Long-term seizure outcomes after pediatric temporal lobectomy: does brain MRI lesion matter?

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OBJECTIVE

There is emerging data that adults with temporal lobe epilepsy (TLE) without a discrete lesion on brain MRI have surgical outcomes comparable to those with hippocampal sclerosis (HS). However, pediatric TLE is different from its adult counterpart. In this study, the authors investigated if the presence of a potentially epileptogenic lesion on presurgical brain MRI influences the long-term seizure outcomes after pediatric temporal lobectomy.

METHODS

Children who underwent temporal lobectomy between 2007 and 2015 and had at least 1 year of seizure outcomes data were identified. These were classified into lesional and MRI-negative groups based on whether an epilepsy-protocol brain MRI showed a lesion sufficiently specific to guide surgical decisions. These patients were also categorized into pure TLE and temporal plus epilepsies based on the neurophysiological localization of the seizure-onset zone. Seizure outcomes at each follow-up visit were incorporated into a repeated-measures generalized linear mixed model (GLMM) with MRI status as a grouping variable. Clinical variables were incorporated into GLMM as covariates.

RESULTS

One hundred nine patients (44 females) were included, aged 5 to 21 years, and were classified as lesional (73%), MRI negative (27%), pure TLE (56%), and temporal plus (44%). After a mean follow-up of 3.2 years (range 1.2–8.8 years), 66% of the patients were seizure free for ≥ 1 year at last follow-up. GLMM analysis revealed that lesional patients were more likely to be seizure free over the long term compared to MRI-negative patients for the overall cohort (OR 2.58, p < 0.0001) and for temporal plus epilepsies (OR 1.85, p = 0.0052). The effect of MRI lesion was not significant for pure TLE (OR 2.64, p = 0.0635). Concordance of ictal electroencephalography (OR 3.46, p < 0.0001), magnetoencephalography (OR 4.26, p < 0.0001), and later age of seizure onset (OR 1.05, p = 0.0091) were associated with a higher likelihood of seizure freedom. The most common histological findings included cortical dysplasia types 1B and 2A, HS (40% with dual pathology), and tuberous sclerosis.

CONCLUSIONS

A lesion on presurgical brain MRI is an important determinant of long-term seizure freedom after pediatric temporal lobectomy. Pediatric TLE is heterogeneous regarding etiologies and organization of seizure-onset zones with many patients qualifying for temporal plus nosology. The presence of an MRI lesion determined seizure outcomes in patients with temporal plus epilepsies. However, pure TLE had comparable surgical seizure outcomes for lesional and MRI-negative groups.

ABBREVIATIONS AED = antiepileptic drug; FSIQ = full-scale intelligence quotient; GLMM = generalized linear mixed model; HS = hippocampal sclerosis; ILAE = International League Against Epilepsy; MEG = magnetoencephalography; PET = positron emission tomography; SISCOM = subtraction ictal SPECT co-registered to MRI; SPECT = single-photon emission CT; SOZ = seizure-onset zone; TLE = temporal lobe epilepsy.

Article Information

Correspondence Ravindra Arya: Cincinnati Children’s Hospital Medical Center, Cincinnati, OH. ravindra.arya@cchmc.org.

INCLUDE WHEN CITING Published online May 31, 2019; DOI: 10.3171/2019.4.PEDS18677.

Sabrina K. Kaul, Serena K. Kaul, and Celie Roth contributed equally to this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Mean ILAE outcome scores (lower scores represent better outcomes) over the duration of follow-up for the entire cohort. ILAE = International League Against Epilepsy; error bars = standard error of mean. Figure is available in color online only.

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    Mean ILAE outcome scores (lower scores represent better outcomes) over the duration of follow-up for temporal plus and pure TLE subgroups. ILAE = International League Against Epilepsy; TLE = temporal lobe epilepsy; error bars = standard error of mean. Figure is available in color online only.

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