Characterization of Hemorrhagic Complications after Surgery for Temporal Lobe Epilepsy

Management of epilepsy in older adults: A critical review by the ILAE Task Force on Epilepsy in the elderly

Older adults represent a highly heterogeneous population, with multiple diverse subgroups. Therefore, an individualized approach to treatment is essential to meet the needs of each unique subgroup. Most comparative studies focusing on treatment of epilepsy in older adults have found that levetiracetam has the best chance of long-term seizure freedom. However, there is a lack of studies investigating other newer generation antiseizure medications (ASMs). Although a number of randomized clinical trials have been performed on older adults with epilepsy, the number of participants studied was generally small, and they only investigated short-term efficacy and tolerability. Quality of life as an outcome is often missing but is necessary to understand the effectiveness and possible side effects of treatment. Prognosis needs to move beyond the focus on seizure control to long-term patient-centered outcomes. Dosing studies with newer generation ASMs are needed to understand which treatments are the best in the older adults with different comorbidities. In particular, more high-level evidence is required for older adults with Alzheimer's disease with epilepsy and status epilepticus. Future treatment studies should use greater homogeneity in the inclusion criteria to allow for clearer findings that can be comparable with other studies to build the existing treatment evidence base.

Temporal Artery and Temporal Region Supplied by the Middle Cerebral Artery: An Anatomical Study

ABSTRACT

This study was conducted to describe in detail the branching patterns of cortical branches from the middle cerebral artery supplying the feeding of the temporal region, to define the arterial structure of temporal artery (TA) and to determine the effect of this arterial supply to the temporal region. The arteries of brains (n = 22; 44 hemispheres) were prepared for dissection after filling them with colored latex. TA was defined, and its classification was described, specifying its relationship with other cortical branches. A new classification was defined related to TA terminology. TA was found in 95% of cadavers, and it originated as an early branch in 75% and from the inferior trunk in 24% of cadavers. TA was classified as Type 0: No TA, Type I: single branch providing two cortical branches, Type II: single branch providing three or more cortical branches and Type III: double TA. Type I-TA (45%) was the most common, and Type II-TA arterial diameter was significantly larger than that of other types. All cadavers showed the cortical branches of temporal region from middle cerebral artery, anterior TA , middle TA, posterior TA and temporooccipital artery, except temporopolar artery (81%). Temporopolar artery, anterior TA, and middle TA primarily originated from TA, an early branch, but posterior TA and temporooccipital artery primarily originated from the inferior trunk. Detailed knowledge about cortical branches together with TA and also this region's blood supply would enable increased prediction of complications, especially in cases with these region-related pathologies, and would make interventions safer.

Age is but a number when considering epilepsy surgery in older adults

BACKGROUND

A quarter of patients with newly diagnosed epilepsy are older, yet they are less likely to be offered resective surgery potentially because of clinical bias that they incur increased surgical risks. There are few peer-reviewed case series that address this cohort and their outcomes.

OBJECTIVE

In the context of current literature, the objective of this study was to report on all epilepsy surgeries in patients aged 50 years or older from a tertiary care center over 15 years with an average follow-up period of 6 years.

METHODS

Patients with epilepsy who underwent surgery between 2001 and 2016 were reviewed retrospectively. Inclusion criteria were age > 50 at surgery, availability of presurgical evaluation data, and minimum one year of follow-up data. We identified 34 patients. Seizure outcome was evaluated using the Engel classification system.

RESULTS

Thirty-four patients aged 50 years and older out of 276 underwent epilepsy surgery. Average age at time of surgery was 55 years, and average duration of epilepsy was 30 years. Average length of follow-up was 6 years (1-15 years). Twenty-two out of 34 patients (64%) were seizure-free (Engel class I) at their last follow-up visit. Patients with lesional pathology on neuroimaging were more likely to achieve seizure freedom (p < 0.02). Parameters associated with poorer outcome included extratemporal epileptogenic focus (p = 0.07) and bitemporal interictal epileptiform activity (p = 0.003).

CONCLUSION

Our study cohort is one of the largest and most representative outcome studies of this age group, following the cohort for 6 years. Our findings demonstrated that when considering epilepsy surgery in an older adult, their age should not play a determining role in the decision-a finding that is more common in modern literature.

Secondary hemorrhagic complications in aneurysmal subarachnoid hemorrhage: when the impact hits hard

OBJECTIVE

Clinical data on secondary hemorrhagic complications (SHCs) in patients with aneurysmal subarachnoid hemorrhage (SAH) are sparse and mostly limited to ventriculostomy-associated SHCs. This study aimed to elucidate the incidence, risk factors, and impact on outcome of SHCs in a large cohort of SAH patients.

