lobe resection produces similar cognitive changes in both groups.

Adult↗
PubMed1975

Electrophysiological correlates of pathology and surgical results in temporal lobe epilepsy.

Routine pre-operative EEG studies as well as direct brain recording and stimulation carried out during operations were analysed for 59 patients subjected to a standard unilateral anterior temporal lobectomy for the treatment of epilepsy. All patients in the present series were 16 years old or older at the time of operation, which was invariably carried out under local scalp analgesia only. Electrophysiological findings was correlated with pathological changes noted in the resected temporal lobes, and with the effects of surgery upon seizure activity. Pre-operative EEG data correlated with each of four pathological categories when sphenoidal electrodes and intravenous barbiturate narcosis were emplyed. Thirty of 31 patients with mesial temporal sclerosis demonstrated medial temporal primary spike foci, frequently with independent contralateral and extratemporal secondary foci. In addition, one-third of these patients demonstrated unilateral focal decreased barbiturate-induced fast activity in the corresponding sphenoidal to ear channels. Twelve patients with other specific medial focal lesions (mostly hamartomas) also had medial temporal primary foci, often with independent contralateral secondaries but never with extratemporal foci. Two patients in this group also demonstrated focal decreased fast activity in the appropriate sphenoidal-ear channel. Both of these groups did very well post-operatively with respect to their epilepsy. Five patients with large temporal convexity cicatrices antedating seizures all demonstrated lateral temporal primary spike foci without independent secondary foci or focal decreased fast activity and did not do as well post-operatively as the first two groups. Eleven patients had only non-specific changes in the resected temporal lobe and in general did not benefit from surgery. Various combinations of primary and independent secondary spike foci were seen. Only this group demonstrated diffuse or bifrontal spikes during initial EEG recording, and basal mid-line spikes with intravenous thiopentone. Pecilar sharp notched spike were also very common in this group, but not unique to it. Focal decreases in barbiturate-induced fast activity were not noted.

Adolescent↗
PubMed2002

Modeling of post-surgical brain and skull defects in the EEG inverse problem with the boundary element method.

OBJECTIVES: In order to obtain accurate EEG inverse solutions in patients subjected to surgery, we have studied the feasibility and influence of incorporating brain and skull defects in realistic head models. METHODS: We first measured the conductivity of the methacrylate used for cranioplasty. Then, we designed realistic boundary element method head models with a skull burr hole, a methacrylate plug or a temporal-lobe resection. We simulated the potentials that would be produced at 71 electrode locations (10/10 system) by dipoles located near the defects. Then, we fitted dipoles on these potentials using a defect-free head model. We also ran simulations in a noisy situation and with higher skull and cerebrospinal fluid (CSF) conductivity. RESULTS: The largest errors were found for burr holes, with a localization error up to 20 mm for a radial dipole located 30 mm below the hole and an amplification factor of 8. Methacrylate plugs lead to errors up to 5 mm and 0.5; the resection only lead to errors of 2 mm and 1.3. Results obtained with noise were consistent with those obtained without noise. Doubling the skull conductivity led to errors that were reduced by 10-20%, while doubling CSF conductivity increased the errors by up to 31%. CONCLUSIONS: We have shown that it is important to incorporate skull defects in realistic head models when sources are located near the defects and precision is sought. Brain cavities of the size of a typical anterior temporal lobe resection may be omitted without a significant impact on dipole localization.

Brain↗
PubMed2001

Magnetic resonance analysis of postsurgical temporal lobectomy.

BACKGROUND AND PURPOSE: The effect of temporal lobe transection area, volume of postoperative gliosis, and surgical technique on patients' seizure-free outcome is unknown. The authors studied the effects of these variables on patients' seizure-free outcome. METHODS: A retrospective review of magnetic resonance imaging examinations acquired 3 to 18 months after temporal lobe resection was carried out for 18 patients with intractable temporal lobe seizures and known postsurgical outcomes for more than 2 years. The total volume of radiologically probable gliosis evident on axial proton-density-weighted images was calculated for each patient using software on an independent console. The total area of temporal lobe surface transected by the scalpel was calculated as well, using sagittal T1-weighted images. The total volume of gliosis, the total area of transected temporal lobe, and the specific type of surgery (sparing vs no sparing of the superior temporal gyrus) were then correlated with the postsurgical outcome of the patients. An examiner with no prior knowledge of the patients' postsurgical outcomes carried out the above calculations and measurements. The patients' postoperative outcome was defined using Engel classifications, and patients were divided into 2 groups: group A with Engel class 1 (n = 9) and group B with Engel classes 2-4 (n = 9). RESULTS: The mean volumes of postoperative gliosis were not significantly different between group A (3592.3 mm3) and group B (4270 mm3). The mean area of transected temporal lobe was also similar between group A (1865.2 mm2) and group B (1930 mm2). With regard to surgical technique, there were 5 patients who had the superior temporal gyrus resected and 13 who did not. Eighty percent of patients with the superior temporal gyrus resected were Engel class 1 or 2, whereas only 20% were of Engel class 3 or 4. CONCLUSIONS: The authors found no clear association between postoperative outcome and residual temporal lobe gliosis, the surgical technique, or the total area of temporal lobe transected by the scalpel.

