Long-term outcome of epilepsy surgery among 399 patients with nonlesional seizure foci including mesial temporal lobe sclerosis

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Object

The authors reviewed the long-term outcome of focal resection in a large group of patients who had intractable partial nonlesional epilepsy, including mesial temporal lobe sclerosis (MTS), and who were treated consecutively at a single institution. The goal of this study was to evaluate the long-term efficacy of epilepsy surgery and the preoperative factors associated with seizure outcome.

Methods

This retrospective analysis included 399 consecutive patients who underwent epilepsy surgery at Mayo Clinic in Rochester, Minnesota, between 1988 and 1996. The mean age of the patients at surgery was 32 ± 12 years (range 3–69 years), and the mean age at seizure onset was 12 ± 11 years (range 0–55 years). There were 214 female (54%) and 185 male (46%) patients. The mean duration of epilepsy was 20 ±12 years (range 1–56 years). The preceding values are given as the mean ± standard deviation.

Of the 399 patients, 237 (59%) had a history of complex partial seizures, 119 (30%) had generalized seizures, 26 (6%) had simple partial seizures, and 17 (4%) had experienced a combination of these. Preoperative evaluation included a routine and video-electroencephalography recordings, magnetic resonance imaging of the head according to the seizure protocol, neuropsychological testing, and a sodium amobarbital study. Patients with an undefined epileptogenic focus and discordant preoperative studies underwent an intracranial study. The mean duration of follow up was 6.2 ± 4.5 years (range 0.6–15.7 years). Seizure outcome was categorized based on the modified Engel classification. Time-to-event analysis was performed using Kaplan–Meier curves and Cox regression models to evaluate the risk factors associated with outcomes.

Among these patients, 372 (93%) underwent temporal and 27 (7%) had extratemporal resection of their epileptogenic focus. Histopathological examination of the resected specimens revealed MTS in 113 patients (28%), gliosis in 237 (59%), and normal findings in 49 (12%). Based on the Kaplan–Meier analysis, the probability of an Engel Class I outcome (seizure free, auras, or seizures related only to medication withdrawal) for the overall patient group was 81% (95% confidence interval [CI] 77–85%) at 6 months, 78% (CI 74–82%) at 1 year, 76% (CI 72–80%) at 2 years, 74% (CI 69–78%) at 5 years, and 72% (CI 67–77%) at 10 years postoperatively. The rate of Class I outcomes remained 72% for 73 patients with more than 10 years of follow up. If a patient was in Class I at 1 year postoperatively, the probability of seizure remission at 10 years postoperatively was 92% (95% CI 89–96%); almost all seizures occurred during the 1st year after surgery. Factors predictive of poor outcome from surgery were normal pathological findings in resected tissue (p = 0.038), male sex (p = 0.035), previous surgery (p < 0.001), and an extratemporal origin of seizures (p < 0.001).

Conclusions

The response to epilepsy surgery during the 1st follow-up year is a reliable indicator of the long-term Engel Class I postoperative outcome. This finding may have important implications for patient counseling and postoperative discontinuation of anticonvulsant medications.

Abbreviations used in this paper: AED = antiepileptic drug; ATL = anterior temporal lobectomy; CI = confidence interval; EEG = electroencephalography; MR = magnetic resonance; MTS = mesial temporal lobe sclerosis; SD = standard deviation; SISCOM = subtracted ictal–interictal SPECT coregistered to MR imaging; SPECT = single-photon emission computerized tomography.

Article Information

Address reprint requests to: Aaron A. Cohen-Gadol, M.D., Department of Neurologic Surgery, Joseph 1-229, Saint Mary’s Hospital, 1216 Second Street SW, Rochester, Minnesota 55902. email: acohenmd@gmail.com.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Kaplan–Meier curve showing the proportion of patients in Engel Class I outcome with time. The inset table presents the number of patients at risk in the three different pathological categories at 1, 2, 5, and 10 years postoperatively.

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    Kaplan–Meier graph showing the proportion of patients in Engel Class I based on location of resection (temporal compared with extratemporal).

  • View in gallery

    Kaplan–Meier graph showing the proportion of patients in each pathological category who underwent temporal lobe resections with Engel Class I outcome. The inset table presents the number of patients at risk in the three different categories at 1, 2, 5, and 10 years postoperatively.

  • View in gallery

    Kaplan–Meier graph showing the proportion of all patients in Engel Class I based on pathological category.

  • View in gallery

    Kaplan–Meier graph showing the proportion of patients in Engel Class I based on age at surgery.

  • View in gallery

    Kaplan–Meier graph showing the quadratic relationship between age and outcome of surgery. The younger and older patients had less satisfactory outcomes.

  • View in gallery

    Kaplan–Meier graph showing the proportion of patients in Engel Class I based on preoperative duration of seizures.

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