Predicting verbal memory decline following anterior temporal lobectomy (ATL)

Neural (re)organisation of language and memory: implications for neuroplasticity and cognition

BACKGROUND

In the presence of neurological insult, how language and memory networks jointly reorganise provides insights into mechanisms of neuroplasticity and can inform presurgical planning. As (re)organisation is often studied within a single cognitive modality, how language and memory interact during (re)organisation in response to epilepsy and the implications for memory outcomes is less clear. We investigated (1) the rates and patterns of joint (re)organisation and (2) their associations with pre- and postsurgical memory function.

METHODS

Individuals with epilepsy (n=162) from three neurosurgical centres underwent the Wada procedure. We examined colateralisation patterns (ie, concordance/discordance) between language and both global and verbal memory (n=34), and associations with clinical characteristics and preoperative and postoperative memory outcomes.

RESULTS

Overall concordance between language and memory colateralisation was minimal-to-weak across both global memory and verbal memory (kappa=0.28-0.44). Discordance was primarily observed in individuals with left-lateralised language, of whom 52% and 32% showed discordance in global and verbal memory, respectively. Discordance was most pronounced in left hemisphere epilepsy and mesial temporal sclerosis. Conversely, right-lateralised language consistently predicted right-lateralised memory (95%-100%), regardless of seizure laterality or memory type. While discordance was not associated with presurgical memory function, discordance predicted superior postsurgical memory outcomes following surgery in the language-dominant hemisphere (p<0.05; ηp 2=0.30).

CONCLUSIONS

When language dominance is atypical, memory tends to colateralise. However, when language remains typical, concordance with memory is weak, particularly for left hemisphere seizure onset. An interhemispheric shift in language may trigger a shift in memory, possibly to maintain efficient communication between medial temporal and neocortical language networks. In contrast, memory appears able to reorganise in isolation, with discordance predicting better postsurgical memory outcomes without detriment to presurgical function. Our findings support the continued need for separate presurgical mapping of language and memory lateralisation, particularly in the case of typical language dominance and left hemisphere seizures.

Verbal Memory Localized in Non-language-dominant Hemisphere: Atypical Lateralization Revealed by Material-specific Memory Evaluation Using Super-selective Wada Test

Hippocampectomy is effective for drug-resistant mesial temporal lobe epilepsy with hippocampal sclerosis. However, multiple studies have reported high risks associated with hippocampectomy in patients with mesial temporal lobe epilepsy without hippocampal sclerosis on magnetic resonance imaging and in those with preserved memory function. Verbal memory and language functions are believed to coexist in the same hemisphere. We present a case of left mesial temporal lobe epilepsy with atypical memory function lateralization revealed by super-selective infusion of propofol to the intracranial artery (super-selective Wada test). A 24-year-old right-handed man with drug-resistant focal impaired awareness seizures was diagnosed with left mesial temporal lobe epilepsy without hippocampal sclerosis, but he showed preserved verbal intelligence quotient and memory, suggesting a high risk of severe memory decline after hippocampectomy. We performed super-selective Wada test to the posterior cerebral artery to assess the lateralization of verbal and visual memory separately, and to the middle cerebral artery to assess language function. The results revealed right-sided dominance for both verbal and visual memory, although the language was left-dominant. Hippocampectomy was performed and resulted in freedom from seizures. Memory assessments 1 year postoperatively showed no decline in all subtests. In patients with drug-resistant epilepsy exhibiting atypical neuropsychological profiles, the memory-dominant, and language-dominant hemispheres may not align; detailed evaluations of function lateralization are necessary for tailored treatment.

Cortico-hippocampal networks underpin verbal memory encoding in temporal lobe epilepsy

Knowledge of the structural underpinnings of human verbal memory is scarce. Understanding the human verbal memory network at a finer anatomical scale will have important clinical implications for the management of patients with verbal memory impairment. In this cross-sectional study, we aimed to assess the contributions of cerebral cortex and hippocampal subfields to verbal memory encoding in temporal lobe epilepsy. We included consecutive patients (n = 84) with radiologically and pathologically defined hippocampal sclerosis (HS) (44 left-sided) and unilateral temporal lobe epilepsy, and healthy volunteers (n = 43) who were comparable regarding age and sex. The morphometric and volumetric measures of cerebral cortex and hippocampal subfields were extracted from high-resolution MRI scans. People included in this study underwent standardized neuropsychological evaluation, including measures of verbal memory assessed through the Adult Memory and Information Processing Battery. Verbal memory performances were Z-scores corrected by using means and standard deviations published for sample standardization. Associations between verbal learning Z-scores and the grey matter volume of the cerebral cortex and hippocampal subfields were investigated. Reduction of grey matter volumes in the left and right medial and dorsolateral prefrontal cortex (P corr < 0.0001), superior and middle temporal gyri (P corr < 0.0001), anterior and posterior cingulate cortex (P corr < 0.0001) and of the left ventrolateral prefrontal cortex (P corr < 0.0001) and parietal-temporal-occipital junction (P corr < 0.0001) were associated with worse verbal learning. These findings were consistent across both the entire cohort and in a subgroup analysis focused exclusively on HS patients. Within hippocampi, smaller volumes of the left dentate gyrus (P = 0.003), cornu ammonis 4 (P = 0.005) and cornu ammonis 3 (P = 0.03) were associated with worse verbal learning Z-scores. This study demonstrates that verbal learning in patients with temporal lobe epilepsy is strongly related to the volume of distinct regions of the prefrontal, temporal and cingulate cortices and left dentate gyrus, cornu ammonis 4 and cornu ammonis 3 hippocampal subfields. It provides the basis to suggest a corticohippocampal network for verbal learning in these patients, improving our understanding of human verbal memory. These biomarkers may inform attractive targets for forthcoming modulating therapies. Future work may also analyse the impact of sparing part of the left dentate gyrus, cornu ammonis 4 and cornu ammonis 3 as a protective measure against verbal memory impairment after surgery for temporal lobe epilepsy.

Factors influencing the adequacy of determining hemispheric language lateralization in presurgical epilepsy patients using functional transcranial Doppler sonography (fTCD)

As the adequacy of determining hemispheric language lateralization (HLL) is of special importance for the planning of epilepsy surgery, this study aimed to identify predictive factors for receiving inconclusive HLL results using functional transcranial Doppler sonography (fTCD). Data from 495 epilepsy patients who received fTCD in a standardized fashion was analyzed retrospectively. HLL was left-sided in 324 patients (65.5 %), right-sided in 76 (15.4 %), and inconclusive in 95 (19.2 %). Univariate logistic regression analyses revealed significant positive associations between inconclusive HLL results and a multiregional localization of epilepsy. Significant negative associations with higher educational qualification, more years of education, and better letter verbal fluency were found. In multiple logistic regression analyses, a multiregional localization of epilepsy (OR = 2.74, p < 0.001) and years of education (OR = 0.86, p < 0.001) remained independent predictors. A cut-off value of 10.77 years of education determined by discriminant function analyses is provided. Our findings indicate that the adequacy of determining HLL using fTCD is highly dependent on the extension of the epileptogenic lesion and the patients' years of education. We therefore recommend not to use the same paradigm for all patients, but to adapt the selection of adequate test materials to their cognitive abilities.

Positron Emission Tomography (PET) in presurgical planning of anterior temporal lobectomy: A systematic review of efficacy and limitations

INTRODUCTION

Temporal lobe epilepsy (TLE), a debilitating neurological disorder, necessitates refined diagnostic and treatment strategies. This comprehensive review appraises the potential of positron emission tomography (PET) in enhancing the presurgical planning of Anterior Temporal Lobectomy (ATL) for patients afflicted with TLE.

METHODS

A comprehensive literature search was conducted using the PubMed, SCOPUS, and ScienceDirect databases from 1985 to 2022, following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for studies investigating PET and ATL. This review studied a range of radiotracers, including FDG, H2O, FMZ, MPPF, and FCWAY, analyzing their efficacy in detecting epileptogenic foci, establishing resection boundaries, and predicting postoperative outcomes. The study paid special attention to cases where MRI findings were inconclusive.

RESULTS

A total of 52 studies were included in the final analysis. Our analysis revealed that FDG-PET imaging was instrumental in identifying seizure foci and predicting postoperative results. It exhibited significant value in situations where structural abnormalities were absent on MRI scans. Furthermore, newer radiotracers such as 5-HT1A antagonists, FCWAY and MPPF, presented promising potential for localizing seizure foci, particularly in MRI-negative TLE, despite their comparatively limited current usage.