METHODS

All consecutive patients with ruptured aneurysms treated between January 2003 and June 2016 were eligible for this study. Patients' charts were reviewed for clinical data, and imaging studies were reviewed for radiographic data. SHCs were divided into those associated with ventriculostomy and those not associated with ventriculostomy, as well as into major and minor bleeding forms, depending on clinical impact.

RESULTS

Sixty-two (6.6%) of the 939 patients included in the final analysis developed SHCs. Ventriculostomy-associated bleedings (n = 16) were independently predicted by mono- or dual-antiplatelet therapy after aneurysm treatment (p = 0.028, adjusted odds ratio [aOR] = 10.28; and p = 0.026, aOR = 14.25, respectively) but showed no impact on functional outcome after SAH. Periinterventional use of thrombolytic agents for early effective anticoagulation was the only independent predictor (p = 0.010, aOR = 4.27) of major SHCs (n = 38, 61.3%) in endovascularly treated patients. In turn, a major SHC was independently associated with poor outcome at the 6-month follow-up (modified Rankin Scale score > 3). Blood thinning drug therapy prior to SAH was not associated with SHC risk.

CONCLUSIONS

SHCs present a rare sequela of SAH. Antiplatelet therapy during (but not before) SAH increases the risk of ventriculostomy-associated bleedings, but without further impact on the course and outcome of SAH. The use of thrombolytic agents for early effective anticoagulation carries relevant risk for major SHCs and poor outcome.

Remote cerebellar hemorrhage after supratentorial procedures (part 1): a systematic review

A remote cerebellar hemorrhage (RCH) is a spontaneous bleeding in the posterior fossa, which may rarely occurs as a complication of supratentorial procedures, and it shows a typical bleeding pattern defined "the zebra sign." However, its pathophysiology still remains unknown. We performed a comprehensive review collecting all cases of RCH after supratentorial craniotomies reported in literature in order to identify the most frequently associated procedures and the possible risk factors. We assessed percentages of incidence and 95 % confidence intervals of all demographic, neuroradiological, and clinical features of the patients. Univariate and multivariate analyses were used to evaluate their association with outcome. We included 49 articles reporting 209 patients with a mean age of 49.09 ± 17.07 years and a male/female ratio 130/77. A RCH was more frequently reported as a complication of supratentorial craniotomies for intracranial aneurysms, tumors debulking, and lobectomies. In the majority of cases, RCH occurrence was associated with impairment of consciousness, although some patients remained asymptomatic or showed only slight cerebellar signs. Coagulation disorders, perioperative cerebrospinal fluid drainage, hypertension, and seizures were the most frequently reported risk factors. Zebra sign was the most common bleeding pattern, being observed in about 65 % out of the cases, followed by parenchymal hematoma and mixed hemorrhage in similar percentages. A multivariate analysis showed that symptomatic onset and intake of antiplatelets/anticoagulants within a week from surgery were independent predictors of poor outcome. However, about 75 % out of patients showed a good outcome and a RCH often appeared as a benign and self-limiting condition, which usually did not require surgical treatment, but only prolonged clinical surveillance, unless in the event of the occurrence of complications.

Minimally Invasive Transpalpebral Endoscopic-Assisted Amygdalohippocampectomy

BACKGROUND: Although anterior temporal lobectomy may be a definitive surgical treatment for epileptic patients with mesial temporal sclerosis, it often results in verbal, visual, and cognitive dysfunction. Studies have consistently reported the advantages of selective procedures compared with a standard anterior temporal lobectomy, mainly in terms of neuropsychological outcomes.

OBJECTIVE: To describe a new technique to perform a selective amygdalohippocampectomy (SAH) through a transpalpebral approach with endoscopic assistance.

METHODS: A mini fronto-orbitozygomatic craniotomy through an eyelid incision was performed in 8 patients. Both a microscope and neuroendoscope were used in the surgeries. An anterior SAH was performed in 5 patients who had the diagnosis of temporal lobe epilepsy with mesial temporal sclerosis. One patient had a mesial temporal lesion suggesting a ganglioglioma. Two patients presented mesial temporal cavernomas with seizures originating from the temporal lobe.

RESULTS: The anterior approach allowed removal of the amygdala and hippocampus. The image-guided system and postoperative evaluation confirmed that the amygdala may be accessed and completely removed through this route. The hippocampus was partially resected. All patients have discontinued medication with no more epileptic seizures. The patients with cavernomas and ganglioglioma also had their lesions completely removed. One-year follow-up has shown no visible scars.

