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Epilepsy Surgery: Temporal Lobe
Epilepsy CON: Selective Amygdalohippocampectomy
December 4, 2011
Gregory D. Cascino, MD
Mayo Clinic
Rochester, MN
American Epilepsy Society | Annual Meeting
Disclosure
Research – Educational Grants
• Neuro Pace, Inc.
• American Epilepsy Society
• American Academy of Neurology
• Neurology (Associate Editor)
• National Institutes of Health R01NS053998
American Epilepsy Society | Annual Meeting
EPILEPSY epidemiology
• Recurrent, unprovoked events
• Two or more seizures
• Prevalence: 4% (80 years of age)
• Incidence: 180,000 per year
• Early and late onset
• 12.5 billion USD
EPILEPSY efficacy of treatment
• Neurology 2003;60(Suppl 4):S2-12
• About 30-40% will have a difficult
to control seizure disorder
• The 1st and 2nd AEDs are highly
predictive of medical outcome
EPILEPSY
improvement in quality of life
• Related to seizure-free
outcome
• DRIVING
• Education, Employment
• No need for caregiver
• Living independently
EPILEPSY adverse effects
• 25,000-50,000 die of seizures or
related causes each year
• Cognitive disorder
• Depression and Anxiety disorders
• SUDEP (sudden unexplained death in
epilepsy)
• Risk of sudden death is 24 times
controls
INTRACTABLE EPILEPSY treatment strategies
• Curative surgical therapy
– focal cortical resection, reoperation
• Palliative surgery
– VNS, corpus callosotomy
• Antiepileptic drug medication
• Ketogenic or Atkins diet
• Investigational studies
EPILEPSY goals of therapy
• Render patient seizure-free
–No seizures
• Avoid neurological morbidity
–No side effects
• Participating and productive
member of society
–No lifestyle limitations
EPILEPSY SURGERY surgical candidates
• Medically refractory seizures
• Physically, socially disabled
• Localization-related epilepsy
• Low risk for morbidity
• Potential for rehabilitation
EPILEPSY SURGERY
syndromes • Lesional epilepsy: tumor, vascular
anomaly, malformation of cortical
development
• Medial temporal lobe epilepsy:
mesial temporal sclerosis
IMAGING IN EPILEPSY focal cortical dysplasia
• T1-weighted image
• Blurring of the gray-white matter
transition
• Thickening of the gray matter
• Signal change in dysplastic cortex
• Normal examination
Epilepsy & functional anatomy of the
human brain
TEMPORAL LOBECTOMY operative outcome
• Neurology 1998;51:465-71
• Radhakrishnan et al.
(Rochester, MN)
• Excellent outcome: 134 (77%)
• Seizure-free: 120 (69%)
• Operative complication: 2 (1%)
TEMPORAL LOBECTOMY concordant MRI, EEG
• Unilateral hippocampal atrophy
• Unilateral epileptiform discharges
• 94% achieve an excellent outcome
EPILEPSY SURGERY long-term outcome
• Lancet 2011; 378:1388-95
• UCL Institute of Neurology
• 615 adult patients
• Median follow-up 8 years (1-19)
• 497 ATL lobectomies
EPILEPSY SURGERY seizure-free outcome
• 5 years: 52%
• 10 years: 47%
• Unfavorable: extratemporal
EPILEPSY SURGERY comparative study
• NEJM 2001;5:311-318
• Randomized controlled study
• 80 pts with TLE
• London, ON, Canada
• Surgery effective (p< 0.001)
• QOL favors surgery (p< 0.001)
EPILEPSY SURGERY Practice Parameter
• Epilepsia 2003;44:741-751
• Engel et al.
• Temporal lobe and localized
neocortical resections
• ATL
• Single Class I and 24 Class IV
studies showing efficacy
WHY SELECTIVE
AMYGDALOHIPPOCAMPECTOMY
• Reduction in operative
morbidity
–Visual field impairment
–Cognitive deficits
• “Unique” operative technique
SELECTIVE
AMYGADOLHIPPOCAMECTOMY Not candidates ??
• Normal MRI (no MTS)
• Neocortical-subcortical lesion
• Dual pathology
• Mesial temporal lesional pathology
• Significant cognitive impairment
• Non-dominant temporal lobe
epilepsy
COMPARATIVE SEIZURE
OUTCOME
• Eur J Neuro 2007;14:90-4
• Bate et al. (Bristol)
• SAH vs ATL
• 114 patients
• Seizure outcome favored ATL
(p< 0.03)
COMPARATIVE MEMORY
OUTCOME
• Epilepsy & Behavior 2006;9:95-100
• Morino et al. (Osaka)
• SAH (n=32) and ATL (n=17)
• ATL decline in verbal and
nonverbal memory
• SAH slight decline in verbal
memory
COMPARATIVE MEMORY
OUTCOME • Neuropsychologia 1997;35:963-73
• Jones-Gotman et al. (Dublin,
Montreal and Zurich)
• 71 patients
• Neocorticectomy- SAH- ATL
• Learning and recall impaired (left)
• Disconnection produces similar
memory deficits
COMPARATIVE MEMORY
OUTCOME
• J Neurosurg 2010;113:1164-75
• Tanriverdi et al. (Montreal)
• 256 patients (SAH and ATL)
• Seizure outcome was similar
• Memory decline in both
operative groups
• Individualize treatment
Is SAH really Selective?
• Epilepsia 2001;42:731-40
• Dupont et al. (Orsay)
• Volumetric MRI and PET
(before and after SAH)
• 9 patients with MTS
• Significant postoperative
anterior temporal neocortical
hypometabolism
WHY NOT SELECTIVE
AMYGDALOHIPPOCAMPECTOMY • Not proven more efficacious than
standard procedure
• Not proven comparative reduction
in morbidity
• May not resect subcortical-
neocortical pathology
• Potential subtotal resection of the
epileptogenic zone
"The function of a physician
is to cure a few, help many
and comfort all"
Percival Bailey 1892 - 1973
neurosurgeon, physiologist,
professor, University of Chicago
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