CONCLUSION

PET imaging, although challenged by issues such as radiation exposure, limited accessibility, and high costs, offers considerable promise. Integration with other imaging modalities, such as EEG and MRI, has contributed to improved localization of epileptogenic foci and subsequently, enhanced surgical outcomes. Further research must focus on establishing the relative efficacy and optimal combinations of these radiotracers in the orchestration of ATL surgical planning and prognostication of postoperative outcomes for TLE patients. Encouragingly, these advancements hold the potential to revolutionize the management of TLE, delivering a better quality of life for patients.

Clinical recommendations for conducting pediatric functional language and memory mapping during the phase I epilepsy presurgical workup

Objective: Pediatric epilepsy surgery effectively controls seizures but may risk cognitive, language, or memory decline. Historically, the intra-carotid anesthetic procedure (IAP or Wada Test) was pivotal for language and memory function. However, advancements in noninvasive mapping, notably functional magnetic resonance imaging (fMRI), have transformed clinical practice, reducing IAP's role in presurgical evaluations. Method: We conducted a critical narrative review on mapping technologies, including factors to consider for discordance. Results: Neuropsychological findings suggest that if pre-surgery function remains intact and the surgery targets the eloquent cortex, there is a high chance for decline. Memory and language decline are particularly pronounced post-left anterior temporal lobe resection (ATL), making presurgical cognitive assessment crucial for predicting postoperative outcomes. However, the risk of functional decline is not always clear - particularly with higher rates of atypical organization in pediatric epilepsy patients and discordant findings from cognitive mapping. We found little research to date on the use of IAP and other newer technologies for lateralization/localization in pediatric epilepsy. Based on this review, we introduce an IAP decision tree to systematically navigate discordance in IAP decisions for epilepsy presurgical workup. Conclusions: Future research should be aimed at pediatric populations to improve the precision of functional mapping, determine which methods predict post-surgical deficits and then create evidence-based practice guidelines to standardize mapping procedures. Explicit directives are needed for resolving conflicts between developing mapping procedures and established clinical measures. The proposed decision tree is the first step to standardize when to consider IAP or invasive mapping, in coordination with the multidisciplinary epilepsy surgical team.

Diffusion spectrum imaging based semi-automatic optic radiation tractography for vision preservation in SEEG-guided radiofrequency thermocoagulation

OBJECTIVE

To assess the efficacy and safety of stereoelectroencephalography (SEEG)-guided radiofrequency thermocoagulation (RFTC), using diffusion spectrum imaging (DSI) tractography to preoperatively delineate the optic radiation (OR) and reduce the risk of visual field defects (VFDs) where the epileptogenic zones (EZs) are located in or close to the eloquent visual areas.

METHODS

We prospectively followed up twenty-four consecutive patients (12 males and 12 females) who underwent SEEG-guided RFTC in or near the OR pathway. A distance of ≥ 3.5 mm away from the OR on the targeted electrodes contacts that exhibited relevant ictal onset patterns, IEDs and EES during SEEG recordings, was required as our selection criterion prior to performing RFTC, enough to theoretically prevent VFDs. Using default tracking parameters, the optic radiation was tracked semi-automatically in DSI-studio.

RESULTS

There were 12 male and 12 female patients ranging in age from 6 to 57 years, with follow-up period ranging from 6 to 37 months. Nineteen patients responded to RFTC (R+, 79.16 %), and 5 patients did not benefit from RFTC (R-, 20.83 %). The preoperative application of DSI semi-automatic based OR tractography was successful in the protection of the OR in all 24 patients. Three patients experienced a neurologic deficit following RFTC, and five patients had a partial quadrant visual field deficit prior to surgery that did not worsen, and none of the remaining nineteen patients had a quadrant visual field deficit.

CONCLUSION

Our study validates the safety and efficacy of SEEG-RFTC as a viable therapeutic approach for epileptic foci situated in or adjacent to the visual eloquent regions. We demonstrate that DSI-based tractography offers superior precision in delineating the OR compared to DTI. We establish that implementing a criterion of a minimum distance of ≥ 3.5 mm in radius from the OR on the targeted electrode contacts prior to conducting RFTC can effectively mitigate the risk of VFDs.

Language MEG predicts postoperative verbal memory change in left mesial temporal lobe epilepsy

OBJECTIVE

To clarify whether preoperative language magnetoencephalography (MEG) predicts postoperative verbal memory (VM) changes in left mesial temporal lobe epilepsy (LMTLE).

METHODS

We reviewed 18 right-handed patients with LMTLE who underwent anterior temporal lobectomy or selective amygdala hippocampectomy, 12 with (HS+) and 6 without hippocampal sclerosis (HS-). Patients underwent neuropsychological assessment before and after surgery. MEG was measured with an auditory verbal learning task in patients preoperatively and in 15 right-handed controls. Dynamic statistical parametric mapping (dSPM) was used for source imaging of task-related activity. Language laterality index (LI) was calculated by z-score of dSPM in language-related regions. LI in the region of HS+ and HS- was compared to controls. The correlation between LI and postoperative VM change was assessed in HS+ and HS-.

RESULTS

Preoperative LI in supramarginal gyrus showed greater right-shifted lateralization in both HS+ and HS- than in controls. Right-shifted LI in supramarginal gyrus was correlated with postoperative VM increase in HS+ (p = 0.019), but not in HS-.

CONCLUSIONS

Right-shifted language lateralization in dSPM of MEG signals may predict favorable VM outcome in HS+ of LMTLE.

SIGNIFICANCE

Findings warrant further investigation of the relation between regional language laterality index and postoperative verbal memory changes.

WADA test for postoperative memory prediction in left TLE. Is it still useful in the 21st century?

BACKGROUND

Epilepsy surgery offers an effective treatment to achieve seizure freedom in refractory temporal lobe epilepsy. Since left temporal lobe surgery can be associated with verbal memory deterioration, control of cognitive decline is a main goal of therapy. This study analyzes the prognostic value of intracarotid amobarbital procedure (Wada test) in addition to specific neuropsychological and clinical variables for postoperative memory changes.

METHOD

Between 2013 and 2021 thirty-six patients (18 females, 18 males, mean age 41.0 years) from the Epilepsy Center Erlangen (ECE) with left hemispheric temporal lobe epilepsy underwent neuropsychological assessment preoperatively - including the Wada test - and six months postoperatively. In addition, a group of 92 patients (40 females, 52 males, mean age 36.1 years) with left or right hemispheric focus who underwent Wada test and surgery before 2013 was included as a standardization group. In all patients Wada test was carried out preoperatively to determine language dominance and memory capacity.

RESULTS

Postoperative verbal memory scores showed no significant difference from preoperative performance. Preoperative verbal memory performance as well as the hippocampal resection extent is particularly important in predicting postoperative verbal memory change. After left temporal lobe surgery, a significantly higher postoperative functional level was shown for figural memory. Specifically, a good contralateral hemispheric performance level assessed by the Wada test proved to be a compensatory factor for postoperative losses.

CONCLUSION

The Wada test is no longer necessary as a diagnostic tool for a broad group of patients with temporal lobe epilepsy. However, it can be useful for a subgroup of patients with clinical indicators such as nonspecific or incongruent preoperative verbal and figural memory impairments. In this study, Wada test data about the functional level of the contralateral hemisphere specifically allowed estimation of postoperative figural memory changes.

Effect of Early Surgical Intervention for Brain Tumors Associated with Epilepsy on the Improvement in Memory Performance

We evaluated the effect of early surgical intervention on the change in memory performance of patients with low-grade brain tumors associated with epilepsy. Twenty-three adult patients with low-grade brain tumors and epilepsy who underwent surgery at our institution between 2010 and 2019 were included. The Wechsler Memory Scale-Revised (WMS-R) was used to assess cognitive memory performance. Memory performance before and after surgery was retrospectively evaluated. In addition, the relationships among preoperative memory function, postoperative seizure outcome, preoperative seizure control, temporal lobe lesion, and change in memory function were examined. There were statistically significant improvements from median preoperative to postoperative WMS-R subscale scores for verbal memory, general memory, and delayed recall (p<0.001, p<0.001, and p=0.0055, respectively) regardless of preoperative sores and tumor location. Good postsurgical seizure control was associated with significant improvements in postoperative WMS-R performance. Our results indicated that early surgical intervention might improve postoperative memory function in patients with low-grade brain tumors and epilepsy.

Surgical Treatments for Epilepsy

PURPOSE OF REVIEW

More than 20 new antiseizure medications have been approved by the US Food and Drug Administration (FDA) in the past 3 decades; however, outcomes in newly diagnosed epilepsy have not improved, and epilepsy remains drug resistant in up to 40% of patients. Evidence supports improved seizure outcomes and quality of life in those who have undergone epilepsy surgery, but epilepsy surgery remains underutilized. This article outlines indications for epilepsy surgery, describes the presurgical workup, and summarizes current available surgical approaches.