CONCLUSION: The anterior route for SAH is a rational and direct approach to the mesial temporal lobe. Anterior SAH is a safe, less invasive procedure that provides early identification of critical vascular and neural structures in the basal cisterns. The transpalpebral approach provides a satisfactory cosmetic outcome.

Temporal lobe epilepsy in children: executive and mnestic impairments

The current definition of epilepsy emphasizes the importance of cognitive impairment for a complete understanding of the disorder. Cognitive deficits have distinct functional manifestations that differentially impact the daily life experiences of children and adolescents with epilepsy and are a particular concern as they frequently impair academic performance. In particular, memory impairment and executive dysfunction are common disabilities in adults with temporal lobe epilepsy but are less easily recognized and studied in the pediatric population. This review focuses on the consequences of early-onset temporal lobe epilepsy for the development of memory and executive function and discusses current theories to explain these deficits.

Complications after mesial temporal lobe surgery via inferiortemporal gyrus approach

Object

The purpose of this study was to identify the complications associated with the inferior temporal gyrus approach to anterior mesial temporal lobe resection for temporal lobe epilepsy.

Methods

This retrospective study examined complications experienced by 483 patients during the 3 months after surgery. All surgeries were performed during 1998–2012 by the senior author (F.L.V.).

Results

A total of 13 complications (2.7%) were reported. Complications were 8 delayed subdural hematomas (1.6%), 2 superficial wound infections (0.4%), 1 delayed intracranial hemorrhage (0.2%), 1 small lacunar stroke (0.2%), and 1 transient frontalis nerve palsy (0.2%). Three patients with subdural hematoma (0.6%) required readmission and surgical intervention. One patient (0.2%) with delayed intracranial hemorrhage required readmission to the neuroscience intensive care unit for observation. No deaths or severe neurological impairments were reported. Among the 8 patients with subdural hematoma, 7 were older than 40 years (87.5%); however, this finding was not statistically significant (p = 0.198).

Conclusions

The inferior temporal gyrus approach to mesial temporal lobe resection is a safe and effective method for treating temporal lobe epilepsy. Morbidity and mortality rates associated with this procedure are lower than those associated with other neurosurgical procedures. The finding that surgical complications seem to be more common among older patients emphasizes the need for early surgical referral of patients with medically refractory epilepsy.

A comprehensive analysis of early outcomes and complication rates after 769 craniotomies in pediatric patients

PURPOSE

Perioperative complications following craniotomy in pediatric neurosurgery have received little attention. We analyzed perioperative complications and early outcomes following craniotomy in a large cohort of pediatric patients.

METHODS

A retrospective chart review identified 769 operations (27 % epilepsy surgery, 26 % trauma, 21 % tumor, 7 % vascular, 4 % infections, 14 % other, and 88 % supratentorial) in 641 patients <16 years (mean age 8.5 years). We recorded all perioperative complications and functional outcomes 30 days after surgery.

RESULTS

Excluding epilepsy surgery cases, 17.5 % patients had emergency surgery. There were 38 new major neurological deficits (5.0 %; excluding deficits incurred as part of the surgical strategy). New neurological deficits occurred more frequently following operations for brain tumors, when compared to other surgeries (P < 0.001), and after surgery for infratentorial lesions (P < 0.001). Local complications occurred in 3.9 %, systemic complications in 2.5 % of patients. Ventricular shunting or endoscopic ventriculostomy was necessary in 87 patients (11.3 %). Surgical mortality was 2.0 % (including moribund patients after trauma or vascular incidence). Preoperative Karnofsky Performance Index (KPI) and the incurrence of new neurological deficits proved the most powerful predictors of functional outcome. Emergency surgery or repeat craniotomies were not correlated with increased rates of local complications.

CONCLUSIONS

Craniotomies for pediatric patients carry a low morbidity and mortality. Systemic complications seem to occur less often in the pediatric than in the adult population. Good surgical outcomes require a proper balance between local pediatric neurosurgical care for emergency cases and centralized treatment of more difficult cases.

Limited access inferior temporal gyrus approach to mesial basal temporal lobe tumors

Object

In this retrospective review, the authors examine the clinical characteristics, diagnosis, and outcome of surgery in 25 consecutive patients with mesial basal temporal lobe (MBTL) tumors. A limited access approach to the inferior temporal gyrus (ITG) was used.

Methods

Patients with MBTL tumors were identified from the epilepsy and tumor surgery database at the authors' institution. Intraaxial tumors localized to the mesial basal structures, and without involvement of the cortical surface of the temporal lobe, temporal stem, and basal ganglia were included. Preoperative and postoperative MR images were obtained in all patients. The mean follow-up period was 24 months (range 9–36 months). Preoperative symptoms, neurological deficits, outcomes, surgical complications, and a technical description of the approach are discussed.