Adult↗
PubMed1996

Evaluation of carbamazepine and carbamazepine-epoxide protein binding in patients undergoing epilepsy surgery.

Carbamazepine (CBZ) serum concentrations increase after epilepsy surgery. A possible mechanism may be acute changes in protein binding, specifically those involving the acute phase reactant alpha(1)-acid glycoprotein (AAG). We prospectively evaluated 16 adults (11 receiving CBZ) with epilepsy (mean age 30 +/- 9.9 years, 8 women and 8 men) undergoing temporal lobe resections and characterized AAG, albumin, CBZ, and CBZ-epoxide (CBZ-E) free fractions over time. AAG, ALB, CBZ, and CBZ-E free fractions were determined before surgery (baseline) and on postoperative days 1-5, 14, and 30. AAG was measured with a radial immunodiffusion assay method, CBZ and CBZ-E serum concentrations were determined by high-performance liquid chromatography (HPLC). Free fractions of CBZ and CBZ-E were calculated as the ratio of unbound (determined after ultracentrifugation) to total serum drug concentrations. Statistical analysis included analysis of variance (ANOVA) and Student's t test for paired data when appropriate, with significance assigned at p<0.05. All data are mean +/- SD. AAG concentrations increased significantly from baseline 61.9 +/- 21.3 mg/dl), peaking at postoperative day 3 (116.8 +/- 20.6 mg/gl) and decreasing to baseline levels between days 14 and 30. CBZ serum concentrations were significantly increased in the immediate postoperative period (day 3), but albumin concentrations and CBZ and CBZ-E free fractions did not differ significantly between baseline and the postoperative time points. Temporal lobe resection results in an acute phase reaction which is manifested in part by significant changes in AAG. Although CBZ and CBZ-E total serum concentrations increased significantly in the immediate postoperative period, epilepsy surgery did not appear to result in significant overall changes in drug binding to plasma proteins.

Adult↗
PubMed2004

Long-term seizure outcome following resective surgery at National Epilepsy Center in Shizuoka, Japan.

We analyzed the seizure outcome of 357 patients who were followed for at least 2 years after resective surgeries; 282 underwent temporal lobe resection and 75 had extratemporal lobe resection. This study confirmed that resective surgery provides sustained, positive benefits with a high seizure-free rate of nearly 80% for most medically refractory patients. In patients with no MRI-detectable lesion who underwent extratemporal lobe resection, however, Engel's class I-II (seizure-free or rare seizures) was achieved in less than 50% of patients. High-resolution MRI should be performed at the early stage of disease in all patients with partial epilepsies. The findings would certainly urge clinicians to actively select surgical intervention.

Adolescent↗
PubMed1990

Cortical resections outside the temporal lobe for intractable epilepsy--excluding multilobar resections and hemispherectomy.

The principles underlying such surgery are reviewed, together with details of the necessary investigation, and a review of long term results from the literature. Cortical Resection for epilepsy remains a useful treatment for drug resistant epilepsy when a cortical focus can be identified by neurophysiological or radiological means. Such a resection has a reasonable chance of relieving or ameliorating the epilepsy with only a small chance of producing or worsening any neurological deficit.

Cerebral Cortex↗
PubMed2001

Extrahippocampal temporal lobe atrophy in temporal lobe epilepsy and mesial temporal sclerosis.

Visual inspection and volumetric analysis of MRIs allow mesial temporal sclerosis (MTS) to be reliably identified in patients with temporal lobe epilepsy. The presence of unilateral MTS ipsilateral to the side of habitual seizure onset is an indicator for the prognosis of good outcome after temporal lobe resection. There is evidence to suggest that widespread temporal lobe pathology, leading to atrophy, may be associated with MTS and such abnormal tissue may play an important role in epileptogenesis. We have analysed quantitatively the volumes of the mesial and lateral temporal lobe substructures in MRIs from 62 patients with intractable mesial temporal lobe epilepsy and in 20 normal controls. We found significant atrophy in these structures in patients, ranging from 8.3 to 18.4% compared with controls. The degree of atrophy in the extrahippocampal structures correlated with the degree of hippocampal atrophy, suggesting that a common process may be responsible. There was no correlation between the degree of atrophy in the extrahippocampal structures and the duration of epilepsy, a history of febrile convulsions or of generalized seizures. These findings suggest that there may be widespread pathological abnormalities in the temporal lobe associated with MTS. The importance of extrahippocampal atrophy to surgical outcome and whether it occurs in temporal lobe epilepsy not associated with MTS remain to be investigated.

Adult↗
PubMed2003

Improvement of aggressive and antisocial behavior after resection of temporal lobe tumors.

Seizures associated with temporal lobe tumors may rarely manifest as episodic aggressive behavior. We describe 2 cases involving pediatric patients who presented with histories of unusually aggressive and antisocial behavior. Magnetic resonance imaging identified right mesial temporal lobe masses in both patients. After craniotomy for tumor removal, both patients were seizure-free and had marked reductions in their aggressive behavior. Tumors in the temporal lobe may be associated with behavioral problems, including aggression and rage attacks, which can be alleviated with surgical intervention. It is important to distinguish this subgroup of pediatric patients from those with alternative diagnoses such as attention-deficit/hyperactivity disorder or oppositional defiant disorder.

Adolescent↗