RECENT FINDINGS

Class I evidence has demonstrated the superiority of resective surgery compared to medical therapy for seizure control and quality of life in patients with drug-resistant epilepsy. The use of minimally invasive options, such as laser interstitial thermal therapy and stereotactic radiosurgery, are alternatives to resective surgery in well-selected patients. Neuromodulation techniques, such as responsive neurostimulation, deep brain stimulation, and vagus nerve stimulation, offer a suitable alternative, especially in those where resective surgery is contraindicated or where patients prefer nonresective surgery. Although neuromodulation approaches reduce seizure frequency, they are less likely to be associated with seizure freedom than resective surgery.

SUMMARY

Appropriate patients with drug-resistant epilepsy benefit from epilepsy surgery. If two well-chosen and tolerated medication trials do not achieve seizure control, referral to a comprehensive epilepsy center for a thorough presurgical workup and discussion of surgical options is appropriate. Mounting Class I evidence supports a significantly higher chance of stopping disabling seizures with surgery than with further medication trials.

Surgery procedures in temporal lobe epilepsies

Temporal lobe epilepsy (TLE) is the most common cause of refractory epilepsy amenable for surgical treatment and seizure control. Surgery for TLE is a safe and effective strategy. The seizure-free rate after surgical resection in patients with mesial or neocortical TLE is about 70%. Resective surgery has an advantage over stereotactic radiosurgery in terms of seizure outcomes for mesial TLE patients. Both techniques have similar results for safety, cognitive outcomes, and associated costs. Stereotactic radiosurgery should therefore be seen as an alternative to open surgery for patients with contraindications for or with reluctance to undergo open surgery. Laser interstitial thermal therapy (LITT) has also shown promising results as a curative technique in mesial TLE but needs to be more deeply evaluated. Brain-responsive stimulation represents a palliative treatment option for patients with unilateral or bilateral MTLE who are not candidates for temporal lobectomy or who have failed a prior mesial temporal lobe resection. Overall, despite the expansion of innovative techniques in recent years, resective surgery remains the reference treatment for TLE and should be proposed as the first-line surgical modality. In the future, ultrasound therapies could become a credible therapeutic option for refractory TLE patients.

Outcomes of epilepsy surgery in the older population: not too old, not too late

OBJECTIVE

The prevalence of epilepsy in the older adult population is increasing. While surgical intervention in younger patients is supported by level I evidence, the safety and efficacy of epilepsy surgery in older individuals is less well established. The aim of this study was to evaluate seizure freedom rates and surgical outcomes in older epilepsy patients.

METHODS

The authors' institutional electronic database was queried for patients older than 50 who had undergone epilepsy surgery during 2002-2018. Cases were grouped into 50-59, 60-69, and 70+ years old. Seizure freedom at the last follow-up constituted the primary outcome of interest. The institutional analysis was supplemented by a literature review and meta-analysis (random effects model) of all published studies on this topic as well as by an analysis of complication rates, mortality rates, and cost data from a nationwide administrative database (Vizient Inc., years 2016-2019).

RESULTS

A total of 73 patients (n = 16 for 50-59 years, n = 47 for 60-69, and n = 10 for 70+) were treated at the authors' institution. The median age was 63 years, and 66% of the patients were female. At a median follow-up of 24 months, seizure freedom was 73% for the overall cohort, 63% for the 50-59 group, 77% for the 60-69 group, and 70% for the 70+ group. The literature search identified 15 additional retrospective studies (474 cases). Temporal lobectomy was the most commonly performed procedure (73%), and mesial temporal sclerosis was the most common pathology (52%), followed by nonspecific gliosis (19%). The pooled mean follow-up was 39 months (range 6-114.8 months) with a pooled seizure freedom rate of 65% (95% CI 59%-72%). On multivariable meta-regression analysis, an older mean age at surgery (coefficient [coeff] 2.1, 95% CI 1.1-3.1, p < 0.001) and the presence of mesial temporal sclerosis (coeff 0.3, 95% CI 0.1-0.6, p = 0.015) were the most important predictors of seizure freedom. Finally, analysis of the Vizient database revealed mortality rates of 0.5%, 1.1%, and 9.6%; complication rates of 7.1%, 10.1%, and 17.3%; and mean hospital costs of $31,977, $34,586, and $40,153 for patients aged 50-59, 60-69, and 70+ years, respectively.

CONCLUSIONS

While seizure-free outcomes of epilepsy surgery are excellent, there is an expected increase in morbidity and mortality with increasing age. Findings in this study on the safety and efficacy of epilepsy surgery in the older population may serve as a useful guide during preoperative decision-making and patient counseling.

Memory outcomes of temporal lobe surgery in adults aged over 45 years

OBJECTIVE

It is assumed that temporal lobe resection in older people is associated with worse seizure outcomes and potential postsurgical memory decline. We studied postsurgical memory development and surgical efficacy in patients over 45 years of age compared with younger patients.

METHODS

We studied 88 patients (51 male and 37 female) after temporal lobe surgery, which involved hippocampal resection. The patients were evaluated before surgery and in the first (72 patients) and/or third (57 patients) postsurgical year. The Wechsler Memory Scale III test was performed to evaluate the MQ postsurgical development. Engel's classification was used to evaluate the postsurgical seizure outcome.

RESULTS

The presurgical MQ (median 88) in ≥45 years age group was significantly lower than in both younger groups (median MQ = 100 for ≤30 years age group, p = 0.002; median MQ = 107 for 31-44 years age group, p = 0.002). Three years after the surgery, the MQ decreased significantly in ≤30 years age group (p = 0.012), while only non-significant MQ decline was observed in both older groups. We found no significant impact of age on the surgical outcome.

CONCLUSION

Higher age at the time of surgery does not significantly increase the risk for postsurgical memory decline; however, older patients are more likely to have lowered presurgical MQ. We did not find significant differences in the impact of surgery on seizure outcome among the age groups. Epilepsy surgery appears to be a safe and effective method in the age over 45 years even though an earlier surgery should be preferred.

Wada test results contribute to the prediction of change in verbal learning and verbal memory function after temporal lobe epilepsy surgery

In recent years, the clinical usefulness of the Wada test (WT) has been debated among researchers in the field. Therefore, we aimed to assess its contribution to the prediction of change in verbal learning and verbal memory function after epilepsy surgery. Data from 56 patients with temporal lobe epilepsy who underwent WT and subsequent surgery were analyzed retrospectively. Additionally, a standard neuropsychological assessment evaluating attentional, learning and memory, visuospatial, language, and executive function was performed both before and 12 months after surgery. Hierarchical linear regression analyses were used to determine the incremental value of WT results over socio-demographic, clinical, and neuropsychological characteristics in predicting postsurgical change in patients' verbal learning and verbal memory function. The incorporation of WT results significantly improved the prediction models of postsurgical change in verbal learning (∆R2 = 0.233, p = .032) and verbal memory function (∆R2 = 0.386, p = .005). Presurgical performance and WT scores accounted for 41.8% of the variance in postsurgical change in verbal learning function, and 51.1% of the variance in postsurgical change in verbal memory function. Our findings confirm that WT results are of significant incremental value for the prediction of postsurgical change in verbal learning and verbal memory function. Thus, the WT contributes to determining the risks of epilepsy surgery and, therefore, remains an important part of the presurgical work-up of selected patients with clear clinical indications.

Long-term efficacy and cognitive effects of bilateral hippocampal deep brain stimulation in patients with drug-resistant temporal lobe epilepsy

PURPOSE

Temporal lobe epilepsy patients treated with hippocampal deep brain stimulation (Hip-DBS) have rarely been reported before. Preoperative and postoperative cognitive function is seldom analyzed.

METHODS

Seven patients with drug-resistant temporal lobe epilepsy were included in this study. Bilateral Hip-DBS was performed in these patients. The stimulator was activated 1 month after the implantation. Then, the patients returned for further adjustments 4 months after the surgery and reprogramming every year. The seizure frequency, Wechsler Adult Intelligence Scale-IV, and Wechsler memory scale-IV were assessed blindly as the outcomes at each follow-up.

RESULTS

After a mean 48-month follow-up, the mean seizure frequency significantly decreased (p = 0.011, paired t test; decrease of 78.1%). One patient (14.3%) was seizure-free by the last follow-up; six of seven (85.7%) patients had reductions in seizure frequency of at least 50%; one patient (14.3%) who did not comply with the antiepileptic drug instructions had a less than 50% reduction in seizure frequency. In addition, there were no significant decreases in intelligence or verbal and visual memory from baseline to the last follow-up (p = 0.736, paired t test; p = 0.380, paired t test, respectively).

CONCLUSION

Hip-DBS could provide acceptable long-term efficacy and safety. For patients with drug-resistant temporal lobe epilepsy who are not suitable for resective surgery, Hip-DBS could become a potential therapeutic option.