Results

Intraaxial MBTL tumors in 25 patients (mean age 44 years, range 8–76 years) were resected using a limited access approach via the ITG. The largest groups of tumors were high-grade gliomas and dysembryoblastic neuroepithelial tumors (8 in each group), followed by oligodendrogliomas, cerebral metastases, and gangliogliomas. Seizures, headaches, and disorientation were the most common preoperative symptoms. Postoperative MR images demonstrated gross-total resection in all cases. There were 2 surgical complications (a superficial wound infection and a transient frontalis branch palsy). There were no permanent neurological complications or significant new hemianoptic defects.

Conclusions

A limited access ITG approach performed with intraoperative image guidance offers an alternative corridor for resection of MBTL tumors (Schramm Type A). This approach may be technically less demanding than the transsylvian or subtemporal approach. Gross-total resection is feasible utilizing this approach and compares favorably with other, more classical approaches.

The surgery of epilepsy

The idea of surgical treatment for epilepsy is not new. However, widespread use and general acceptance of this treatment has only been achieved during the past three decades. A crucial step in this direction was the development of video electroencephalographic monitoring. Improvements in imaging resulted in an increased ability for preoperative identification of intracerebral and potentially epileptogenic lesions. High resolution magnetic resonance imaging plays a major role in structural and functional imaging; other functional imaging techniques (e.g., positron emission tomography and single-photon emission computed tomography) provide complementary data and, together with corresponding electroencephalographic findings, result in a hypothesis of the epileptogenic lesion, epileptogenic zone, and the functional deficit zone. The development of microneurosurgical techniques was a prerequisite for the general acceptance of elective intracranial surgery. New less invasive and safer resection techniques have been developed, and new palliative and augmentative techniques have been introduced. Today, epilepsy surgery is more effective and conveys a better seizure control rate. It has become safer and less invasive, with lower morbidity and mortality rates. This article summarizes the various developments of the past three decades and describes the present tools for presurgical evaluation and surgical strategy, as well as ideas and future perspectives for epilepsy surgery.

Remote cerebellar hemorrhage and iliofemoral vein thrombosis after supratentorial craniotomy

INTRODUCTION

Cerebellar hemorrhage following supratentorial craniotomy is rare. Its clinical symptoms are often mild and transient.

DISCUSSION

Here, we report a case of cerebellar hemorrhage associated with iliofemoral vein thrombosis as a complication of anterior temporal lobectomy and amygdalohippocampectomy for refractory medial temporal epilepsy.

Lumbar subdural haematoma after temporomesial resection in epilepsy patients-report of two cases and review of the literature

We present two cases of lumbar subdural haematoma, both occurring after an uneventful temporomesial focus resection in patients suffering from medically intractable epilepsy. Initial symptom was back pain and sciatica 4 days and 13 days postoperatively, but no neurological deficits were observed. The diagnosis was confirmed by MRI. No risk factor could be identified. The pain responded well to conservative treatment and the haematomas resolved without neurological sequelae. A review of the literature reveals that the characteristics of spinal subdural haematoma following craniotomy are very similar. Six out of 12 reported cases occurred in temporal epilepsy surgery. All had a benign course and did not require an operative procedure. Back pain after epilepsy surgery may be caused by an intraspinal haematoma and should be investigated by MRI.

Surgery for temporal mediobasal tumors: experience based on a series of 235 patients

OBJECTIVE

To describe the clinical characteristics, diagnosis, various approaches, and outcomes in a retrospective review of a large series of temporomediobasal (TMB) tumors.

METHODS

Charts from 235 patients with TMB tumors were identified from the glioma and epilepsy surgery database and from the electronic operations log. Preoperative magnetic resonance imaging scans were available for all patients and postoperative follow-up was available for 155 of these patients (mean follow-up period, 59 mo; range, 2-172 mo). Preoperative symptoms, approaches, technical problems, and surgical complications are described.

