Anterior temporal lobectomy with amygdalohippocampectomy for mesial temporal sclerosis: predictors of long-term seizure control

Clinical article

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Object

In this paper the authors' goal was to identify preoperative variables that predict long-term seizure freedom among patients with mesial temporal sclerosis (MTS) after single-stage anterior temporal lobectomy and amygdalohippocampectomy (ATL-AH).

Methods

The authors retrospectively reviewed 116 consecutive patients (66 females, mean age at surgery 40.7 years) with refractory seizures and pathologically confirmed MTS who underwent ATL-AH with at least 2 years of follow-up. All patients underwent preoperative MRI and video-electroencephalography (EEG); 106 patients (91.4%) underwent Wada testing and 107 patients (92.2%) had neuropsychological evaluations. The authors assessed the concordance of these 4 studies (defined as test consistent with the side of eventual surgery) and analyzed the impact of preoperative variables on seizure freedom.

Results

The median follow-up after surgery was 6.7 years (mean 6.9 years). Overall, 103 patients (89%) were seizure free, and 109 patients (94%) had Engel Class I or II outcome. Concordant findings were highest for video-EEG (100%), PET (100%), MRI (99.0%), and Wada testing (90.4%) and lowest for SPECT (84.6%) and neuropsychological testing (82.5%). Using binary logistic regression analysis (seizure free or not) and Cox proportional hazard analysis (seizure-free survival), less disparity in the Wada memory scores between the ipsilateral and contralateral sides was associated with persistent seizures.

Conclusions

Seizure freedom of nearly 90% can be achieved with ATL-AH in properly selected patients with MTS and concordant preoperative studies. The low number of poor outcomes and exclusion of multistage patients limit the statistical power to determine preoperative variables that predict failure. Strong Wada memory lateralization was associated with excellent long-term outcome and adds important localization information to structural and neurophysiological data in predicting outcome after ATL-AH for MTS.

Abbreviations used in this paper:AED = antiepileptic drug; ATL-AH = anterior temporal lobectomy and amygdalohippocampectomy; CPS = complex partial seizure; EEG = electroencephalography; HR = hazard ratio; IAT = intracarotid amobarbital test; ILAE = International League Against Epilepsy; MTS = mesial temporal sclerosis; TLE = temporal lobe epilepsy.

Article Information

Address correspondence to: Robert E. Elliott, M.D., Chestmont Neurosurgical, Mainline Health, 3855 West Chester Pike, Suite 245, Newtown Square, Pennsylvania 19073. email: robertelliottmd@gmail.com.

Please include this information when citing this paper: published online May 24, 2013; DOI: 10.3171/2013.4.JNS121829.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Histogram illustrating the duration of follow-up for all 116 patients who underwent ATL-AH for MTS.

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    Kaplan-Meier curve showing seizure-free survival for all 116 patients who underwent ATL-AH for MTS. Note the asymptotic tail that remained relatively stable over time, signifying few failures after 2 years from surgery and only 1 case of seizure recurrence beyond 5 years.

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