Advantages of methohexital over amobarbital in determining hemispheric language and memory lateralization in the Wada test - A retrospective study

OBJECTIVE

Due to supply shortage, amobarbital, the traditional anesthetic agent in Wada testing, was replaced by methohexital in many epilepsy centers. This study aimed to compare the two barbiturates to identify possible advantages or disadvantages of methohexital as compared to amobarbital with regard to the adequacy of language and memory testing during the Wada test.

METHODS

Data from 75 patients with temporal lobe epilepsy who underwent bilateral Wada tests using either amobarbital (n = 53) or methohexital (n = 22) as part of presurgical work-up were analyzed retrospectively. The two subgroups were compared regarding hemispheric language and memory lateralization results and Wada testing characteristics, and the adequacy of language and memory testing was assessed.

RESULTS

We observed shorter durations of motor-, speech-, and EEG recovery after each injection in patients receiving methohexital compared to amobarbital. In addition, significantly more items could be presented during effective hemispheric inactivation in the methohexital group. Moreover, significant correlations of Wada memory scores with standard neuropsychological memory test scores could be found in the methohexital group.

SIGNIFICANCE

Our findings confirm that methohexital is not only equally suitable for Wada testing but has several advantages over amobarbital. Wada testing can be performed more efficiently and under more constant hemispheric inactivation using methohexital. Furthermore, the adequacy of language and memory testing during the Wada test might be affected by the anesthetic agent used.

Advances in the Surgical Management of Epilepsy: Drug-Resistant Focal Epilepsy in the Adult Patient

Pharmacoresistant seizures occur in nearly one-third of people with epilepsy. Medial temporal lobe and lesional epilepsy are the most favorable surgically remediable epileptic syndromes. Successful surgery may render the patient seizure-free, reduce antiseizure drug(s) adverse effects, improve quality of life, and decrease mortality. Surgical management should not be considered a procedure of "last resort." Despite the results of randomized controlled trials, surgery remains an underutilized treatment modality for patients with drug-resistant epilepsy (DRE). Important disparities affect patient referral and selection for surgical treatment. This article discusses the advances in surgical treatment of DRE in adults with focal seizures.

The association of cognitive phenotypes with postoperative outcomes after epilepsy surgery in patients with temporal lobe epilepsy

INTRODUCTION

The concept of cognitive phenotypes has been developed to categorize the heterogeneity of neuropsychological profiles in patients with temporal lobe epilepsy (TLE). This study examines the utility of cognitive phenotypes derived from clinical criteria in the prediction of postoperative outcomes.

METHODS

Scores from 9 standardized neuropsychological tests were used to sample preoperative performance in 4 core domains (intellectual, memory, language, & executive function) in 445 patients with TLE (206 right: 236 left). Patients were grouped into 3 clinical phenotypes using clinical criteria: 1. intact cognition, 2. isolated memory and/or language impairment, and 3. widespread impairment. Patients who did not meet the criteria for these phenotypes were characterized as having a mixed profile phenotype.

RESULTS

Approximately half of the sample had intact cognitive function, with one-quarter demonstrating isolated impairments in language and memory function. The remainder demonstrated widespread impairment or a mixed pattern of cognitive impairments. The clinically derived cognitive phenotypes were associated with demographic and clinical characteristics. Patients with widespread cognitive impairments had an earlier onset of seizures than those with other cognitive phenotypes. They also reported higher levels of depression. Higher levels of anxiety were reported in those with isolated memory/language impairments. Phenotypes were not associated with postoperative seizure outcome or postoperative declines in verbal memory or language function, but an intact phenotype was associated with a greater risk of decline in visual learning than right-sided surgery.

CONCLUSIONS

Distinct cognitive phenotypes in TLE can be identified using clinical criteria and may reflect neurodevelopmental influences and mood in addition to progression of the disease. Phenotype may be a more powerful predictor of postoperative decline in visual memory than laterality of surgery.

Surgery of the amygdala and uncus: a case series of glioneuronal tumors

BACKGROUND

Patients with a lesion within the amygdala and uncus may develop temporal lobe epilepsy despite having functional mesial structures. Resection of functional hippocampus and surrounding structures may lead to unacceptable iatrogenic deficits. To our knowledge, there is limited descriptions of surgical techniques for selectively resecting the amygdala and uncus lesions while preserving the hippocampus in patients with language-dominant temporal lobe pathology.

METHODS

Thirteen patients with language-dominant temporal lobe epilepsy related to amygdala-centric lesions were identified. Patients with sclerosis of the mesial structures or evidence of pathology outside of the amygdala-uncus region were excluded. Neuropsychological evaluation confirmed normal function of the mesial structures ipsilateral to the lesion. All patients were worked up with video-EEG, high-resolution brain MRI, neuro-psychology evaluation, and either Wada or functional MRI testing.

RESULTS

All patients underwent selective resection of the lesion including amygdala and uncus with preservation of the hippocampus via a transcortical inferior temporal gyrus approach to the mesial temporal lobe. Pathology was compatible with glioneuronal tumors. Post-operative MRI demonstrated complete resection in all patients. Eight of the thirteen patients underwent post-operative neuropsychology evaluations and did not demonstrate any significant decline in tasks of delayed verbal recall or visual memory based on the Rey Auditory Verbal Learning Test (RAVLT). One patient showed a slight decrease in confrontation naming using the Boston Naming Test (BNT). Seizure freedom (Engel class I) was achieved in 12 of 13 patients.

CONCLUSION

Selective transcortical amygdala and uncus resection with hippocampus preservation may be a reasonable way to achieve seizure control while sparing functional mesial structures.

Temporal lobe surgery and memory: Lessons, risks, and opportunities

Careful study of the clinical outcomes of temporal lobe epilepsy (TLE) surgery has greatly advanced our knowledge of the neuroanatomy of human memory. After early cases resulted in profound amnesia, the critical role of the hippocampus and associated medial temporal lobe (MTL) structures to declarative memory became evident. Surgical approaches quickly changed to become unilateral and later, to be more precise, potentially reducing cognitive morbidity. Neuropsychological studies following unilateral temporal lobe resection (TLR) have challenged early models, which simplified the lateralization of verbal and visual memory function. Diagnostic tests, including intracarotid sodium amobarbital procedure (WADA), structural magnetic resonance imaging (MRI), and functional neuroimaging (functional MRI (fMRI), positron emission tomography (PET), and single-photon emission computed tomography (SPECT)), can more accurately lateralize and localize epileptogenic cortex and predict memory outcomes from surgery. Longitudinal studies have shown that memory may even improve in seizure-free patients. From 70 years of experience with epilepsy surgery, we now have a richer understanding of the clinical, neuroimaging, and surgical predictors of memory decline-and improvement-after TLR. "Special Issue: Epilepsy & Behavior's 20th Anniversary".

Verbal associative memory outcomes in pediatric surgical temporal lobe epilepsy: Exploring the impact of mesial structures

OBJECTIVE

We examined verbal associative memory outcomes in children with left- or right-sided temporal lobe epilepsy (TLE) who received combined lateral and mesial resections versus lateral resections sparing mesial structures. We hypothesized that children who underwent left-sided resections including mesial structures would show the greatest verbal associative memory declines following surgery.

METHOD

We retrospectively analyzed neuropsychology assessment results from a sample of 65 children with TLE who completed pre- and postoperative evaluation at the Hospital for Sick Children in Toronto, Canada. We examined verbal associative memory score changes between groups by laterality (left versus right) and resection type (lateral only versus lateral and mesial resection). We also explored potential associations between certain epilepsy-related characteristics and verbal associative memory changes.

RESULTS

Postoperative decline was found in children with left-sided resections, but not those with right-sided resections. In children who received left-sided resections, there was some suggestion of verbal associative memory decline in those who had both lateral and mesial tissues excised, but not in those with lateral resections only. Notably, there was also a language dominance (typical versus atypical) by resection type interaction. Specifically, for the typical language group, children with left lateral plus mesial resections (but not mesial sparing resections) showed postoperative verbal associative memory declines, whereas the opposite was true for the atypical language group.

SIGNIFICANCE

These data contribute to our growing understanding of verbal memory outcomes following TLE in childhood, with consideration of the extent of resection to mesial structures. Our findings also highlight the importance of language laterality when interpreting neuropsychological assessment findings and making predictions regarding risk of functional loss following surgery.

Predicting verbal memory decline following temporal lobe resection for epilepsy

OBJECTIVES

The aim of the study was to develop a prediction model for verbal memory decline after temporal lobe resection (TLR) for epilepsy. The model will be used in the preoperative counselling of patients to give individualized information about risk for verbal memory decline.

MATERIALS AND METHODS

A sample of 110 consecutive patients who underwent TLR for epilepsy at Sahlgrenska University Hospital between 1987 and 2011 constituted the basis for the prediction model. They had all gone through a formal neuropsychological assessment before surgery and 2 years after. Penalized regression and 20 × 10-fold cross-validation were used in order to build a reliable model for predicting individual risks.