RESULTS

Two hundred and thirty-five patients with intra-axial TMB tumors (mean age, 35 yr) were collected during an 11-year period. The largest tumor groups were astrocytomas (38.0%), gangliogliomas (29.8%), dysembryoplastic neuroepithelial tumor (11.1%), and glioblastomas (11.1%). The most frequent tumor location was the mesial Type A tumor (45.1%), with this type also showing the highest proportion of benign (World Health Organization Grades I and II) histological features (91.3%). Of all tumors, 76.2% were benign. Larger tumor size was associated with higher frequency of malignant histopathological findings. The leading symptom was epilepsy in 91% of patients, followed by drug-resistant epilepsy in 71.5%. Significant preoperative neurological deficits, such as hemiparesis or aphasia, were seen in 3.8% of the patients; another 12% had visual field deficits. Thirty-eight patients with low-grade tumors had undergone surgery previously. Several surgical approaches were chosen: transsylvian in 28%, anterior two-thirds temporal lobe resection in 23%, temporal pole resection in 15.3%, subtemporal in 19%, and transcortical in 6%. The most frequent neurological complications were transient: dysphasia (4.2%), hemiparesis (5%), and oculomotor disturbance (2.5%). Permanent nonvisual neurological complications occurred in fewer than 2% of the patients and significant new hemianopic defects were found in another 5.4% of the patients. The most severe complication was one intraoperative internal carotid artery lesion. One patient died.

CONCLUSION

Small tumor size, magnetic resonance imaging, and microsurgery have made resection of mostly benign TMB tumors possible in a large number of patients. This series supports the conclusion that these tumors can be operated on with a relative degree of safety for the patient, provided that the anatomy of the mesial temporal lobe and the variety of approaches are well known to the surgeon. However, because of the complex anatomic structures in the vicinity, transient neurological deterioration is not infrequent and certain neurological disturbances (e.g., quadrantanopia) even seem to be unavoidable, whereas permanent significant deficits are rare.

Surgical Treatment for Refractory Temporal Lobe Epilepsy in the Elderly: Seizure Outcome and Neuropsychological Sequels Compared with a Younger Cohort

PURPOSE

Surgical treatment of refractory temporal lobe epilepsy (TLE) is promising for selected patients, but only little experience has been acquired in operating on older patients, especially with limited resections. We intend to delineate clinical and surgical factors influencing outcome in patients older than 50 years at operation and to compare the results with those of a younger patient cohort.

METHODS

Fifty-two patients older than 50 years were operated on for intractable mesial or combined mesiolateral TLE between 1991 and 2002. The mean age at operation was 55 years, and the mean duration of epilepsy was 33 years. Forty selective amygdalohippocampectomies (33 for hippocampal sclerosis, seven for removal of a mesiotemporal lesion), five lateral temporal lesionectomies plus amygdalohippocampectomy, and seven anterior temporal lobectomies were performed. Eleven (21%) patients had undergone invasive presurgical video-EEG monitoring. The mean follow-up period was 33 months. We compared the results with those of a younger cohort operated on in the same time period.

RESULTS

Thirty-seven older patients attained complete seizure control (71% class I), and 10 patients had only rare postoperative seizures (19% class II). Four patients improved >75% (8% class III), and one patient did not improve (2% class IV). The same rate of seizure control was attained by 11 patients older than 60 years at surgery. These results were not significantly different from those in a younger patient group. A trend toward better seizure control was noted in 16 patients with an epilepsy duration of <30 years (all class I or II), and in 20 patients with a seizure frequency of fewer than five seizures per month (all class I or II). No mortality resulted from a total of 65 diagnostic and therapeutic procedures. A 3.8% permanent neurologic morbidity (dysphasia and hemiparesis) was noted. Hemianopia occurred in three (5.9%) patients. Neuropsychological testing revealed low preoperative performances and some gradual further deterioration after surgery.

CONCLUSIONS

Results of surgery for TLE with mainly limited resections are promising in patients older than 50 years and older 60 years, despite the long seizure history. As expected, the risk of complications is somewhat higher compared with that in a younger control group. The impact of low neuropsychological performance is a concern.

Remote cerebellar hemorrhage: A review

Remote cerebellar hemorrhage remains a complication rarely occurring after supratentorial surgery (<5%) and presumably even less frequent after spinal surgery. Although the pathomechanisms leading to RCH with its typical bleeding pattern are still not definitely understood, intra- or even more likely postoperative loss of larger volumes of CSF seem to be related to this complication. Prognosis significantly depends on severity of hemorrhage and patient age. Outcome in more than 50% of all cases is good with only mild remaining neurological symptoms or complete recovery, while death occurs in approximately 10-15%. Close monitoring of patients undergoing surgery that involves the risk of draining large volumes of CSF is mandatory and patients with postoperative drainage of larger amounts of fluid acquire increased attentiveness. Early detection and correct interpretation of the typical bleeding pattern might help to avoid further aggravation of symptoms. This review will address incidence, typical appearance and pathophysiological considerations, as well as risk factors, treatment options, and outcome related with RCH.