1 / 18

Anterior temporal lobectomy for epilepsy: success and shortcomings

Department of Neurosurgery Department of Neurosurgery. Anterior temporal lobectomy for epilepsy: success and shortcomings. Dario J. Englot, visiting student Yale MD/PhD Program September 24, 2009. Patient history. 61-year-old right-handed male with seizures for past 20 years

gore
Download Presentation

Anterior temporal lobectomy for epilepsy: success and shortcomings

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Department of Neurosurgery Department of Neurosurgery Anterior temporal lobectomy for epilepsy: success and shortcomings Dario J. Englot, visiting student Yale MD/PhD Program September 24, 2009

  2. Patient history • 61-year-old right-handed male with seizures for past 20 years • per pt: daily “day dreaming” spells, losing touch with reality • per wife: during seizures, face droops, clears throat, says “okay” repeatedly, non responsive for ~30s • no aura; somewhat confused for several minutes afterwards • has failed management with multiple anti-epileptics: depakote, carbamazepine, lamotrigine, levetiracetam • PMH/PSH: retinal and shoulder surgeries • Meds: levetiracetam, ASA, MVI NKDA • SH: married engineer, no substance abuseFH: no epilepsy

  3. Physical exam and tests • All vital signs in normal limits, and normal cardiopulmonary exam • Neurological exam: no deficits detected in mental status, cranial nerves, strength, sensation, reflexes, cerebellar function, or gait • Scalp EEG monitoring shows clinical episodes are associated with left temporal seizure activity • MRI, PET (outside hospital)

  4. MRI

  5. MRI

  6. PET

  7. Operative course • Left anterior temporal lobectomy • Dr. Emad Eskandar • Assist: Dr. Jason Gerrard • Post-operatively • expressive aphasia for a few hours • urinary retention: treated • full, uneventful recovery afterwards

  8. Post-Op MRI

  9. Hippocampus in mesial temporal lobe epilepsy (MTLE) Blumenfeld (2002) Neuroanatomy Eid et al (2007) Acta Neuropathol Hippocampal sclerosis: in 50-70% of resected hippocampi DeLanerolle (2003) Epilepsia

  10. MTLE: Who should have surgery? • Medically refractory seizures with diminished QOL? • History, neurology consultations, and neuropsychology reports • Localizable lesion or seizure focus? • Scalp or intracranial electrode EEG (ictal, interictal) • MRI (interictal) • PET (interictal) • SPECT (ictal, interictal) • Localized seizure focus in a resectable region? • fMRI • Wada • Language mapping • Neuropsychological evaluation Spencer (2002) The Lancet Berg et al (2003) Epilepsia

  11. Temporal Lobectomy Outcomes Spencer and Huh (2008) The Lancet

  12. Why does surgery sometimes fail? • Identifiable lesions and consistent imaging and electrophysiological findings improve outcomes • Some “good” surgical candidates, including those with unilateral temporal lobe sclerosis, nevertheless have recurrence post-operatively • Pathogenesis: Incomplete resection of epileptogenic lesions vs. new epileptogenicity

  13. Why does surgery sometimes fail? • Extent of resection: anterior lobectomy vs. selective amygdalohippocampectomy • Cohort study,100 patients (50 each surgery), followed 5 yr: no statistical difference in recurrence rates1 • Demographics: age, sex, or duration of epilepsy • Retrospective chart review, 105 patients, followed up to 3 yr: no relationship between factors & recurrence2 1) Tanriverdi et al (2008) J Neurosurg 2) Ramos et al (2009) J Neurosurg

  14. Why does surgery sometimes fail? • Pre-op electrophysiology and imaging results • Retrospective review, 118 pts, followed 1 yr: similar data with/without recurrence1 (also found in previously mentioned study2) • Historical risk factors: head trauma, tuberous sclerosis, VP shunts, AVMs, CNS infection, global hypoxia, febrile seizures, status epilepticus • 118 patients followed 1 yr: only status epilepticus showed prediction (p = 0.0276) of a higher recurrence rate1 1) Hardey et al (2003) Epilepsia 2) Ramos et al (2009) J Neurosurg

  15. Why does surgery sometimes fail? • Discontinuation of antiepileptic drugs (AEDs) • 6 retrospective clinical studies each with > 5 patients taken off meds (total N = 54-210 per study) • Sironi et al (1983) Riv Neurol; Murro et al (1991) J Epilepsy; Schiller et al (2000) Neurology; Van Veelan (2001) Ned Tijdschr Geneeskd; Al-Kaylani (2002) Epilepsia; Lachhwani (2003) Neurology • Relapse rate after AEDs D/Ced: 32-36% (f/u 1-6 yr) • Relapse rate with AEDs onboard: 7-17% (f/u 1-5 yr) • No benefit of waiting to attempt AED D/C after 2 yr in adults and 1 yr children Reviewed in: Hardey et al (2003) Epilepsia

  16. Seizure-free (%) Schmidt (2004) Epilepsia

  17. AED discontinuation after temporal lobectomy • Limitation: possible selection bias with retrospective observations • Further study: need randomized, double-blind, placebo-controlled trial of AED continuation vs. discontinuation 2 yr post-op • Hardey et al (2003) Epilepsia (review); Sironi et al (1983) Riv Neurol; Murro et al (1991) J Epilepsy; Schiller et al (2000) Neurology; Van Veelan (2001) Ned • Tijdschr Geneeskd; Al-Kaylani (2002) Epilepsia; Lachhwani (2003) Neurology

  18. Conclusions • Medically-refractory mesial TLE can often be treated successfully with temporal lobe resection • Seizure recurrence post-operatively can be difficult to predict, but may be reduced with sustained (> 2 yr) anti-epileptic therapy • To the faculty, residents, and staff of MGH neurosurgery Thank you

More Related