RESULTS

The final model included four predictors: side of surgery; inclusion or not of the hippocampus in the resection; preoperative verbal memory function; and presence/absence of focal to bilateral tonic-clonic seizures (TCS) the last year prior to the presurgical investigation. The impact of a history of TCS is a new finding which we interpret as a sign of a more widespread network disease which influences neuropsychological function and the cognitive reserve. The model correctly identified 82% of patients with post-operative decline in verbal memory, and the overall accuracy was 70%-85% depending on choice of risk thresholds.

CONCLUSIONS

The model makes it possible to provide patients with individualized prediction regarding the risk of verbal memory decline following TLR. This will help them make more informed decisions regarding treatment, and it will also enable the epilepsy surgery team to prepare them better for the rehabilitation process.

Neuropsychology Outcomes Following Trephine Epilepsy Surgery: The Inferior Temporal Gyrus Approach for Amygdalohippocampectomy in Medically Refractory Mesial Temporal Lobe Epilepsy

BACKGROUND

Surgery is indicated in cases of mesial temporal lobe epilepsy(MTLE) that are refractory to medical management. The inferior temporal gyrus (ITG) approach provides access to the mesial temporal lobe (MTL) structures with minimal tissue disruption. Reported neuropsychology outcomes following this approach are limited.

OBJECTIVE

To report neuropsychological outcomes using an ITG approach to amygdalohippocampectomy (AH) in patients with medically refractory MTLE based on a prospective design.

METHODS

Fifty-four participants had Engel class I/II outcome following resection of MTL using the ITG approach. All participants had localization-related epilepsy confirmed by long-term surface video-electroencephalography and completed pre/postsurgical evaluations that included magnetic resonance imaging (MRI), Wada test or functional MRI, and neuropsychology assessment.

RESULTS

Clinical semiology/video-electroencephalography indicated that of the 54 patients, 28 (52%) had left MTLE and 26 (48%) had right MTLE. Dominant hemisphere resections were performed on 23 patients (43%), nondominant on 31(57%). Twenty-nine (29) had pathology-confirmed mesial temporal sclerosis (MTS). Group level analyses found declines in verbal memory for patients with language-dominant resections (P < .05). No significant decline in neuropsychological measures occurred for patients with MTS. Participants without MTS who underwent a language-dominant lobe resection exhibited a significant decline in verbal and visual memory (P < .05). Nondominant resection participants did not exhibit significant change in neuropsychology scores (P > .05).

CONCLUSION

Neuropsychology outcomes of an ITG approach for selective mesial temporal resection are comparable to other selective AH techniques showing minimal adverse cognitive effects. These data lend support to the ITG approach for selective AH as an option for MTLE.

Efficacy of limited hippocampal radiofrequency thermocoagulation for mesial temporal lobe epilepsy

OBJECTIVE

Radiofrequency thermocoagulation (RFTC), which has been developed for drug-resistant epilepsy patients, involves less brain tissue loss due to surgery, fewer surgical adverse effects, and generally good seizure control. This study demonstrates the effectiveness of RFTC performed at limited hippocampal locations.

METHODS

Daily seizure diaries were prospectively maintained for at least 6 months by 9 patients (ages 30-59 years) with drug-resistant mesial temporal lobe epilepsy (MTLE) before treatment with RFTC. The limited target for stereotactic RFTC was chosen based on intraoperative electroencephalography (EEG) recording and was initially tested with a Radionics electrode at a low temperature, 45°C, for 60 seconds. The therapeutic RFTC heating parameters were 78°C-80°C for 90 seconds. All patients who received the RFTC treatment underwent both MRI and EEG recording immediately postoperatively and at the 3-month follow-up. Monthly outpatient clinic visits were arranged over 6 months to document seizure frequency and severity to clarify the changes noted in imaging studies and EEG patterns.

RESULTS

Two patients were excluded from our analysis because one had undergone multiple seizure surgeries and the other had a poor recording of seizure frequency, before the RFTC surgery. Five and two patients underwent left-sided and right-sided RFTC, respectively. None of the patients had generalized tonic-clonic attacks postoperatively, and no adverse effects or complications occurred. According to MRI data, the effect of coagulation was limited to less than 1.0 cm in diameter and perifocal edema was also in limited range. The seizure frequency within 6 months decreased postoperatively with a mean reduction in seizures of 78% (range 36%-100%). Only two patients had a temporary increase in seizure frequency within 2 weeks of the surgery, and over 50% of all patients showed a decrease in average seizure frequency.

CONCLUSIONS

The study results confirm that limited RFTC provides a more effective surgery with similar seizure control but fewer complications than resective surgery for drug-resistant MTLE patients.

What Is the Best Target for Ablation of Mesial Temporal Lobe Epilepsy?

[Box: see text].

Postoperative memory prognosis in temporal lobe epilepsy surgery: The contribution of postictal memory

OBJECTIVE

The prediction of verbal memory decline after temporal lobe epilepsy (TLE) surgery remains difficult at an individual level. We evaluated the prognostic value of postictal memory testing in predicting the postoperative verbal memory function.

METHODS

Sixty-three consecutive patients were included in the analysis who underwent TLE surgery at our center with preoperative interictal/postictal and postoperative memory testing. Verbal memory was evaluated using the Rey Auditory Verbal Learning Test (RAVLT). We used reliable change indices with 90% confidence interval (90% RCIs) to evaluate a significant postoperative memory decline. The sensitivity (Sn), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), area under the curve (AUC), and accuracy (ACC) were calculated. The analysis was performed for all TLE patients and for the subgroup with hippocampal sclerosis (HS).

RESULTS

Left-TLE patients (n = 31) had lower verbal memory scores on RAVLT than right-TLE at 3 months (57% vs 78%) and 12 months (53% vs 78%) after surgery. The 90% RCI was estimated to be a loss of 4 out of 15 items. The predictive value was Sn = 42%, Sp = 84%, PPV = 39%, NPV = 86%, AUC = 0.630, and ACC = 76% to predict a verbal memory decline in the whole group (n = 63). In HS patients (n = 41), the postictal verbal memory test had Sn = 50%, Sp = 88%, PPV = 50%, NPV = 88%, AUC = 0.689, and ACC = 81% to predict a significant postoperative decline.

SIGNIFICANCE

Postictal memory is a noninvasive bedside memory test that can help predict the postoperative verbal memory decline in patients with HS with an overall accuracy of 81%.

Comparing the Wada Test and Functional MRI for the Presurgical Evaluation of Memory in Temporal Lobe Epilepsy

PURPOSE OF REVIEW

The usefulness of the Wada test (WT) predicting memory impairment from temporal lobe epilepsy (TLE) surgery has been debated, and it has progressively been replaced by functional MRI (fMRI). We review the current role of WT and fMRI in the presurgical assessment of TLE, and how novel surgical techniques might improve cognitive outcomes.

RECENT FINDINGS

fMRI's ability to predict global amnesia has not been assessed. Although WT can produce false-positive results, it is still indicated in patients at risk for developing global amnesia: those with significant bilateral or contralateral memory deficits. In the current review, WT exhibited no added value, beyond preclinical data, for predicting material-specific memory impairment, whereas fMRI was reliable for either verbal or non-verbal memory decline. Abnormal functional connectivity on resting state fMRI (rs-fMRI) between the posterior cingulate and the hippocampus may be a predictor of postsurgical memory outcomes. Restricted resections to the pathogenic tissue, stereotactic laser, radiosurgery, and SEEG-guided thermos-coagulation were associated with better cognitive outcome. fMRI should be used routinely in the presurgical workup of TLE to predict verbal and/or non-verbal memory decline, whereas WT may be indicated when there is a high risk of postsurgical global amnesia. Rs-fMRI is a promising tool for the presurgical workup of TLE, and more restricted resections are recommended to enhance cognitive outcomes.

The incremental value of neuropsychological assessment: A critical review

Objective: The purpose of this critical review was to evaluate the current state of research regarding the incremental value of neuropsychological assessment in clinical practice, above and beyond what can be accounted for on the basis of demographic, medical, and other diagnostic variables. The focus was on neurological and other medical conditions across the lifespan where there is known risk for presence or future development of cognitive impairment.Method: Eligible investigations were group studies that had been published after 01/01/2000 in English in peer-reviewed journals and that had used standardized neuropsychological measures and reported on objective outcome criterion variables. They were identified through PubMed and PsychInfo electronic databases on the basis of predefined specific selection criteria. Reference lists of identified articles were also reviewed to identify potential additional sources. The Grades of Recommendation, Assessment, Development and Evaluation Working Group's (GRADE) criteria were used to evaluate quality of studies.Results: Fifty-six studies met the final selection criteria, including 2 randomized-controlled trials, 9 prospective cohort studies, 12 retrospective cohort studies, 21 inception cohort studies, 2 case control studies, and 10 case series studies. The preponderance of the evidence was strongly supportive with regard to the incremental value of neuropsychological assessment in the care of persons with mild cognitive impairment/dementia and traumatic brain injury. Evidence was moderately supportive with regard to stroke, epilepsy, multiple sclerosis, and attention-deficit/hyperactivity disorder. Participation in neuropsychological evaluations was also associated with cost savings.Conclusions: Neuropsychological assessment can improve both diagnostic classification and prediction of long-term daily-life outcomes in patients across the lifespan. Future high-quality prospective cohort studies and randomized-controlled trials are necessary to demonstrate more definitively the incremental value of neuropsychological assessment in the management of patients with various neurological and other medical conditions.

Hemispheric language lateralization in presurgical patients with temporal lobe epilepsy: Improving the retest reliability of functional transcranial Doppler sonography

Since its introduction, functional transcranial Doppler sonography (fTCD) has been extensively applied in research and clinical settings and has now become part of the routine presurgical work-up of patients with epilepsy. Because of its importance in planning neurosurgical interventions and predicting possible cognitive risks, the reproducibility of fTCD in determining hemispheric language lateralization (HLL) has to be ensured. In the present study, fTCD was performed twice in 33 initially lateralized patients with temporal lobe epilepsy (TLE) as part of their presurgical work-up, using a standard word generation paradigm. Initially, the standard analysis, including only the statistical examination of fTCD data, was applied, and a rather poor retest reliability of r = 0.41 was obtained (p = 0.017). Because of doubts concerning appropriate task performance in some patients, subsequently, a two-step data analysis was introduced, including an additional qualitative evaluation of fTCD data regarding (1) instruction-compliant task performance, (2) sufficient quality of the baseline phase, and (3) adequate increase in cerebral blood flow velocity (CBFV) during the activation phase. Attributable to a more valid interpretation of fTCD data after the application of the qualitative step, the reproducibility of HLL significantly improved (p = 0.007) to a high retest reliability of r = 0.84 (p < 0.000). In clinical settings, psychological and situational factors seem to strongly influence the reproducibility of fTCD determining HLL. Accordingly, we highly recommend the complementation of the standard statistical examination of fTCD data by an additional qualitative evaluation (two-step data analysis), as this extra security is particularly desirable because of its direct implications for the further evaluation of neurosurgical interventions. This article is part of the Special Issue "Individualized Epilepsy Management: Medicines, Surgery and Beyond".

Clinically indicated electrical stimulation strategies to treat patients with medically refractory epilepsy

Focal epilepsies represent approximately half of all diagnoses, and more than one-third of these patients are refractory to pharmacologic treatment. Although resection can result in seizure freedom, many patients do not meet surgical criteria, as seizures may be multifocal in origin or have a focus in an eloquent region of the brain. For these individuals, several U.S. Food and Drug Administration (FDA)-approved electrical stimulation paradigms serve as alternative options, including vagus nerve stimulation, responsive neurostimulation, and stimulation of the anterior nucleus of the thalamus. All of these are safe, flexible, and lead to progressive seizure control over time when used as an adjunctive therapy to antiepileptic drugs. Focal epilepsies frequently involve significant comorbidities such as cognitive decline. Similar to antiepilepsy medications and surgical resection, current stimulation targets and parameters have yet to address cognitive impairments directly, with patients reporting persistent comorbidities associated with focal epilepsy despite a significant reduction in the number of their seizures. Although low-frequency theta oscillations of the septohippocampal network are critical for modulating cellular activity and, in turn, cognitive processing, the coordination of neural excitability is also imperative for preventing seizures. In this review, we summarize current FDA-approved electrical stimulation paradigms and propose that theta oscillations of the medial septal nucleus represent a novel neuromodulation target for concurrent seizure reduction and cognitive improvement in epilepsy. Ultimately, further advancements in clinical neurostimulation strategies will allow for the efficient treatment of both seizures and comorbidities, thereby improving overall quality of life for patients with epilepsy.

Nomograms to predict naming decline after temporal lobe surgery in adults with epilepsy

OBJECTIVE

To develop and externally validate models to predict the probability of postoperative naming decline in adults following temporal lobe epilepsy surgery using easily accessible preoperative clinical predictors.

METHODS

In this retrospective, prediction model development study, multivariable models were developed in a cohort of 719 patients who underwent temporal lobe epilepsy surgery at Cleveland Clinic and externally validated in a cohort of 138 patients who underwent temporal lobe surgery at one of 3 epilepsy surgery centers in the United States (Columbia University Medical Center, Emory University School of Medicine, University of Washington School of Medicine).

RESULTS

The development cohort was 54% female with an average age at surgery of 36 years (SD 12). Twenty-six percent of this cohort experienced clinically relevant postoperative naming decline. The model included 5 variables: side of surgery, age at epilepsy onset, age at surgery, sex, and education. When applied to the external validation cohort, the model performed very well, with excellent calibration and a c statistic (reflecting discriminatory ability) of 0.81. A second model predicting moderate to severe postoperative naming decline included 3 variables: side of surgery, age at epilepsy onset, and preoperative naming score. This model generated a c statistic of 0.84 in the external validation cohort and showed good calibration.

CONCLUSION

Externally validated nomograms are provided in 2 easy-to-use formats (paper version and online calculator) clinicians can use to estimate the probability of naming decline in patients considering epilepsy surgery for treatment of pharmacoresistant temporal lobe epilepsy.

Putting it all together: Options for intractable epilepsy: An updated algorithm on the use of epilepsy surgery and neurostimulation

For drug-resistant epilepsy, nonpharmacologic treatments should be considered early rather than late. Of the nondrug treatments, only resective surgery can be curative. Neurostimulation is palliative, i.e., not expected to achieve a seizure-free outcome. While resective surgery is the goal, other options are necessary because the majority of patients with drug-resistant epilepsy are not surgical candidates, and others have seizures that fail to improve with surgery or have only partial improvement but not seizure freedom. Neurostimulation modalities include vagus nerve stimulation (VNS), responsive neurostimulation (RNS), and deep brain stimulation (DBS), each with its own advantages, disadvantages, and side effects. In most scenarios, determined by noninvasive evaluation, especially EEG and MRI, several strategies are reasonable. For focal epilepsies, the choices are between resective surgery, with or without intracranial EEG, and all three modalities of neurostimulation. In situations where resective surgery is likely to result in seizure freedom, such as mesiotemporal lobe epilepsy or lesional focal epilepsy, resection (standard, laser, or radiofrequency) is preferred. For difficult cases like extratemporal nonlesional epilepsies, neurostimulation offers a less invasive option than resective surgery. For generalized and multifocal epilepsies, VNS is an option, RNS is not, and DBS has only limited evidence. "This article is part of the Supplement issue Neurostimulation for Epilepsy."

Seizure freedom from temporal lobe epilepsy with mesial temporal lobe tumor by tumor removal alone without hippocampectomy despite remaining abnormal discharges on intraoperative electrocorticography: Report of two pediatric cases and reconsideration of the surgical strategy

Background:

In the surgical treatment of temporal lobe epilepsy with mesial temporal lobe tumor, whether to remove the hippocampus aiming for a better seizure outcome in addition to removing the tumor is a dilemma. Two pediatric cases treated successfully with tumor removal alone are presented.

Case Description:

The first case was an 11-year-old girl with a ganglioglioma in the left uncus, and the second case was a 9-year-old girl with a pleomorphic xanthoastrocytoma in the left parahippocampal gyrus. In both cases, the hippocampus was not invaded, merely compressed by the tumor. Tumor removal was performed under intraoperative electrocorticography (ECoG) monitoring. After tumor removal, abnormal discharges remained at the hippocampus and adjacent temporal cortices, but further surgical interventions were not performed. The seizures disappeared completely in both cases.

Conclusions:

When we must decide whether to remove the hippocampus, the side of the lesion, the severity and chronicity of the seizures, and the presence of invasion to the hippocampus are the factors that should be considered. Abnormal discharges on ECoG at the hippocampus or adjacent cortices are one of the factors related to epileptogenicity, but it is simply a result of interictal irritation, and it is not an absolute indication for additional surgical intervention.

Wada asymmetry in patients with drug-resistant mesial temporal lobe epilepsy: Implications for postoperative neuropsychological outcomes

Objective

This study reports neuropsychological outcomes based on preoperative Wada testing in patients with drug‐resistant mesial temporal lobe epilepsy (mTLE).

Methods

Patient records were retrospectively reviewed as part of a larger database. Patients with a diagnosis of TLE based on seizure semiology and long‐term surface video–electroencephalography (EEG) were identified. These patients underwent preoperative and postoperative testing including advanced imaging (magnetic resonance imaging [MRI]), Wada testing, and neuropsychological assessment. Decrements in neuropsychological function were noted in comparison of pre‐ and postoperative studies. Patients had regular follow‐up in the multidisciplinary epilepsy clinic to assess seizure outcomes. All participants had Engel class I/II outcome following selective amygdalohippocampectomy (AH) via the inferior temporal gyrus (ITG) approach.

Results

Forty‐eight patients with electrographic and clinical semiology consistent with unilateral mTLE were identified. Left mTLE was identified in 28 patients (58.3%), whereas 20 patients (41.7%) had right mTLE. Language‐dominant hemisphere resections were performed on 23 patients (47.9%) (all left‐sided surgery), whereas 25 (52.1%) had language nondominant resection (all right‐sided and five left‐sided surgery). Twenty‐two participants (45.8%) showed no Wada memory asymmetry (No‐WMA), whereas 26 (54.2%) exhibited Wada memory asymmetry (WMA). Postoperatively, analysis of variance (ANOVA) found that the No‐WMA group exhibited a decline in verbal memory, but average scores on measures of nonverbal reasoning, general intelligence, and mood improved. Alternatively, patients with WMA did not show declines in memory postoperatively, and also exhibited improved nonverbal reasoning and general intelligence. Neither group exhibited reliable decline in verbal fluency or visual confrontation naming.

Significance

Wada procedures for predicting surgical outcome from elective temporal surgery have been criticized and remain an area of active debate. However, decades of data across multiple epilepsy centers have demonstrated the value of Wada for reducing unanticipated neuropsychological adverse effects of surgical treatment. These data show that no Wada memory asymmetry increases the risk for neuropsychological decline following ITG approach for selective AH for drug‐resistant mTLE.

Radiosurgery versus open surgery for mesial temporal lobe epilepsy: The randomized, controlled ROSE trial

OBJECTIVE

To compare stereotactic radiosurgery (SRS) versus anterior temporal lobectomy (ATL) for patients with pharmacoresistant unilateral mesial temporal lobe epilepsy (MTLE).

METHODS

This randomized, single-blinded, controlled trial recruited adults eligible for open surgery among 14 centers in the USA, UK, and India. Treatment was either SRS at 24 Gy to the 50% isodose targeting mesial structures, or standardized ATL. Outcomes were seizure remission (absence of disabling seizures between 25 and 36 months), verbal memory (VM), and quality of life (QOL) at 36-month follow-up.

RESULTS

A total of 58 patients (31 in SRS, 27 in ATL) were treated. Sixteen (52%) SRS and 21 (78%) ATL patients achieved seizure remission (difference between ATL and SRS = 26%, upper 1-sided 95% confidence interval = 46%, P value at the 15% noninferiority margin = .82). Mean VM changes from baseline for 21 English-speaking, dominant-hemisphere patients did not differ between groups; consistent worsening occurred in 36% of SRS and 57% of ATL patients. QOL improved with seizure remission. Adverse events were anticipated cerebral edema and related symptoms for some SRS patients, and cerebritis, subdural hematoma, and others for ATL patients.

SIGNIFICANCE

These data suggest that ATL has an advantage over SRS in terms of proportion of seizure remission, and both SRS and ATL appear to have effectiveness and reasonable safety as treatments for MTLE. SRS is an alternative to ATL for patients with contraindications for or with reluctance to undergo open surgery.

Stereotactic EEG-guided laser interstitial thermal therapy for mesial temporal lobe epilepsy

OBJECTIVE

To determine the outcomes of combined stereo-electroencephalography-guided and MRI-guided stereotactic laser interstitial thermal therapy (LITT) in the treatment of patients with drug-resistant mesial temporal lobe epilepsy (mTLE).

METHODS

We prospectively assessed the surgical and neuropsychological outcomes in 21 patients with medically refractory mTLE who underwent LITT at the University of Chicago Medical Center. We further compared the surgical outcomes in patients with and without mesial temporal sclerosis (MTS).

RESULTS

Of the 21 patients, 19 (90%) underwent Invasive EEG study and 11 (52%) achieved freedom from disabling seizures with a mean duration of postoperative follow-up of 24±11 months after LITT. Eight (73%) of 11 patients with MTS achieved freedom from disabling seizures, whereas 3 (30 %) of 10 patients without MTS achieved freedom from disabling seizures. Patients with MTS were significantly more likely to become seizure-free, as compared with those without MTS (P=0.002). There was no significant difference in total ablation volume and the percentage of the ablated amygdalohippocampal complex between seizure-free and non-seizure-free patients. Presurgical and postsurgical neuropsychological assessments were obtained in 10 of 21 patients. While there was no group decline in any neuropsychological assessment, a significant postoperative decline in verbal memory and confrontational naming was observed in individual patients.

CONCLUSIONS

MRI-guided LITT is a safe and effective alternative to selective amygdalohippocampectomy and anterior temporal lobectomy for mTLE with MTS. Nevertheless, its efficacy in those without MTS seems modest. Large multicentre and prospective studies are warranted to further determine the efficacy and safety of LITT.

Curative and palliative MRI-guided laser ablation for drug-resistant epilepsy

Epilepsy is a common neurological disorder occurring in 3% of the US adult population. It is characterised by seizures resulting from aberrant hypersynchronous neural activity. Approximately one-third of newly diagnosed epilepsy cases fail to become seizure-free in response to antiseizure drugs. Optimal seizure control, in cases of drug-resistant epilepsy, often requires neurosurgical intervention targeting seizure foci, such as the temporal lobe. Advances in minimally invasive ablative surgical approaches have led to the development of MRI-guided laser interstitial thermal therapy (LITT). For refractory epilepsy, this surgical intervention offers many advantages over traditional approaches, including real-time lesion monitoring, reduced morbidity, and in some reports increased preservation of cognitive and language processes. We review the use of LITT for epileptic indications in the context of its application as a curative (seizure freedom) or palliative (seizure reduction) measure for both lesional and non-lesional forms of epilepsy. Furthermore, we address the use of LITT for a variety of extratemporal lobe epilepsies. Finally, we describe clinical outcomes, limitations and future applications of LITT for epilepsy.

Adapting a memory fMRI research protocol in clinical routine: Feasibility and results

OBJECTIVE

The objective of this study was to test the reliability of functional magnetic resonance imaging (fMRI) evaluation of memory function in clinical practice to predict postoperative memory decline in patients with refractory medial temporal lobe epilepsy (MTLE) candidate to surgery.

METHODS

Twenty-six consecutive patients with MTLE who underwent a complete presurgical evaluation were included. All patients underwent fMRI memory study and complete neuropsychological assessment. Lesions consisted in hippocampal sclerosis in 18 patients (12 right and 6 left), dysembryoplastic neuroepithelial tumor (DNET) in 5 cases (4 right, 1 left), epidermoid cyst in one patient (right). Two patients had no lesion (2 left).

RESULTS

Nineteen patients (73%) underwent surgery. The other seven patients (27%) declined surgery, mainly because of the risk of memory deficit. The fMRI procedure correctly predicted both verbal and nonverbal memory postoperative outcome in 13 of the patients (72%), failed to predict a postoperative memory worsening in only two patients (12%), and predicted worsening in three patients (17%) that remained stable (versus 44%, 39%, and 17% with the sole neuropsychological testing). The reliability of the fMRI procedure was not influenced by the type of lesion, the side of the epileptic focus, or the type of preoperative memory profile (typical or atypical).

SIGNIFICANCE

Appearing as a valuable clinical tool to predict postoperative memory outcome, fMRI may add information over and above other available tests.

Volumetric Trends Associated with MR-guided Stereotactic Laser Amygdalohippocampectomy in Mesial Temporal Lobe Epilepsy

Objective: Magnetic resonance (MR)-guided stereotactic laser amygdalohippocampectomy is a minimally invasive procedure for the treatment of refractory epilepsy in patients with mesial temporal sclerosis. Limited data exist on post-ablation volumetric trends associated with the procedure.

Methods: 10 patients with mesial temporal sclerosis underwent MR-guided stereotactic laser amygdalohippocampectomy. Three independent raters computed ablation volumes at the following time points: pre-ablation (PreA), immediate post-ablation (IPA), 24 hours post-ablation (24PA), first follow-up post-ablation (FPA), and greater than three months follow-up post-ablation (>3MPA), using OsiriX DICOM Viewer (Pixmeo, Bernex, Switzerland). Statistical trends in post-ablation volumes were determined for the time points.

Results: MR-guided stereotactic laser amygdalohippocampectomy produces a rapid rise and distinct peak in post-ablation volume immediately following the procedure. IPA volumes are significantly higher than all other time points. Comparing individual time points within each raters dataset (intra-rater), a significant difference was seen between the IPA time point and all others. There was no statistical difference between the 24PA, FPA, and >3MPA time points. A correlation analysis demonstrated the strongest correlations at the 24PA (r=0.97), FPA (r=0.95), and 3MPA time points (r=0.99), with a weaker correlation at IPA (r=0.92).

Conclusion: MR-guided stereotactic laser amygdalohippocampectomy produces a maximal increase in post-ablation volume immediately following the procedure, which decreases and stabilizes at 24 hours post-procedure and beyond three months follow-up. Based on the correlation analysis, the lower inter-rater reliability at the IPA time point suggests it may be less accurate to assess volume at this time point. We recommend post-ablation volume assessments be made at least 24 hours post-selective ablation of the amygdalohippocampal complex (SLAH).

Prognostic significance of postoperative spikes varied in different surgical procedures for mesial temporal sclerosis

PURPOSE

We conducted this study to compare the occurrence and prognostic significance of early postoperative interictal epileptiform discharges (IEDs) on seizure outcomes between corticoamygdalohippocampectomy (CAH) and selective amygdalohippocampectomy (SAH).

METHODS

We reviewed our database of patients who had epilepsy surgery with hippocampus atrophy or signal changes on brain MRIs and pathology of mesial temporal sclerosis. One hundred and seventy-seven CAH and 39 SAH patients were enrolled. Postoperative EEG within 30days, other preoperative variables and seizure outcome 2years after surgery were obtained for analysis. Engel's IA and IB were defined as seizure-free.

RESULTS

There was no significant difference in the seizure-free rate between the two procedures (127 (71.8%) of CAH vs 30 (76.9%) of SAH, p=0.51). Postoperative IEDs were more frequently seen in the SAH group (64.1%) than in the CAH group (29.9%), p<0.001. The IEDs in the SAH group did not show correlation with the seizure outcome 2 years after surgery. In the CAH group, patients who had no postoperative IEDs showed a higher seizure-free rate compared to those with IEDs (78.2% vs 56.6%, p=0.003; OR 2.267, 95% CI 1.09-4.73, p=0.029 in multivariate logistic regression).

CONCLUSIONS

Early postoperative IEDs are more frequently seen in SAH than in CAH. Unlike in patients with CAH, the presence of IEDs after SAH was not a predictor of seizure recurrence. The type of surgery should be considered while utilizing postoperative IEDs for evaluating the prognosis.

MRI-Guided stereotactic laser ablation for epilepsy surgery: Promising preliminary results for cognitive outcome

Cognitive outcome data are reviewed with respect to the use of magnetic-resonance guided stereotactic laser ablation (SLA) as an epilepsy surgical procedure, with comparisons drawn to traditional open resection procedures. Cognitive outcome with stereotactic laser amygdalohippocampotomy (SLAH) appears better than open resection for several functions dependent on extra-mesial temporal lobe (TL) structures, including category-related naming, verbal fluency, and object/familiar person recognition. Preliminary data suggests episodic, declarative verbal memory can decline following SLAH in the language dominant hemisphere, although early findings suggest comparable or even superior outcomes compared with open resection. The hippocampus has long been considered a central structure supporting episodic, declarative memory, with epilepsy surgical teams attempting to spare it whenever possible. However, ample data from animal and human neuroscience research suggests declarative memory deficits are greater following broader mesial TL lesions that include parahippocampal gyrus and lateral TL inputs. Therefore, employing a neurosurgical technique that restricts the surgical lesion zone holds promise for achieving a better cognitive outcome. Focal SLA lesions outside of the amygdalohippocampal complex may impair select cognitive functions, although few data have been published in such patients to date. SLA is being effectively employed with adults and children with TL or lesional epilepsies across several U.S. epilepsy centers, which may simultaneously optimize cognitive outcome while providing a curative treatment for seizures.

Use of an intraventricular strip electrode for mesial temporal monitoring in children with medically intractable epilepsy

OBJECTIVE The objective of this study was to evaluate mesial temporal electroencephalographic (EEG) monitoring, using an intraventricular strip electrode (IVSE) along the ventricular surface of the hippocampus, in children with medically intractable epilepsy. METHODS The authors reviewed 10 consecutive cases in which subdural electrode placements and mesial temporal monitoring were recommended. The median age of the patients was 12.7 years (range 4.5-19.3 years). Both grids and IVSE were placed in all patients. The 4-contact IVSE was used in 5 cases, and the 6-contact IVSE in the other 5 cases. The median number of contacts, including IVSE contacts, was 122 (range 66-181). A total of 182 seizures were analyzed. RESULTS The IVSE localized seizure-onset zones in 8 patients. The seizure-onset zone was identified exclusively by IVSE in 3 patients and was simultaneous in IVSE and subdural electrodes in 5 patients. Among the 5 patients with simultaneous onset on both IVSE and subdural electrodes, 4 had basal temporal onset and one had orbitofrontal and lateral midtemporal onset. In the remaining 2 patients, the absence of IVSE seizure onset permitted sparing of mesial temporal structures. An Engel Class Ia outcome was achieved in 9 of 10 cases. No complication was associated with IVSE placement. CONCLUSIONS Intracranial monitoring using IVSE offers an alternative in terms of quality of EEG recording. IVSE was useful in children who already required open craniotomy for intracranial monitoring over an extensive network of hyper-excitability.

Resection of Temporal Neocortex During Multiple Hippocampal Transections for Mesial Temporal Lobe Epilepsy Does not Affect Seizure or Memory Outcome

BACKGROUND

Multiple hippocampal transection (MHT) is a surgical treatment for mesial temporal lobe epilepsy associated with improved postoperative neuropsychological outcomes compared with lobectomy.

OBJECTIVE

To determine whether resection of the amygdala and anterior temporal neocortex during MHT affects postoperative seizure/memory outcome.

METHODS

Seventeen patients with normal magnetic resonance imaging and stereo-electroencephalogram-proven drug-resistant dominant mesial temporal lobe epilepsy were treated with MHT. Nine patients underwent MHT alone (MHT–) and 8 patients underwent MHT plus removal of the amygdala and anterior 4.5 cm of temporal neocortex lateral to the fusiform gyrus (MHT+). Verbal and visual-spatial memory were assessed in all patients preoperatively and in 14 patients postoperatively using the Wechsler Memory Scale. Postoperative seizure control was assessed at 12 months for all patients.

RESULTS

Overall, 11 of 17 patients (64.7%) were Engel class 1 at 1 year (6/9 MHT–, 5/8 MHT+, P = .38), and 10 of 14 patients (71.4%) had no significant postoperative decline in either verbal or visual memory (6/8 MHT–, 4/6 MHT+, P = .42). Verbal memory declined in 2 of 8 MHT– and 1 of 6 MHT+ patients, and visual memory declined in 1 of 8 MHT– and 2 of 6 MHT+ patients. Two patients had improved visual memory postoperatively, both in the MHT+ group.

CONCLUSION

MHT on the dominant side is associated with high rates of seizure freedom and favorable memory preservation outcomes regardless of the extent of neocortical resection. Preservation of the temporal neocortex and amygdala during MHT does not appear to decrease the risk of postoperative memory decline, nor does it alter seizure outcome.

Verbal memory after temporal lobe epilepsy surgery in children: Do only mesial structures matter?

OBJECTIVE

Previous findings have been mixed regarding verbal memory outcome after left temporal lobectomy in children, and there are few studies comparing verbal memory change after lateral versus mesial temporal lobe resections. We compared verbal memory outcome associated with sparing or including the mesial structures in children who underwent left or right temporal lobe resection. We also investigated predictors of postsurgical verbal memory change.

METHODS

We retrospectively assessed verbal memory change approximately 1 year after unilateral temporal lobe epilepsy surgery using a list learning task. Participants included 23 children who underwent temporal lobe surgery with sparing of the mesial structures (13 left), and 40 children who had a temporal lobectomy that included resection of mesial structures (22 left).

RESULTS

Children who underwent resection from the left lateral and mesial temporal lobe were the only group to show decline in verbal memory. Furthermore, when we considered language representation in the left temporal resection group, patients with left language representation and spared mesial structures showed essentially no change in verbal memory from preoperative to follow-up, whereas those with left language representation and excised mesial structures showed a decline. Postoperative seizure status had no effect on verbal memory change in children after left temporal lobe surgery. Finally, we found that patients with intact preoperative verbal memory experienced a significant decline compared to those with below average preoperative verbal memory.

SIGNIFICANCE

Our findings provide evidence of significant risk factors for verbal memory decline in children, specific to left mesial temporal lobe epilepsy. Children who undergo left temporal lobe surgery that includes mesial structures may be most vulnerable for verbal memory decline, especially when language representation is localized to the left hemisphere and when preoperative verbal memory is intact.